Efficacy of cognitive bias modification interventions in anxiety and depression: Meta-analysis
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Background: Cognitive bias modification (CBM) interventions are strongly advocated in research and clinical practice. Aims: To examine the efficiency of CBM for clinically relevant outcomes, along with study quality, publication bias and potential moderators. Method: We included randomised controlled trials (RCTs) of CBM interventions that reported clinically relevant outcomes assessed with standardised instruments. Results: We identified 49 trials and grouped outcomes into anxiety and depression. Effect sizes were small considering all the samples, and mostly non-significant for patient samples. Effect sizes became non-significant when outliers were excluded and after adjustment for publication bias. The quality of the RCTs was suboptimal. Conclusions: CBM may have small effects on mental health problems, but it is also very well possible that there are no significant clinically relevant effects. Research in this field is hampered by small and low-quality trials, and by risk of publication bias. Many positive outcomes are driven by extreme outliers.
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Such training has robust effects upon attentional or interpretation bias per se, but studies tend to show small effect sizes on anxiety symptoms in clinical samples.
“However, while such training has robust effects upon attentional or interpretation bias per se , studies tend to show small effect sizes on anxiety symptoms in clinical samples 255,256 .”
From The clinical characterization of the adult patient with an anxiety or related disorder aimed at personalization of management (2021) · cites this paper as [255]
The General anxiety results for clinical samples report a non-significant effect (g = 0.29), falling to g = −0.01 after an outlier was removed. But the Summary of main findings says this meta-analysis did not specifically examine effects on attentional or interpretation bias, so it does not establish the claim that those effects are robust. Page numbers were unavailable in our copy. (LLM, conf=0.90)
Experimental — accuracy not yet measuredEvidence for the efficacy of ApBM for nonclinical samples is inconclusive.
“Although the evidence for the efficacy of ApBM for nonclinical samples is inconclusive (Boffo et al., 2019; Cristea et al., 2015; Wiers et al., 2018)”
From Acceptability and Co-Development of an Online Cognitive Bias Modification Intervention for Emerging Adults With Hazardous Alcohol Use and Social Anxiety: A Mixed Methods Study (2020) · cites this paper as Cristea et al., 2015
The Abstract (page unavailable) says the efficacy of cognitive bias modification (CBM) is uncertain, and the Characteristics of included studies section reports that the review included unselected participants. But the paper does not establish that conclusion specifically for approach bias modification (ApBM) in nonclinical samples; its reported effects pool different CBM interventions and samples. (LLM, conf=0.82)
Experimental — accuracy not yet measuredCBM's efficacy among nonclinical samples is inconsistent.
“While CBM's efficacy among nonclinical samples is inconsistent (Boffo et al., 2019; Cristea et al., 2015; Wiers et al., 2018), there are particularly promising findings in clinical contexts as clients are motivated to change their thoughts and behavior (Wiers et al., 2018).”
From Acceptability and Co-Development of an Online Cognitive Bias Modification Intervention for Emerging Adults With Hazardous Alcohol Use and Social Anxiety: A Mixed Methods Study (2020) · cites this paper as Cristea et al., 2015
The Summary of main findings reports small CBM effects and high heterogeneity across all samples, and Characteristics of included studies confirms that unselected and subclinical participants were included. But the reported inconsistency is for the combined sample, not specifically for nonclinical samples. The later claim about promising clinical findings is attributed to a different citation, not this paper. (LLM, conf=0.83)
Experimental — accuracy not yet measuredSome attention bias modification projects have been limited by small sample sizes and poor trial methodology.
“Unfortunately, some projects have been limited by small sample sizes and poor trial methodology [20–23].”
A possibility of some effect of CBM-I was suggested, but not at a level matching initial enthusiasm.
“A possibility of some effect of CBM-I was suggested, however, not at the level that would match initial enthusiasm.”
From Cognitive neuropsychological theory of antidepressant action: a modern-day approach to depression and its treatment (2021) · cites this paper as Cristea et al. 2015
A recent meta-analysis failed to support a treatment effect of CBM, in particular CBM-A.
“a more recent meta-analysis (Cristea et al. 2015) failed to support this treatment effect, in particular in case of CBM-A.”
From Cognitive neuropsychological theory of antidepressant action: a modern-day approach to depression and its treatment (2021) · cites this paper as Cristea et al. 2015
Although these approaches have been shown to effectively retrain biases, estimates of the effects on clinical outcomes in adults are modest.
“Although these approaches have been shown to effectively retrain biases, estimates of the effects on clinical outcomes in adults are modest [108].”
From Positive and Negative Emotion Regulation in Adolescence: Links to Anxiety and Depression (2019) · cites this paper as [108]
Conclusions about the co-occurrence of reductions in anxiety and AB measures during ABM training are complicated by methodological issues such as differing outcome measures, confounding variables, low-quality studies, and publication bias.
“However, this cooccurrence is not consistently found [7], and conclusions are complicated by methodological issues (e.g., differing outcome measures, confounding variables, low-quality studies, publication bias) [9,79].”
From Anxiety and Threat-Related Attention: Cognitive-Motivational Framework and Treatment (2018) · cites this paper as [9]
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- Authors
- Cristea, I. A., Kok, R. N., & Cuijpers, P.
- Affiliations
- University of Pisa (IT)
- Venue
- British Journal of Psychiatry
- Publisher
- Royal College of Psychiatrists
- Published
- 2015-01
- Volume
- 206
- Issue
- 1
- Pages
- 7-16
- ISSN
- 0007-1250 (ISSN-L)
- 1472-1465
- OpenAlex
- W2051006097
- Cited by
- 553
- References
- 80
- Citations by year
- 2026: 21 · 2025: 20 · 2024: 41 · 2023: 33 · 2022: 30 · 2021: 39 · 2020: 86 · 2019: 66 · 2018: 82 · 2017: 48 · 2016: 54 · 2015: 32 · 2014: 1
- FWCI
- 9.38
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The British Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- VU Research Portal (publishedVersion)
- Multilingual Matters (Channel View Publications) (submittedVersion, other-oa)
- Padua Research Archive (University of Padova) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Keywords
- cognitive bias modification, anxiety, depression, treatment efficacy, publication bias, trial quality, effect size, outliers, mental health interventions
- MeSH terms
- Anxiety, Depression, Humans, Cognitive Behavioral Therapy, Treatment Outcome, Publication Bias
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