Addressing critical gaps in the treatment of eating disorders

Reach Out and Recover: Intentions to seek treatment in individuals using online support for eating disorders

OBJECTIVE

The aim of this study was to explore characteristics and treatment-seeking intentions of consumers accessing an online resource for eating disorders support, Reach Out and Recover (ROAR). Factors associated with treatment-seeking intent among visitors to ROAR were also examined.

METHOD

Participants were 200 visitors to the website aged 18 to 60 plus. The majority of participants (93.5%) identified as women. Responses to self-report questions assessing treatment-seeking intention, eating disorder symptoms and their impact on health, and attitudes to treatment were collected.

RESULTS

Participants experienced a range of eating disorder symptoms, yet the majority (86.0%) was not receiving treatment. Importantly, of those not in treatment, the majority (82.6%) indicated that they planned to get treatment. In addition, more than half of participants (52.9%) downloaded a report to present to their health practitioner to facilitate communication with a health professional. Intention to seek treatment and download of the report were positively associated with motivation to change, confidence to achieve change, greater frequency of binge eating, and greater recognition of the impact of eating disorder symptoms on relationships and well-being but not with stigma or ambivalence.

DISCUSSION

Study findings indicated that the ROAR website was accessed by individuals for whom it was designed, namely those experiencing eating disorder symptoms who are not receiving treatment. Encouragingly, participants had strong intentions to seek treatment, and the majority downloaded a report that could be used to facilitate the first step toward treatment. Greater focus on enhancing motivation and confidence to change may further promote treatment-seeking.

Screening for Eating Disorders on College Campuses: a Review of the Recent Literature

PURPOSE OF REVIEW

This paper provides a review of the recent literature on screening for eating disorders (EDs) on college campuses, and reports on methodology, prevalence rates, treatment receipt, and ED screening tools.

RECENT FINDINGS

Recent research highlights relatively high prevalence rates of EDs among students on college campuses, with the majority of studies demonstrating elevated prevalence compared to the general population. Among students who screened positive for an ED, approximately 20% or less reported having received treatment for their ED. Findings also revealed various recruitment strategies, methods, ED screening tools, and clinical cutoffs used to study this topic, making it challenging to draw firm conclusions about prevalence of EDs on college campuses. Recent research on ED screening on college campuses reveals that EDs are a significant problem among college students, and there is a marked treatment gap between those who need care and those who receive it. Implications and future research are discussed.

Results of disseminating an online screen for eating disorders across the U.S.: Reach, respondent characteristics, and unmet treatment need

OBJECTIVE

The treatment gap between those who need and those who receive care for eating disorders is wide. Scaling a validated, online screener that makes individuals aware of the significance of their symptoms/behaviors is a crucial first step for increasing access to care. The objective of the current study was to determine the reach of disseminating an online eating disorder screener in partnership with the National Eating Disorders Association (NEDA), as well to examine the probable eating disorder diagnostic and risk breakdown of adult respondents. We also assessed receipt of any treatment.

METHOD

Participants completed a validated eating disorder screen on the NEDA website over 6 months in 2017.

RESULTS

Of 71,362 respondents, 91.0% were female, 57.7% 18-24 years, 89.6% non-Hispanic, and 84.7% White. Most (86.3%) screened positive for an eating disorder. In addition, 10.2% screened as high risk for the development of an eating disorder, and only 3.4% as not at risk. Of those screening positive for an eating disorder, 85.9% had never received treatment and only 3.0% were currently in treatment.

DISCUSSION

The NEDA online screen may represent an important eating disorder detection tool, as it was completed by >71,000 adult respondents over just 6 months, the majority of whom screened positive for a clinical/subclinical eating disorder. The extremely high percentage of individuals screening positive for an eating disorder who reported not being in treatment suggests a wide treatment gap and the need to offer accessible, affordable, evidence-based intervention options, directly linked with screening.

Interpersonal Psychotherapy and the Treatment of Eating Disorders

Interpersonal psychotherapy (IPT) for the treatment of eating disorders is a brief treatment that addresses the social and interpersonal context in which the disorder begins and is maintained. IPT is classified as a strongly supported evidence-based treatment of bulimia nervosa and binge-eating disorder, and more research is needed to understand the effectiveness of IPT for anorexia nervosa and IPT for preventing excess weight gain. This article describes the core components and elements of IPT, the empirical evidence that supports its effectiveness, efforts to increase the dissemination and implementation of IPT, and future directions.

