RCT Protocol for 'OverThinking': A Mobile EMI for Reducing Experiential Avoidance

Official title

A Mobile Ecological Momentary Intervention for Reducing Experiential Avoidance in the Context of Rumination: Protocol for a Randomised-Controlled Trial

Overview

The goal of this trial is to examine whether a mobile app intervention for rumination can modify a maladaptive feature of repetitive negative thinking (RNT) - this is understood by the link between daily RNT and well-being, depressive and anxiety symptoms. The main questions it aims to answer are: 1. If the intervention can modify the maladaptive feature of repetitive negative thinking - the investigators anticipate the link between daily rumination and maladaptive outcomes (poorer wellbeing, higher depressive/anxious symptoms) will be weaker in the intervention groups. 2. By examining (1) above, to confirm the role played by avoidance in repetitive negative thinking. 3. By splitting the intervention condition into two groups (one receiving concurrent support from a therapist, one not), to evaluate if interventions such as these might be enhanced by therapist support. 4. To examine if the impact of the intervention on depressive and anxious symptoms might be mediated by changes in beliefs regarding emotions (e.g. the valuation of negative emotions). Researchers will compare across four groups to examine the above effects: (1) intervention condition (therapist support); (2) intervention condition (no therapist support); (3) Partial intervention (daily sampling and emotion valuation questions); (4) Control group (only daily sampling questions). Participants will: * Be requested to participate in a four-week intervention, providing daily assessments of depressive and anxiety symptoms, affect, repetitive negative thinking, and rumination outcomes. * Use a mobile application during the intervention period, which has been designed by the research team (intervention groups), or provide daily assessment scores only (control groups). * Be assessed at pre-intervention (all groups), post-intervention (all groups), 1-month follow-up (all groups), and 3-month follow-up (intervention groups only).

Detailed description

The trial aims to examine whether a mobile application-based intervention for experiential avoidance in the context of rumination can modify a maladaptive feature of repetitive negative thinking (RNT) - this is understood by the link between daily RNT and well-being, depressive and anxiety symptoms.

The main questions which the trial aims to answer are as follows:

1. If the intervention can modify the maladaptive feature of repetitive negative thinking - the investigators anticipate the link between daily rumination and maladaptive outcomes (poorer wellbeing, higher depressive/anxious symptoms) will be weaker in the intervention groups. 2. By examining (1) above, to confirm the role played by avoidance in repetitive negative thinking. 3. By splitting the intervention condition into two groups (one receiving concurrent support from a therapist, one not), to evaluate if interventions such as these might be enhanced by therapist support. 4. To examine if the impact of the intervention on depressive and anxious symptoms might be mediated by changes in beliefs regarding emotions (e.g. the valuation of negative emotions).

Researchers will compare across four groups to examine the above effects:

(1) intervention condition (therapist support); (2) intervention condition (no therapist support); (3) Partial intervention (daily sampling and emotion valuation questions); (4) Control group (only daily sampling questions).

The trial comprises of a four-arm, parallel group randomised-controlled trial (RCT). Participation lasts approximately 2 months (including eligibility screening and random allocation to condition (random number generator), a four-week intervention period delivered via the mobile application and supplemented with daily assessments, post-intervention assessments, and 1-month follow-up (wherein the app will remain available for self-directed use without daily sampling), concluding with follow-up assessments and measurement of any engagement with the application during this period.

At the point of 1-month follow-up, participants previously allocated to the control groups will receive access to the application (without the feature of daily sampling) and will be provided with guidance on using the intervention content. While a 3-month follow-up assessment of intervention participants is planned, the 1-month interval allows for control participants to access intervention content without being subject to extensive waitlist delay. Active control groups have been chosen to not artificially inflate comparisons with outcomes in the intervention conditions.

Analysis:

Analysis of changes in outcomes across pre-, post- and follow-up-measures (PTQ, EBQ, PBRS, NBRS, HADS, CAQ, and BEAQ) across all four conditions will be conducted using mixed-design ANOVA.

