Background: The aim of this randomized controlled trial was to investigate the effects of conventional face-to-face group cognitive behavioral therapy (GCBT) and an Internet-delivered guided self-help treatment (Internet-based CBT, ICBT) on tinnitus distress. Methods: A total of 128 adults with at least mild levels of chronic tinnitus distress were randomly assigned to GCBT (n = 43), ICBT (n = 41), or a web-based discussion forum (DF) that served as a control condition (n = 44). Standardized self-report measures [the Tinnitus Handicap Inventory (THI), Mini-Tinnitus Questionnaire (Mini-TQ), Hospital Anxiety and Depression Scale, Insomnia Severity Index and Tinnitus Acceptance Questionnaire] were completed at the pre- and post-assessments and at the 6-month follow-up. Results: Repeated-measures ANOVAs revealed significant time × group interaction effects on the primary outcomes (THI and Mini-TQ scores) in favor of both CBT interventions compared with the DF at post-assessment (0.56 ≤ g ≤ 0.93; all p ≤ 0.001). There were no significant differences between GCBT and ICBT (all p > 0.05) and the treatment effects remained stable at the 6-month follow-up. Conclusions: This study provides evidence that ICBT might be an equally effective alternative to conventional CBT in the management of chronic tinnitus. Despite encouraging results, further research is necessary to determine the actual potential of ICBT as a viable alternative to CBT, and under which circumstances it is effective.

Keywords:
Internet-based therapy, Group cognitive behavioral therapy, Guided self-help, Cognitive behavioral therapy, Tinnitus
1.
Lockwood AH, Salvi RJ, Burkard RF: Tinnitus. N Engl J Med 2002;347:904-910.
2.
Davis A, El Refaie A: Epidemiology of tinnitus; in Tyler RS (ed): Tinnitus Handbook. San Diego, Singular, 2000, pp 1-23.
3.
Andersson G: Psychological aspects of tinnitus and the application of cognitive-behavioral therapy. Clin Psychol Rev 2002;22:977-990.
4.
Gander PE, Hoare DJ, Collins L, Smith S, Hall DA: Tinnitus referral pathways within the National Health Service in England: a survey of their perceived effectiveness among audiology staff. BMC Health Serv Res 2011;11:162.
5.
Andersson G, Lyttkens L: A meta-analytic review of psychological treatments for tinnitus. Br J Audiol 1999;33:201-210.
6.
Hesser H, Weise C, Westin VZ, Andersson G: A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress. Clin Psychol Rev 2011;31:545-553.
7.
Weise C, Heinecke K, Rief W: Biofeedback-based behavioral treatment for chronic tinnitus: results of a randomized controlled trial. J Consult Clin Psychol 2008;76:1046-1057.
8.
Cima RFF, Maes IH, Joore MA, Scheyen DJWM, El Refaie A, Baguley DM, Anteunis LJC, van Breukelen GJP, Vlaeyen JWS: Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: a randomised controlled trial. Lancet 2012;379:1951-1959.
9.
Ritterband LM, Andersson G, Christensen HM, Carlbring P, Cuijpers P: Directions for the International Society for Research on Internet Interventions (ISRII). J Med Internet Res 2006;8:e23.
10.
Andersson G: Using the Internet to provide cognitive behaviour therapy. Behav Res Ther 2009;47:175-180.
11.
Nijhof SL, Bleijenberg G, Uiterwaal CS, Kimpen JL, van de Putte EM: Effectiveness of internet-based cognitive behavioural treatment for adolescents with chronic fatigue syndrome (FITNET): a randomised controlled trial. Lancet 2012;379:1412-1418.
12.
Carpenter KM, Stoner SA, Mundt JM, Stoelb B: An online self-help CBT intervention for chronic lower back pain. Clin J Pain 2012;28:14-22.
13.
Hunt MG, Moshier S, Milonova M: Brief cognitive-behavioral internet therapy for irritable bowel syndrome. Behav Res Ther 2009;47:797-802.
14.
Ljótsson B, Hedman E, Andersson E, Hesser H, Lindfors P, Hursti T, Rydh S, Rück C, Lindefors N, Andersson G: Internet-delivered exposure-based treatment vs stress management for irritable bowel syndrome: a randomized trial. Am J Gastroenterol 2011;106:1481-1491.
15.
Andersson G, Strömgren T, Ström L, Lyttkens L: Randomized controlled trial of internet-based cognitive behavior therapy for distress associated with tinnitus. Psychosom Med 2002;64:810-816.
16.
Kaldo V, Levin S, Widarsson J, Buhrman M, Larsen HC, Andersson G: Internet versus group cognitive-behavioral treatment of distress associated with tinnitus: a randomized controlled trial. Behav Ther 2008;39:348-359.
17.
Hesser H, Gustafsson T, Lundén C, Henrikson O, Fattahi K, Johnsson E, Westin VZ, Carlbring P, Mäki-Torkko E, Kaldo V, Andersson G: A randomized controlled trial of internet-delivered cognitive behavior therapy and acceptance and commitment therapy in the treatment of tinnitus. J Consult Clin Psychol 2012;80:649-661.
