[Skip to Content]
[Skip to Content Landing]

Effect of Cognitive Bias Modification on Early Relapse Among Adults Undergoing Inpatient Alcohol Withdrawal TreatmentA Randomized Clinical Trial

Educational Objective
To test the hypothesis that cognitive bias modification (CBM) would increase the likelihood of abstaining from alcohol during the 2 weeks following discharge from inpatient withdrawal treatment.
1 Credit CME
Key Points

Question  Is computerized cognitive bias modification training during inpatient alcohol withdrawal treatment associated with the likelihood of relapse in the first 2 weeks after discharge?

Findings  In a randomized clinical trial of 300 patients with alcohol use disorder receiving inpatient withdrawal treatment, cognitive bias modification significantly increased the proportion who maintained abstinence during the follow-up period (54.4% vs 42.5% with sham training) in intention-to-treat analysis and by 17% (63.8% vs 46.8%) in per-protocol analysis.

Meaning  The findings of this trial show that cognitive bias modification during alcohol withdrawal helps prevent relapse during the high-risk early period following discharge from treatment; its implementation as an adjunctive intervention in this setting is recommended.

Abstract

Importance  More than half of patients with alcohol use disorder who receive inpatient withdrawal treatment relapse within weeks of discharge, hampering subsequent uptake and effectiveness of psychological and pharmacologic interventions. Cognitive bias modification (CBM) improves outcomes after alcohol rehabilitation, but the efficacy of delivering CBM during withdrawal treatment has not yet been established.

Objective  To test the hypothesis that CBM would increase the likelihood of abstaining from alcohol during the 2 weeks following discharge from inpatient withdrawal treatment.

Design, Setting, and Participants  In a randomized clinical trial, 950 patients in 4 inpatient withdrawal units in Melbourne, Australia, were screened for eligibility between June 4, 2017, and July 14, 2019, to receive CBM or sham treatment. Patients with moderate or severe alcohol use disorder aged 18 to 65 years who had no neurologic illness or traumatic brain injury were eligible. Two-week follow-up, conducted by researchers blinded to the participant’s condition, was the primary end point. Both per-protocol and intention-to-treat analysis were conducted.

Interventions  Randomized to 4 consecutive daily sessions of CBM designed to reduce alcohol approach bias or sham training not designed to modify approach bias.

Main Outcomes and Measures  Primary outcome was abstinence assessed using a timeline followback interview. Participants were classified as abstinent (no alcohol use in the first 14 days following discharge) or relapsed (any alcohol use during the first 14 days following discharge or lost to follow-up).

Results  Of the 950 patients screened for eligibility, 338 did not meet inclusion criteria, 108 were discharged before being approached, and 192 refused. Of the 312 patients who consented (referred sample), 12 withdrew before being randomized. In the final population of 300 randomized patients (CBM, n = 147; sham, n = 153), 248 completed the intervention and 272 completed the follow-up. Of the 300 participants (173 [57.7%] men; mean [SD] age, 43.47 [10.43] years), 7 patients (3 controls, 4 CBM) withdrew after finding the training uncomfortable. Abstinence rates were 42.5% (95% CI, 34.3%-50.6%) in controls and 54.4% (95% CI, 46.0%-62.8%) in CBM participants, yielding an 11.9% (95% CI, 0.04%-23.8%; P = .04) difference in abstinence rates. In a per-protocol analysis including only those who completed 4 sessions of training and the follow-up, the difference in abstinence rate between groups was 17.0% (95% CI, 3.8%-30.2%; P = .008).

Conclusions and Relevance  The findings of this clinical trial support the efficacy of CBM for treatment of alcohol use disorder. Being safe and easy to implement, requiring only a computer and joystick, and needing no specialist staff/training, CBM could be routinely offered as an adjunctive intervention during withdrawal treatment to optimize outcomes.

Trial Registration  Australian New Zealand Clinical Trials Registry Identifier: ACTRN12617001241325

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: August 28, 2020.

Published Online: November 4, 2020. doi:10.1001/jamapsychiatry.2020.3446

Corresponding Author: Victoria Manning, PhD, Turning Point, Eastern Health, 110 Church St, Richmond, VIC 3121, Australia (victoria.manning@monash.edu).

Author Contributions: Dr Reynolds had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Manning, Garfield, Staiger, Lubman, Lum, Reynolds, Hall, Lloyd-Jones, Wiers, Verdejo-Garcia.

Acquisition, analysis, or interpretation of data: Manning, Garfield, Lum, Reynolds, Bonomo, Lloyd-Jones, Piercy, Jacka, Verdejo-Garcia.

Drafting of the manuscript: Manning, Garfield, Lubman, Lum, Reynolds, Lloyd-Jones, Wiers, Piercy.

