Implementing Approach-Bias Modification as Add-On to Varieties of Clinical Treatment for Alcohol Use Disorders: Results of a Multicenter RCT.

INTRODUCTION: Abstinence rates after inpatient treatment for alcohol use disorder (AUD) are modest (1-year rate around 50%). One promising approach is to re-train the automatically activated action tendency to approach alcohol-related stimuli (alcohol-approach bias) in AUD patients, as add-on to regular treatment. As efficacy has been demonstrated in well-controlled randomized controlled trials, the important next step is to add alcohol-approach-bias modification (alcohol-ApBM) to varieties of existing treatments for AUD. Therefore, this prospective, multicenter implementation-RCT examined whether adding alcohol-ApBM to regular treatments (various abstinence-oriented treatments including both individual and group-based interventions) would significantly increase abstinence rates compared to receiving regular treatment only, in a variety of naturalistic settings with different therapeutic approaches. METHODS: A total of 1,586 AUD inpatients from 9 German rehabilitation clinics were randomly assigned to receive either ApBM in addition to regular treatment or not. Training satisfaction of patients and therapists was measured after training. Success rates were determined at 3, 6, and 12 months post-treatment. RESULTS: Return rates of the post-treatment assessments varied greatly between clinics, often being low (18-76%). Nevertheless, ApBM significantly increased success rates after 3 months. After 6 and 12 months, the differences were not significant. ApBM was evaluated mostly positively by patients and therapists. DISCUSSION/CONCLUSION: ApBM was an effective add-on to regular treatment of AUD at 3 months follow-up, across a variety of AUD treatment settings. However, low return rates for the clinical outcomes reduced the effect size of ApBM considerably. The application of ApBM proved feasible in varying clinical settings, offering the opportunity to modify automatic processes and to promote abstinence.

German Guidelines on Screening, Diagnosis, and Treatment of Alcohol Use Disorders: Update 2021.

INTRODUCTION: Alcohol consumption in Germany is associated with considerable health and economic consequences. In addition to prevention, the early detection and differential treatment of those affected play an important role. The guideline "Screening, Diagnosis, and Treatment of Alcohol Use Disorders" forms the basis of this care for people suffering from alcohol use disorders. Regular updates integrate the current state of research evidence and clinical expertise. METHODS: Under the auspices of the German Society for Psychiatry, Psychotherapy, Psychosomatics, and Neurology and the German Society for Addiction Research and Addiction Therapy e.V. (DG-Sucht), the 2019-2020 S3 guideline on alcohol was revised by eight working groups. Thirty-five professional societies participated in a structured consensus process to deliberate the recommendations. Potential conflicts of interest were examined in advance, documented, and taken into account during the voting on the recommendations. RESULTS: The guideline provides recommendations on screening and brief interventions for different groups of people, as well as on treatment of individuals in the acute and post-acute phases of withdrawal. Special emphasis was placed on the treatment of comorbid somatic and psychological disorders. In addition, recommendations for specific groups of people (e.g., children and adolescents, pregnant women) have been made and adapted to the German care landscape.

A Clinical Trial with Combined Transcranial Direct Current Stimulation and Attentional Bias Modification in Alcohol-Dependent Patients.

BACKGROUND: Modifying attentional processes with attentional bias modification (ABM) might be a relevant add-on to treatment in addiction. This study investigated whether influencing cortical plasticity with transcranial direct current stimulation (tDCS) could increase training effects. tDCS could also help alcohol-dependent patients to overcome craving and reduce relapse, independent of training. These approaches were combined to investigate effects in the treatment of alcoholism. METHODS: Ninety-eight patients (analytical sample = 83) were randomly assigned to 4 groups in a 2-by-2 factorial design. Patients received 4 sessions of ABM (control or real training) combined with 2 mA tDCS (active: 20 minutes or sham: 30 seconds) over the left dorsolateral prefrontal cortex. Alcohol bias and craving were assessed, and treatment outcome was measured as relapse after 1 year. RESULTS: Attentional bias scores indicated that during the training only the group with active tDCS and real ABM displayed an overall avoidance bias (p < 0.05). From pre- to postassessment, there were no main or interaction effects of tDCS and ABM on the bias scores, craving, or relapse (p > 0.2). However, effects on relapse after active tDCS were in the expected direction. CONCLUSIONS: There was no evidence of a beneficial effect of tDCS or ABM or the combination. Whether the absence of effect was due to issues with the outcome measurements (e.g., lack of craving, high dropout, and unreliable measurements) or aspects of the intervention should be further investigated.

