Pilot Program

Cognitive Behavioral Therapy for Veterans With Tinnitus

Cognitive behavioral therapy encourages acquisition, practice, and use of a range of specific coping strategies to enhance perceptions of self-control and self-efficacy for patients with tinnitus.

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

Author(s):

Caroline J. Schmidt, PhD

Robert D. Kerns, PhD

Suzanne Finkel, AuD,

Elias Michaelides, MD

James A. Henry, PhD

The article has been corrected from the original version.

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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.

20. Zivin K, McCarthy JF, McCammon RJ, et al. Health-related quality of life and utilities among patients with depression in the Department of Veterans Affairs. Psychiatr Serv. 2008;59(11):1331-1334.

21. Costa DL, Kahn ME. Health, wartime stress, and unit cohesion: evidence from Union Army veterans. Demography. 2010;47(1):45-66.

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

23. Henry JA, Schechter MA, Loovis CL, et al. Clinical management of tinnitus using a “progressive intervention” approach. J Rehabil Res Dev. 2005;42(4 suppl 2):95-116.

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Chronic tinnitus is defined as nonsensical, persistent sound in the head or ears with no external sound source that persists for more than 6 months.¹ It is most commonly associated with sound trauma, aging, head injury, and damage to the ear structures.² Tinnitus affects up to 30% of military veterans, a prevalence rate that is twice that of the nonveteran population.³ It also is the most common service-connected disability for veterans.⁴ In 2016, more than 1.6 million veterans had service-connected tinnitus.

Clinical management of tinnitus is the purview of audiologists, although their role in providing this service is not well defined.⁵ Following an audiologic evaluation for hearing loss, devices such as hearing aids, ear-level sound generators, or sounds played through speakers may be prescribed. However, effectiveness of these devices has been shown only when coupled with counseling.⁶ Counseling provided by audiologists often includes education about tinnitus etiology, maintaining hearing health, and use of sound to manage tinnitus. Length, content of care, and follow-up services vary among audiologists.

Given the importance of counseling and the added complexities of mental health and behavioral health comorbidities (eg, depression, anxiety, sleep disorders), various psychological therapies delivered by mental health specialists for tinnitus management have been explored.^7-11 In fact, only psychological therapies have been documented to be efficacious for mitigating the negative effects of tinnitus on sleep, concentration, communication, and emotions.¹² Among these approaches, cognitive behavioral therapy (CBT) has the strongest empirical support, particularly in terms of improving quality of life (QOL) and reducing depressive symptoms.^11,12 Cognitive behavioral therapy for tinnitus is derived from social cognitive theory (SCT) and modeled after CBT for depression, anxiety, pain, and insomnia.^11,13-15

Cognitive behavioral therapy helps patients with tinnitus reconceptualize the auditory problem as manageable and encourages acquisition, practice, and use of a range of specific tinnitus coping strategies to enhance perceptions of self-control and self-efficacy. Cognitive behavioral therapy involves a number of distinct therapeutic components, and there is no consensus about the efficacious components of CBT for tinnitus. For example, use of sound and purposeful exposure to tinnitus varies among providers.¹⁶ Additional questions about CBT pertain to its clinical implementation (eg, group vs individual sessions, frequency and length of sessions, in-person sessions vs delivery via telephone or Internet).

Programs offered at the Department of Veterans Affairs (VA) facilities take veteran-specific factors into account to promote optimal engagement and outcomes. Factors that differentiate veterans from civilians include (1) increased probability of low health literacy and low socioeconomic status among seniors¹⁷; (2) increased likelihood of acoustic and/or psychological trauma^3,18; (3) overrepresentation of males; and (4) increased probability of mental health diagnoses.^19,20 At the same time, veterans are highly diverse with respect to age, academic achievement, cultural background, medical and mental health comorbidities, and economic resources.¹⁷ In spite of this diversity, most veterans are unified by their sense of camaraderie, loyalty to country, and adherence to discipline and order.²¹ Peer support and other variables such as compassionate understanding of their military experiences may be especially important to consider when designing behavioral interventions for veterans.

The present phenomenologic study was motivated by the need to develop and test a veteran-specific CBT for tinnitus protocol (VET CBT-T). To examine veterans’ experiences with VET CBT-T, we designed a small pilot randomized controlled trial (RCT) of VET CBT-T comparing it to structured audiologist counseling (AC). A mixed quantitative and qualitative approach was employed, including assessing veterans’ acceptance of care, identifying aspects that can be modified to improve outcomes, and obtaining feasibility data to guide refinements to VET CBT-T to inform a larger RCT.