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Abstract

The notion that cognitive bias modification should be appraised exclusively on the basis of trials where its postulated mechanisms were successfully changed starkly contradicts the standards of evidence-based psychotherapy. In the laboratory or as a treatment, cognitive bias modification cannot continue to eschew the rigorous scrutiny applied to other interventions.

Footnotes

See analysis, pp. 266–271, this issue.

Declaration of Interest

None

Selective exclusion of studies or outcomes from meta-analyses based on post-hoc criteria or applied without transparency or a solid theoretical justification is a pernicious practice that distorts results, 1 thus usually considered a grave error. Yet Grafton and colleagues seem to do exactly that with our meta-analysis. 2 They misconstrue it as investigating whether cognitive bias modification (CBM) alters ‘emotional vulnerability’, a vague concept of uncertain clinical relevance. Instead, as evident throughout, we examined post-intervention anxiety and depression outcomes. Using our data for anxiety outcomes at post-test, they employ three arbitrary filters to selectively exclude studies and subsequently perform a strictly qualitative and unclear classification of the remaining ones.

The most conspicuous filter is the exclusion of ten studies for measuring ‘resting mood state’ instead of ‘emotional vulnerability’. Eight of these used the State–Trait Anxiety Inventory (STAI)-State, one a specific phobia inventory, 3 another social anxiety measures. 4 Hence, we are at a loss as to what the authors mean, as all of these measure symptoms of ‘anxiety’. Moreover, all our effect size calculations were, as described, at post-test. If for instance authors of a trial would use the STAI-State at both post-test and after a so-called stressor task, we only considered the former. So, in this sense everything was ‘resting mood’. Furthermore, if Grafton et al deemed state anxiety measures as improper, they should have also excluded them from effect size calculations for the other included trials. Their analysis nonetheless retained five other studies that solely used the STAI-State. 5,6 Finally, Grafton et al do not substantiate their reanalysis with any actual data analysis, except for tallying findings as yes or no. We undertook this task for them. Presuming they intended to exclude state anxiety, we recalculated effect size for the 12 remaining studies measuring anxiety. The eight where bias change occurred resulted into a small Hedges g of 0.38, virtually identical to our original findings 2 (Duval-Tweedie publication bias adjusted g = 0.28). We conducted meta-regression analyses combining bias change with other significant moderators of outcome. 2 Bias change no longer predicted outcomes (Table 1).

Table 1 Meta-regression analysis for bias change, alone and in combination with other significant predictors of outcome 2

Bias change
Alone And participant

compensation
And delivery And impact

factor
b = 0.42, P = 0.032 b = 0.37, P = 0.18 b = 0.25, P = 0.50 b = 0.24, P = 0.38

More generally, the claim that CBM should be assessed for effectiveness only in the presence of change in its postulated mechanisms conflicts with the current standards for evaluating psychotherapies. For instance, the effectiveness of cognitive–behavioural therapy 7 is not restricted to trials where dysfunctional thoughts were successfully changed. Process variables are commonly conjectural, unclear, multiple, confounded with outcome measures, assessed in miscellaneous ways, and produce contradictory results. Even when a hypothesised process changes in a trial, it does not follow this is indeed a mechanism of change. 8 For CBM, the nature and direction of bias change needed to engender symptom change have been targets of speculation and debate, 9,10 although posited as self-evident facts by Grafton et al.

Ultimately, CBM researchers should decide at which table they want to sit. If CBM is cast as a laboratory development, encouraging but as yet inconsequential for clinical practice, exploring procedures to modify assumed processes is an adequate goal. Conversely, if – as repeatedly claimed 10 – CBM is a promising psychotherapy for use on patients and in clinical trials, it should comply with the same standards as all psychotherapies. These standards involve evaluating effectiveness on clinically relevant outcomes, using all available evidence, as we did, 2 and cannot hinge on whether or not purported processes have changed. Grafton et al summarily gloss over other serious problems we evidenced, such as lack of effects for clinical samples, pervasive publication bias and low study quality. Vague and debatable distinctions qualitatively applied post-hoc to a subset of the available data cannot substitute for modest if extant symptom change.

References

1 Page, MJ, McKenzie, JE, Kirkham, J, Dwan, K, Kramer, S, Green, S, et al. Bias due to selective inclusion and reporting of outcomes and analyses in systematic reviews of randomised trials of healthcare interventions. Cochrane Database Syst Rev 2014; 10: MR000035.
2 Cristea, IA, Kok, RN, Cuijpers, P. Efficacy of cognitive bias modification interventions in anxiety and depression: meta-analysis. Br J Psychiatry 2015; 206: 716.
3 Harris, LM, Menzies, RG. Changing attentional bias: can it effect self-reported anxiety? Anxiety Stress Coping 1998; 11: 167–79.
4 Heeren, A, Reese, HE, McNally, RJ, Philippot, P. Attention training toward and away from threat in social phobia: effects on subjective, behavioral, and physiological measures of anxiety. Behav Res Ther 2012; 50: 30–9.
5 Hirsch, CR, Mathews, A, Clark, DM. Inducing an interpretation bias changes self-imagery: a preliminary investigation. Behav Res Ther 2007; 45: 2173–81.
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8 Kazdin, AE. Mediators and mechanisms of change in psychotherapy research. Annu Rev Clin Psychol 2007; 3: 127.
9 Koster, EHW, Bernstein, A. Introduction to the special issue on cognitive bias modification: taking a step back to move forward? J Behav Ther Exp Psychiatry 2015; 49: 14.
10 MacLeod, C, Mathews, A. Cognitive bias modification approaches to anxiety. Annu Rev Clin Psychol 2012; 8: 189217.