A Clinician-Controlled Just-in-time Adaptive Intervention System (CBT+) Designed to Promote Acquisition and Utilization of Cognitive Behavioral Therapy Skills in Bulimia Nervosa: Development and Preliminary Evaluation Study.

Adrienne Juarascio,Emily Presseller,Stephanie Manasse,Paakhi Srivastava,Evan Forman,Kelsey Clark

doi:10.2196/18261

Abstract

BackgroundCognitive behavioral therapy (CBT) for bulimia nervosa (BN) is most effective when patients demonstrate adequate skill utilization (ie, the frequency with which a patient practices or uses therapeutic skills) and skill acquisition (ie, the ability to successfully perform a skill learned in treatment). However, rates of utilization and acquisition of key treatment skills (eg, regular eating, urge management skills, and mood management skills) by the end of the treatment are frequently low; as a result, outcomes from CBT for BN are affected. Just-in-time adaptive interventions (JITAIs) may improve skill acquisition and utilization by delivering real-time interventions during algorithm-identified opportunities for skill practice.ObjectiveIn this manuscript, we describe a newly developed JITAI system called CBT+ that is designed to facilitate the acquisition and utilization of CBT for BN treatment skills when used as a treatment augmentation. We also present feasibility, acceptability, and preliminary outcomes data from a small proof-of-concept pilot trial (n=5 patients and n=3 clinicians) designed to identify opportunities for iterative development of CBT+ ahead of a larger ongoing randomized controlled trial.MethodsA total of 5 individuals with BN received 16 sessions of outpatient CBT for BN while using the CBT+ app. Data were collected from patients and clinicians to evaluate the feasibility (eg, app use and user adherence), acceptability (eg, qualitative patient and clinician feedback, including usefulness ratings of CBT+ on a 6-point Likert scale ranging from 1=extremely useless to 6=extremely useful), and preliminary outcomes (eg, improvements in skill utilization and acquisition and BN symptoms) of the CBT+ system.ResultsPatients reported that CBT+ was a relatively low burden (eg, quick and easy-to-use self-monitoring interface), and adherence to in-app self-monitoring was high (mean entries per day 3.13, SD 1.03). JITAIs were perceived as useful by both patients (median rating 5/6) and clinicians (median rating 5/6) for encouraging the use of CBT skills. Large improvements in CBT skills and clinically significant reductions in BN symptoms were observed post treatment. Although preliminary findings indicated that the CBT+ system was acceptable to most patients and clinicians, the overall study dropout was relatively high (ie, 2/5, 40% patients), which could indicate some moderate concerns regarding feasibility.ConclusionsCBT+, the first-ever JITAI system designed to facilitate the acquisition and utilization of CBT for BN treatment skills when used as a treatment augmentation, was shown to be feasible and acceptable. The results indicate that the CBT+ system should be subjected to more rigorous evaluations with larger samples and should be considered for wider implementation if found effective. Areas for iterative improvement of the CBT+ system ahead of a randomized controlled trial are also discussed.

Highlights

BackgroundBulimia nervosa (BN) is characterized by recurrent episodes of binge eating and compensatory behaviors such as purging, fasting, or driven exercise [1]
Cognitive behavioral therapy (CBT)+, the first-ever Just-in-time adaptive interventions (JITAIs) system designed to facilitate the acquisition and utilization of CBT for bulimia nervosa (BN) treatment skills when used as a treatment augmentation, was shown to be feasible and acceptable
The results indicate that the CBT+ system should be subjected to more rigorous evaluations with larger samples and should be considered for wider implementation if found effective

Summary

Introduction

BackgroundBulimia nervosa (BN) is characterized by recurrent episodes of binge eating (ie, eating a large amount of food within a discrete period accompanied by a sense of loss of control over eating) and compensatory behaviors such as purging (eg, self-induced vomiting and misuse of a laxative or diuretic), fasting, or driven exercise [1]. A growing body of literature has identified that the use of therapeutic skills such as mood management techniques and the resulting improvements in the ability to manage negative affect during CBT for BN are associated with symptom improvement [12,14]. Cognitive behavioral therapy (CBT) for bulimia nervosa (BN) is most effective when patients demonstrate adequate skill utilization (ie, the frequency with which a patient practices or uses therapeutic skills) and skill acquisition (ie, the ability to successfully perform a skill learned in treatment). Rates of utilization and acquisition of key treatment skills (eg, regular eating, urge management skills, and mood management skills) by the end of the treatment are frequently low; as a result, outcomes from CBT for BN are affected. Just-in-time adaptive interventions (JITAIs) may improve skill acquisition and utilization by delivering real-time interventions during algorithm-identified opportunities for skill practice

Methods

Results

Conclusion