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Substance use disorders are highly prevalent globally. Relapse rates following conventional psychological interventions for substance use disorders remain high. Recent reviews have highlighted attentional and approach or avoidance biases to be responsible for multiple relapses. Other studies have reported the efficacy of interventions to modify biases. With advances in technologies, there are now mobile versions of conventional bias modification interventions. However, to date, no study has evaluated bias modification in a substance-using, non-Western sample. Existing evaluations of mobile technologies for the delivery of bias interventions are also limited to alcohol or tobacco use disorders.
This study aims to examine the feasibility of mobile-based attention bias modification intervention among treatment-seeking individuals with substance use and alcohol use disorders.
This is a feasibility study, in which inpatients who are in their rehabilitation phase of clinical management will be recruited. On each day that they are in the study, they will be required to complete a craving visual analogue scale and undertake both a visual probe-based assessment and and modification task in a smartphone app . Reaction time data will be collated for the computation of baseline attentional biases and to determine whether there is a reduction of attentional bias across the interventions. Feasibility will be determined by the number of participants recruited and participants’ adherence to the planned interventions up until the completion of their rehabilitation program and by the ability of the app in detecting baseline biases and changes in biases. Acceptability of the intervention will be assessed by a short questionnaire of users’ perceptions of the intervention. Statistical analyses will be performed using SPSS version 22.0, while qualitative analysis of the perspectives will be performed using NVivo version 10.0.
This study was approved by the National Healthcare Group Domain Specific Research Board, with approval number (2018/00316). Results will be disseminated by means of conferences and publications.Currently, we are in the process of recruitment for this study.
To the best of our knowledge, this is the first study to evaluate the feasibility and acceptability of a mobile attention bias modification intervention for individuals with substance use disorders. The data pertaining to the feasibility and acceptability are undoubtedly crucial because they imply the potential use of mobile technologies in retraining attentional biases among inpatients admitted for medical-assisted detoxification and rehabilitation. Participants’ feedback pertaining to the ease of use, interactivity, and motivation to continue using the app is crucial because it will determine whether a codesign approach might be warranted to design an app that is acceptable for participants and that participants themselves would be motivated to use.
PRR1-10.2196/11822
Illicit drug and alcohol use are highly prevalent globally. The United Nations Office on Drugs and Crime reported that in 2015, a quarter of a billion individuals experimented with substances, and 29.5 million individuals were diagnosed with substance disorders [
The treatment options for substance use are both pharmacological and nonpharmacological. Pharmacological options are varied; for opioid use disorders, opiate substitution therapy such as that with methadone or buprenorphine could be considered. In Singapore, opiate substitution therapy is only prescribed for elderly individuals and pregnant women [
Recent advances in experimental psychology have reported how automatic attentional biases could predispose individuals toward a relapse. Field et al [
There has been an extensive evaluation of bias modification for substance use disorders, and a recent meta-analysis study synthesized the overall effectiveness of bias modification [
Advances in technologies in the last decade have transformed how bias modification interventions are delivered. An increase in the number of remote Web-based therapies has been attributed to the advances in electronic health (eHealth). eHealth technologies facilitate the delivery of low-cost psychotherapy, which is highly accessible and enables anonymity of use [
To date, no study has evaluated bias modification in a substance-using, non-Western, treatment-seeking sample. In addition, while technologies like eHealth and mHealth have been widely utilized for the delivery of bias modification interventions, our prior review [
The primary aim of this study is to determine the feasibility of an attention bias modification mobile app for the reduction of attention biases to substance-related cures among individuals with addictive disorders. Feasibility is determined by the number of participants recruited, participants’ adherence to the planned interventions up until the day of discharge, and the ability of the app to detect baseline biases and changes in biases. The secondary aim is to determine the acceptability of the intervention, which will be assessed through a questionnaire of users’ perceptions.
Will the mobile attention bias modification intervention be feasible and acceptable among individuals with addictive disorders?
Is the developed mHealth app capable of detecting the changes in biases?
