Current forms of inhibitory training produce no greater reduction in drinking than simple assessment: A preliminary study

Inhibitory control training to reduce appetitive behaviour: a meta-analytic investigation of effectiveness, potential moderators, and underlying mechanisms of change

BACKGROUND/AIMS

Inhibitory control training (ICT) is a cognitive intervention that has been suggested to reduce problematic appetitive behaviours, such as unhealthy eating and excessive alcohol consumption. We conducted a meta-analytic review of ICT for reducing appetitive behaviours.

METHODS

Two meta-analyses were conducted for behavioural (objective) outcomes and self-report outcomes, along with 14 moderator analyses, and two secondary analyses investigating changes in cue-devaluation and inhibitory control.

RESULTS

The review included 46 articles (67 effect sizes and 4231 participants) and four appetitive health behaviours (eating, drinking, smoking, gambling). A significant effect of ICT on behavioural outcomes was found (SMD = 0.241, p .001). The self-report outcomes meta-analysis was not significant (p > .05). Secondary analyses also demonstrated greater inhibitory control (p < .05) and cue devaluation (p < .05) following ICT.

CONCLUSIONS

This meta-analytic review is the largest synthesis of ICT interventions for appetitive behaviours. ICT significantly reduced problematic eating behaviours when adopting behavioural outcomes, but this was not found for other appetitive behaviours. ICT also significantly improved inhibitory control and reduced cue evaluations. Further studies are required before drawing any conclusions regarding impacts on other appetitive behaviours.

Alcohol-specific inhibition training in patients with alcohol use disorder: a multi-centre, double-blind randomized clinical trial examining drinking outcome and working mechanisms

AIMS

For the first time, to our knowledge, in a clinical sample with alcohol use disorder (AUD), this study compared the effects of two versions of alcohol-specific inhibition training (Alc-IT) on drinking outcomes and on experimental parameters assessing two possible working mechanisms: stimulus devaluation and inhibitory enhancement.

DESIGN

Multi-centre, double-blind, three-arm clinical RCT with 3-, 6- and 12-month follow-up comparing standard Alc-IT, improved Alc-IT and an active control condition.

SETTING

Three specialized AUD treatment centres in Switzerland.

PARTICIPANTS

A total of 242 detoxified, recently abstinent patients with severe AUD (18-60 years; 29.8% female).

INTERVENTION AND COMPARATOR

Both interventions [standard Alc-IT (n = 84) and improved Alc-IT (n = 79)] and the comparator [unspecific inhibition training (n = 79)] consisted of six sessions of a modified inhibitory task (Go/NoGo task) with alcohol-related and neutral stimuli. Both versions of Alc-IT required response inhibition in alcohol-related trials but differed in Go/NoGo ratios (standard: 50/50; improved: 75/25), with improved Alc-IT posing higher inhibitory demands. The control condition, an unspecific inhibition training, featured alcohol-related pictures in Go as well as NoGo trials.

MEASUREMENTS

The primary outcome, percentage of days abstinent, was assessed at 3-month follow-up with a time-line follow-back interview.

FINDINGS

The group receiving improved Alc-IT showed a significantly higher percentage of days abstinent at 3-month follow-up compared with the control group [γ_control  = 74.30; γ_improved  = 85.78; β = 11.48, 95% confidence interval (CI) = 2.57, 20.40, P = 0.012, adjusted r²  = 0.062], while for standard Alc-IT no effect significantly different from zero was detected (γ_standard  = 70.95; β = -3.35, 95% CI = -12.20, 5.50, P = 0.457, adjusted r²  = -0.04).

CONCLUSIONS

Alcohol-specific inhibition training with high inhibitory demands increased days abstinent at 3-month follow-up in patients with severe alcohol use disorder. Such an improved, inhibitory-demanding, alcohol-specific inhibition training outperformed the standard version of alcohol-specific inhibition training, suggesting an inhibitory working mechanism.

