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

Abstract

Background 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). 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. Objective In 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. Methods A 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. Results Patients 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. Conclusions CBT+, 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.

Self‐regulation deficits moderate treatment outcomes in a clinical trial evaluating just‐in‐time adaptive interventions as an augmentation to cognitive‐behavioral therapy for bulimia‐spectrum eating disorders

“…Half of the participants ( n = 29) also received JITAIs to promote CBT‐E skill use in daily life, delivered in response to information about eating behaviors, ED behaviors, and mood from self‐monitoring records. See Juarascio et al (2021) for description of the treatment, including development and pilot evaluation, and Juarascio, Presseller, Srivastava, Manasse, and Forman (Under review) for primary feasibility, acceptability, and target engagement outcomes from the trial. Participants made 3.01 self‐monitoring entries per day on average and self‐monitoring compliance was comparable across conditions (t = .17, p = .86).…”

Latent trajectories of symptom change during cognitive-behavior therapy predict post-treatment worsening of symptoms: a preliminary examination among outpatients with bulimia-spectrum eating disorders

“…The present study is a secondary data analysis of a trial examining the efficacy of a smartphone application as an adjunct to CBT for BN-spectrum EDs (see [ 7 ] for a description of the treatment and smartphone application). Participants were recruited from the Philadelphia area (pre-COVID-19 pandemic; n = 51) and nationally (during COVID-19 pandemic; n = 5).…”

“…Assessment procedures, conducted at baseline, mid-treatment, post-treatment, and 3-month follow-up, included an ED diagnostic interview (i.e., the Eating Disorder Examination [EDE; 8 ]), self-report measures, and behavioral tasks. Participants received 16 sessions of outpatient CBT ( n = 613 sessions in-person; n = 227 sessions over Zoom) based on the focused version of CBT-E [ 9 ] while completing digital self-monitoring records to track eating episodes and ED behaviors (see [ 7 ]). Participants in the experimental condition ( n = 29) received just-in-time adaptive interventions reminding them to practice therapeutic skills (see [ 7 ]), while participants in the control condition ( n = 26) did not receive just-in-time adaptive interventions.…”

“…Participants received 16 sessions of outpatient CBT ( n = 613 sessions in-person; n = 227 sessions over Zoom) based on the focused version of CBT-E [ 9 ] while completing digital self-monitoring records to track eating episodes and ED behaviors (see [ 7 ]). Participants in the experimental condition ( n = 29) received just-in-time adaptive interventions reminding them to practice therapeutic skills (see [ 7 ]), while participants in the control condition ( n = 26) did not receive just-in-time adaptive interventions. One participant received some, but not all relevant just-in-time adaptive interventions, and therefore was excluded from analyses.…”

Associations between emotion regulation and remission following cognitive behavioural therapy for adults with bulimia nervosa

“…The present study is a secondary data analysis of a study of CBT‐E for bulimia‐spectrum EDs (for more information on the parent study, see Juarascio et al., 2021). Treatment was 16 sessions of CBT‐E based on the treatment approach developed by Fairburn (2008) with a supplemental mobile app component.…”