This study will be conducted among individuals who are admitted for inpatient medication-assisted detoxification and rehabilitation at the National Addictions Management Service (NAMS), Institute of Mental Health Singapore. Notably, at NAMS, all patients are admitted voluntarily for treatment, which implies that patients are free to discharge should they be not willing to complete the detoxification or rehabilitation phase of the program. At any one time, a maximum of 30 patients could be accommodated in the ward environment. Patients are managed by an attending psychiatrist with a multidisciplinary team comprising addiction-trained counselors, nurses, and social workers. In the first week of the treatment program, patients would undergo medication-assisted detoxification. In the second week of their treatment program, patients would attend community meetings and group-based counseling. Individual counseling will also be provided to patients. Only participants who have completed their detoxification phase (first week of their stay) will be recruited for this study as participants would be free from withdrawal symptoms. This is a feasibility study, where participants’ attention biases will be assessed following the bias modification intervention. The study protocol has been approved by the National Healthcare Group’s Domain Specific Research Board (May 2, 2018; Ethics Approval Reference Number: 2018/00316).
All participants will be recruited from the inpatient unit at the NAMS, Institute of Mental Health, Singapore. Participants will be informed of the study by their attending health care professionals on admission and will be approached by the study team on the first day of their rehabilitation phase. The study team will provide participants with further information about the study, and if participants agree to participate, they will complete the informed consent form.
Power computation has not been undertaken for this study as study design is that of a feasibility study. Considering the diversity of the addictive disorders included, the proposed sample size is 30 participants.
Participants will be eligible for the feasibility study if they meet the inclusion criteria presented in
Participants will not be eligible if they meet any of the exclusion criteria presented in
Participants with moderate to severe symptoms of comorbid psychiatric disorders are excluded from this feasibility study as there is a high likelihood that their comorbid psychiatric disorder will affect their attentional bias scores. Moreover, patients with other psychiatric disorders will usually be on other psychotropic medications. Zhang et al have highlighted that several pharmacological agents, such as those targeting dopaminergic, noradrenaline, glutaminergic, and serotonergic neurotransmissions, have an acute effect on attentional biases [
Patients will be invited to participate in this study only upon the completion of their medical detoxification treatment. If they consent to participate, they will complete a set of baseline questionnaires including a demographic and clinical information questionnaire, the Addiction Severity Index (ASI)-Lite questionnaire, the Severity of Substance Dependence (SDS) questionnaire, and the Short-Form 12 (SF-12) questionnaire. In addition, participants are required to complete a visual analogue scale for craving before and after the completion of each session.
Participants aged 21-65 years
Participants diagnosed with a primary psychiatric disorder of alcohol dependence, opioid dependence, cannabis dependence, stimulant dependence, or polysubstance use disorder
For participants diagnosed with polysubstance use disorder, the main substance of use must be alcohol, opioid, cannabis, or a stimulant
Participants need to be able to read and write in English
Participants need to be able to use a smartphone or a tablet device
Exclusion criteria
Having a known history of cognitive impairment or dementia
Having a history of seizures (apart from febrile seizures) or a prior history of withdrawal seizures
Having a medical history of migraines (triggered by flashing lights)
Having moderate to severe symptoms of comorbid psychiatric disorders (affective disorders, anxiety disorders, and psychotic disorders) based on clinical assessment
An overview of the outcome measures that participants need to complete for each session.
Instrument | Aim | Day of rehabilitation | ||||
1 | 2 | 3 | 4 | 5a | ||
Baseline demographic and clinical information questionnaire | Baseline characteristic of participants | ✓ | ||||
Addiction Severity Index questionnaire | Details about substance use | ✓ | ||||
Severity of Substance Dependence questionnaire | Assessment of severity of psychological dependence | ✓ | ||||
Short-Form 12 | Baseline health status | ✓ | ||||
Attention bias modification assessment task | Measurement of attentional biases | ✓b | ✓ | ✓ | ✓ | ✓ |
Attention bias modification intervention task | Retraining of attentional biases | ✓ | ✓ | ✓ | ✓ | ✓ |
Visual analogue scale for craving | Assessment of cravings | ✓c | ✓c | ✓c | ✓c | ✓c |
Perspective questionnaire | Acceptability of intervention | ✓ |
aParticipants will undertake a maximum of 5 sessions considering that the study will not be conducted on weekends.
bThe attention bias modification assessment task will be completed twice on the first day: first assessment will provide information pertaining to the baseline attentional biases; second assessment will assess for the change in attentional biases following the first intervention.
cStart and end of each session.