Predictors of Utilization of an Addiction-Specific Behavioural Couple Therapy in Alcohol Dependence.

PURPOSE: The aim of this study was to examine predictors that lead to the utilization of Behavioural Couple Therapy (BCT) for patients with alcohol dependence (AD) in a -European health care system and to identify groups that have a low probability of utilizing BCT. METHODS: Using routinely collected data from a German rehabilitation clinic, a sample of 1,843 inpatients with AD living in a couple relationship was examined. Each patient could freely choose to participate in an addiction-specific BCT as a voluntary additional intervention during an inpatient treatment program. RESULTS: The logistic regression analysis indicated that female gender, older age and a higher number of comorbid disorders were associated with a decreased probability of utilizing BCT. The decision tree found that for men, the lowest utilization rate was in the age range of 51-54 and from the age of 58 years; women with higher pressure by their partner in combination with more than 1 comorbid mental disorder and women with lower pressure by their partner (regardless of comorbid disorders) showed the lowest utilization rate. CONCLUSIONS: Certain subgroups of patients with AD are less likely to participate in BCT during inpatient treatment.

Retraining of automatic action tendencies in individuals with obesity: A randomized controlled trial.

Obesity is a major health concern, characterized by an automatically activated tendency to (over)-eat. Recent research suggests that an effective way to counteract automatic approach tendencies in unhealthy consumption behavior might be approach bias modification. Therefore, we investigated an approach-avoidance training for unhealthy food cues in 189 patients with obesity of a psychosomatic inpatient clinic who were participating in a nutrition advice program. Patients in the active training group were trained to make avoidance movements (pushing a joystick) in response to unhealthy food pictures and approach movements (pulling the joystick) in response to positive pictures, while the control group received sham training (approaching and avoiding both picture types). Approach-avoidance bias, body mass index, eating pathology and food-specific implicit associations were assessed before and after the training. In line with our hypothesis, approach-avoidance bias improved in the active training group after the training, in comparison to the sham training group. Moreover, this effect generalized to new, untrained stimuli. However, no effects of the training were found in a food-specific Single-Target Implicit Association Test, or on eating pathology questionnaires or body mass index. While the training results are promising, the effect of approach-avoidance bias modification on relevant behavior in obesity has yet to be established before it may be implemented as an add-on treatment.

A clinical trial with combined transcranial direct current stimulation and alcohol approach bias retraining.

Two studies showed an improvement in clinical outcomes after alcohol approach bias retraining, a form of Cognitive Bias Modification (CBM). We investigated whether transcranial direct current stimulation (tDCS) could enhance effects of CBM. TDCS is a neuromodulation technique that can increase neuroplasticity and has previously been found to reduce craving. One hundred alcohol-dependent inpatients (91 used for analysis) were randomized into three experimental groups in a double-blind parallel design. The experimental group received four sessions of CBM while receiving 2 mA of anodal tDCS over the dorsolateral prefrontal cortex (DLPFC). There were two control groups: One received sham stimulation during training and one received active stimulation at a different moment. Treatment outcomes were abstinence duration (primary) and relapse after 3 and 12 months, craving and approach bias (secondary). Craving and approach bias scores decreased over time; there were no significant interactions with experimental condition. There was no effect on abstinence duration after three months (χ2(2) = 3.53, p = 0.77). However, a logistic regression on relapse rates after one year (standard outcome in the clinic, but not-preregistered) showed a trend when relevant predictors were included; relapse was lower in the condition receiving active stimulation during CBM only when comparing to sham stimulation (B = 1.52, S.E. = .836, p = .07, without predictors: p = .19). No strong evidence for a specific enhancement effect of tDCS on CBM was found. However, in a post-hoc analysis, tDCS combined with CBM showed a promising trend on treatment outcome. Important limitations are discussed, and replication is necessary to find more reliable effects.