18.
Abbott JA, Kaldo V, Klein B, Austin D, Hamilton C, Piterman L, Williams B, Andersson G: A cluster randomised trial of an internet-based intervention program for tinnitus distress in an industrial setting. Cogn Behav Ther 2009;38:162-173.
19.
Kaldo-Sandström V, Larsen HC, Andersson G: Internet-based cognitive-behavioral self-help treatment of tinnitus: clinical effectiveness and predictors of outcome. Am J Audiol 2004;13:185-192.
20.
Cuijpers P, van Straten A, Andersson G: Internet-administered cognitive behavior therapy for health problems: a systematic review. J Behav Med 2008;31:169-177.
21.
Cuijpers P, Donker T, van Straten A, Li J, Andersson G: Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies. Psychol Med 2010;40:1943-1957.
22.
Kröner-Herwig B, Frenzel A, Fritsche G, Schilkowsky G, Esser G: The management of chronic tinnitus: comparison of an outpatient cognitive-behavioral group training to minimal-contact interventions. J Psychosom Res 2003;54:381-389.
23.
Kröner-Herwig B, Hebing G, van Rijn-Kalkmann U, Frenzel A, Schilkowsky G, Esser G: The management of chronic tinnitus: comparison of a cognitive-behavioural group training with yoga. J Psychosom Res 1995;39:153-165.
24.
Hiller W, Haerkötter C: Does sound stimulation have additive effects on cognitive-behavioral treatment of chronic tinnitus? Behav Res Ther 2005;43:595-612.
25.
Winzelberg AJ, Classen C, Alpers GW, Roberts H, Koopman C, Adams RE, Ernst H, Dev P, Taylor CB: Evaluation of an internet support group for women with primary breast cancer. Cancer 2003;97:1164-1173.
26.
Hiller W, Goebel G: Rapid assessment of tinnitus-related psychological distress using the Mini-TQ. Int J Audiol 2004;43:600-604.
27.
Donker T, van Straten A, Marks I, Cuijpers P: A brief Web-based screening questionnaire for common mental disorders: development and validation. J Med Internet Res 2009;11:e19.
28.
Janca A, Hiller W: ICD-10 checklists: a tool for clinicians' use of the ICD-10 classification of mental and behavioral disorders. Compr Psychiatry 1996;37:180-187.
29.
Kaldo V, Andersson G: Kognitiv beteendeterapi vid tinnitus [Cognitive-Behavioural Therapy of Tinnitus]. Lund, Studentlitteratur, 2004.
30.
Dobie RA: A review of randomized clinical trials in tinnitus. Laryngoscope 1999;109:1202-1211.
31.
Andersson G, Kaldo-Sandström V, Ström L, Strömgren T: Internet administration of the Hospital Anxiety and Depression Scale in a sample of tinnitus patients. J Psychosom Res 2003;55:259-262.
32.
Newman CW, Jacobson GP, Spitzer JB: Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg 1996;122:143-148.
33.
Kleinjung T, Fischer B, Langguth B, Sand PG, Hajak G, Dvorakova J, Eichhammer P: Validierung einer deutschsprachigen Version des Tinnitus Handicap Inventory [Validation of the German version of the Tinnitus Handicap Inventory]. Psychiatr Prax 2007;34:140-142.
34.
Hallam RS: Manual of the Tinnitus Questionnaire (TQ). London, Psychological Corporation, 1996.
35.
Zigmond AS, Snaith RP: The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67:361-370.
36.
Herrmann-Lingen C, Buss U, Snaith RP: Hospital Anxiety and Depression Scale: Deutsche Version (HADS-D), ed 3, updated, newly normalized. Bern, Hans Huber, 2011.
37.
Morin CM: Insomnia: Psychological Assessment and Management. New York, Guilford, 1993.
38.
Pillmann F: Das Hallenser Schlafinterview [The Halle Sleep Interview]; unpubl MS, 2004.
39.
Westin V, Hayes SC, Andersson G: Is it the sound or your relationship to it? The role of acceptance in predicting tinnitus impact. Behav Res Ther 2008;46:1259-1265.
40.
Weise C, Kleinstäuber M, Hesser H, Westin VZ, Andersson G: Acceptance of tinnitus: validation of the tinnitus acceptance questionnaire. Cogn Behav Ther 2013;42:100-115.
41.
Devilly GJ, Borkovec TD: Psychometric properties of the credibility/expectancy questionnaire. J Behav Ther Exp Psychiatry 2000;31:73-86.
42.
Schafer JL: Analysis of Incomplete Multivariate Data. New York, Chapman & Hall, 2000.
43.
Jacobson NS, Truax P: Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 1991;59:12-19.
44.
Nyenhuis N, Golm D, Kröner-Herwig B: A systematic review and meta-analysis on the efficacy of self-help interventions in tinnitus. Cogn Behav Ther 2013;42:159-169.
45.
Hedman E, Andersson G, Ljótsson B, Andersson E, Rück C, Mortberg E, Lindefors N: Internet-based cognitive behavior therapy vs cognitive behavioral group therapy for social anxiety disorder: a randomized controlled non-inferiority trial. PLoS One 2011;6:e18001.
