Mental Health Care Practice

Need for Mental Health Providers in Progressive Tinnitus Management

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Hearing loss and tinnitus (ringing or other noises in the ears or head) have been problematic for military service members and veterans for many years. Military personnel are exposed to high levels of noise in operational and training settings. In spite of hearing conservation efforts, hearing loss and auditory injuries (including tinnitus) continue to occur. Although current military leadership teaches the importance of hearing protection, that was not usually the case until the past few decades. Military leadership provides the means for hearing protection and monitors risk through conservation and hearing readiness programs. Unfortunately, the need for hearing during battle often overrides the expediency of using hearing protective devices.

Military members often equate hearing protection with increased vulnerability, widening the gap between preventive efforts and hearing preservation. It is therefore not surprising that tinnitus and hearing loss have been the 2 most common service-connected disabilities for veterans for a decade.1 These conditions are irreversible; affected service members and veterans need strategies to cope with distress associated with these chronic conditions. Clinical care often is essential to manage the associated distress and mental health (MH) symptoms, such as sleep disturbance, irritability, isolation, tension, and low mood.

There is no cure for tinnitus, meaning there is no proven method to permanently eliminate or even reduce the perception of tinnitus. Intervention for tinnitus therefore is limited to methods intended to mitigate reactions to tinnitus, with the ultimate goal to facilitate good quality of life in spite of the perception of this unwanted auditory anomaly. These methods include numerous means of utilizing therapeutic sound.2 Sound therapy, however, has been shown in controlled trials to be effective only when accompanied by counseling, which often focuses on teaching different coping skills.3 In such instances, MH providers can become an integral part of the hearing health team to assist patients in the management of their tinnitus.

Evidence-Based Practice

Evidence-based research should guide clinical services that are offered for tinnitus. Randomized controlled trials (RCTs) comprise the most important source for such evidence.4 Cochrane Reviews uses meta-analyses to examine rigorous RCTs to determine which methods have credible evidence. One of these reviews conducted in 2007 and updated in 2010 concluded that cognitive behavioral therapy (CBT) can improve depression scores and reduce distress for many people with bothersome tinnitus.5,6 Another Cochrane Review concluded that sound therapy combined with counseling can be beneficial, but on its own, sound therapy has not been shown to result in significant benefit.3 Yet another Cochrane Review focused on using hearing aids with patients who have both hearing loss and bothersome tinnitus; the researchers concluded that “there is currently no evidence to support or refute their use as a more routine intervention for tinnitus.”7 However, many patients and clinicians report hearing aids are helpful for coping with tinnitus.

The American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) published a clinical practice guideline (CPG) for the management of tinnitus.8 Developing the CPG involved a comprehensive evaluation of the peer-reviewed literature, including the available Cochrane Reviews, to identify appropriate RCTs to inform evidence-based recommendations. Cognitive behavioral therapy was the only intervention for tinnitus recommended in the CPG. Cognitive behavioral therapy targets emotional response by identifying behaviors, thoughts, and beliefs that may be altered.9 For tinnitus, CBT typically includes stress management including relaxation exercises, purposeful distraction, and changing how individuals view and appraise their tinnitus.

Both the CPG and Cochrane Reviews concluded that CBT has the strongest evidence base for reducing effects of tinnitus. It should be noted that the CPG recommended teaching patients basic information about tinnitus management and stated that it was optional (due to limited research evidence) to use sound therapy to augment coping skills training.

Progressive Tinnitus Management

Tinnitus research at the VA National Center for Rehabilitative Auditory Research (NCRAR) has led to the development and refinement of an interdisciplinary program called Progressive Tinnitus Management (PTM). Audiologists and MH providers work together to deliver portions of the protocol. In addition, otolaryngologists are important for patients requiring a medical examination. Audiologists, MH providers, and otolaryngologists comprise the hearing health team for tinnitus management. The PTM program involves 5 stepped-care levels of management, and patients receive only the levels they need.

Level 1 is the referral level, which specifies guidelines for any clinician who encounters patients experiencing tinnitus. The “standard” referral is to audiology for a hearing evaluation (PTM level 2)—every patient reporting tinnitus should have a hearing evaluation and brief tinnitus assessment. Less typical would be an urgent referral to a different provider for certain symptoms such as referral to ENT for sudden hearing loss.

Patients who desire intervention for bothersome tinnitus are offered PTM skills education (level 3). At this level, patients are taught facts and skills that they need to self-manage their tinnitus-related problems. Ideally, the audiologist and MH provider collaborate to deliver the level 3 intervention, which utilizes a 5-session (2 with an audiologist and 3 with a MH provider) problem-solving method. Audiologists explain different forms of sound therapy, and MH providers deliver brief CBT. The research studies and clinics that use PTM have shown that the majority of patients who receive the level 3 skills education interventions have their tinnitus needs met to the degree that they do not desire further services.

Those relatively few patients who desire further services are invited for a PTM interdisciplinary evaluation (level 4), which involves a more in-depth needs evaluation by both an audiologist and a MH provider. Based on the outcome of the level 4 evaluation, clear treatment goals are discussed with the patient. If the patient and providers mutually agree that further intervention is needed, then the patient is offered PTM individualized support (level 5), which involves one-on-one services by an audiologist and/or a MH provider. The providers then build on the lessons taught during level 3 and address barriers to enacting the already discussed skills. The MH provider also may expand on CBT skills that were provided in level 3, offering care such as CBT for insomnia during level 5, depending on the specific needs and desires of the patient.

At the NCRAR, a pilot study and 2 RCTs of PTM have been completed.10 The first of these 2 RCTs was a clinical effectiveness study of PTM that was conducted in 2 VA audiology clinics: Memphis, Tennessee, and West Haven, Connecticut.11 Patients who came to the clinics signed up for the study if they felt that the PTM level 3 intervention might be helpful. Half of the 300 veterans in the study were enrolled to receive PTM right away, and half were put on a 6-month wait list. The PTM group showed significantly greater benefit than that of the wait-list group.

The second RCT of PTM was motivated by the high number of service members and veterans with a history of traumatic brain injury (TBI), which is strongly associated with tinnitus.12 The PTM level 3 skills education was administered to participants individually over the telephone by both an audiologist and a psychologist. Participants, located all over the U.S., had bothersome tinnitus, and some had experienced ≥ 1 TBI. They were randomized to receive either Tele-PTM immediately for 6 months or to be put on a 6-month wait list. The Tele-PTM group showed much greater improvement than that of the wait-list group.

Both of these recent RCTs have validated the effectiveness of PTM and demonstrated that PTM should be considered for the practice of evidence-based tinnitus management. PTM is mostly consistent with the AAO-HNSF CPG and provides a structured and defined framework for implementing both assessment and intervention services for patients who report tinnitus. As such, VA Central Office has endorsed PTM as an effective intervention for tinnitus management and has recommended its use at VAMCs. The NCRAR researchers have provided PTM training to hundreds of VA audiologists and MH providers, yet the level of implementation across the VA system of care varies widely.

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Providing Mental Health Care to All Veterans Regardless of Discharge Status

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