Mediation of cognitive bias modification for alcohol addiction via stimulus-specific alcohol avoidance association.

BACKGROUND: Cognitive bias modification (CBM) studies have provided evidence that cognitive biases play a causal role in alcohol use disorders. In this study, data from a CBM experiment in alcoholic patients were re-analyzed. In the original study, no mediation by associations measured with an Implicit Association Test (IAT) was found. In this study, we explored the possibility that relevant alcohol-related automatic processes may be cue-specific. METHODS: Data from a previous clinical study in a sample of 214 alcohol-addicted patients were re-analyzed. Patients were assigned to a CBM intervention or control condition, performed an alcohol-approach IAT, and were followed up for relapse data a year after training. In this study, bias scores measured via the IAT were calculated and analyzed separately for different stimulus categories: Alcohol, Soft drink, Approach, and Avoid. RESULTS: Training reversed the alcohol-approach bias for all categories. This reversal of bias also predicted reduced relapse, but involved a complex stimulus category-dependent pattern in which an avoidance bias for Alcohol stimuli was most predictive of reduced relapse. CONCLUSIONS: The results contribute to evidence that CBM indeed affects relapse probability via changes in automatic processes, although future study is needed to determine the precise nature of mediating processes. Automatic processes underlying alcohol-related associations may be stimulus-specific, which may be important for the methods of future studies involving implicit measures.

Effects of cognitive bias modification training on neural signatures of alcohol approach tendencies in male alcohol-dependent patients.

Alcohol-dependent patients have been shown to faster approach than avoid alcohol stimuli on the Approach Avoidance Task (AAT). This so-called alcohol approach bias has been associated with increased brain activation in the medial prefrontal cortex and nucleus accumbens. Cognitive bias modification (CBM) has been used to retrain the approach bias with the clinically relevant effect of decreasing relapse rates one year later. The effects of CBM on neural signatures of approach/avoidance tendencies remain hitherto unknown. In a double-blind placebo-controlled design, 26 alcohol-dependent in-patients were assigned to a CBM or a placebo training group. Both groups performed the AAT for three weeks: in CBM training, patients pushed away 90 percent of alcohol cues; this rate was 50 percent in placebo training. Before and after training, patients performed the AAT offline, and in a 3 T magnetic resonance imaging scanner. The relevant neuroimaging contrast for the alcohol approach bias was the difference between approaching versus avoiding alcohol cues relative to soft drink cues: [(alcohol pull > alcohol push) > (soft drink pull > soft drink push)]. Before training, both groups showed significant alcohol approach bias-related activation in the medial prefrontal cortex. After training, patients in the CBM group showed stronger reductions in medial prefrontal cortex activation compared with the placebo group. Moreover, these reductions correlated with reductions in approach bias scores in the CBM group only. This suggests that CBM affects neural mechanisms involved in the automatic alcohol approach bias, which may be important for the clinical effectiveness of CBM.

Implementation of approach bias re-training in alcoholism-how many sessions are needed?