Body-, Eating-, and Exercise-Related Comparisons During Eating Disorder Recovery and Validation of the BEECOM-R

Social comparison tendencies are strongly associated with body dissatisfaction and disordered eating. In the current study, we quantitatively examined the structure and predictive value of these constructs during eating disorder recovery. We revised an existing measure of body-, eating-, and exercise-related social comparisons, the Body, Eating, and Exercise Comparison Orientation Measure (BEECOM), to improve psychometric properties. We also assessed the psychometric properties of the shortened Body, Eating, and Exercise Comparison Orientation Measure-Revised (BEECOM-R) in a comparison sample, resulting in an abbreviated measure suitable for recovering, clinical, and non-clinical samples. Finally, we used the revised measure to examine the additive influence of body-, eating-, and exercise-related comparisons on shape and weight dissatisfaction and disordered eating cognitions among 150 women (ages of 18–35 years) in self-identified recovery. Results suggest that body-, eating-, and exercise-related social comparisons all continue to correlate with body dissatisfaction and disordered eating during recovery. A minority of participants reported these comparisons to be helpful during the recovery process. We recommend social comparison as a clinical target for most women seeking support for eating pathology. Additional online materials for this article are available on PWQ’s website at http://journals.sagepub.com/doi/suppl/ 10.1177/0361684319851718

Health behaviors and disordered eating in adolescents and young adults with spina bifida: results from a national survey

Purpose: Youth with disabilities are at higher risk for obesity, disordered eating, and poor body image but are often excluded from research on these domains. The current study is the first to characterize health behaviors, body mass index, and disordered eating cognitions and behaviors in a national sample of adolescent and young adult males and females with spina bifida.Methods: Participants were recruited nationally through the support of a national spina bifida-related organization to complete an anonymous survey assessing health behaviors and disordered eating.Results: Participants were primarily Caucasian, had myelomeningocele, and were between 15-24 years of age. Body mass indices ranged from underweight to Class Three obesity. Health behaviors (e.g., healthy food consumption, physical activity) were often subthreshold compared to Centers for Disease Control recommendations made to the general public. Both male and female respondents endorsed higher purging and restricting behaviors than norms established with typically-developing college aged peers.Conclusions: Findings revealed that there are few sex-based differences. Additionally, the need for thorough assessment of disordered eating behaviors in this population is warranted, including those with a lower body mass index who might be overlooked for assessment of unhealthy attempts to lose or maintain their weight.Implications for rehabilitationAdolescents and young adults with spina bifida are often advised to lose weight without clear guidelines on how to do so, putting them at risk for disordered eating.Professionals should expect variable body mass indices in this population, with some health behaviors falling short of recommendations made for the general public by the Centers for Disease Control.Professionals should fully assess disordered eating behaviors in youth with disabilities, even when at a healthy weight.

Usability and Engagement Evaluation of an Unguided Online Program for Promoting a Healthy Lifestyle and Reducing the Risk for Eating Disorders and Obesity in the School Setting

Implementing integrated online prevention to reduce the risk of both obesity and eating disorders, in the school setting, is a promising approach. The challenge is to develop highly user-friendly and motivating programs, to foster adherence and effectiveness. The purpose of this study was to evaluate the usability of such a universal prevention program for students aged 14⁻19 years, and to address engagement issues. A mixed-methods approach was chosen, consisting of a think-aloud task, a semi-structured interview, and a questionnaire including items on sociodemographic characteristics and the System Usability Scale (SUS). Usability tests were conducted in two rounds, with five adolescents participating per round. Mean score in the SUS was 92.5 of 100 points (range 85⁻100), in the second round, after some adaptations from the participants' feedback. In the course of the think-aloud tasks and interviews, five major themes emerged-visual design, navigation, mode of transfer, content, and engagement conditions. Interesting headlines, gamification, and monitoring tools are crucial for engagement. Apart from the importance of using the program during school hours, the study showed that problems currently perceived as important by the target group, need to be considered and addressed, prior to offering them prevention programs, which highlights the importance of a user-centered design.