On the first day of their rehabilitation, participants will be required to complete a baseline attention bias assessment task and an attention bias modification task. They will be allowed to rest for 15 minutes before they complete a reassessment of their attention bias. Participants can rest for slightly longer on the first day, given that they are required to complete two tasks—an assessment and a modification task. On the subsequent days of their rehabilitation, they will complete the attention bias modification task and will be allowed 10 minutes of rest before retaking an attention bias assessment task. Participants will be required to complete the visual analogue scale for craving before and after the completion of each of the bias modification task. Participants who have completed 3 sessions will be asked to complete the app perception questionnaire. Participants are expected to undertake the intervention throughout their rehabilitation stay on the ward, except for weekends and public holidays. The intervention is not administered on these days due to the possibility of image-triggered cravings and the absence of a counselor to address the heightened cravings.
The mobile version of the visual probe task that participants will use adheres to the protocol of the original visual probe task [
Overview of the task that participants undertake on the smartphone or tablet device.
The primary outcome feasibility is defined by the number of participants recruited and participants’ adherence to the intervention. In our protocol, we have proposed a total recruitment sample size of 30 participants, and the study is considered feasible if we manage to recruit 25% of the invited number of participants (8 participants). We have proposed a 25% recruitment target for feasibility as we anticipate that there will be challenges to recruitment as the inpatient treatment program is a voluntary program (ie, patients could be discharged voluntarily from the program at any time) and that some patients would leave following the completion of their medical-assisted detoxification. In addition, 25% has been proposed as the target, due also, in part, to our strict inclusion and exclusion criteria. We have specifically mentioned that we will exclude participants with medical comorbidities such as seizures and migraines. To a large extent, most individuals with alcohol disorders often have a history of withdrawal seizures and, hence, they are not eligible for the study, thus, potentially affecting the overall recruitment. Furthermore, we have specifically mentioned that individuals with moderate to severe psychiatric comorbidities are not included. As other psychiatric conditions like depression or anxiety disorders are often comorbidities of substance use disorder, a large group of individuals cannot be recruited. The other criterion for feasibility is patients’ adherence to the planned interventions, and we will consider the study to be feasible if all participants complete at least 60% of the planned interventions.
Attention bias will be computed using the mean reaction time that participants take to react to asterisks or probes that replace the neutral and alcohol or substance images in the assessment task. Attention bias is present if the mean reaction time taken by participants to react to probes that replace the neutral image is longer in comparison to that of alcohol or substance images. The underlying rationale is that an alcohol or substance image would preferentially draw one’s attention, and the reaction time taken to react to asterisk or probes replacing the image is naturally much faster. Attention bias, as measured by the assessment tasks, will be compared to determine if the interventions result in a reduction in overall biases (by comparing the final attention bias score with the baseline score). Cravings will be assessed using the single-item measure, the visual analogue scale [
The secondary outcome acceptability will be assessed through a perception questionnaire, which consists of the following questions:
Prior to using the app, how confident are you in managing your addiction problems? (rated on a 5-point Likert scale)
How easy was it to use the app? (rated on a 5-point Likert scale and participants are asked to provide verbatim comments)
How interactive was the app? (rated on a 5-point Likert scale and participants are asked to provide verbatim comments)
Do you feel motivated to continue using the app? (rated on a 5-point Likert scale and participants are asked to provide verbatim comments)
Do the images in the app remind you of your substance use? (rated on a 5-point Likert scale)
After using the app, how confident are you in managing your addiction problem? (rated on a 5-point Likert scale).
