Combined cognitive behavioral therapy and sound therapy for chronic tinnitus: a systematic review and meta-analysis

Chronic tinnitus is a prevalent condition associated with significant distress and functional impairment. Despite various therapeutic attempts, there is currently no curative treatment. Although clinical management has advanced in recent years, overall outcomes remain unsatisfactory. Cognitive behavioral therapy (CBT) and sound therapy (ST) are established interventions; however, the efficacy of their combination (CBT + ST) relative to monotherapies or standard care remains uncertain. This systematic review and meta-analysis aims to evaluate the efficacy of combined CBT and ST for adults with chronic tinnitus.

We systematically searched PubMed, Scopus, Web of Science, and Cochrane Library databases for relevant randomized controlled trials (RCTs) and cohort studies published up to 12 December 2025. Studies involving adults with chronic subjective tinnitus receiving combined CBT + ST were included. Statistical analysis was performed using R software with a random-effects model. Continuous outcomes were analyzed as mean differences (MD) or standardized mean differences (SMD), and dichotomous data as risk ratios (RR), with 95% confidence intervals (CI). Heterogeneity was assessed using I² statistics.

Our review included four RCTs and one cohort with 610 participants. CBT + ST was associated with a statistically significant reduction in tinnitus-related handicap assessed by THI (MD = -8.72, 95% CI -13.23 to -4.20) with substantial heterogeneity, which resolved upon RCT-only analysis. Pooled sensitivity analysis of RCTs only showed that CBT + ST significantly reduced THI scores (MD = -11.19, 95% CI -14.67 to -7.70), exceeding the minimal clinically important difference (MCID) compared to ST alone. Our results yielded significant change in Tinnitus Functional Index (TFI) (MD = -5.11, 95% CI -8.14 to -2.09), yet not clinically meaningful. No significant difference was found for subjective loudness assessed by Visual Analogue Scale/Numeric Rating Scale (VAS/NRS) (SMD = -0.29, 95% CI -0.62 to 0.03).

Our findings indicate that combined CBT and sound therapy might provide meaningful reductions in tinnitus-related distress and handicap (exceeding MCID thresholds for THI) in comparison to sound therapy alone. Benefits appear confined to distress and functional outcomes, with no significant effect on perceived loudness. These findings should be considered preliminary given the small number of studies, clinical heterogeneity, the inclusion of one retrospective cohort, and the absence of individual-level responder data. Future large-scale RCTs with larger sample sizes are needed to validate these findings.