A randomized comparison of long acting methylphenidate and cognitive behavioral therapy in the treatment of binge eating disorder

Cognitive behavioral therapy (CBT) is a well-established treatment for binge eating disorder (BED); however, this treatment is underutilized, highlighting the need for additional treatment alternatives. Dopamine neurotransmission has been associated with dysregulated eating, and pharmaceutical agents targeting the dopamine system are associated with decreased binge eating and weight. The primary objective of the current investigation was to evaluate the efficacy of psychostimulant medication versus current best practices in the treatment of BED symptoms, in a randomized trial of methylphenidate versus CBT for BED. The secondary objective was to evaluate the ability of impulsivity to predict treatment outcomes. Female outpatients with BED were randomized to receive methylphenidate (n = 22) or CBT (n = 27) for 12 weeks. The primary outcome was objective binge episode frequency; secondary outcomes included subjective binge episode frequency, body mass index (BMI), BED symptoms, and quality of life. Results showed that both treatments had a significant impact on primary and secondary outcomes. Methylphenidate and CBT were associated with decreases in subjective and objective binge episodes; methylphenidate was associated with greater decreases in BMI. Two impulsivity traits predicted clinical outcomes. Results provide preliminary support for the therapeutic benefit of methylphenidate in BED treatment, and prognostic utility of impulsivity in this context.

Binge-Eating Disorder

Binge-eating disorder (BED), first included as a diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, is characterized by recurrent episodes of binge eating without regular compensatory behaviors to prevent weight gain. With a complex multifactorial etiology, BED is the most frequent eating disorder co-occuring with significant psychopathology, mental and physical comorbidity, obesity, and life impairment. Despite its significance, BED is not sufficiently diagnosed or treated. Evidence-based treatments for BED include psychotherapy and structured self-help treatment, with cognitive-behavioral therapy as most well-established approach, and pharmacotherapy with lisdexamfetamine as FDA approved medication with a limitation of use.

[E-Therapies for Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder]

E-Therapies for Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder Abstract. Eating disorders can often be treated with psychotherapy, but mostly due to a lack of trained clinicians, the majority of the persons concerned do not receive any treatment. In recent years, internet-based psychotherapy (e-therapy) was proposed and tested in several pilot projects as a novel possibility to offer a larger number of places on a treatment program with a constant number of available clinicians. Recent results are promising, but before an implementation into standard care can take place, more detailed knowledge must be provided as to which patients may be recommended this type of therapy as an equivalent alternative to traditional face-to-face therapy.

Is it Important to Talk About Technologies with Eating Disorder Clients? The Health-Care Professional Perspective

Nowadays, the use of digital technology is an important issue that should be addressed during the treatment of people who have eating disorders. The involvement or absence of this issue reflects the understanding, experience, and atttude of health-care professionals toward their clients' use of technology. The aim of the present study was to investigate the perceptions of health-care professionals and their assessment of their clients' usage of digital technology while developing strategies for treatment. Semistructured interviews with 30 professionals were performed from October 2015 to June 2016 and a thematic analysis was used to analyze the data. The health-care professionals' views could be summarized in three thematic groups: (1) technology use is not relevant for the cooperation; (2) technology use is relevant for the cooperation and addressed generally; and (3) technology use is relevant for the cooperation and addressed specifically. The results are discussed in relation to the theoretical model presented by Rodgers about the impact of technology on disordered eating behaviors and the implications for practice.

Psychotropic usage by patients presenting to an academic eating disorders program

PURPOSE

To assess psychotropic use patterns and possible associations with age, eating disorder diagnosis and psychiatric comorbidity in adolescents and young adults with a primary eating disorder.

METHODS

A retrospective chart review of 86 consecutive patients with a primary eating disorder from August 2012 to December 2014 was conducted. Patients presented for a multidisciplinary evaluation at a United States-based academic program for eating disorders.

RESULTS

Nearly half (45.3%) of the patients reported being on a psychotropic medication. Antidepressants were the most reported category, prescribed in 38.4% of the patients evaluated. There was a significant association between the type of eating disorder and the number of psychotropics prescribed. Patients with a diagnosis of other specified feeding or eating disorder reported more prescriptions upon presentation than patients with anorexia nervosa. Despite the finding that a significant minority of patients had a psychiatric comorbidity, this did not appear to increase the likelihood of psychotropic usage over those diagnosed with an eating disorder alone. In addition, patients with a longer duration of illness and patients with a history of non-suicidal self-injury were more likely to present to treatment on psychotropic medications.

