Adapting an Effective CBT for Comorbidity to a Computer-Delivered Format

ABSTRACT Up to one-half of those in treatment for alcohol use disorder (AUD) has a co-occurring anxiety disorder (?comorbidity?), a condition that marks a high degree of treatment resistance, severity and relapse risk in AUD treatment patients. We conceptualize comorbidity as a feed-forward system (?vicious cycle?, [VC]) of interacting negative affect/stress, drinking motives/behavior, coping skills deficits, environmental circumstances, and neurobiological adaptations. Based on this model, we developed and validated the VC cognitive-behavioral therapy (VC-CBT) to disrupt this system at several key linkage points. In a recently completed randomized controlled trial (RCT), we found that adding the VC-CBT to standard AUD inpatient treatment resulted in better alcohol outcomes 4 months following treatment than did adding an anxiety treatment or standard AUD treatment alone. With a number needed to treat (NNT) index of 8 (relative to standard AUD treatment alone), the VC-CBT could, if broadly disseminated, have a large positive impact on AUD treatment. Unfortunately, several significant barriers related to the resource- and expertise-intensive delivery of the VC-CBT limit its dissemination potential and, hence, the impact of this otherwise effective treatment. Therefore, to maximize the public health and scientific potential of our work, we propose to adapt the therapist-delivered VC-CBT to a computer-delivered format to facilitate reliable and economical dissemination of the VC-CBT while maintaining its established efficacy. The first phase of the work (Year 1) will be to adapt the 6-session therapist-delivered VC-CBT for delivery on an internet-based computer platform. This work will be done using a standard iterative process for developing e-content in partnership with local technology experts experienced in producing engaging and effective e-learning products. Approximately 24 patients (6 to test and supply feedback on each of three 2-session therapy modules and 6 to test and supply feedback on all 3 modules given together) will be employed in this phase. The second phase (Years 2 and 3) will be devoted to conducting an RCT to test the efficacy of the refined computer-delivered VC-CBT. We will randomize AUD treatment patients with co- occurring anxiety disorder to receive either the computer-delivered VC-CBT or standard AUD treatment alone (50 patients in each group) to establish significance and effect size estimates of clinical effect for the adapted e-therapy. In addition to analyzing the RCT data, we will perform quasi-experimental contrasts of the process and outcome measures from the computer-delivered VC-CBT group in the RCT with parallel data from the therapist-delivered VC-CBT obtained in an earlier clinical trial. These contrasts will provide a reasonable estimate of how well the computer format compares to the therapist format of the VC-CBT. The proposed work aims to provide an easy and inexpensive computer-delivered version of the VC-CBT that has comparable efficacy to the validated but resource-intensive therapist-delivered version. Achieving this will enable the VC- CBT therapy to benefit more AUD treatment patients and to be more easily studied by other investigators.