46.
Ljótsson B, Hedman E, Andersson E, Hesser H, Lindfors P, Hursti T, Rydh S, Rück C, Lindefors N, Andersson G: Internet-delivered exposure-based treatment vs stress management for irritable bowel syndrome: a randomized trial. Am J Gastroenterol 2011;106:1481-1491.
47.
Spek V, Nyklicek I, Smits N, Cuijpers P, Riper H, Keyzer J, Pop V: Internet-based cognitive behavioural therapy for subthreshold depression in people over 50 years old: a randomized controlled clinical trial. Psychol Med 2007;37:1797-1806.
48.
Couper MP, Kapteyn A, Schonlau M, Winter J: Noncoverage and nonresponse in an Internet survey. Soc Sci Res 2007;36:131-148.
49.
Gosling SD, Vazire S, Srivastava S, John OP: Should we trust web-based studies? A comparative analysis of six preconceptions about internet questionnaires. Am Psychol 2004;59:93-104.
50.
Donkin L, Hickie IB, Christensen H, Naismith SL, Neal B, Cockayne NL, Glozier N: Sampling bias in an internet treatment trial for depression. Transl Psychiatry 2012;2:e174.
51.
Cosco TD, Doyle F, Ward M, McGee H: Latent structure of the Hospital Anxiety and Depression Scale: a 10-year systematic review. J Psychosom Res 2012;72:180-184.
52.
Coyne JC, van Sonderen E: No further research needed: abandoning the Hospital and Anxiety [sic!] Depression Scale (HADS). J Psychosom Res 2012;72:173-174.
53.
Derogatis LR, Melisaratos N: The Brief Symptom Inventory: an introductory report. Psychol Med 1983;13:595-605.
54.
Malouff JM, Schutte NS, Zucker LA: Tinnitus-related distress: a review of recent findings. Curr Psychiatry Rep 2011;13:31-36.
55.
Zirke N, Seydel C, Szczepek AJ, Olze H, Haupt H, Mazurek B: Psychological comorbidity in patients with chronic tinnitus: analysis and comparison with chronic pain, asthma or atopic dermatitis patients. Qual Life Res 2013;22:263-272.
56.
MacKenzie KR: Time-Managed Group Psychotherapy: Effective Clinical Applications. Washington, American Psychiatric Press, 1997.
57.
Kivlighan DM Jr, Kivlighan MC: Counselor intentions in individual and group treatment. J Couns Psychol 2004;51:347-353.
58.
Holmes SE, Kivlighan DM Jr: Comparison of therapeutic factors in group and individual treatment processes. J Couns Psychol 2000;47:478-484.
59.
McRoberts C, Burlingame GM, Hoag MJ: Comparative efficacy of individual and group psychotherapy: a meta-analytic perspective. Group Dyn 1998;2:101-117.
60.
Hiller W, Goebel G: Assessing audiological, pathophysiological, and psychological variables in chronic tinnitus: a study of reliability and search for prognostic factors. Int J Behav Med 1999;6:312-330.
61.
Hiller W, Goebel G, Schindelmann U: Developing a structured interview to assess audiological, aetiological and psychological variables of tinnitus; in Hazell JWP (ed): Proceedings of the Sixth International Tinnitus Seminar. London, Tinnitus and Hyperacusis Centre, 1999, pp 277-282.
62.
Landgrebe M, Azevedo A, Baguley D, Bauer C, Cacace A, Coelho C, Dornhoffer J, Figueiredo R, Flor H, Hajak G, van de Heyning P, Hiller W, Khedr E, Kleinjung T, Koller M, Lainez JM, Londero A, Martin WH, Mennemeier M, Piccirillo J, de Ridder D, Rupprecht R, Searchfield G, Vanneste S, Zeman F, Langguth B: Methodological aspects of clinical trials in tinnitus: a proposal for an international standard. J Psychosom Res 2012;73:112-121.
63.
Marx RG, Bombardier C, Hogg-Johnson S, Wright JG: Clinimetric and psychometric strategies for development of a health measurement scale. J Clin Epidemiol 1999;52:105-111.
64.
Tomba E, Bech P: Clinimetrics and clinical psychometrics: macro- and micro-analysis. Psychother Psychosom 2012;81:333-343.
65.
Kaldo V, Haak T, Buhrman M, Alfonsson S, Larsen HC, Andersson G: Internet-based cognitive behaviour therapy for tinnitus patients delivered in a regular clinical setting: outcome and analysis of treatment dropout. Cogn Behav Ther 2013;42:146-158.
66.
Cima RF, Maes IH, Joore MA, Scheyen DJ, El Refaie A, Baguley DM, Anteunis LJ, van Breukelen GJ, Vlaeyen JW: Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: a randomised controlled trial. Lancet 2012;379:1951-1959.
67.
Haaga DA: Introduction to the special section on stepped care models in psychotherapy. J Consult Clin Psychol 2000;68:547-548.
© 2014 S. Karger AG, Basel
2014
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.