CONCLUSIONS

Psychotropic medications appear to be commonly prescribed among individuals evaluated in a tertiary care center for an eating disorder. Given that psychotropics are not recommended as the primary intervention for eating disorders, the frequency may be indicative of practitioners not following research-informed practice guidelines. The differences observed may also reflect complexities related to clinical features or illness history.

LEVEL OF EVIDENCE

Level V: Descriptive study.

State-wide university implementation of an online platform for eating disorders screening and intervention

The Internet-based Healthy Body Image (HBI) Program platform uses online screening to identify individuals at low risk for, high risk for, or with an eating disorder (ED) and then directs users to tailored, evidence-based online/mobile interventions or referral to in-person care to address individuals' risk/clinical status. We examined findings from the first state-wide deployment of HBI over the course of 3 years in Missouri public universities, sponsored by the Missouri Eating Disorders Council and the Missouri Mental Health Foundation. First, the screen was completed 2,454 times, with an average of 2.5% of the undergraduate student body on each campus taking the screen. Second, ED risk level in the participating students was high-over 56% of students screened were identified as being at high risk for ED onset or having a clinical/subclinical ED. Third, uptake for the HBI online/mobile interventions ranged from 44-51%, with higher rates of uptake in the high-risk compared with low-risk group. Fourth, results showed that, for students with a clinical/subclinical ED, use of the clinical mobile application Student Bodies-Eating Disorders intervention resulted in significantly decreased restrictive eating and binge eating. Neither vomiting nor diet pill/laxative use was found to decrease, but reports of these behaviors were very low. This is the first deployment of a comprehensive online platform for screening and delivering tailored interventions to a population of individuals with varying ED risk and symptom profiles in an organized care setting. Implications for future research and sustaining and broadening the reach of HBI are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Pathways into treatment for eating disorders: A quantitative examination of treatment barriers and treatment attitudes

Most individuals with eating disorders do not receive treatment for their eating disorder. Closing this "treatment gap" requires a quantitative examination of individuals' attitudes towards accessing various types of treatment and of individuals' perceived barriers to seeking treatment. Thus, we recruited a sample of 425 individuals with either diagnosed or undiagnosed eating disorders and asked them to complete a survey assessing treatment attitudes, treatment barriers, and eating disorder symptom severity. Undiagnosed individuals reported more positive attitudes towards novel Internet- and smartphone-delivered treatments, and stronger barriers relating to eating disorders mental health literacy, than diagnosed individuals. Nevertheless, both diagnosed and undiagnosed individuals were broadly more positive towards established (i.e., non-novel) treatments than novel treatments. The strongest barriers to seeking treatment were fear of losing control, fear of change, and finding motivation to change. Eating disorder symptoms were positively associated with the strength of most treatment barriers. Results were broadly unchanged after adjusting for individuals' past experiences of treatment. In conclusion, the development and dissemination of novel treatments and the provision of eating disorders mental health literacy may offer promising potential pathways into treatment for individuals with undiagnosed eating disorders. Nevertheless, researchers must pay attention to and improve, individuals' attitudes towards accessing these novel treatments. The positive correlations of symptom severity with treatment barrier strength highlights the importance of early intervention for individuals with eating disorders. Finally, the fear of losing control may be a uniquely salient treatment barrier for individuals with eating disorders that requires greater attention in future research on eating disorder treatment seeking.

Disordered Society: Women in Eating Disorder Recovery Advise Policymakers on Change

This qualitative study draws on a photo-elicitation method ("PhotoVoice") and semi-structured interviews to examine the key areas stakeholders (30 young women between the ages of 18 and 35 in eating disorder recovery) identify as meaningful venues of policy-based change. Photography and the accompanying narratives capturing personally-meaningful social, cultural, and systemic influences on recovery were shared with the research team. Photographs and interviews were examined for policy implications using thematic analysis, and six areas of improvement emerged: media, healthcare practice and access, health insurance reform, education, objectification of the female body, and mental health stigma. Implications for reform are discussed.

The Utility and Acceptability of a Self-Help Smartphone Application for Eating Disorder Behaviors

OBJECTIVE

Smartphone applications (apps) for eating disorders are a promising approach to assist individuals who do not receive traditional treatment. This study examines usage characteristics, perceptions regarding the acceptability of a new self-help intervention developed for users with eating disorders, and associations between attitudes and use patterns.

