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          Original Investigation
          November?4, 2020

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

          Author Affiliations
          • 1Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
          • 2Turning Point, Eastern Health, Melbourne, Victoria, Australia
          • 3Deakin University School of Psychology, Geelong, Victoria, Australia
          • 4Centre for Drug Use, Addictive and Antisocial Behaviour Research, Deakin University, Geelong, Victoria, Australia
          • 5Alfred Health and Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
          • 6Department of Addiction Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
          • 7Division of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
          • 8Addiction Development and Psychopathology Lab, Center for Urban Mental Health, Department of Psychology, University of Amsterdam, Amsterdam, the Netherlands
          • 9Monash Health Drug and Alcohol Service, Monash Health, Melbourne, Victoria, Australia
          • 10Turner Institute for Brain and Mental Health, Monash University School of Psychological Sciences, Melbourne, Victoria, Australia
          JAMA Psychiatry. Published online November 4, 2020. doi:10.1001/jamapsychiatry.2020.3446
          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.


          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

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