Pilot Program

Cognitive Behavioral Therapy for Veterans With Tinnitus

Fed Pract. 2018 August;35(8):36-46

References

1. Henry JA. “Measurement” of tinnitus. Otol Neurotol. 2016;37(8):e276-e285.

2. Hoffman HJ, Reed GW. Epidemiology of tinnitus. In Snow JB, ed. Tinnitus: Theory and Management. Hamilton, Canada: BC Becker; 2004:16-41.

3. Folmer RL, Theodoroff SM, Martin WH, Shi Y. Experimental, controversial, and futuristic treatments for chronic tinnitus. J Am Acad Audiol. 2014;25(1):106-125.

4. US Department of Veterans Affairs. Veterans Benefits Administration annual benefits report fiscal year 2016. https://www.benefits.va.gov/REPORTS/abr/ABR-All_Sec tions_FY16_06292017.pdf . Accessed June 19, 2018.

5. Henry JA, Zaugg TL, Myers PJ, Schechter MA. The role of audiologic evaluation in progressive audiologic tinnitus management. Trends Amplif. 2008;12(3):170-187.

6. Hoare DJ, Searchfield GD, El Refaie A, Henry JA. Sound therapy for tinnitus management: practicable options. J Am Acad Audiol. 2014;25(1):62-75.

7. Andersson G, Porsaeus D, Wiklund M, Kaldo V, Larsen HC. Treatment of tinnitus in the elderly: a controlled trial of cognitive behavior therapy. Int J Audiol. 2005;44(11):671-675.

8. Henry JL, Wilson PH. Coping with tinnitus: two studies of psychological and audiological characteristics of patients with high and low tinnitus-related distress. Int Tinnitus J. 1995;1(2):85-92.

9. Henry JL, Wilson PH. The psychological management of tinnitus: comparison of a combined cognitive educational program, education alone and a waiting-list control. Int Tinnitus J. 1996;2:9-20.

10. Robinson SK, Viirre ES, Bailey KA, et al. A randomized controlled trial of cognitive-behavior therapy for tinnitus. Int Tinnitus J. 2008;14(2):119-126.

11. Martinez-Devesa P, Perera R, Theodoulou M, Waddell A. Cognitive behavioural therapy for tinnitus. Cochrane Database Syst Rev. 2010(9):CD005233.

12. Tunkel DE, Bauer CA, Sun GH, et al. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014;151(Suppl)(2):S1-S40.

13. Beck JS. Cognitive Behavior Therapy: Basics and Beyond. 2nd ed. New York, NY: Guilford Press; 2011.

14. Henry JL, Wilson PH. The Psychological Management of Chronic Tinnitus : A Cognitive-Behavioral Approach. Boston, MA: Allyn and Bacon; 2001.

15. Bandura A. Health promotion by social cognitive means. Health Educ Behav. 2004;31(2):143-164.

16. Cima RF, Andersson G, Schmidt CJ, Henry JA. Cognitive-behavioral treatments for tinnitus: a review of the literature. J Am Acad Audiol. 2014;25(1):29-61.

17. Rodriguez V, Andrade AD, García-Retamero R, et al. Health literacy, numeracy, and graphical literacy among veterans in primary care and their effect on shared decision making and trust in physicians. J Health Commun. 2013;18(suppl 1):273-289.

18. Seal KH, Metzler TJ, Gima KS, Bertenthal D, Maguen S, Marmar CR. Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002-2008. Am J Public Health. 2009;99(9):1651-1658.

19. Thomas JL, Wilk JE, Riviere LA, et al. Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Arch Gen Psychiatry. 2010;67(6):614-623.

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22. Henry JA, Zaugg TL, Myers PJ, Kendall (Schmidt) CJ. Progressive Tinnitus Management: Clinical Handbook for Audiologists. San Diego, CA: Plural Publishing; 2010.

