A pragmatic approach to mobile attention bias modification in a clinical setting

• Main Author: Zhang, Melvyn Weibin
• Other Authors: -
• Format: Thesis-Doctor of Philosophy
• Language: English
• Published: Nanyang Technological University 2023
• Subjects: Social sciences::Psychology
• Online Access: https://hdl.handle.net/10356/170488
• Institution: Nanyang Technological University

Substance use & alcohol use disorders are highly prevalent globally, and Singapore is no exception. In Singapore, pharmacological approaches are available for the treatment of alcohol use disorders and the maintenance of abstinence, but for other substance use disorders (opioid use, cannabis use and stimulant use), the pharmacological options available are limited. Psychological approaches are paramount in the maintenance of abstinence. Despite the effectiveness of conventional psychological approaches, such as cognitive behavioural therapy for relapse prevention, a significant proportion of individuals still lapse or even relapse. The advances in experimental psychology and increased recognition of cognitive deficits among individuals with addictive disorders, have in turn led to a better understanding of unconscious, automatic biases, that of attention and approach biases that might result in individuals relapsing. Attentional biases are the most fundamental of these unconscious processes, as they refer to how attentional processes are preferentially being allocated to the substance-related stimulus. Despite advances in experimental psychology, there remains several research gaps. These include a lack of synthesized evidence demonstrating that attentional biases are consistently present amongst individuals with substance use disorders and reviews synthesizing the evidence for bias modification in these highly prevalent substance disorders. Whilst the advances in technologies have led to the delivery of these bias modification interventions using web or mobile technologies, there has not been any prior reviews of the published literature, or content analyses of commercial applications. More recently, gamification technologies have been applied to bias modification interventions, but there remains limited understanding of the rationale for gamification, and the gamification strategies that render interventions effective. Most importantly, there have not been any exploration of such interventions amongst an Asian cohort of treatment-seeking individuals with addictive disorders. Also, the interventions that have been used to date for bias modification often are developed by academics and developers but rarely have addressed the needs of patient participants. In consideration of the research gaps, the aim of my doctoral work was to develop a mobile attention bias modification intervention that could be used as an adjunct to conventional pharmaceutical and psychological therapies for treatment-seeking Asian individuals with addictive disorders. There was a total of nine objectives. In addressing the research gap pertaining to attentional biases amongst individuals with highly prevalent addictive disorders (objective 1), two systematic reviews were undertaken. Both demonstrated that attentional biases are consistently present amongst individuals with opioid, cannabis, and stimulant use disorders. Unfortunately, evidence synthesis for bias modification cannot be undertaken in view of the heterogeneity of the outcomes used. For objective 2 (Review of Mobile Interventions), my systematic review of mobile bias interventions found that 7 out of the 8 identified published studies have reported the effectiveness of mobile bias modification. My content analyses of commercial applications found 5 out of 17 commercial applications targeted bias modification for addictive disorders. Only one has been scientifically evaluated, indicating a large disconnect between academics and developers. To better understand gamification as applied to bias modification interventions (objective 3), I undertook a literature review, and found two out of four studies reporting gamified bias intervention to be effective. The review also highlighted some of the gamification strategies applied that render interventions to be effective. Another content analysis of commercially available gamified application was conducted, to identify common gamification strategies adopted. A review of the task paradigms was undertaken (objective 4), to conceptualise the mobile attention bias intervention that will be further tested. The feasibility and acceptability study (objective 5) I undertook demonstrated the feasibility of recruitment and the administration of the intervention; and the acceptability of the intervention, judged by the ease of use, interactivity, and the change in confidence following intervention. To accommodate patients’ perspective (objective 6), I undertook a series of codesign workshops involving healthcare professional and patient participants. The codesign workshops identified limitations of the conventional mobile attention bias modification interventions; the participants also suggested ways to improve the existing application, such as the lengthening the stimulus presentation intervals and the consideration of gamification strategies. I undertook a pilot study to examine if the intended processes of the definitive study (such as the recruitment of participants, the process of randomization, the administration of intervention) (Objective 7) would work. Whilst the pilot study could not be taken to completion in view of COVID-19, it enabled the conduct of a risk assessment that identified all issues that might affect the definitive randomized trial. I undertook another study (Objective 8) to determine if a new method of computing attentional biases (trial-level bias score) could identify more baseline biases; and another study examining the feasibility of a single-session approach in modifying attentional biases. These were planned for in order to mitigate against the risk of recruitment and attrition, and they helped to revise the methods for the definitive trial. The work undertaken to date has enabled the conceptualization of a protocol for a definitive randomized trial (Objective 9), which on completion of this PhD I will seek extramural funding and time to conduct.