Defining and evaluating the Hawthorne effect in primary care, a systematic review and meta-analysis

In 2015, we conducted a randomized controlled trial (RCT) in primary care to evaluate if posters and pamphlets dispensed in general practice waiting rooms enhanced vaccination uptake for seasonal influenza. Unexpectedly, vaccination uptake rose in both arms of the RCT whereas public health data indicated a decrease. We wondered if the design of the trial had led to a Hawthorne effect (HE). Searching the literature, we noticed that the definition of the HE was unclear if stated. Our objectives were to refine a definition of the HE for primary care, to evaluate its size, and to draw consequences for primary care research. We designed a Preferred Reporting Items for Systematic reviews and Meta-Analyses review and meta-analysis between January 2012 and March 2022. We included original reports defining the HE and reports measuring it without setting limitations. Definitions of the HE were collected and summarized. Main published outcomes were extracted and measures were analyzed to evaluate odds ratios (ORs) in primary care. The search led to 180 records, reduced on review to 74 for definition and 15 for quantification. Our definition of HE is "an aware or unconscious complex behavior change in a study environment, related to the complex interaction of four biases affecting the study subjects and investigators: selection bias, commitment and congruence bias, conformity and social desirability bias and observation and measurement bias." Its size varies in time and depends on the education and professional position of the investigators and subjects, the study environment, and the outcome. There are overlap areas between the HE, placebo effect, and regression to the mean. In binary outcomes, the overall OR of the HE computed in primary care was 1.41 (95% CI: [1.13; 1.75]; I 2 = 97%), but the significance of the HE disappears in well-designed studies. We conclude that the HE results from a complex system of interacting phenomena and appears to some degree in all experimental research, but its size can considerably be reduced by refining study designs.

Pilot testing of an adaptive, individualized inhibitory control training for binge drinking: first evidence on feasibility, acceptance, and efficacy

Background

Deficits in inhibitory control seem to promote habit behavior and therefore play an important role in the development and maintenance of addictive diseases. Although several training approaches have been suggested, there is a considerable lack of knowledge about the best way to improve inhibitory control. Based on a literature review regarding shortcomings of existing trainings, an individualized, adaptive inhibitory control training was developed. We aimed to assess feasibility and acceptance of this training and to provide preliminary results on its efficacy regarding inhibitory control and binge drinking.

Methods

Sixty-one individuals (30 female) with binge drinking behavior were randomly allocated to either an experimental group receiving three sessions of the inhibitory control training or a waitlist control group receiving no training. Before and after the training, the participants performed a Go/NoGo task to assess inhibitory control (commission errors and false reaction time), completed a questionnaire on drinking-related self-control, and reported drinking behavior.

Results

Although the training was feasible and accepted by participants, it did not affect self-control over drinking, inhibitory control or drinking behavior. The relationship between session number and false reaction time was linear for alcohol stimuli, but squared for neutral stimuli.

Conclusion

Although our findings have to be interpreted in the light of some shortcomings, they demonstrate that further research is needed to enhance our understanding of how to improve inhibitory control and which factors might moderate this process.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00426-022-01725-4.

Forgetting Alcohol: A Double-Blind, Randomized Controlled Trial Investigating Memory Inhibition Training in Young Binge Drinkers

Background

Binge Drinking (BD) has been associated with altered inhibitory control and augmented alcohol-cue reactivity. Memory inhibition (MI), the ability to voluntarily suppress unwanted thoughts/memories, may lead to forgetting of memories in several psychiatric conditions. However, despite its potential clinical implications, no study to date has explored the MI abilities in populations with substance misuse, such as binge drinkers (BDs).

Method

This study—registered in the NIH Clinical Trials Database (ClinicalTrials.gov identifier: NCT05237414)—aims firstly to examine the behavioral and electroencephalographic (EEG) correlates of MI among college BDs. For this purpose, 45 BDs and 45 age-matched non/low-drinkers (50% female) will be assessed by EEG while performing the Think/No-Think Alcohol task, a paradigm that evaluates alcohol-related MI. Additionally, this work aims to evaluate an alcohol-specific MI intervention protocol using cognitive training (CT) and transcranial direct current stimulation (tDCS) while its effects on behavioral and EEG outcomes are assessed. BDs will be randomly assigned to one MI training group: combined [CT and verum tDCS applied over the right dorsolateral prefrontal cortex (DLPFC)], cognitive (CT and sham tDCS), or control (sham CT and sham tDCS). Training will occur in three consecutive days, in three sessions. MI will be re-assessed in BDs through a post-training EEG assessment. Alcohol use and craving will be measured at the first EEG assessment, and both 10-days and 3-months post-training. In addition, behavioral and EEG data will be collected during the performance of an alcohol cue reactivity (ACR) task, which evaluates attentional bias toward alcoholic stimuli, before, and after the MI training sessions.

