JMIR Publications

ABSTRACT

Background:

Cognitive behavioral therapy (CBT) for bulimia nervosa (BN) is most effective when patients demonstrate adequate skill utilization (i.e., the frequency with which a patient practices or uses therapeutic skills) and skill acquisition (i.e., the ability to successfully perform a skill learned in treatment). However, rates of utilization and acquisition of key treatment skills (e.g. regular eating, urge management skills, mood management skills) by the end of treatment are frequently low and outcomes from CBT for BN suffer as a result. Just-in-time adaptive interventions (JITAIs) may be able to improve skill acquisition and utilization via the delivery of real time interventions during algorithm-identified opportunities for skill practice.

Objective:

In the current manuscript, we describe a newly-developed JITAI system called CBT+ that is designed to facilitate 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, n=3 clinicians) designed to identify opportunities for iterative development of CBT+ ahead of a larger ongoing RCT.

Methods:

Five 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 (e.g., app usage, user compliance), acceptability (e.g., qualitative patient and clinician feedback), and preliminary outcomes (e.g., improvements in skill use and acquisition, BN symptoms) of the CBT+ system.

Results:

Preliminary findings indicated that the CBT+ system was acceptable to both patients and clinicians. Patients reported that CBT+ was relatively low burden (e.g., quick and easy to use self-monitoring interface) and compliance with in-app self -monitoring was high (mean entries per day =3.13). JITAIs were perceived as useful by both patients (M= 4.63/6.00) and clinicians (M=4.94/6.00) in encouraging the use of CBT skills. Large improvements in CBT skills and clinically significant declines in BN symptoms were observed by post-treatment.

Conclusions:

CBT+, the first-ever JITAI system designed to facilitate acquisition and utilization of CBT for BN treatment skills when used as a treatment augmentation, was shown to be feasible and acceptable. Areas for iterative improvement of the CBT+ system ahead of an RCT are discussed.