The study is deemed acceptable if participants are willing to use the app daily; if at least 30% of participants rate ease of use, interactivity, motivation, and reality (questions 2-5) positively (either very or extremely on the 5-point Likert scale); and if at least 30% of participants perceive a change in their confidence level after having received 3 sessions of the intervention task (questions 1 and 6). The app is also deemed acceptable by the absence of any severe adverse events (such as intense cravings leading to a premature discharge from the inpatient program).
Baseline demographic and clinical information will be collected from participants. This includes information about nationality, gender, martial status, race, religion, highest level of employment, housing conditions, current substance use, method of consumption of substance, quantity of substance consumed each time, frequency of use, previous treatment history, chronic diseases, (psychiatric or physical disorders), and current psychiatric medications. Furthermore, participants are required to complete a modified ASI-Lite, SDS, and SF-12 questionnaires.
The ASI-Lite collates information for the following domains: drug and alcohol use, medical, employment or school, legal, family, and social and psychiatric [
All participants will be allocated a subject number upon recruitment. No participant-related identifiers will be captured on the hard copy forms. The completed hard copy forms and questionnaires will be stored in secure, locked cabinets in a restricted area. The electronic data from the smartphone app will be automatically synchronized onto a secured, password-protected cloud database. The main investigator will back-up a copy of the electronic data records onto a local secured computer. The principal investigator and the research assistants will take the responsibility for coding the data from the hard copy forms. An independent coinvestigator will routinely check the data entry for reliability and quality. All records will be kept securely for at least 6 years after the completion of the study.
Data collated with be analyzed using SPSS version 22 (SPSS Inc, IL, USA). Baseline demographic information of subjects will be summarized using descriptive statistics, including means and SDs. Chi-square tests or Fisher’s test will be considered to examine any differences in the baseline demographic characteristics among the different substance disorders. The presence of attentional biases will be determined based on the mean reaction times taken to respond to the position of the probes that replace drug or neutral stimuli. In addition, statistical tests (analysis of variance) will be performed to determine whether there are statistically significant differences in the attentional bias scores across the sessions for participants.
Any adverse events that occur during the conduct of the feasibility study will be reported to the Domain Specific Research Board in accordance with the local institutional policy.
We will publish our research in peer-reviewed journals and will also present the findings at regional and international conferences.
Patients and public were not involved in planning for this protocol.
This study was approved by the National Healthcare Group Domain Specific Research Board, with approval number (2018/00316). Results will be disseminated by means of conferences and publications. Currently, we are in the process of recruitment for this study.
To the best of our knowledge, this is the first study to evaluate the feasibility and acceptability of a mobile attention bias modification intervention for individuals with substance use disorders such as cannabis opioid, stimulant, and alcohol disorders. The data pertaining to the feasibility and acceptability are undoubtedly crucial because they imply the potential use of mobile technologies in retraining attentional biases among inpatients who are admitted for medical-assisted detoxification and rehabilitation. Participants’ feedback pertaining to the ease of use, interactivity, and motivation to continue using the app is crucial because it will determine whether a codesign approach might be warranted to design an app that is acceptable for participants and that participants themselves would be motivated to use. Apart from substance use disorders, increasing research has demonstrated the presence of attentional biases in behavioral disorders such as gambling and internet gaming disorders [
Addiction Severity Index
electronic health
mobile health
National Addictions Management Service
Severity of Substance Dependence
Short Form-12
We thank the department (NAMS) for supporting this project. The study will be conducted using funding from the NAMS. MZ is supported by a grant under the Singapore Ministry of Health’s National Medical Research Council (Grant number NMRC/Fellowship/0048/2017) for PhD training. The funding source was not involved in any part of this project.
MZ, JY, GS, DSSF, and HS conceived the study and were involved in study design and protocol development. MZ wrote the initial draft of the manuscript, which was revised by JY, GS, DSSF and HS.
None declared.