Critical revision of the manuscript for important intellectual content: Manning, Garfield, Staiger, Lubman, Reynolds, Hall, Bonomo, Lloyd-Jones, Piercy, Jacka, Verdejo-Garcia.

Statistical analysis: Lum, Reynolds.

Obtained funding: Manning, Staiger, Lubman, Lum, Reynolds, Hall, Verdejo-Garcia.

Administrative, technical, or material support: Manning, Garfield, Staiger, Lubman, Lum, Bonomo, Piercy, Jacka.

Supervision: Manning, Piercy.

Conflict of Interest Disclosures: Dr Manning reported receiving grants from the National Health and Medical Research Council (NHMRC) during the conduct of the study. Dr Garfield reported receiving salary support through an NHMRC grant during the conduct of the study. Dr Lubman has provided consultancy advice to Lundbeck and Indivior outside the submitted work; has received travel support and speaker honoraria from AstraZeneca, Camurus, Indivior, Janssen, Lundbeck, Shire, and Servier outside the submitted work; and has been an investigator on an untied education grant from Sequirus unrelated to the current work. Dr Reynolds reported receiving grants from the NHMRC during the conduct of the study, grants from AbbVie outside the submitted work, being a former employee of Novartis AG (2009-2012), and holding shares in Novartis AG and ALCON. Dr Bonomo has received research grants from St Vincent's Health Australia Research Foundation and the NHMRC unrelated to the current work; has received research support from Merck Sharp & Dohme, Victorian Medical Research Acceleration Fund, and Perpetual IMPACT Philanthropy Fund, all unrelated to the current work; has been on advisory boards for Indivior and Seqiris; and is a principal investigator for an industry-sponsored clinical trial of the pharmacokinetics of medicinal cannabis for Zelira Therapeutics unrelated to the current work. Dr Lloyd-Jones reported receiving personal fees from Indivior outside the submitted work. Mr Piercy reported salary support through an NHMRC grant during the conduct of the study. Dr Verdejo-Garcia reported receiving grants from the Australian Medical Research Future Fund and grants from the NHMRC during the conduct of the study, personal fees from Servier and Elsevier outside the submitted work, and being part of the Scientific Advisory Board of Monclarity/Brainwell, which produces cognitive training games, but does not receive any honorarium. No other disclosures were reported.

Funding/Support: This study was funded by grant 1124604 from the NHMRC.

Role of the Funder/Sponsor: The NHMRC had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We appreciate the work done by research assistants and volunteers in collecting these data who are employed by Monash University and Eastern Health, including Katherine Mroz, JD, Samuel Campbell, MDS, Patrick Haylock, BSc (Hons), Kristina Vujcic, BA, and Nyssa Fergusson, MPH, who received a salary in compensation for their work, and Alexandra Turnbull, BHSc (Hons), a volunteer affiliated with Monash University who did not receive compensation for her involvement. Also included are honors students from the Monash University School of Psychological Sciences: Thomas Tolliday, BA (Hons), and Emily Darmanin, BSc (Hons), who did not receive compensation for supporting this research. We also thank the nursing, administrative, and other staff at the recruitment sites, including but not limited to Angela Fazio, BNurs, and Jennifer Kelly, RN (Depaul House, Saint Vincent’s Hospital Melbourne), Molly O’Reilly, DipSocSc (Windana Drug and Alcohol Recovery), Michelle Cody, Cert IV (Monash Health Community Residential Withdrawal Unit), and Alex Lebani, BSc, Trudy Trice, DipNurs, and Bernadette De Boer (Turning Point, Eastern Health). These staff did not receive compensation for supporting this study. Paul Sanfilippo, PhD, a biostatistician (Monash Addiction Research Centre, Monash University), assisted with statistical analyses and received no compensation beyond his salary for this work.

