Interpretation Training to Reduce Anxiety: Evaluating Technology-based Delivery Models and Methods to Reduce Attrition

Study Overview
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Brief Summary
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The project aims to compare effectiveness and target engagement of CBM-I delivered via computer vs. mobile phone, and test if adding minimal human contact for participants at risk of dropout improves retention and outcomes.

Detailed Description
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Approximately 25-30% of the U.S. population will experience anxiety pathology severe enough to qualify for an anxiety disorder diagnosis during their lifetime. Critically, the majority will not receive treatment, creating a serious need to consider alternative approaches to delivering mental health services that can meet needs on a larger scale. Cognitive Bias Modification (CBM) interventions for anxiety hold considerable promise as a way to meet these needs. These programs alter biased ways of thinking, such as selective assignment of threat interpretations, which are known to cause and maintain anxiety. CBM for interpretation bias (CBM-I) has established efficacy when administered via computer in the laboratory, and there is clear evidence for target engagement (i.e., change in interpretations, the identified mechanism). Now, effectiveness needs to be tested in the community, using sufficiently large samples to evaluate key moderators of its effects, including delivery method (computer vs. mobile phone) and the addition of minimal human contact (for those at risk of attrition). Addressing attrition is critical given high rates of drop out for web-based interventions. Via the PI's MindTrails web site (established with the lab's prior NIMH R34MH106770 award), the lab already has the infrastructure to deliver CBM to the public and recruit large anxious samples. Moreover, the PI and Co-I have established infrastructure to do mobile sensing of mood and CBM-I delivery via mobile phones. Thus, the project can respond to NIMH's request for Effectiveness trials that can contribute to advancing the personalization of mental health care. The current proposal aims to compare effectiveness and target engagement of CBM-I delivered via computer vs. mobile phone, and test if adding minimal human contact for participants at risk of dropout improves retention and outcomes. Study 1 will provide a pilot feasibility and user experience test of the CBM-I program on mobile phones. Study 2 will examine the lab's current online, computer-based CBM-I data to help determine empirical indicators of attrition. Study 3 will provide the primary test of moderators of effectiveness. Namely, in Study 3, high anxious participants will be randomized to one of 2 conditions: 1) CBM-I training delivered by computer or mobile phone (at existing MindTrails site); 2) Alternate intervention group-Psychoeducation only. CBM-I and Psychoeducation conditions include 5 weekly training sessions. Based on theoretically- and empirically-derived predictors of attrition, participants identified as high-risk for dropout in condition 1 will then be randomly assigned to add minimal human contact (using a modified TeleCoach protocol) or no change. Using this adaptive intervention, known as Sequential, Multiple Assignment, Randomized Trial (SMART), the project can test both the effects of CBM-I delivery method and the added value of human contact to improve retention for participants at high-risk for dropping out.

Official Title
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Effectiveness of Interpretation of Training to Reduce Anxiety: Evaluating Technology-based Delivery Models and Methods to Reduce Attrition

Conditions
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Anxiety

Intervention / Treatment
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* Behavioral: Cognitive Bias Modification - Interpretation training
* Behavioral: Coaching
* Behavioral: Online psychoeducation about anxiety


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 18 and over Moderate to extremely severe anxiety range (i.e., 10 or higher) on the Depression, Anxiety, Stress Scales - Short Form: Anxiety Subscale Regular access to the Internet via Smartphone or computer Exclusion Criteria: • None