BACKGROUND: Computerized cognitive bias modification (CBM) programs have generated promising results regarding the treatment of alcohol dependence and anxiety disorders. However, there is hardly any research yet on the implementation of alcohol-CBM into clinical practice. This article addresses the question of the optimal number of training sessions for a specific form of CBM: approach bias re-training in alcohol-dependent patients. METHODS: Participants were 111 alcohol-dependent patients of an inpatient rehabilitation clinic. In addition to treatment as usual, they took part in a 12-session CBM protocol, aimed at re-training alcohol approach tendencies, with an adapted Alcohol Approach-Avoidance Task. Learning curves and 2-level fitted mean trends were analyzed. Furthermore, parameters of the fitted mean trend and information on the most effective number of training sessions were used to predict 1-year follow-up data. RESULTS: Two-level analyses revealed 6 training sessions to be the mean optimum, yet many patients improve further after that. Prediction of the individual optimum (speed of response) and parameters of the fitted mean trends failed. The linear term of the graph describing the mean trend of training effects, but not the speed of response, predicted 1-year follow-up data. CONCLUSIONS: Suggestions for practical implementations of CBM are discussed.

Alcohol-related interpretation bias in alcohol-dependent patients.

BACKGROUND: Models of addictive behaviors postulate that implicit alcohol-related memory associations and biased interpretation processes contribute to the development and maintenance of alcohol misuse and abuse. The present study examined whether alcohol-dependent patients (AP) show an alcohol-related interpretation bias. Second, the relationship between the interpretation bias and levels of harmful drinking was investigated. METHODS: The sample included 125 clinically diagnosed AP and 69 clinically diagnosed control patients (CP) who had either a mood or an anxiety disorder. Participants completed a booklet containing 12 open-ended ambiguous scenarios. Seven scenarios were alcohol-relevant, and 5 were emotionally relevant, that is, panic- or depression-relevant. Participants were asked to read each scenario and to generate a continuation. In addition, the Alcohol Use Disorder Identification Test (AUDIT) and Beck Depression Inventory were administered. RESULTS: Logistic multivariate multilevel analyses revealed that AP' probability of generating an alcohol-related continuation on all 3 scenario types was higher than that of CP. Moreover, alcohol-related interpretation biases were positively associated with levels of harmful drinking (i.e., AUDIT scores). CONCLUSIONS: These findings are the first to show that AP show an alcohol-related interpretation bias, which generalizes to other ambiguous emotionally relevant contexts, and therefore advance our understanding of the role of implicit biased alcohol-related memory associations and interpretation processes.

Approach-Bias Retraining and Other Training Interventions as Add-On in the Treatment of AUD Patients.

In the past two decades, a variety of cognitive training interventions have been developed to help people overcome their addictive behaviors. Conceptually, it is important to distinguish between programs in which reactions to addiction-relevant cues are trained (varieties of cognitive bias modification, CBM) and programs in which general abilities are trained such as working memory or mindfulness. CBM was first developed to study the hypothesized causal role in mental disorders: by directly manipulating the bias, it was investigated to what extent this influenced disorder-relevant behavior. In these proof-of-principle studies, the bias was temporarily modified in volunteers, either temporarily increased or decreased, with corresponding effects on behavior (e.g., beer consumption), in case the bias was successfully manipulated. In subsequent clinical randomized controlled trials (RCTs), training (away from the substance vs. sham training) was added to clinical treatment. These studies have demonstrated that CBM, as added to treatment, reduces relapse with a small effect of about 10% (similar effect size as for medication, with the strongest evidence for approach-bias modification). This has not been found for general ability training (e.g., working memory training), although effects on other psychological functions have been found (e.g., impulsivity). Mindfulness also has been found to help people overcome addictions, and different from CBM, also as stand-alone intervention. Research on (neuro-)cognitive mechanisms underlying approach-bias modification has pointed to a new perspective in which automatic inferences rather than associations are influenced by training, which has led to the development of a new variety of training: ABC training.

Does selective inhibition training reduce relapse rates when added to standard treatment of alcohol use disorder? A randomized controlled trial.