METHODS

189 individuals pilot-tested a personalized app-based program, and 133 completed the required components of the pilot-test over an 8-day period. Of these, 64 individuals (49%) completed an exit survey pertaining to acceptability.

RESULTS

Seventy percent of those who pilot-tested the app-based program completed the required components, i.e. a baseline review and then a 1-week assessment. Body mass index was associated with the total number of recorded meal logs. Study participants rated the app as highly suitable and acceptable, providing evidence of the feasibility and appropriateness of the program.

CONCLUSION

The app-based program demonstrated feasibility of deploying the app across user groups and high acceptability.

Training models for implementing evidence-based psychological treatment for college mental health: A cluster randomized trial study protocol

Mental disorders often emerge in adolescence and young adulthood, and these disorders can have lasting effects on students' health, social functioning, and education. Although evidence-based treatments have been established for many mental disorders, few community therapists use such treatments. What is needed is a practical, economically feasible means of training clinicians to implement evidence-based treatments suitable for widespread use. This cluster randomized trial will randomize 26 college counseling centers to one of two implementation strategies for training counselors to use interpersonal psychotherapy (IPT), an evidence-based treatment for depression and eating disorders: 1) an external expert consultation model comprising a workshop, therapy manual, and expert follow-up consultation (n = 13); or 2) a train-the-trainer model in which a staff member from the counseling center is coached to train other staff members to implement IPT (n = 13). The primary outcome is therapist adherence to IPT, with secondary outcomes of therapist competence in IPT and client outcomes for depression and eating disorders. Therapist and organizational characteristics will be explored as potential moderators and mediators of implementation outcomes. Implementation costs for each of the training methods will also be assessed. The present study involves partnering with college counseling centers to determine the most effective method to implement IPT for depression and eating disorders in these settings. The results of this study will inform future large-scale dissemination of clinical interventions to mental health service providers by providing evidence for the selection of training methods when an agency chooses to adopt new interventions.

Online prevention of disordered eating in at-risk young-adult women: a two-country pragmatic randomized controlled trial

BACKGROUND

Disordered eating (DE) is a widespread, serious problem. Efficacious prevention programs that can be delivered at-scale are needed.

METHODS

A pragmatic randomized controlled trial of two online programs was conducted. Participants were young-adult women from Australia and New Zealand seeking to improve their body image. Media Smart-Targeted (MS-T) and Student Bodies (SB) were both 9-module interventions released weekly, whilst control participants received positive body image information. Primary [Eating Disorder Examination-Questionnaire (EDE-Q) Global], secondary (DE risk factors) and tertiary (DE) outcome measures were completed at baseline, post-program, 6- and 12-month follow-up.

RESULTS

Baseline was completed by 608 women (M age = 20.71 years); 33 were excluded leaving 575 randomized to: MS-T (N = 191); SB (N = 190) or control (N = 194). Only 66% of those randomized to MS-T or SB accessed the intervention and were included in analyses with controls; 78% of this sample completed measures subsequent to baseline. Primary intent-to-treat (ITT) analyses revealed no differences between groups, while measure completer analyses found MS-T had significantly lower EDE-Q Global than controls at 12-month follow-up. Secondary ITT analyses found MS-T participants reported significantly higher quality of life-mental relative to both SB and controls (6-month follow-up), while MS-T and controls had lower clinical impairment relative to SB (post-program). Amongst measure completers, MS-T scored significantly lower than controls and SB on 5 variables. Of those with baseline DE, MS-T participants were significantly less likely than controls to have DE at 12-month follow-up.

CONCLUSIONS

Given both programs were not therapist-moderated, MS-T has potential to achieve reductions in DE risk at low implementation costs.

Outpatient CBT for Underweight Patients with Eating Disorders: Effectiveness Within a National Health Service (NHS) Eating Disorders Service

Background: Underweight eating disorders (EDs) are notoriously difficult to treat, although a growing evidence base suggests that outpatient cognitive behaviour therapy for EDs (CBT-ED) can be effective for a large proportion of individuals. Aims: To investigate the effectiveness of CBT-ED for underweight EDs in a ‘real-world’ settings. Method: Sixty-three adults with underweight EDs (anorexia nervosa or atypical anorexia nervosa) began outpatient CBT-ED in a National Health Service setting. Results: Fifty-four per cent completed treatment, for whom significant changes were observed on measures of ED symptoms, psychological distress and psychosocial impairment. There was also a large effect on body weight at end-of-treatment. Conclusions: The results suggest that good outcomes can be achieved by the majority of those who complete treatment, although treatment non-completion remains a significant barrier to recovery. Future studies should focus on improving treatment retention, as evidence suggests that CBT-ED in ‘real-world’ settings is effective.