Discussion

This study protocol will provide the first behavioral and neurofunctional MI assessment in BDs. Along with poor MI abilities, BDs are expected to show alterations in event-related potentials and functional connectivity patterns associated with MI. Results should also demonstrate the effectiveness of the protocol, with BDs exhibiting an improved capacity to suppress alcohol-related memories after both combined and cognitive training, along with a reduction in alcohol use and craving in the short/medium-term. Collectively, these findings might have major implications for the understanding and treatment of alcohol misuse.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [NCT05237414].

A Comparison Between Ecological Momentary Assessment and the Adapted-Quick Drinking Screen: Alcohol Mixed With Energy Drinks

Aims

To compare alcohol consumption and risk-taking behaviours on alcohol mixed with energy drink (AMED) and alcohol-only (AO) drinking occasions collected via ecological momentary assessment (EMA) versus retrospective survey methods (adapted-Quick Drinking Screen: a-QDS).

Methods

Completing participants were 52 university students who reported AMED consumption during the 30-day data collection period. Alcohol consumption and risk-taking behaviours were captured for recreational AMED and AO consumption occasions using a smartphone-based app across 30 days. Data were aggregated for comparison with the a-QDS conducted at the end of data collection.

Results

Irrespective of data collection method, alcohol was consumed more frequently and at higher quantities on the heaviest drinking occasions when consumed alone compared with when it was mixed with energy drinks. Consistent with this finding, more risk-taking behaviours were experienced on AO occasions compared with AMED occasions. Compared with the a-QDS, the quantity of alcohol consumed on the average and heaviest drinking occasion was significantly higher when reported via EMA. This was consistent across both AO and AMED drinking occasions.

Conclusion

EMA provides a more valid measure of consumption quantity compared with retrospective recall, which was susceptible to under-reporting, although this was not differentially affected across consumption occasions. In line with previous research, this study demonstrated that mixing alcohol with energy drinks does not increase alcohol consumption or risk-taking behaviours.

Does alcohol cue inhibitory control training survive a context shift?

Inhibitory control training (ICT) is a novel psychological intervention that aims to improve inhibitory control in response to alcohol-related cues through associative learning. Laboratory studies have demonstrated reductions in alcohol consumption following ICT compared with control/sham training, but it is unclear if these effects are robust to a change of context. In a preregistered study, we examined whether the effects of ICT would survive a context shift from a neutral context to a seminaturalistic bar setting. In a mixed design, 60 heavy drinkers (40 female) were randomly allocated to receive either ICT or control/sham training in a neutral laboratory over 2 sessions. We developed a novel variation of ICT that used multiple stop signals to establish direct stimulus-stop associations. The effects of ICT/control were measured once in the same context and once following a shift to a novel (alcohol-related) context. Our dependent variables were ad libitum alcohol consumption following training, change in inhibitory control processes, and change in alcohol value. ICT did not reduce alcohol consumption in either context compared with the control group. Furthermore, we demonstrated no effects of ICT on inhibitory control processes or alcohol value. Bayesian analyses demonstrated overall support for the null hypotheses. This study failed to find any effects of ICT on alcohol consumption or candidate psychological mechanisms. These findings illustrate the difficulty in training alcohol-inhibition associations and add to a growing body of literature suggesting that ICT holds little evidential value as a psychological intervention for alcohol use disorders. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Learning to resist the urge: a double-blind, randomized controlled trial investigating alcohol-specific inhibition training in abstinent patients with alcohol use disorder

Background

Alcohol use disorder (AUD) leads to a significant individual and societal burden. To achieve higher therapy success rates, therapeutic interventions still need to be improved. Most current neuroscientific conceptualizations of AUD focus on the imbalance between an enhanced automatic reaction to alcohol cues and impaired inhibition. Complementary to traditional relapse prevention strategies, novel computerized training interventions aim to directly alter these processes. This study tests a computerized alcohol-specific inhibition training in a large clinical sample and investigates its effects on behavioral, experimental and neurophysiological outcomes. It also analyzes whether variations in inhibition difficulty and/or endogenous cortisol levels during training impact these effects.