BACKGROUND: Alcohol-dependent individuals tend to selectively approach alcohol cues in the environment, demonstrating an alcohol approach bias. Because approach bias modification (ApBM) training can reduce the approach bias and decrease relapse rates in alcohol-dependent patients when added to abstinence-focused treatment, it has become a part of regular treatment. Moreover, in selective inhibition (SI) training, responses to one category of stimuli (i.e., alcohol stimuli) are selectively inhibited in an adapted Go/No-Go task. SI-Training has been found to effectively devalue the inhibited category and to reduce consumption of alcohol among social drinkers. This study investigated whether SI-Training can further improve the effects of treatment as usual that includes ApBM, and if so, whether the effect is mediated by a devaluation of the inhibited alcohol stimuli. METHODS: Abstinent alcohol-dependent inpatients (N=434) were randomly assigned to receive 6 sessions of either active (n = 214, 32% female) or sham (n = 220, 38% female) SI-Training, in addition to standard treatment that includes active ApBM. Ratings were used to assess changes in the evaluation of alcohol stimuli after the training. Relapse rates were assessed 3 and 12 months after treatment discharge. RESULTS: Alcohol stimuli were rated negatively before and after the training, and the training did not influence these ratings. Evaluation of nonalcoholic drinks became more positive after active SI-Training. Both ApBM and SI-Training showed the expected training effects on reaction times. Contrary to expectations, SI-Training conditions did not yield different abstinence rates 3 or 12 months after treatment. CONCLUSIONS: We found no evidence supporting the hypothesis that SI-Training amplifies the relapse-preventing effect of ApBM. Moreover, alcohol stimuli were rated negatively before and after treatment and were not influenced by SI-Training.

Cognitive training and remediation interventions for substance use disorders: a Delphi consensus study.

AIMS: Substance use disorders (SUD) are associated with cognitive deficits that are not always addressed in current treatments, and this hampers recovery. Cognitive training and remediation interventions are well suited to fill the gap for managing cognitive deficits in SUD. We aimed to reach consensus on recommendations for developing and applying these interventions. DESIGN, SETTING AND PARTICIPANTS: We used a Delphi approach with two sequential phases: survey development and iterative surveying of experts. This was an on-line study. During survey development, we engaged a group of 15 experts from a working group of the International Society of Addiction Medicine (Steering Committee). During the surveying process, we engaged a larger pool of experts (n = 54) identified via recommendations from the Steering Committee and a systematic review. MEASUREMENTS: Survey with 67 items covering four key areas of intervention development: targets, intervention approaches, active ingredients and modes of delivery. FINDINGS: Across two iterative rounds (98% retention rate), the experts reached a consensus on 50 items including: (i) implicit biases, positive affect, arousal, executive functions and social processing as key targets of interventions; (ii) cognitive bias modification, contingency management, emotion regulation training and cognitive remediation as preferred approaches; (iii) practice, feedback, difficulty-titration, bias modification, goal-setting, strategy learning and meta-awareness as active ingredients; and (iv) both addiction treatment work-force and specialized neuropsychologists facilitating delivery, together with novel digital-based delivery modalities. CONCLUSIONS: Expert recommendations on cognitive training and remediation for substance use disorders highlight the relevance of targeting implicit biases, reward, emotion regulation and higher-order cognitive skills via well-validated intervention approaches qualified with mechanistic techniques and flexible delivery options.

Does comorbid anxiety or depression moderate effects of approach bias modification in the treatment of alcohol use disorders?