Rates of abstinence following psychological or behavioral treatments for binge-eating disorder: Meta-analysis

OBJECTIVE

Standardized effect sizes reported in previous meta-analyses of binge-eating disorder (BED) treatment are sometimes difficult to interpret and are criticized for not being a useful indicator of the clinical importance of a treatment. Abstinence from binge eating is a clinically relevant component of a definition of a successful treatment outcome. This meta-analysis estimated the prevalence of patients with BED who achieved binge eating abstinence following psychological or behavioral treatments.

METHOD

This meta-analysis included 39 randomized controlled trials, with 65 treatment conditions and 2,349 patients. Most conditions comprised cognitive-behavioral therapy (n = 40). Pooled event rates were calculated at posttreatment and follow-up using random effects models.

RESULTS

The total weighted percentage of treatment-completers who achieved abstinence at posttreatment was 50.9% (95% CI = 43.9, 57.8); this estimate was almost identical at follow-up (50.3%; 95% CI = 43.6, 56.9). The total weighted percentage of patients who achieved abstinence at posttreatment in the intention-to-treat analysis (all randomized patients) was 45.1% (95% CI =40.7, 49.5), and at follow-up it was 42.3% (95% CI =37.5, 47.2). Interpersonal psychotherapy (IPT) produced the highest abstinence rates. Clinician-led group treatments produced significantly higher posttreatment (but not follow-up) abstinence estimates than guided self-help treatments. Neither timeframe for achieving abstinence, assessment type (interview/questionnaire), number of treatment sessions, patient demographics, nor trial quality, moderated the abstinence estimates.

DISCUSSION

The present findings demonstrate that 50% of patients with BED do not fully respond to treatment. Continued efforts toward improving eating disorder treatments are needed.

Dropout from interpersonal psychotherapy for mental health disorders: A systematic review and meta-analysis

Objective: Dropout is one factor that might limit the effectiveness of interpersonal psychotherapy (IPT). Improved understanding of IPT dropout is an important research priority. This meta-analysis examined dropout rates from IPT in randomized controlled trials. Method: Seventy-two trials met inclusion criteria. Results: The weighted mean dropout rate from IPT was 20.6% (95% CI = 17.4-24.2). Dropout rates were similar for depressive (20.9%; 95% CI = 17.2-25.2), anxiety (16.1%; 95% CI = 11.1-22.9), and eating disorders (18.7%; 95% CI = 11.6-28.8). Dropout was highest when more stringent definitions of dropout were applied (e.g., failure to complete the entire IPT protocol versus failure to complete at least 50% of sessions) and was lowest when adolescent patients were sampled. There was some evidence that IPT was associated with significantly lower rates of dropout than both CBT and non-specific supportive therapies. These effects were generally replicated when analysing trials that provided a clear definition of treatment (rather than study) dropout. Conclusions: Overall, findings provide preliminary evidence to suggest that IPT may be an accepted and tolerated treatment option for patients with common mental health disorders. This review also highlights the need for future trials to rigorously report detail pertaining to patient dropout.

Increasing the Availability of Psychological Treatments: A Multinational Study of a Scalable Method for Training Therapists

BACKGROUND

One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. A highly scalable form of Web-centered therapist training, undertaken without external support, has recently been shown to have promise in promoting therapist competence.

OBJECTIVE

The aim of this study was to conduct an evaluation of the acceptability and effectiveness of a scalable independent form of Web-centered training in a multinational sample of therapists and investigate the characteristics of those most likely to benefit.

METHODS

A cohort of eligible therapists was recruited internationally and offered access to Web-centered training in enhanced cognitive behavioral therapy, a multicomponent, evidence-based, psychological treatment for any form of eating disorder. No external support was provided during training. Therapist competence was assessed using a validated competence measure before training and after 20 weeks.

