Effectiveness of Guided Internet-Based Cognitive Behavioral Therapy vs Face-to-Face Clinical Care for Treatment of Tinnitus: A Randomized Clinical Trial | Otolaryngology | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Original Investigation
December 2018

Effectiveness of Guided Internet-Based Cognitive Behavioral Therapy vs Face-to-Face Clinical Care for Treatment of Tinnitus: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Vision and Hearing Sciences, Anglia Ruskin University, Cambridge, United Kingdom
  • 2Department of Speech and Hearing Sciences, Lamar University, Beaumont, Texas
  • 3Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
  • 4Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institute, Stockholm, Sweden
  • 5Vision and Eye Research Unit, Anglia Ruskin University, Cambridge, United Kingdom
  • 6Audiology India, Mysore, Karnataka, India
  • 7Department of Speech and Hearing, School of Allied Health Sciences, Manipal University, Karnataka, India
  • 8National Institute for Health Research, Nottingham Biomedical Research Centre, Ropewalk House, Nottingham, United Kingdom
  • 9Hearing Sciences, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom
  • 10Department of Audiology, Nottingham University Hospitals, Nottingham, United Kingdom
JAMA Otolaryngol Head Neck Surg. 2018;144(12):1126-1133. doi:10.1001/jamaoto.2018.2238
Key Points

Question  Is undertaking an internet-based cognitive behavioral therapy program as effective as undergoing individualized face-to-face clinical care in reducing distress from tinnitus?

Findings  In this randomized, multicenter, noninferiority clinical trial of 92 adults, internet-based cognitive behavioral therapy for tinnitus led to outcomes similar to those of individualized face-to-face clinical care for tinnitus.

Meaning  Internet-based cognitive behavioral therapy has shown potential as an evidence-based intervention that could increase access to managing tinnitus care.


Importance  Accessible clinical care is not always available to individuals with distressing tinnitus. Internet-based cognitive behavioral therapy has the potential to increase access to evidence-based services that manage tinnitus. Research comparing the effectiveness of this internet-based intervention with face-to-face care is required.

Objective  To evaluate whether an internet-based cognitive behavioral therapy intervention is at least as effective as established individualized face-to-face clinical care in reducing tinnitus distress and tinnitus-related difficulties.

Design, Setting, and Participants  A randomized, multicenter, 2-arm parallel group, noninferiority trial with 2-month follow-up was performed between October 4, 2016, and July 14, 2017. Invited to participate were 374 adults based in the United Kingdom who had been referred to their local tinnitus clinics because of bothersome tinnitus. The experimental group received the internet-based intervention online, and the active control group underwent the usual face-to-face tinnitus care at 1 of 3 UK-based National Health Service hospitals. Participants were randomly assigned (1:1) to either intervention using variable permuted block sizes of 4 and 6. Of 92 participants who were randomized (46 each in the experimental and control groups), 88 participants completed the assessment immediately after intervention and 74 participants completed the follow-up assessment.

Interventions  Participants were randomized to receive either 8 weeks of guided internet-based cognitive behavioral therapy or a mean of 2 to 3 individualized face-to-face appointments in a tinnitus clinic.

Main Outcomes and Measures  The primary outcome was a change in tinnitus distress (assessed by the Tinnitus Functional Index). Secondary assessment measures were included for insomnia, anxiety, depression, hearing disability, hyperacusis, cognitive failures, and satisfaction with life.

Results  Of 92 patients overall, 55 (60%) were men with a mean (SD) age of 52.96 (12.07) years and mean (SD) tinnitus duration of 6.54 (9.25) years. The between-group difference in the Tinnitus Functional Index scores after intervention were 5.18 (95% CI, –4.17 to 14.53) at the initial assessment and 5.52 (95% CI, –4.60 to 15.61) at follow-up; both differences were within the noninferiority margin of 13 points for the lower 95% CI. For the secondary outcomes, only outcomes for insomnia fell outside the noninferiority margin, both after intervention and at follow-up, favoring internet-based cognitive behavioral therapy.

Conclusions and Relevance  This is the first trial, to our knowledge, to compare an internet-based intervention with standard individualized face-to-face care for tinnitus. It revealed that both interventions are equally effective for reducing tinnitus distress and most tinnitus-related difficulties.

Trial Registration  ClinicalTrials.gov identifier: NCT02665975