References
1.
WHO.  Global Status Report on Alcohol and Health 2018: Executive Summary. World Health Organization; 2018.
2.
Bonomo  Y , Norman  A , Biondo  S ,  et al.  The Australian drug harms ranking study.   J Psychopharmacol. 2019;33(7):759-768. doi:10.1177/0269881119841569 PubMedGoogle ScholarCrossref
3.
Slade  T , Chiu  WT , Glantz  M ,  et al.  A cross-national examination of differences in classification of lifetime alcohol use disorder between DSM-IV and DSM-5: findings from the World Mental Health Survey.   Alcohol Clin Exp Res. 2016;40(8):1728-1736. doi:10.1111/acer.13134 PubMedGoogle ScholarCrossref
4.
Connor  JP , Haber  PS , Hall  WD .  Alcohol use disorders.   Lancet. 2016;387(10022):988-998. doi:10.1016/S0140-6736(15)00122-1 PubMedGoogle ScholarCrossref
5.
Batra  A , Müller  CA , Mann  K , Heinz  A .  Alcohol dependence and harmful use of alcohol.   Dtsch Arztebl Int. 2016;113(17):301-310. doi:10.3238/arztebl.2016.0301PubMedGoogle Scholar
6.
Manning  V , Staiger  PK , Hall  K ,  et al.  Cognitive bias modification training during inpatient alcohol detoxification reduces early relapse: a randomized controlled trial.   Alcohol Clin Exp Res. 2016;40(9):2011-2019. doi:10.1111/acer.13163 PubMedGoogle ScholarCrossref
7.
Jonas  DE , Amick  HR , Feltner  C ,  et al.  Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis.   JAMA. 2014;311(18):1889-1900. doi:10.1001/jama.2014.3628 PubMedGoogle ScholarCrossref
8.
Yahn  SL , Watterson  LR , Olive  MF .  Safety and efficacy of acamprosate for the treatment of alcohol dependence.   Subst Abuse. 2013;6:1-12. doi:10.4137/SART.S9345 PubMedGoogle Scholar
9.
Magill  M , Ray  L , Kiluk  B ,  et al.  A meta-analysis of cognitive-behavioral therapy for alcohol or other drug use disorders: treatment efficacy by contrast condition.   J Consult Clin Psychol. 2019;87(12):1093-1105. doi:10.1037/ccp0000447 PubMedGoogle ScholarCrossref
10.
Smedslund  G , Berg  RC , Hammerstrøm  KT ,  et al.  Motivational interviewing for substance abuse.   Cochrane Database Syst Rev. 2011;(5):CD008063. doi:10.1002/14651858.CD008063.pub2PubMedGoogle Scholar
11.
Wiers  RW , Gladwin  TE , Hofmann  W , Salemink  E , Ridderinkhof  KR .  Cognitive bias modification and cognitive control training in addiction and related psychopathology: mechanisms, clinical perspectives, and ways forward.   Clin Psychol Sci. 2013;1(2):192-212. doi:10.1177/2167702612466547 Google ScholarCrossref
12.
Eberl  C , Wiers  RW , Pawelczack  S , Rinck  M , Becker  ES , Lindenmeyer  J .  Approach bias modification in alcohol dependence: do clinical effects replicate and for whom does it work best?   Dev Cogn Neurosci. 2013;4:38-51. doi:10.1016/j.dcn.2012.11.002 PubMedGoogle ScholarCrossref
13.
Rinck  M , Wiers  RW , Becker  ES , Lindenmeyer  J .  Relapse prevention in abstinent alcoholics by cognitive bias modification: clinical effects of combining approach bias modification and attention bias modification.   J Consult Clin Psychol. 2018;86(12):1005-1016. doi:10.1037/ccp0000321 PubMedGoogle ScholarCrossref
14.
Wiers  RW , Eberl  C , Rinck  M , Becker  ES , Lindenmeyer  J .  Retraining automatic action tendencies changes alcoholic patients’ approach bias for alcohol and improves treatment outcome.   Psychol Sci. 2011;22(4):490-497. doi:10.1177/0956797611400615 PubMedGoogle ScholarCrossref
15.
Manning  V , Garfield  JBB , Campbell  SC ,  et al.  Protocol for a randomised controlled trial of cognitive bias modification training during inpatient withdrawal from alcohol use disorder.   Trials. 2018;19(1):598. doi:10.1186/s13063-018-2999-3 PubMedGoogle ScholarCrossref
16.
American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
17.
First  MB , Williams  JBW , Karg  RS , Spitzer  RL .  User’s Guide for the Structured Clinical Interview for DSM-5 Disorders, Research Version (SCID-5-RV). American Psychiatric Association; 2015.
18.
Stockwell  T , Sitharthan  T , McGrath  D , Lang  E .  The measurement of alcohol dependence and impaired control in community samples.   Addiction. 1994;89(2):167-174. doi:10.1111/j.1360-0443.1994.tb00875.x PubMedGoogle ScholarCrossref
19.
Sobell  LC , Sobell  MB .  Timeline Followback User's Guide: A Calendar Method for Assessing Alcohol and Drug Use. Addiction Research Foundation; 1996.
20.