Objective: Approach bias modification (ApBM) is a promising new add-on training intervention for patients with alcohol use disorder (AUD). Given that comorbid anxiety and major depressive disorders are very common in AUD, and that such comorbidity affects psychological treatments negatively, the primary aim of the present study was investigating whether ApBM training is moderated by anxiety/major depressive disorder comorbidity. The secondary aim was to examine whether ApBM's relapse-preventive effect can be replicated. Method: We conducted a large-scale randomized controlled trial (RCT) in a clinical sample of AUD inpatients (n = 729) with a follow-up assessment after 1 year. All patients received 12 weeks of inpatient treatment as usual (TAU). On top of that, patients were randomized to a 12-session ApBM (TAU + ApBM), and a no-training control condition (TAU-only). Treatment success was defined as either no relapse or a single lapse shorter than 3 days in duration, ended by the patient and followed by at least 4 weeks of abstinence. Failure was defined as relapse, passed away, no contact, or refusal to provide information. Results: We found that TAU + ApBM had significantly higher success rates than TAU-only at 1-year follow-up. Importantly, anxiety/depressive comorbidity moderated ApBM's effects: Adding ApBM to TAU increased success rates more for patients with a comorbid anxiety and/or depressive disorder than for patients without such comorbidity. Conclusions: Our data suggest that adding ApBM to TAU works better in patients with a comorbid anxiety and/or depressive disorder; a promising finding gave the high rates of comorbidity in clinical practice. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Retraining automatic action tendencies changes alcoholic patients' approach bias for alcohol and improves treatment outcome.

This study tested the effects of a new cognitive-bias modification (CBM) intervention that targeted an approach bias for alcohol in 214 alcoholic inpatients. Patients were assigned to one of two experimental conditions, in which they were explicitly or implicitly trained to make avoidance movements (pushing a joystick) in response to alcohol pictures, or to one of two control conditions, in which they received no training or sham training. Four brief sessions of experimental CBM preceded regular inpatient treatment. In the experimental conditions only, patients' approach bias changed into an avoidance bias for alcohol. This effect generalized to untrained pictures in the task used in the CBM and to an Implicit Association Test, in which alcohol and soft-drink words were categorized with approach and avoidance words. Patients in the experimental conditions showed better treatment outcomes a year later. These findings indicate that a short intervention can change alcoholics' automatic approach bias for alcohol and may improve treatment outcome.

When paranoia fails to enhance self-esteem: explicit and implicit self-esteem and its discrepancy in patients with persecutory delusions compared to depressed and healthy controls.

The hypothesis that persecutory delusions function to enhance self-esteem implies that patients will show normal explicit, but low implicit self-esteem. As evidence for this has been inconsistent, our study assessed delusional state, explicit and implicit self-esteem and depression in a large sample (n=139) of schizophrenia patients with acute persecutory delusions (n=28), patients with remitted persecutory delusions (n=31), healthy controls (n=59), and depressed controls (n=21). Patients with delusions and patients with depression both showed decreased levels of explicit, but normal levels of implicit self-esteem when compared to healthy controls. The direct comparison of levels of explicit and implicit self-esteem within each group revealed that healthy controls had higher explicit than implicit self-esteem, while the converse pattern was found for depressed controls. No discrepancy between explicit and implicit self-esteem was found for acute deluded or remitted patients with schizophrenia. Although these findings do not support the hypothesis that delusions serve to enhance self-esteem, they underline the relevance of low self-esteem in patients with persecutory delusions and point to the necessity of enhancing self-esteem in therapy.

Effects of alcohol cue exposure on response inhibition in detoxified alcohol-dependent patients.

BACKGROUND: There is evidence that exerting self-control during alcohol craving can diminish performance on subsequent tasks that require self-control. Based on the resource depletion model (Muraven and Baumeister, 2000), we examined the influence of alcohol cue exposure on detoxified alcohol-dependent patients' ability to inhibit ongoing responses. METHODS: Twenty alcohol-dependent patients were randomly assigned to an alcohol-cue exposure and a control-cue exposure condition and thereafter had to perform an inhibition task (i.e., stop-signal task). RESULTS: Participants who sniffed alcohol before performing the inhibition task reported a stronger urge to drink alcohol than the control group that sniffed water. Participants who sniffed alcohol were also impaired in their inhibitory performance but not in their noninhibitory performance on the stop-signal task. CONCLUSIONS: The urge to drink presumably reduced participants' self-control, and this interfered with their ability to inhibit responding.

A comparison of implicit and explicit reward learning in low risk alcohol users versus people who binge drink and people with alcohol dependence.