RESULTS

A total of 806 therapists from 33 different countries expressed interest in the study, and 765 (94.9%) completed a pretraining assessment. The median number of training modules completed was 15 out of a possible 18 (interquartile range, IQR: 4-18), and 87.9% (531/604) reported that they treated at least one patient during training as recommended. Median pretraining competence score was 7 (IQR: 5-10, range: 0-19; N=765), and following training, it was 12 (IQR: 9-15, range: 0-20; N=577). The expected change in competence scores from pretraining to posttraining was 3.5 (95% CI 3.1-3.8; P<.001). After training, 52% (300/574) of therapists with complete competence data met or exceeded the competence threshold, and 45% (95% CI 41-50) of those who had not met this threshold before training did so after training. Compliance with training predicted both an increase in competence scores and meeting or exceeding the competence threshold. Expected change in competence score increased for each extra training module completed (0.19, 95% CI 0.13-0.25), and those who treated a suitable patient during training had an expected change in competence score 1.2 (95% CI 0.4-2.1) points higher than those who did not. Similarly, there was an association between meeting the competence threshold after training and the number of modules completed (odds ratio, OR=1.11, 95% CI 1.07-1.15), and treating at least one patient during training was associated with competence after training (OR=2.2, 95% CI 1.2-4.1).

CONCLUSIONS

Independent Web-centered training can successfully train large numbers of therapists dispersed across a wide geographical area. This finding is of importance because the availability of a highly scalable method of training potentially increases the number of people who might receive effective psychological treatments.

Advances in the treatment of anorexia nervosa: a review of established and emerging interventions

BACKGROUND

Anorexia nervosa (AN) is a disabling, deadly and costly mental disorder. Until recently, treatment recommendations were based on expert opinion and limited evidence. The aim of this systematic review is to synthesise recent evidence on established and emerging AN treatments and to forecast trends for future developments.

METHODS

We systematically review trials of established treatments and associated process outcome studies from the last 5 years, published since a previous review in this journal. 'Established' treatments were those that are widely used in AN, recommended by guidelines and/or have been tested in at least one large randomised controlled trial. Secondly, we summarise emerging treatments for AN, i.e. those that have only been (or are currently being) tested in proof-of concept, feasibility or pilot trials.

RESULTS

We identified 19 published trials of established treatments (15 of high or moderate quality), mostly assessing psychological therapies (n = 17). We also found 11 published trials of emerging treatments, and a total of 34 registered, as yet unpublished trials. Promising emerging treatments include cognitive remediation therapy, exposure therapy and non-invasive neuromodulation.

CONCLUSIONS

Evidence generation on the treatment of AN has dramatically accelerated, with our understanding of the role of family-based approaches for adolescents more nuanced and a range of psychological approaches available for the treatment of adults. Evidence on emerging treatments and from forthcoming trials suggests that there is a shift towards more targeted brain-based interventions. Future studies need to focus on elucidating mechanisms of action of treatments and what works best for whom.

Innovation in eating disorders research and practice: Expanding our community and perspectives at the 2018 International Conference on Eating Disorders: Editorial to accompany IJED Virtual Issue in honor of the 2018 International Conference on Eating Disorders

OBJECTIVE

This virtual issue of the International Journal of Eating Disorders (IJED) highlights the excellent and innovative research and practice discussed at the 2018 International Conference on Eating Disorders held in Chicago, Illinois, USA.

METHOD AND RESULTS

The virtual issue contains a series of articles recently published in IJED, which we have curated to reflect and expand on the insights delivered during the conference keynote and plenary presentations.

DISCUSSION

In line with the conference theme of Innovation in Research and Practice: Expanding our Community and Perspectives, we hope this collection of articles will spark new ideas for research, practice, and collaboration to accelerate knowledge on eating disorder risk factors and recovery, and the reach and impact of evidence-based treatment, prevention, and policy efforts.

Clinicians' perspective on an app for patient self-monitoring in eating disorder treatment

OBJECTIVE

The Recovery Record smartphone app is a self-monitoring tool for individuals recovering from eating disorders. Oppositely to traditional pen-and-paper meal diaries, the app allows for in-app patient-clinician linkage enabling clinicians to access patient app data anytime. The aim of our study was to explore the interdisciplinary clinical perspective on Recovery Record and its impact on treatment.

METHOD

Thirty-one clinicians from a Danish eating disorder treatment facility participated in field studies and 23 of these in interviews. Data were generated and analyzed concurrently applying the inductive methodology of Interpretive Description.