Wiers  RW , Rinck  M , Dictus  M , van den Wildenberg  E .  Relatively strong automatic appetitive action-tendencies in male carriers of the OPRM1 G-allele.   Genes Brain Behav. 2009;8(1):101-106. doi:10.1111/j.1601-183X.2008.00454.x PubMedGoogle ScholarCrossref
21.
LaPlante  DA .  Replication is fundamental, but is it common? a call for scientific self-reflection and contemporary research practices in gambling-related research.   Int Gambling Studies. 2019;19(3):362-368. doi:10.1080/14459795.2019.1672768 Google ScholarCrossref
22.
Lubman  DI , Garfield  JBB , Manning  V ,  et al.  Characteristics of individuals presenting to treatment for primary alcohol problems versus other drug problems in the Australian patient pathways study.   BMC Psychiatry. 2016;16(1):250. doi:10.1186/s12888-016-0956-9 PubMedGoogle ScholarCrossref
23.
Duka  T , Townshend  JM , Collier  K , Stephens  DN .  Impairment in cognitive functions after multiple detoxifications in alcoholic inpatients.   Alcohol Clin Exp Res. 2003;27(10):1563-1572. doi:10.1097/01.ALC.0000090142.11260.D7 PubMedGoogle ScholarCrossref
24.
Loeber  S , Duka  T , Welzel  H ,  et al.  Impairment of cognitive abilities and decision making after chronic use of alcohol: the impact of multiple detoxifications.   Alcohol. 2009;44(4):372-381. doi:10.1093/alcalc/agp030 PubMedGoogle ScholarCrossref
25.
Loeber  S , Duka  T , Welzel Márquez  H ,  et al.  Effects of repeated withdrawal from alcohol on recovery of cognitive impairment under abstinence and rate of relapse.   Alcohol. 2010;45(6):541-547. doi:10.1093/alcalc/agq065 PubMedGoogle ScholarCrossref
26.
Stahl  SM .  Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 4th ed. Cambridge University Press; 2013.
27.
Singh  A , Kar  SK .  How electroconvulsive therapy works? understanding the neurobiological mechanisms.   Clin Psychopharmacol Neurosci. 2017;15(3):210-221. doi:10.9758/cpn.2017.15.3.210 PubMedGoogle ScholarCrossref
28.
Hogarth  L , Field  M .  Relative expected value of drugs versus competing rewards underpins vulnerability to and recovery from addiction.   Behav Brain Res. 2020;394:112815. doi:10.1016/j.bbr.2020.112815 PubMedGoogle Scholar
29.
Wiers  RW , Verschure  P .  Curing the broken brain model of addiction: neurorehabilitation from a systems perspective.   Addict Behav. 2020;112:106602. doi:10.1016/j.addbeh.2020.106602 PubMedGoogle Scholar
30.
Blackwell  SE .  Clinical efficacy of cognitive bias modification interventions.   Lancet Psychiatry. 2020;7(6):465-467. doi:10.1016/S2215-0366(20)30170-X PubMedGoogle ScholarCrossref
31.
Mann  K , Günther  A , Stetter  F , Ackermann  K .  Rapid recovery from cognitive deficits in abstinent alcoholics: a controlled test-retest study.   Alcohol. 1999;34(4):567-574. doi:10.1093/alcalc/34.4.567 PubMedGoogle ScholarCrossref
32.
Manning  V , Wanigaratne  S , Best  D ,  et al.  Changes in neuropsychological functioning during alcohol detoxification.   Eur Addict Res. 2008;14(4):226-233. doi:10.1159/000156479 PubMedGoogle ScholarCrossref
33.
Collins  SE , Eck  S , Torchalla  I , Schröter  M , Batra  A .  Validity of the timeline followback among treatment-seeking smokers in Germany.   Drug Alcohol Depend. 2009;105(1-2):164-167. doi:10.1016/j.drugalcdep.2009.05.023 PubMedGoogle ScholarCrossref
34.
Napper  LE , Fisher  DG , Johnson  ME , Wood  MM .  The reliability and validity of drug users’ self reports of amphetamine use among primarily heroin and cocaine users.   Addict Behav. 2010;35(4):350-354. doi:10.1016/j.addbeh.2009.12.006 PubMedGoogle ScholarCrossref
35.
Simons  JS , Wills  TA , Emery  NN , Marks  RM .  Quantifying alcohol consumption: self-report, transdermal assessment, and prediction of dependence symptoms.   Addict Behav. 2015;50:205-212. doi:10.1016/j.addbeh.2015.06.042 PubMedGoogle ScholarCrossref
36.
Mann  K , Batra  A , Fauth-Bühler  M , Hoch  E ; the Guideline Group.  German guidelines on screening, diagnosis and treatment of alcohol use disorders.   Eur Addict Res. 2017;23(1):45-60. doi:10.1159/000455841 PubMedGoogle ScholarCrossref
37.
Verdejo-Garcia  A , Lorenzetti  V , Manning  V ,  et al.  A roadmap for integrating neuroscience into addiction treatment: a consensus of the Neuroscience Interest Group of the International Society of Addiction Medicine.   Front Psychiatry. 2019;10:877. doi:10.3389/fpsyt.2019.00877 PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close