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Although the number of alcohol-related treatments in app stores is proliferating, none of them are based on a psychological framework and supported by empirical evidence. Cue exposure treatment (CET) with urge-specific coping skills (USCS) is often used in Danish treatment settings. It is an evidence-based psychological approach that focuses on promoting “confrontation with alcohol cues” as a means of reducing urges and the likelihood of relapse.
The objective of this study was to describe the design and development of a CET-based smartphone app; an innovative delivery pathway for treating alcohol use disorder (AUD).
The treatment is based on Monty and coworkers’ manual for CET with USCS (2002). It was created by a multidisciplinary team of psychiatrists, psychologists, programmers, and graphic designers as well as patients with AUD. A database was developed for the purpose of registering and monitoring training activities. A final version of the CET app and database was developed after several user tests.
The final version of the CET app includes an introduction, 4 sessions featuring USCS, 8 alcohol exposure videos promoting the use of one of the USCS, and a results component providing an overview of training activities and potential progress. Real-time urges are measured before, during, and after exposure to alcohol cues and are registered in the app together with other training activity variables. Data packages are continuously sent in encrypted form to an external database and will be merged with other data (in an internal database) in the future.
The CET smartphone app is currently being tested at a large-scale, randomized controlled trial with the aim of clarifying whether it can be classified as an evidence-based treatment solution. The app has the potential to augment the reach of psychological treatment for AUD.
Alcohol use disorder (AUD) contributes to a substantial number of contacts with the treatment system [
Within the Danish treatment system, individuals with AUD are most commonly treated with motivational interviewing, cognitive behavior therapy and family therapy, classified as evidence-based treatments [
When addressing the need for AUD treatment (such as CET), it is evident that the duration of the treatment is decreasing and that it is increasingly being used in group—rather than individual sessions were found appropriate and reasonable [
Mobile eHealth interventions have the potential to play a crucial role in the future provision of continuing care and relapse prevention helping to lower the socioeconomic burden on the health care system by decreasing the number of contacts it gets, as well as augmenting the reach of relevant treatment. However, there is a need for more transparency regarding the underlying psychological framework of mobile eHealth interventions, their design, and development, as well as the provision of evidence to gain more knowledge about their effectiveness.
In order to add to the evidence base for mobile eHealth interventions, a CET smartphone app that mimics CET with USCS was designed and developed and is currently being tested in a large-scale, randomized controlled trial (ClinicalTrials.gov NCT02298751) [
The objective of this paper was to describe the design and development of a manual-based smartphone app that mimics CET with USCS, which is currently being delivered in Danish inpatient and outpatient clinics. The CET app has the potential to contribute to the reach of evidence-based psychological treatment for AUD.
CET features in treatment programs being used in Danish alcohol clinics in both inpatient and outpatient treatment settings. CET is most commonly used in combination with various urge-specific coping-strategies (USCS), due to the promising outcomes shown [
The initial plan for the structure and content of the app was developed by a group of psychiatrists and a psychologist relying on the aforementioned manual. When converting the manual, designing the app as simply, intuitively, and feasibly as possible was of utmost importance, given that the target population may have very different cognitive profiles [
Along with the smartphone app, an online database was designed and developed in the system which can monitor patients’ data in real-time.
The open-source Linux-based operating system Android was selected as the platform for developing the smartphone app. A customized version of Java in Eclipse (Oracle Corporation) was used as the main programming language. An online server is registered for the database and monitoring of the treatment process remotely.
The information in the app is presented in text format and read out loud simultaneously.
The software requires patients to train on a regular basis and sends a text reminder for this. As little is known about the effectiveness of intensive CET [
Structure of the cue exposure treatment (CET) app.
A CET therapist provides patients with both oral and written information about the app prior to the commencement of treatment. Patients can download the app directly onto their smartphones if they already have one. Otherwise, they can borrow a smartphone from the alcohol treatment clinic.
As can be seen on the
Log-in page (part A), introduction (part B and C), and main menu (part D).
The
The technical functions such as
If patients wish to replay the Introduction, they can click on the icon illustrated in the
As shown in
T he recommended strategies are as follows:
Strategies (part A); session 1: waiting it out, introduction to the USCS (part B), selection of exposure video (part C), and session 1: waiting it out, summary of the USCS (part D). USCS: urge-specific coping skills.
This is used as a cognitive strategy, whereby patients are explained what to expect when waiting out an urge. It is elucidated that they perhaps haven’t ever waited for a strong urge to pass naturally, and that urges actually reduce quite quickly to a manageable level. The urge passes if one waits. It can be expected to peak within 4 min, start to decline after approximately 8 min, and fall completely within 10-15 min. Moreover, the urge declines faster each time exposure occurs without resulting in alcohol consumption. This approach stands in contrast to the exclusively behavioral version of CET in which no information is provided about what to expect.
Patients are encouraged to imagine the most negative future consequences associated with resuming alcohol abuse. In order to systemize and register the negative consequences in the database, patients are required to select between 1 and 3 consequence categories from a list comprising physical health, mental health, family and friends, work and education, economy, offences, and loss of control. To the best of our knowledge, these categories incorporate the vast majority of negative consequences that individuals with AUD may experience [
Patients are encouraged to imagine the positive future consequences associated with restraining from alcohol abuse. In accordance with session 2, patients are required to select between 1 and 3 consequence categories from a list comprising the same domains, and are also guided in rehearsing the USCS. In contrast to the prior USCS, it is explained that this strategy is effective when negative emotions and feelings prevail, and when one has the urge to drink in order to distance oneself. In such a situation, it may be useful to think of the positive consequences that lie ahead if the urge is resisted.
