Pooled patient-level meta-analysis of children and adults completing a computer-based anxiety intervention targeting attentional bias

Abstract

Computer-based approaches, such as Attention Bias Modification (ABM), could help improve access to care for anxiety. Study-level meta-analyses of ABM have produced conflicting findings and leave critical questions unresolved regarding ABM’s mechanisms of action and clinical potential. We pooled patient-level datasets from randomized controlled trials of children and adults with high-anxiety. Attentional bias (AB) towards threat, the target mechanism of ABM, was tested as an outcome and a mechanistic mediator and moderator of anxiety reduction. Diagnostic remission and Liebowitz Social Anxiety Scale (LSAS) were clinical outcomes available in enough studies to enable pooling. Per-patient data were obtained on at least one outcome from 13/16 eligible studies [86% of eligible participants; n=778]. Significant main effects of ABM on diagnostic remission (ABM—22.6%, control—10.8%; OR=2.57; p=.006) and AB (β*(95%CI)=−.63(−.83, −.42); p<.00005) were observed. There was no main effect of ABM on LSAS. However, moderator analyses suggested ABM was effective for patients who were younger (≤37y), trained in the lab, and/or assessed by clinicians. Under the same conditions where ABM was effective, mechanistic links between AB and anxiety reduction were supported. Under these specific circumstances, ABM reduces anxiety and acts through its target mechanism, supporting ABM’s theoretical basis while simultaneously suggesting clinical indications and refinements to improve its currently limited clinical potential.

Can less be more? Open trial of a stepped care approach for child and adolescent anxiety disorders

“…Finally, it shows promising anxiety reduction effects in youth with anxiety disorders. In open trials (Bechor et al, 2014; Cowart & Ollendick, 2011; Rozenman et al, 2011) and randomized controlled trials (Eldar et al, 2012; Pergamin-Hight et al, 2016) using samples of youth with anxiety disorders, ABM has resulted in statistically significant reductions in anxiety symptoms (for reviews, see Lowther & Newman, 2014; Price et al, 2016). …”

“…Based on the theory underlying ABM and past research (e.g., Price et al, 2016), we expected that attention to threat would be significantly reduced after Step 1 (ABM). Given mixed findings on the effects of CBT on attention to threat in anxious youth (Reinholdt-Dunne, Mogg, Vangkilde, Bradley, & Esbjorn, 2015; Waters, Wharton, Zimmer-Gembeck, & Craske, 2008), we did not make a hypothesis about levels of attention to threat after Step 2 (CBT).…”

Hjärnan formas av psykologisk behandling

“…However, the promising findings found with ABM conducted in a laboratory setting have not been replicated when the same treatment has been delivered via the internet (Boettcher, Berger, & Renneberg, 2011;Carlbring et al, 2012;Neubauer et al, 2013). It is possible that ABM only works for individuals showing an attentional bias before treatment initiation and the context where ABM is delivered may also be important (MacLeod & Grafton, 2016;Price et al, 2016). Nonetheless, a recent critical meta-analysis found non-significant effect sizes (Hedges g = 0.11, 95% CI -0.13 to 0.35) after adjustment for publication bias and study outliers (Cristea, Kok, & Cuijpers, 2015) and stressed that ABM for patients with social anxiety only has limited clinical relevance.…”

Less is more: Patient-level meta-analysis reveals paradoxical dose-response effects of a computer-based social anxiety intervention targeting attentional bias

“…Finally, in order to measure ABM’s target mechanism (AB) using reasonably uniform procedures, a dot-probe task (described below) was required at the start and end of the intervention (either as a distinct pre/post-training assessment, or as a first and last ABM training session; see details below). Raw trial-by-trial reaction time and accuracy data were requested for each participant to allow uniform methods to be applied in calculating AB indices [see (Price, Wallace, et al, 2016)]. In cases where trial-level data were not retained, pre-calculated AB scores per-participant were requested.…”

“…However, more recent studies have lessened enthusiasm, reporting null or clinically insignificant effects (e.g., Beard, Sawyer, & Hofmann, 2012; Carlbring et al, 2012). Critically, the extant literature suggests that if and when interventions are effective in modulating attentional patterns, symptoms are reduced in turn (Clarke, Notebaert, & Macleod, 2014; MacLeod & Clarke, 2015; Price, Wallace, et al, 2016). Thus, the mechanistic target itself—AB—has been well validated, while the ability to manipulate the target remains inconsistent, hindering clinical translation.…”