Highlights
Guided internet-based cognitive behavior therapy (ICBT) for tinnitus was associated with large and sustained within-group reductions in tinnitus distress over 6 years.
At 6-year follow-up, 39% of participants met a Reliable Change Index threshold and 55% met a minimal clinically important difference threshold for tinnitus distress improvement.
Smaller long-term benefits were observed for anxiety, depression, insomnia, satisfaction with life, and hyperacusis, whereas hearing disability and hyperacusis did not show durable improvement when posttreatment outcomes were compared over time.
The findings support digital CBT as a potentially scalable tinnitus service model, but interpretation is limited by attrition, nonrandomized follow-up, and the absence of a long-term active comparator.
Background and Clinical Context
Tinnitus is the perception of sound without an external acoustic source, commonly described as ringing, buzzing, hissing, or tonal noise. For many individuals it is transient and only mildly intrusive, but for a clinically significant subgroup it becomes chronic, distressing, and functionally impairing. Patients may experience concentration problems, sleep disturbance, anxiety, depressive symptoms, hypervigilance to sound, and reduced quality of life. Tinnitus often coexists with hearing loss, hyperacusis, and broader emotional distress, making treatment multidimensional rather than purely otologic.
The burden on health systems is considerable. Tinnitus drives repeated consultations across primary care, audiology, otolaryngology, and mental health settings, yet there remains no universally effective pharmacologic therapy that directly eliminates the phantom percept. Contemporary management therefore emphasizes symptom reduction, functional adaptation, and distress mitigation. Cognitive behavior therapy (CBT) has the strongest evidence base among nonpharmacologic interventions for bothersome tinnitus, with guideline-level support in several jurisdictions. However, access barriers remain substantial, including limited specialist availability, geographic constraints, cost, and variability in therapist expertise.
Internet-based CBT has emerged as a pragmatic way to extend access to evidence-based tinnitus care. It can standardize core therapeutic content, reduce travel burden, and potentially lower delivery costs while preserving clinician guidance. What has been less certain is whether benefits persist meaningfully beyond the first year after treatment. That gap is clinically important: durability determines whether a digital intervention is a transient symptom-management tool or a sustainable health service strategy.
The follow-up analysis by Beukes, Andersson, and Manchaiah addresses that question by examining outcomes up to 6 years after a guided 8-week ICBT program for tinnitus.
Study Design and Methods
Design
This investigation was a follow-up of a nonrandomized clinical trial using a repeated-measures design with six time points. Participants from the original online tinnitus intervention trial were invited to complete follow-up assessments at 1, 4, 5, and 6 years after treatment. The original study included a delayed-intervention group design, meaning that by the 6-year time point the initial control group had also received the intervention. As a result, there was no untreated or active control comparator available for the long-term analysis.
Participants
Recruitment for the original trial began in January 2016. The present follow-up invited 138 individuals from that trial. Of these, 49 participants completed the 6-year assessment, corresponding to a response rate of 35.5%. The mean age of completers was 54.49 years (SD, 13.29 years); 18 participants were female (37%) and 31 were male (63%). The study population comprised adults with significant tinnitus who had participated in the online intervention.
Intervention
The intervention was a guided ICBT program consisting of 21 modules delivered over 8 weeks. Although the abstract does not list each module, internet-based tinnitus CBT programs typically include psychoeducation, cognitive restructuring, attention and arousal regulation, sleep strategies, relaxation training, graded exposure or sound-related coping techniques, and behavioral methods aimed at reducing tinnitus-related avoidance and distress. Guided delivery is important because clinician or coach input may improve adherence and help participants apply the material to their symptom profile.
Outcomes
The primary outcome was tinnitus distress. Secondary outcomes included anxiety, depression, insomnia, cognitive failures, satisfaction with life, hyperacusis, and hearing disability. These outcome domains are clinically appropriate because tinnitus severity is often mediated less by the sensory percept itself than by associated emotional, attentional, and sleep-related consequences.
The authors also examined clinical significance using two thresholds: a Reliable Change Index (RCI) criterion of 23.86 points improvement and a minimal clinically important difference (MCID) of 14 points improvement for tinnitus distress. This distinction matters. Statistical significance may demonstrate change at the group level, but RCI and MCID estimates speak more directly to whether individual patients experienced meaningful benefit.
Key Findings
Primary outcome: tinnitus distress
The central finding is that undertaking ICBT for tinnitus was associated with significant improvements that showed little variability over the 6-year follow-up period. At 6 years postintervention, the within-group effect size for tinnitus distress remained large, with Cohen d = 1.00 (95% CI, 0.80-1.32). In practical terms, this suggests that average symptom improvement was not only statistically robust but also clinically substantial, at least among those who remained engaged in long-term follow-up.
Durability is the notable feature here. Long-term maintenance of treatment gains is often difficult in chronic symptom conditions, especially when interventions are relatively brief. An 8-week digital behavioral program producing effects that remain detectable 6 years later is a clinically consequential observation. It suggests that for some patients the intervention may alter coping style, symptom appraisal, and behavioral responses in ways that become self-sustaining over time.