Chronic alcohol use leads to specific neurobiological alterations in the dopaminergic brain reward system, which probably are leading to a reward deficiency syndrome in alcohol dependence. The purpose of our study was to examine the effects of such hypothesized neurobiological alterations on the behavioral level, and more precisely on the implicit and explicit reward learning. Alcohol users were classified as dependent drinkers (using the DSM-IV criteria), binge drinkers (using criteria of the USA National Institute on Alcohol Abuse and Alcoholism) or low-risk drinkers (following recommendations of the Scientific board of trustees of the German Health Ministry). The final sample (n = 94) consisted of 36 low-risk alcohol users, 37 binge drinkers and 21 abstinent alcohol dependent patients. Participants were administered a probabilistic implicit reward learning task and an explicit reward- and punishment-based trial-and-error-learning task. Alcohol dependent patients showed a lower performance in implicit and explicit reward learning than low risk drinkers. Binge drinkers learned less than low-risk drinkers in the implicit learning task. The results support the assumption that binge drinking and alcohol dependence are related to a chronic reward deficit. Binge drinking accompanied by implicit reward learning deficits could increase the risk for the development of an alcohol dependence.

Positivity-approach training for depressive symptoms: A randomized controlled trial.

OBJECTIVE: Depression is highly comorbid and depressive symptoms are very common. Symptom severity adversely affects treatment outcome and later health status. Established interventions for depression leave ample room for improvement. Short interventions that target specific vulnerabilities emerge as plausible augmentation strategies. In this study, we tested the efficacy of a computerized general positivity-approach training and its effect on depressive symptoms. METHODS: Patients (N = 240) with various diagnoses of mental disorders who received treatment-as-usual in an inpatient setting were randomly assigned to also receive either 4 sessions of a positivity-approach training or 4 sessions of sham training. Depression severity was assessed at baseline and post-treatment. Training data were analyzed for a subset of 111 patients. RESULTS: Depressive symptoms were reduced more after positivity-approach training than after sham training. Initial depression symptom severity moderated the intervention effects, such that approach tendencies and depression symptoms were only affected positively among patients with higher levels of initial depression symptom severity. CONCLUSIONS: The findings provide preliminary support for positivity-approach training as an add-on treatment option for depressive symptoms.

Relapse prevention in abstinent alcoholics by cognitive bias modification: Clinical effects of combining approach bias modification and attention bias modification.

OBJECTIVE: Alcohol-dependent patients show attentional and approach biases for alcohol-related stimuli. Computerized cognitive bias modification (CBM) programs aim to retrain these biases and reduce relapse rates as add-ons to treatment. Retraining of alcohol-approach tendencies has already yielded significant reductions of relapse rates in previous studies, and retraining of biased attention toward alcohol is promising approach. The current large-scale randomized controlled trial compared the clinical effects of these training methods-separately and in combination-to those of sham training methods and a no-training control, as an add-on to regular treatment. METHODS: Participants were 1,405 alcohol-dependent patients of an inpatient rehabilitation clinic. In addition to regular treatment, patients were randomized to receive 6 sessions of approach-bias retraining, 6 sessions of attention-bias retraining, 3 sessions of each of these CBM training varieties, 6 sessions of variants of sham training, or no training. Effects of the training methods were evaluated by measuring treatment success at 1-year follow-up. RESULTS: Primary outcome: The 3 active training conditions yielded higher success rates at 1-year follow-up than sham training or no training (8.4%, on average). Secondary results (available for half of the sample): Both varieties of CBM had only small effects on the targeted biases (significant only for the combined training). Moreover, neither significant mediation of the clinical effect by the change in trained bias nor significant moderation of the clinical effect was found. CONCLUSIONS: Both alcohol-avoidance training and alcohol-attention training increased success rates effectively, as did the combination of both methods. Future studies should test ways to increase training effectiveness further. (PsycINFO Database Record (c) 2018 APA, all rights reserved).