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Sequential Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: CBM-I, low attrition<br>Computer- or phone-based Cognitive Bias Modification - Interpretation training | Behavioral: Cognitive Bias Modification - Interpretation training<br>* Training involves presenting participants with brief scenarios that introduce an ambiguous potential threat. Critically, the ambiguity regarding how the situation is resolved remains until the last word of the scenario, which is presented as a word fragment that the participant must solve, which will typically then assign a benign (rather than threatening) meaning to the scenario.<br>|
| Experimental: CBM-I, high attrition, coach<br>Computer- or phone-based Cognitive Bias Modification - Interpretation training + Coaching | Behavioral: Cognitive Bias Modification - Interpretation training<br>* Training involves presenting participants with brief scenarios that introduce an ambiguous potential threat. Critically, the ambiguity regarding how the situation is resolved remains until the last word of the scenario, which is presented as a word fragment that the participant must solve, which will typically then assign a benign (rather than threatening) meaning to the scenario.<br>Behavioral: Coaching<br>* Participants identified as high risk for attrition will receive low-intensity coaching, which includes a mix of brief phone calls, texts, and/or emails with a trained member of the study team to help address challenges with adherence to and application of the training.<br>|
| Experimental: CBM-I, high attrition, no coach<br>Computer- or phone-based Cognitive Bias Modification - Interpretation training | Behavioral: Cognitive Bias Modification - Interpretation training<br>* Training involves presenting participants with brief scenarios that introduce an ambiguous potential threat. Critically, the ambiguity regarding how the situation is resolved remains until the last word of the scenario, which is presented as a word fragment that the participant must solve, which will typically then assign a benign (rather than threatening) meaning to the scenario.<br>|
| Active Comparator: Psychoeducation<br>Online psychoeducation about anxiety | Behavioral: Online psychoeducation about anxiety<br>* Participants will review webpages that describe information about symptoms and causes of anxiety, including the nature of biased thinking in anxiety.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Recognition Ratings | To measure interpretation bias, participants will read ambiguous scenarios with titles, after which they will see the titles of each scenario, followed by 2 disambiguated interpretations of the scenario: 1 positive and 1 negative. Participants will rate each disambiguated interpretation based on how similar in meaning it is to the original scenario. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 
| Change in Overall Anxiety Severity and Impairment Scale | This 5-item measure of anxiety symptom severity and impairment has good psychometric properties, shows treatment sensitivity, and is valid in community and clinical samples. Item range = 0 to 4. Total scale range = 0-20, with a higher score indicating more severe anxiety. | Baseline, and after sessions 1,2, 3, 4, 5 (sessions will be spaced  1 week apart) & at 2-month follow-up ( 2 months after session 5). Session 1 occurs  0-7 days after baseline. Measure will be completed immediately following that day's training session. | 
| Change in Brief Bodily Sensations Interpretations Questionnaire | To assess interpretation change, participants are presented with ambiguous events and then asked to rate three alternative explanations for why the event might have occurred. One option is always negative, whereas the other responses are either neutral and/or positive. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 
| Change in Depression, Anxiety, Stress Scales-Short Form: Anxiety Subscale | This 7-item measure of anxiety symptoms has good psychometric properties, shows treatment sensitivity, and is valid in community and clinical samples. Item range = 0 to 3. Total DASS-21 subscale range = 0-21 (multiplied by 2 for DASS-42 = 0-42), with a higher score indicating more severe depression symptoms. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Depression Comorbid symptoms | The Patient Health Questionnaire 2 (PHQ-2) inquires about the frequency of depressed mood and anhedonia. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 
| Change in Alcohol Use Comorbid symptoms | The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is a 3-item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorders. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 
| Change in Wellness measures - Optimism | Items 3 and 7 from the Life Orientation Test-Revised (LOT-R) will assess generalized optimism versus pessimism. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 
| Change in Wellness measures - Growth mindset | Items 1, 5, and 7 from the Growth Mindset Measure will be administered to measure changes in thinking styles (altered from the original items that reference intelligence). | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 
| Change in Wellness measures - Self-efficacy | Items 2, 6, and 7 from the New General Self-Efficacy Scale (NGSES) will be administered to measure self-efficacy. Item range = 0 to 4. Total range for aggregated 3 items = 0-12, with a higher score indicating more self-efficacy. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 
| Change in Wellness measures - Life Satisfaction | Single-Item Life Satisfaction measure will be administered to measure overall satisfaction with one's life. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 
| Change in Mechanisms underlying bias change - Cognitive flexibility | Item 14 of the Cognitive Flexibility Inventory (CFI) will be administered to measure cognitive flexibility. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 
| Change in Mechanisms underlying bias change - Experiential avoidance | Item 11 from the Comprehensive Assessment of ACT processes (CompACT) will be administered to measure experiential avoidance. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 
| Change in Mechanisms underlying bias change - Cognitive reappraisal | Items 7 and 10 from the Emotion Regulation Questionnaire (ERQ) will be administered to measure cognitive reappraisal. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 
| Change in Mechanisms underlying bias change - Intolerance of uncertainty | Items 1 and 7 from the Intolerance of Uncertainty Scale-Short Form (IUS-12) will be administered to measure intolerance of uncertainty. Item range = 1 to 7. Total range for aggregated 2 items = 2-14, with a higher score indicating more intolerance of uncertainty. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 
| Change in Anxiety and Identity Circles | We will assess change in the extent anxiety is viewed as central to the person's self-concept. | Baseline, and after session 3 (2-3 weeks following baseline), session 5 ( 2 weeks after session 3), & at 2-month follow-up (  2 months after session 5). Measure will be completed immediately following that day's training session. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Anxiety, Cognitive bias, Telemedicine