Clinical significance at 6 years
When assessed using categorical thresholds, 19 of 49 participants (39%) achieved clinically significant improvement according to the RCI criterion of 23.86 points (95% CI, 7.96-39.76), and 27 of 49 participants (55%) met the MCID threshold of 14 points (95% CI, 1.9-29.9). These proportions are important because they temper the large average effect size with a more patient-centered perspective.
The difference between 39% and 55% reflects the stringency of the chosen benchmark. RCI identifies change likely to exceed measurement error, whereas MCID captures smaller but still meaningful symptom improvement. For clinicians, this means that roughly half of long-term respondents experienced a benefit likely to matter in daily life, while a smaller but still substantial subgroup achieved a more stringent level of reliable change.
Secondary outcomes
Small effects were found for anxiety, depression, insomnia, satisfaction with life, and hyperacusis. This pattern is clinically plausible. Tinnitus-focused CBT is expected to improve emotional reactivity and coping around the tinnitus experience more than it directly changes hearing function or the auditory percept itself. Improvements in mood and sleep may therefore be secondary gains arising from reduced threat perception, less rumination, and better self-management.
When the authors evaluated durability relative to posttreatment status, treatment effects appeared to be maintained for tinnitus distress as well as measures of anxiety, depression, insomnia, and satisfaction with life. In contrast, durability was not demonstrated for auditory-related effects such as hearing disability and hyperacusis. This distinction deserves emphasis. CBT is well suited to modifying maladaptive beliefs, distress, and behavioral responses, but it is less likely to reverse underlying auditory dysfunction. Patients and clinicians should therefore view tinnitus ICBT primarily as a treatment for tinnitus-related burden rather than as a hearing restoration strategy.
Interpretation of the pattern of benefit
The outcome profile supports an important conceptual point in tinnitus care: successful treatment does not necessarily require elimination of the sound percept. Many effective tinnitus interventions work by reducing distress, improving sleep, normalizing attention, and decreasing avoidance, thereby diminishing the functional significance of tinnitus even when the percept persists. The sustained effect on tinnitus distress, with more modest changes in hearing-related outcomes, is consistent with that therapeutic model.
Clinical and Health Service Relevance
The study has practical implications for service design. First, it strengthens the case for offering ICBT as part of stepped care for bothersome tinnitus. In settings where access to in-person CBT is limited, a guided online program could broaden reach without fully sacrificing therapeutic structure. Second, the long follow-up interval is particularly relevant to policymakers. If even a proportion of patients sustain meaningful benefit over several years after a brief intervention, the downstream value in reduced repeat consultations, lower symptom burden, and improved functioning could be substantial.
For otolaryngology and audiology practices, these findings support closer integration with behavioral health models. Tinnitus frequently sits at the boundary of sensory symptomatology and psychological distress. A digital platform may help bridge that divide, allowing ear and hearing services to direct appropriate patients toward evidence-based psychological care without requiring extensive local CBT infrastructure.
For mental health clinicians, the results reinforce the transdiagnostic utility of CBT principles. The observed gains in anxiety, depression, and insomnia are not surprising, given that maladaptive cognitions, heightened autonomic arousal, selective attention, and sleep disruption are common maintaining factors across these conditions and tinnitus-related distress.
Strengths of the Study
The most obvious strength is duration. Six-year data are rare in tinnitus intervention research and are particularly valuable in digital health, where enthusiasm often outpaces long-term evaluation. The repeated-measures design across multiple follow-up points also provides a more informative trajectory than a single late assessment.
Another strength is the inclusion of both symptom-specific and broader psychosocial outcomes. Tinnitus is not adequately characterized by loudness or percept alone; distress, sleep, mood, and cognitive burden are clinically meaningful endpoints. The use of clinical significance thresholds, not just effect sizes, further improves interpretability.
Finally, the intervention itself is relevant to real-world care delivery. A guided 21-module online program over 8 weeks is intensive enough to be clinically credible yet scalable enough to be operationally realistic.
Limitations and Methodological Caveats
Despite its strengths, the study should not be overinterpreted. The most significant limitation is attrition. Only 49 of 138 invited participants completed the 6-year assessment. A 35.5% completion rate raises the possibility of response bias. Individuals who benefited from treatment may have been more likely to remain engaged, whereas those with limited benefit, symptom recurrence, or competing illness burden may have been less likely to respond. This could inflate estimates of long-term durability.
The second major limitation is the lack of a long-term control group. Because the initial delayed-intervention control group had also received the intervention by the 6-year follow-up, the analysis is effectively within-group rather than comparative. Natural symptom fluctuation, regression to the mean, additional treatments obtained over time, or broader life-course changes cannot be fully disentangled from intervention effects.