Methods

This is a double-blind, randomized controlled trial (RCT) with 246 inpatients with AUD participating. After baseline assessment, participants are randomly assigned to one of three computerized Go-NoGo-based inhibition training interventions (two alcohol-specific versions with different Go/NoGo ratios, or neutral control training) and one of two intervention times (morning/afternoon), resulting in six study arms. All patients perform six training sessions within 2 weeks. Endogenous cortisol is measured in 80 patients before and after the first training session. Inhibitory control and implicit associations towards alcohol are assessed pre and post training, at which point electroencephalography (EEG) is additionally measured in 60 patients. Patients’ alcohol consumption and relevant psychological constructs (e.g., craving, self-efficacy, treatment motivation) are measured at discharge and at 3-, 6- and 12-month follow-ups. Fifty healthy participants are assessed (20 with EEG) at one time point as a healthy control group.

Discussion

This study investigates the effects of a computerized, alcohol-specific inhibition training for the first time in patients with AUD. Results should give insight into the effectiveness of this potential add-on to standard AUD treatment, including proximal and distal measures and effects on behavioral, experimental and neurophysiological measures. Information about working mechanisms and potential optimizations of this training are gathered through variations regarding difficulty of inhibition training and training time. This study may thus contribute to a deepened understanding of AUD and the improvement of its evidence-based treatment.

Trial registration

ClinicalTrials.gov, ID: NCT02968537. Registered on 18 November 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3505-2) contains supplementary material, which is available to authorized users.

Feasibility, Acceptability, and Initial Efficacy of Delivering Alcohol Use Cognitive Interventions via Crowdsourcing

BACKGROUND

Inhibitory control training and working memory training are 2 cognitive interventions that have been considered for alcohol use disorder (AUD). Existing studies have typically relied on small samples that preclude the evaluation of small effects. Crowdsourcing is a sampling method that can address these limitations by effectively and efficiently recruiting large samples with varying health histories. This study tested the feasibility and acceptability of delivering cognitive training interventions via crowdsourcing.

METHODS

Participants with AUD were recruited from the crowdsourcing website Amazon Mechanical Turk (mTurk) (ClinicalTrials.gov; NCT03438539). Following completion of a baseline survey, participants were randomized to an inhibitory control, working memory, or control training condition. Participants were asked to complete training tasks daily over a 2-week period. Follow-up assessments evaluating acceptability measures and alcohol and soda consumption were completed immediately following and 2 weeks after training.

RESULTS

Response rates were satisfactory over the 2-week intervention period (65% of training tasks completed), and performance on training tasks was consistent with expected effects. A majority of participants indicated that they were satisfied with the study procedures (94.6%), would participate again (97.4%), and would consider incorporating the training task in their daily life (81.1%). Modest reductions in alcohol consumption were observed (e.g., 0.5 drinking day/wk), primarily in the inhibitory control group, and these effects were selective to alcohol use and did not extend to soda consumption.

CONCLUSIONS

These findings demonstrate the feasibility and acceptability of utilizing crowdsourcing methods for interventions development. Such a demonstration helps establish the crowdsourcing setting for future large sample studies testing novel interventions for AUD and other substance use disorders.

Alcohol-Specific Computerized Interventions to Alter Cognitive Biases: A Systematic Review of Effects on Experimental Tasks, Drinking Behavior, and Neuronal Activation