In this last session, patients are encouraged to consume alternative food and drink during exposure in order to reduce urges. It is explained that people have a tendency to prefer the food and drink that is most readily available in risky situations, and that it is a good idea to distinguish between 2 types of risk situations: (1) Alone or alone at home after work, watching TV, bored, and (2) Social events: after work, with friends, or celebration. Patients are encouraged to choose healthy alternatives that will form the basis for new habits.
In the
To ensure that each strategy is trained at least once, it is not possible for patients to proceed to the next session until they have completed the previous session. While the strategies are being trained, the
The
As illustrated in
The app contains 8 different alcohol videos comprising the following categories: ordinary beer, strong beer, alchopops, red wine, white wine, brown spirits (eg, whiskey and cognac), white spirits (eg, vodka and rum), and hard liquor. One of these should be selected. Patients can select for their preferred beverage to feature in the exposure material or vary the beverage used from one session to the next. The alcohol video is selected from the list presented in
It is possible for patients to go directly to the exposure videos after they have been trained for all the USCS, as there is no need to repeat the abovementioned information to them every time they watch a video. When patients click on the
Examples of the alcohol exposure videos.
Real-time cue-induced urges are measured at 3 time points: (1) at the baseline (before exposure), (2) when the urge is expected to peak (during exposure/4 min), and (3) at the endpoint (after exposure). Urges are measured on an 11-point Likert scale, ranging from 0 (no urges) to 10 (severe urges). As can be seen in
Based on these measures, 3-point graphic illustrations of urge development during exposure can be produced. Proxy measures of the intensity of the urge induced by the selected exposure video and the effectiveness of the selected USCS in reducing the urge can also be calculated. The first measure is calculated by subtracting the baseline measure from the peak measure. The effectiveness of the USCS is calculated by subtracting the endpoint measure from the peak measure. These algorithms together with other training activity variables are used to calculate the results in
Real-time measures of cue-induced cravings.
As illustrated in
A s shown in
Data from these measures are recorded in the database in order to register and monitor training activities. The data would be used to measure the extent to which each USCS is applied by patients, as well as the effectiveness of each USCS and the CET intervention in general.
My progress (part A), calendar (part B), best results across strategies (part C), and measures across strategies (part D).
Along with the smartphone app, an online database was designed and developed in the system which can monitor patients’ data in real-time. After the patients have used a USCS, the app saves the data package locally on their phones and directs them automatically to the online database (as long as there is Internet connection). The data package includes
The user IDs will be used to merge data from the database with data from other sources (in an internal database) suitable for personal identifiers.
This paper describes the design and development of a smartphone app that mimics the CET treatment delivered to AUD patients in Danish inpatient and outpatient clinics.
Although CET along with USCS is widely used in Denmark, studies providing evidence for the effectiveness of this treatment are yet to be conducted. If we draw on the evidence from international studies, CET has, in its conventional delivery form, demonstrated superior performance to meditation and relaxation techniques [
The critical question, then, is whether this evidence-based AUD intervention demonstrates an effect when converted into a smartphone app. To answer this question, we based the present app on a behavioristic psychological framework and embedded the examination of it in a large-scale, randomized controlled trial. About 300 AUD individuals were randomized into 1 of the following 3 aftercare treatment groups: (1) CET as a mobile phone app (n=100); (2) CET as a group therapy (n=100); and (3) treatment as usual (n=100). The 2 experimental CET conditions were based on the same manual, and the treatment as usual consisted of a single follow-up session to observe how patients were doing and whether further treatment was needed. The real-time urge measures were applied in both experimental CET conditions, and a number of effect measures were conducted for all enrolled participants [
The experimental design allows for comparison between the experimental groups and the nonactive controls, which adds to the general knowledge base pertaining to the effectiveness of CET targeting AUD. Of more importance is the fact that the study design allows for a comparison between the 2 experimental conditions on USCS, real-time urges and effect measures, which clarifies whether it is beneficial for patients to progress from CET group sessions to using a CET smartphone app.
It is hypothesized that the experimental groups will achieve better outcomes compared with controls on primary and secondary effect measures, including alcohol consumption, urges or cravings and coping skills. It is a more of an explorative research question that answers whether similar or improved results for one of the CET conditions will be found. Thus, the study context will either validate or falsify the app as an evidenced-based treatment form.
Obviously, the app might have a number of disadvantages compared with CET group sessions, which may hinder its effectiveness as a pathway for treatment delivery. First, the alcohol exposure videos aim to target possibly all the individuals in the study population, hereby including several alcohol brands at the expense of the individually tailored exposure. Second, patients cannot smell the alcohol shown in the videos, and we know that smell is the only sense that is linked directly to the frontolimbic reward system [
Although there exists a gap in knowledge about the effectiveness of evidence-based psychological treatment delivered through mobile devices [
Despite the lack of availability of theory-driven and empirically supported apps, many new intervention initiatives targeting both subclinical and clinical AUD populations are seen in research [
It is our hope that the present CET app will contribute to the availability of evidence-based mental health apps targeting AUD. Future work will customize the CET app according to the findings generated by the longitudinal randomized controlled trial in which the examination of this app is embedded in.
alcohol use disorder
cue exposure treatment
urge-specific coping skills
None declared.