Third, the study is nonrandomized at follow-up and depends on self-reported outcomes. These are appropriate for subjective conditions such as tinnitus distress, but they remain vulnerable to recall context, expectancy effects, and selective participation. The abstract also does not provide detailed information on cointerventions over the 6-year interval, such as hearing aid use, sound therapy, medication changes, psychotherapy, or major medical events, all of which could affect outcomes.
Generalizability also requires caution. Participants were willing to engage in an online intervention, suggesting a degree of digital literacy and motivation that may not characterize all tinnitus patients, especially those with severe psychiatric comorbidity, limited internet access, or complex audiologic needs.
How These Findings Fit With the Broader Evidence Base
The current findings align with the broader literature showing that CBT reduces tinnitus-related distress even when effects on tinnitus loudness are modest or absent. The 2020 clinical practice guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation recommends CBT for patients with persistent, bothersome tinnitus. Systematic reviews, including Cochrane analyses, have generally concluded that CBT can improve quality of life and reduce tinnitus impact, though certainty varies depending on comparator and outcome measure.
What this study adds is not proof that ICBT is superior to other approaches over 6 years, but evidence that gains achieved after guided online CBT may persist in a substantial subset of patients. That is especially relevant given increasing interest in telehealth and digitally enabled behavioral care.
The weaker durability for hearing disability and hyperacusis is also consistent with current understanding. These auditory symptoms may require additional or different management strategies, such as hearing rehabilitation, sound tolerance interventions, environmental modifications, or more specialized multidisciplinary assessment. Digital CBT may still help patients cope with these issues, but it should not be presented as a stand-alone corrective therapy for auditory dysfunction.
Implications for Clinical Practice
For clinicians counseling patients with chronic bothersome tinnitus, this study supports several practical messages. First, CBT-based care can produce durable reductions in distress, even when delivered online. Second, treatment goals should be framed around improved coping, reduced intrusiveness, better sleep, and restored function rather than complete elimination of tinnitus. Third, patient selection matters: those most likely to benefit may be individuals with significant distress, preserved capacity for self-directed learning, and willingness to engage with structured behavioral exercises.
In routine care, ICBT may be particularly useful as a first-line or early specialty intervention after basic otologic evaluation has excluded remediable causes and identified hearing-related comorbidities. It may also serve as part of stepped care: digital CBT for many, with escalation to more intensive multidisciplinary or psychiatric input for those with severe insomnia, major depressive disorder, prominent hyperacusis, trauma-related symptoms, suicidality, or disabling functional decline.
Research Priorities
Future studies should focus on reducing uncertainty rather than merely extending follow-up duration. Randomized long-term comparisons with active controls would help clarify the specific contribution of ICBT. Better characterization of responders and nonresponders is also needed. Predictors could include baseline tinnitus severity, hearing loss profile, comorbid anxiety or insomnia, treatment adherence, age, digital literacy, and socioeconomic factors.
Attrition mitigation should be a design priority in digital trials, since long-term evidence is only as credible as participant retention permits. Hybrid effectiveness-implementation studies may also be useful, especially if they incorporate healthcare utilization, work productivity, and cost-effectiveness outcomes. In a condition with high prevalence and chronicity, even modest durable benefit can have major public health implications if the intervention scales well.
Conclusion
This 6-year follow-up suggests that guided internet-based CBT for tinnitus may yield durable reductions in tinnitus distress, with accompanying smaller sustained benefits in anxiety, depression, insomnia, and life satisfaction. The pattern of results reinforces the role of CBT as a treatment for tinnitus-related burden rather than for hearing impairment itself. For clinicians and health systems, the study offers encouraging support for digital tinnitus care pathways. However, high attrition and the absence of a long-term comparator mean the results should be viewed as promising rather than definitive. The central message is clinically useful: a brief, structured online behavioral intervention may help a meaningful proportion of patients live better with chronic tinnitus over the long term.
Funding and Trial Registration
ClinicalTrials.gov Identifier: NCT02370810.
The provided abstract and citation do not specify the funding source. Readers should consult the full JAMA Otolaryngology–Head & Neck Surgery article for detailed funding, conflict-of-interest, and protocol information.
References
Beukes E, Andersson G, Manchaiah V. Long-Term Outcomes of an Internet-Based Cognitive Behavior Therapy Intervention for Tinnitus: Follow-Up Analysis of a Nonrandomized Clinical Trial. JAMA Otolaryngology–Head & Neck Surgery. 2026;152(5):503-512. PMID: 41854598.
Tunkel DE, Bauer CA, Sun GH, et al. Clinical practice guideline: tinnitus. Otolaryngology–Head and Neck Surgery. 2014;151(2 Suppl):S1-S40.
Fuller T, Cima R, Langguth B, Mazurek B, Vlaeyen JWS, Hoare DJ. Cognitive behavioural therapy for tinnitus. Cochrane Database of Systematic Reviews. 2020;1(1):CD012614.
Cima RFF, Andersson G, Schmidt CJ, Henry JA. Cognitive-behavioral treatments for tinnitus: a review of the literature. Journal of the American Academy of Audiology. 2014;25(1):29-61.
