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

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.

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