Additionally for all conditions, multilevel models (daily observations on level 1 nested in participants on level 2) will be used on daily sampling data to assess the links between avoidance and mood and between rumination and mood, and to determine if each of these links is moderated by condition. Participants respond to these items once daily in the evening, in response an in-app reminder alert (the time of the alert can be determined by the participant). All daily sampling items have been provided in the 'Measures' section.

Mixed-design ANCOVA will be used for the two intervention groups to examine if time spent engaging with the application content acts as a covariate in intervention outcomes (PTQ, EBQ, PBRS, NBRS, HADS, CAQ, and BEAQ).

Finally, ongoing development of the application will be assisted using in-app user-feedback data obtained via CORTO implementation (three items with gather a combination of quantitative and qualitative data \[Lukka et al,. 2024\]). This data will be coded deductively using the process outlined by Saldana (2016) and using the four categories identified by Lukka et al. (2024) as high-level guidance ((1) contextual use, (2) interaction-elicited emotional experience, (3) usability, and (4) technical issues.), with more detailed coding examined as subdomains.

Interventions

• Behavioral OverThinking
  OverThinking is a mobile application ecological momentary intervention for iOS and Android, which has been designed for the reduction of experiential avoidance in rumination. The application primarily consists of psychoeducation content and related exercises intended to be delivered over a four-week period. In order to examine the effectiveness of the application during the course of the intervention and to examine user-experiences of using the application for the purpose of rumination intervent

Primary outcome measures

• Perseverative thinking as measured by the Perseverative Thinking Questionnaire (PTQ) [Time frame: Two months (4-week intervention plus 1-month follow-up)]
• Beliefs about emotions as measured by the Emotion Beliefs Questionnaire EBQ [Time frame: Two months (4-week intervention plus 1-month follow-up)]
• Metacognitive beliefs about rumination using PBRS/NBRS [Time frame: Two months (4-week intervention plus 1-month follow-up)]
• Hospital Anxiety and Depression Scale (HADS) [Time frame: Two months (4-week intervention plus 1-month follow-up)]
• Cognitive avoidance using the CAQ [Time frame: Two months (4-week intervention plus 1-month follow-up)]
• Experiential avoidance using the BEAQ. [Time frame: Two months (4-week intervention plus 1-month follow-up)]
• Daily Sampling Items (1: Repetitive Negative Thinking Items) [Time frame: Once daily for 30 days]
• Daily Sampling Items (2: Depression) [Time frame: Once daily for 30 days]
• Daily Sampling Items (3: Affect) [Time frame: Once daily for 30 days]
• Daily Sampling Items (4: Goals) [Time frame: Once daily for 30 days]

Secondary outcome measures (1)

• Time spent using the application [Time frame: During the 4-week intervention period and 1-month follow-up period]

Eligibility criteria

Inclusion criteria

\- Self-reporting problems with repetitive negative thinking.

Exclusion criteria

• Aged below 18 years at the commencement of the trial.
• Currently in receipt of any form of psychotherapy.
• Currently in receipt of any form of psychiatric medication.

Note: Participants who hold a psychiatric diagnosis will not be excluded from the trial provided they meet the inclusion criterion and do not meet any of the exclusion criteria listed above.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Single blind

Primary purpose

Treatment

Study locations

Center list to be confirmed — check the primary protocol.

Publications

• Barnes S, Szastok M, Para M, Morawiec F, Grzeszczuk M, Wojcik S, Karpowicz B, Zinevych P, Jaskulska A, Kopec W, Kornacka M. A Mobile Ecological Momentary Intervention for Reducing Experiential Avoidance in the Context of Rumination: Protocol for a Randomized Controlled Trial. JMIR Res Protoc. 2025 May 27;14:e66067. doi: 10.2196/66067. PMID 40424024

Identifiers

NCT: NCT06570694 · SWPS-ECL-WKEB90/11/2023

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