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Methods

The study used a single-blind, randomized, parallel treatment (VET CBT-T vs AC) concurrent design complemented by collection of qualitative data. This study was approved by the institutional review board at the VA Connecticut Healthcare System (VACHS) and was registered at ClinicalTrials.gov (NCT00724152).

Veterans with chronic (> 6 mo) tinnitus were recruited using flyers placed in common areas of the VACHS, a complex, tertiary care VA facility. Target candidates were veterans exposed to acoustic trauma as assessed by the study otologist and who had severe tinnitus distress (eTable 1).

Measures

Four standardized measures were administered to potential participants. Callers were screened for eligibility by the research coordinator using Section A of the Tinnitus and Hearing Survey (THS), which had been developed to screen candidates for tinnitus studies by phone.²² The THS contains 3 sections to identify problems related to tinnitus (Section A), hearing (Section B), and sound tolerance (Section C). Section A contains 4 items, each with a possible score of 0 to 4, which identifies tinnitus problems. Callers who were veterans and who met the necessary cutoff of 4 out of 16 possible points on Section A were invited to meet in-person with the research coordinator to obtain written informed consent and conduct a thorough assessment of eligibility.²³

Three additional assessment measures were then administered sequentially to determine eligibility. The first 2 of these measures were readministered to eligible candidates who agreed to participate in the study and were used to examine outcomes:

(1) Tinnitus Handicap Inventory (THI): The 25-item THI provides an index score (0-100), with higher scores reflecting poorer QOL and more perceived functional limitations due to tinnitus.²⁴ Candidates with scores of ≤ 19 were excluded.

(2) Tinnitus Reaction Questionnaire (TRQ): The TRQ measures perceived impact of tinnitus on QOL with emphasis on emotional consequences of tinnitus.²⁵ Higher scores indicate more severe impact. Scores of ≥ 17 points purportedly indicate significant tinnitus disturbance. Candidates scoring < 17 were excluded.

(3) Structured Clinical Interview for Diagnosis, Abbreviated-Interview/Nonpatient (SCIDa-I/NP): The SCIDa-I/NP is a measure used to assess symptoms of psychopathology.²⁶ Candidates with a lifetime history of psychosis were excluded.

Interventions

Each of the interventions was offered using 6 group sessions, with 2 or more participants, on an approximate weekly schedule.

VET CBT-T. Two primary texts served as resources for developing the VET CBT-T protocol: (1) the Psychological Management of Chronic Tinnitus: A Cognitive-Behavioral Approach¹⁴; and (2) a manual for providing CBT for the treatment of chronic pain.^27,28 Draft materials were developed by the clinical psychologist, including a clinician’s manual for providing VET CBT-T. Handouts were provided to each veteran. Components were compared to another unpublished CBT for tinnitus workbook.¹⁰

Key components targeted psychological difficulties including sleep disturbance, reduced functioning, low mood, nervousness, reduced pleasure from activities, and negative changes in relationships. The protocol emphasized basic information about tinnitus; relationships among tinnitus, acoustic trauma, and mental health symptoms; veterans’ sense of camaraderie and loyalty; and goal setting, making use of discipline and order veterans may desire.

To build rapport, the psychologist used reflective listening, encouraged interactive dialogue, and promoted participant understanding. Since tinnitus is thought to be exacerbated by stress, participants learned ways to manage stress and practiced relaxation exercises. Participants learned to create individualized, intersession goals that were realistic, specific, and measurable to promote self-efficacy. They also learned to list and increase pleasant activities to distract from tinnitus, improve QOL, and enable behavioral activation. Motivational interviewing addressed readiness, ambivalence, and resistance to achieving these specific goals. Participants also learned to identify and modify unhelpful thoughts about tinnitus (ie, cognitive restructuring).

Homework included recommendations for intersession coping skills practice. Table 1 lists details of the components included in each of the 6 sessions. The VET CBT-T sessions were led by one of 3 doctoral-level psychologists experienced in providing CBT for tinnitus or for other health conditions with veterans.