We are pleased to note how much of the correspondence in response to our article emphasized the importance of forging a continuous therapeutic relationship and using an interdisciplinary treatment approach (1), including the willingness to mutually look beyond one’s own perspective. We wish to comment briefly on some of the criticisms:
The representatives from the Deutsche Tinnitus Liga (German tinnitus association) and those from a specialized psychosomatic hospital (Dr Stattrop, Professor Goebel, and Professor Voderholzer) correctly remind us, that the currently available therapeutic options are mainly dealing with tinnitus management, not cure. We agree with this statement, but we think that the availability of treatment options for tinnitus management should not prevent us from optimizing these approaches further and from working on techniques aiming for a cure.
We also wish to focus more closely on the statement that cognitive behavioral therapy is the only “genuinely” evidence based therapy. In our article we presented, for all therapeutic approaches, the available evidence according to generally used criteria. In our opinion, the argument that certain interventions cannot be studied in randomized controlled trials is as unrewarding as the wholesale rejection of apparatus-based approaches. It should also be borne in mind that the questionnaires commonly used in clinical studies are suitable for reflecting the degree of stress due to tinnitus over the course of the treatment, but that the perception of the tinnitus is not incorporated in any way. In the reality of clinical care, many of those affected desire not only help in managing their tinnitus but also an actual reduction in their impression of the noise. We leave it to our readers to decide what counts as “only genuinely evidence based” on this background.
Regarding the categorization of tinnitus according to Biesinger, criticized by Albert and Bergmann in their reader’s letter: we aimed to provide general practitioners and otorhinolaryngologists working in Germany’s statutory health insurance system with a pragmatic decision aid, to enable them to distinguish quickly between those affected and those more severely impaired by tinnitus. In our experience, the patient’s own comments in the personal encounter are much more reliable for a clinical assessment than the total score in a self-assessment questionnaire, which may result in a distorted picture. This in no way diminishes the importance of questionnaires for scientific purposes and for quality assurance. Because of space limitations we were not able to discuss all the different available self-rating scales.
Space was also the primary reason for not being able to discuss self-help services in any detail. A recent review article (published in July 2013) (2), which was not yet available at the time our article went to print, found that specific self-help interventions offer significant benefits compared with mere information provision or discussion groups.
With regard to the comments of Dr Schaaf and Professor Hesse we wish to add that we did not postulate any categorical distinction between psychiatric and psychosomatic approaches anywhere in our article. Without wanting to go into detail about health political contexts, we are of the opinion that the therapist’s individual experience and willingness to enter into an interdisciplinary dialogue provide the key to successful treatment. Usually a general practitioner or otorhinolaryngologist would be the first port of call for persons affected by tinnitus, not a psychiatrist or psychosomatic specialist (3). In contrast to what Sattrop et al. say in their letter, we are convinced that counseling should not be subsumed as an advisory and information-providing talk under “psychologically oriented tinnitus therapy” but as an integral component of any tinnitus therapy. It was our central aim to provide doctors working within the statutory health insurance system with an overview of the currently available, evidence-based therapeutic options as an orientation for clinical decision making—in addition to emphasizing the reasonableness of an interdisciplinary therapeutic approach.
Dr. med. Peter M. Kreuzer
Dr. med. Veronika Vielsmeier
PD Dr. med. Berthold Langguth
Conflict of interest statement
Dr. Kreuzer has received third-party funding for study projects from Cerbomed GmbH. He has received reimbursement of congress attendance fees and travel costs from the Tinnitus Research Initiative. In addition, travel and training costs have been paid on his behalf by Servier, Pfizer, AstraZeneca, Lilly, Bristol Myers Squibb, and Lundbeck.
Dr. Vielsmeier has received reimbursement of congress attendance fees and travel costs from the Tinnitus Research Initiative.
Dr. Langguth has received consulting fees from ANM, Autifony, Merz, Novartis, and Sanofi, and lecture fees from Merz and ANM. He holds patents for the method of neuronavigational positioning of the TMS coil for treatment of tinnitus and of treatment with cyclobenzaprine and naltrexone. Furthermore, he has received revenue from sales of the “Textbook of Tinnitus”.
|1.||Cima RF, Maes IH, Joore MA, et al.: Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: a randomised controlled trial. Lancet 2012; 379: 1951–9 CrossRef MEDLINE|
|2.||Nyenhuis N, Golm D, Kroner-Herwig B: A systematic review and meta-analysis on the efficacy of self-help interventions in tinnitus. Cogn Behav Ther 2013; 42: 159–69 CrossRef MEDLINE|
|3.||Hall DA, Lainez MJ, Newman CW, et al.: Treatment options for subjective tinnitus: self reports from a sample of general practitioners and ENT physicians within Europe and the USA. BMC Health Serv Res 2011; 11: 302 CrossRef MEDLINE PubMed Central|
|4.||Kreuzer PM, Vielsmeier V, Langguth B: Chronic tinnitus: an interdisciplinary challenge. Dtsch Arztebl Int 2013; 110(16): 278–84 VOLLTEXT|