Strength in numbers: are two treatments better than one?

Is it better to use one tinnitus treatment at a time, or to combine several treatment options?

This uncertainty was the starting point for an international study, led by Stefan Schoisswohl of the University of Regensburg. This month, Stefan takes us through the research and explains how it could help you manage your tinnitus.

I am Stefan Schoisswohl, an Austrian neuroscientist and psychologist, and the Scientific Head of the Centre for Neuromodulation at the University of Regensburg in Germany. I first studied tinnitus for my PhD, which I completed as part of the European School for Interdisciplinary Tinnitus Research.

A significant undertaking

Together with colleagues from several European countries, I worked within the EU-funded UNITI-project (Unification of Treatments and Interventions for Tinnitus Patients), which brought together an international team of researchers and clinicians.[1] Experts from many different fields – including psychiatry/psychology, audiology, genetics, ENT, data science and epidemiology – worked closely together.

What did we actually do?

As part of the UNITI-project, we performed the largest clinical study on tinnitus in Europe so far.

The study took place in five different clinical centres located in Athens, Berlin, Granada, Leuven and Regensburg, and included 461 patients with chronic tinnitus. Four well established tinnitus treatments (app-based sound therapy, hearing aids, Cognitive Behavioural Therapy (CBT) and app-based counselling) were directly compared against each other within one study for the first time. Our main goal was to investigate whether using two treatments in combination might help more than using just one treatment option on its own.

It was a major study – we were investigating ten different arms covering both single and combination treatments, such as hearing aids plus structured counselling, or CBT plus sound therapy. All treatments were delivered over a period of 12 weeks.

We assessed changes in the impact of tinnitus on individuals’ daily life using the Tinnitus Handicap Inventory (THI) questionnaire before and after treatment. You may have seen the THI yourself, as many clinicians use it to help assess people’s tinnitus.

So, are combinations better?

The short answer is yes. On average a combination of two treatments reduced tinnitus handicap slightly more than single treatments.

Overall, all treatments lessened how much tinnitus bothered people, which helps validate the existing advice on each of them. Most participants reported that after 12 weeks of treatment, tinnitus had less impact on their daily lives.

The combination of hearing aids (with an identified hearing loss) and structured counselling showed the strongest effect. Moreover, our results suggest that structured counselling and hearing aids as stand-alone treatments can help people with tinnitus to a similar extent as CBT.

Comparing single versus combination treatments, we found a small advantage for combination treatments. On average, people who received two treatments together reported that their tinnitus was improved more than those who received only one.

This can probably be explained by some kind of “boosting” effect when combining two treatments, meaning that a more effective treatment can compensate for a less effective one and raise the overall impact on your life. For example, sound therapy alone had only a small effect, whereas in combination with a second treatment like counselling the improvement was much larger.

How this could help you

You can think of it like this: if one treatment already works well for you on and another one works less well, using them together can mean that the stronger treatment “pulls up” the effect of the weaker one.

Already have hearing aids? Try counselling – it could help too. Going through a CBT course? Give sound therapy a try in those quiet moments between sessions.

In everyday clinical practice, where it is not clear which treatment option will help a particular person, combining different treatment types may increase the chances of treatment success.

Hopes for the future

I hope that in the coming years, we can move forward to truly personalised, active interventions, with brain imaging, genetics and increased understanding of tinnitus types combined with sophisticated data analysis to help us to better understand why certain treatments work for you – but maybe not for the next person.

I also want to encourage the next generation of researchers and clinicians to engage in interdisciplinary work, uniting different perspectives and approaches, because in my opinion this is the most promising way forward to better understand and treat the complex and varied phenomenon that is tinnitus.

Most of all, my ambition is that people with tinnitus feel heard, informed and empowered – with access to evidence-based treatment options no matter where they live.