Background: In patients with alcohol use disorder, novel interventions to increase abstinence have attracted growing attention. Interventions aimed at modifying cognitive biases linked to alcohol use [i.e. cognitive bias modification (CBM)] may serve as an add-on to standard therapy. This systematic review thoroughly aggregates existing data on the effects of three alcohol-specific computerized interventions, namely attentional bias modification (AtBM), approach bias modification (ApBM), and inhibition training (IT). In doing so, each CBM's effects on experimental tasks assessing the relevant biases, drinking behavior, and neurophysiology are summarized. Also, the influence of drinking behavior severity and motivation to change drinking behavior are discussed. Methods: A literature search was conducted in four databases for original research articles published between 2000 and May 2019. Studies were eligible if investigating the effects of alcohol-specific computerized interventions (AtBM, ApBM, IT) on drinking behavior, bias change, and/or neurophysiology. Forty eligible articles were classified as being either a non-clinical experimental lab study (ELS) or clinical randomized-controlled trial (RCT) and summarized. Results: While AtBM seems to influence attentional bias, its effects on drinking behavior are inconsistent. As for ApBM, the best effects on drinking behavior are obtained in clinical samples. Effects of ApBM on approach bias are mixed. Interestingly, those clinical RCTs which investigated ApBM effects on bias change as well as on drinking outcome, reported consistent effects in both measures (i.e. either effects on bias and drinking or no effects). Studies on IT are limited to non-clinical samples and show inconsistent effects on drinking behavior. Considering ITs effects on implicit semantic associations, most studies do not support the conceptualization of IT as a form of memory bias modification, while reports on IT's effects on inhibitory control are still incomplete. Conclusions about the overall influence of drinking behavior severity are hampered by the non-uniform use of sample descriptions. Conclusions: In clinical samples, ApBM has shown more consistent beneficial effects, while evidence on AtBM is more inconsistent, and data on IT still lacks important information. Conclusions about the influence of drinking behavior severity would be facilitated by a uniform use of clearly defined sample descriptions.

A randomized controlled trial of inhibitory control training for the reduction of alcohol consumption in problem drinkers

OBJECTIVE

We conducted a randomized controlled trial to compare the effects of three types of Internet-delivered Inhibitory Control Training (ICT) with each other and with an active control intervention on alcohol consumption in a community sample of problem drinkers.

METHOD

Two hundred and 46 heavy drinkers, who were motivated to reduce their alcohol consumption (mean age 41.32, 130 female) self-monitored their alcohol consumption for 1 week before being randomized to receive 1 of 3 variants of ICT (Associative No-Go, Associative Stop Signal, General Inhibition) or an active control. Participants then completed up to 14 ICT/control sessions on the Internet over a 4-week period, while regularly recording their alcohol consumption.

RESULTS

There were significant reductions in alcohol consumption across all groups over the 4-week training period (main effect of time, F(2, 402) = 77.12, p < .01, ηp2 = .28, BF10 > 99), however there were no differences between ICT groups, or between ICT groups and the active control group (Group × Time interaction, F(6, 402) = 1.10, p = .36, ηp2 = .02, BF10 = 0.03). Contrary to hypotheses, there were no changes in general inhibitory control, the disinhibiting effects of alcohol cues, or alcohol affective associations after ICT.

CONCLUSIONS

In this study, which attempted to translate findings from proof-of-concept laboratory studies into a viable behavior change intervention, we found that multiple sessions of ICT delivered over the Internet did not help heavy drinkers to reduce their alcohol consumption beyond nonspecific effects associated with taking part in a trial. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Assessment of alcohol intake: Retrospective measures versus a smartphone application

INTRODUCTION

Research investigating problem drinking often relies on retrospective measures to assess alcohol consumption behaviour. Limitations associated with such instruments can, however, distort actual consumption levels and patterns. We developed the smartphone application (app), CNLab-A, to assess alcohol intake behaviour in real-time.

METHODS

Healthy individuals (N=671, M age 23.12) completed demographic questions plus the Alcohol Use Questionnaire and a 21-day Timeline Followback before using CNLab-A for 21days. The app asked participants to record alcohol consumption details in real time. We compared data reported via retrospective measures with that captured using CNLab-A.

RESULTS

On average, participants submitted data on 20.27days using CNLab-A. Compared to Timeline Followback, a significantly greater percentage of drinking days (24.79% vs. 26.44%) and significantly higher total intake (20.30 vs. 24.26 standard drinks) was recorded via the app. CNLab-A captured a substantially greater number of high intake occasions at all levels from 8 or more drinks than Timeline Followback. Additionally, relative to the Alcohol Use Questionnaire, a significantly faster rate of consumption was recorded via the app.

CONCLUSIONS

CNLab-A provided more nuanced information regarding quantity and pattern of alcohol intake than the retrospective measures. In particular, it revealed higher levels of drinking than retrospective reporting. This will have implications for how particular at-risk alcohol consumption patterns are identified in future and might enable a more sophisticated exploration of the causes and consequences of drinking behaviour.