RESULTS

We found two overarching themes: "Access to app data between treatment sessions", and "The patient-clinician relationship". Sub-themes associated with the former were "Online obligations" in relation to the added workload of continuously monitoring patient app data, and "Prepared or prejudiced" relating to advantages and disadvantages of using patient app data as preparation for treatment sessions. Sub-themes pertaining to the latter were "Expectation discrepancy" in relation to patients' and clinicians' divergent expectations for app usage, and "Pacified patients" regarding the clinicians' experience that the app potentially compromised the patient initiative in treatment sessions.

DISCUSSION

Recovery Record induced new and affected pre-existing treatment and work conditions for clinicians. Clinicians were preoccupied with challenges associated with the app, for example, an added work load and potential harm to the patient-clinician collaboration. Thus, prior to adopting the app, we encourage clinicians and managements to discuss the objectives, advantages and disadvantages of adopting the app, and outline specific guidelines for patient and clinician app usage.

Updates on Genome-Wide Association Findings in Eating Disorders and Future Application to Precision Medicine

Heterogeneity, frequent diagnostic fluctuation across presentations, and global concerns with the absence of effective treatments all encourage science that moves the field toward individualized or precision medicine in eating disorders. We review recent advances in psychiatric genetics focusing on genome-wide association studies (GWAS) in eating disorders. Given that the only eating disorder to be the subject of GWAS to date is anorexia nervosa, we review anorexia GWAS and enumerate the prospects and challenges of a genomics-driven approach towards personalized intervention in eating disorders.

Maximizing the public health impact of eating disorder services: A simulation study

OBJECTIVE

Although effective interventions for eating disorders (ED) are available, the impact of health care services on a population level is far from satisfactory. A mathematical model of how health care for ED affects the population's disease burden can stimulate discussions and provide guidance about promising strategies to reduce ED-related suffering on the population level.

METHOD

The current health care situation for ED is modeled taking into account the reach and effectiveness of prevention, treatment, and aftercare, as well as incidence rates, relapse rates, and rates for spontaneous remissions. A first-order Markov model is applied and the effect of changes in single service parameters on the populations overall disease burden are simulated.

RESULTS

Improvements of treatment utilization and the reach of prevention programs would have the largest effects on the population's disease burden. Improving the efficacy of treatment, prevention, and aftercare show only limited effects.

DISCUSSION

In order to maximize the public health impact of health care for ED new models of treatment delivery as well as public health approaches to the prevention of ED are critical.

Randomized controlled trial comparing smartphone assisted versus traditional guided self-help for adults with binge eating

OBJECTIVE

Guided self-help treatments based on cognitive-behavior therapy (CBT-GSH) are efficacious for binge eating. With limited availability of CBT-GSH in the community, mobile technology offers a means to increase use of these interventions. The purpose of this study was to test the initial efficacy of Noom Monitor, a smartphone application designed to facilitate CBT-GSH (CBT-GSH + Noom), on study retention, adherence, and eating disorder symptoms compared to traditional CBT-GSH.

METHOD

Sixty-six men and women with DSM-5 binge-eating disorder (BED) or bulimia nervosa (BN) were randomized to receive eight sessions of CBT-GSH + Noom (n = 33) or CBT-GSH (n = 33) over 12 weeks. Primary symptom outcomes were eating disorder examination objective bulimic episodes (OBEs), subjective bulimic episodes (SBEs), and compensatory behaviors. Assessments were collected at 0, 4, 8, 12, 24, and 36 weeks. Behavioral outcomes were modeled using zero-inflated negative-binomial latent growth curve models with intent-to-treat.

RESULTS

There was a significant effect of treatment on change in OBEs (β = -0.84, 95% CI = -1.49, -0.19) favoring CBT-GSH + Noom. Remission rates were not statistically different between treatments for OBEs (βlogit  = -0.73, 95% CI = -1.86, 3.27; CBT-GSH-Noom = 17/27, 63.0% vs. CBT-GSH 11/27, 40.7%, NNT = 4.5), but CBT-GSH-Noom participants reported greater meal and snack adherence and regular meal adherence mediated treatment effects on OBEs. The treatments did not differ at the 6-month follow-up.

DISCUSSION

Smartphone applications for the treatment binge eating appear to have advantages for adherence, a critical component of treatment dissemination.

Evidence-based clinical guidelines for eating disorders: international comparison

PURPOSE OF REVIEW

The current systematic review sought to compare available evidence-based clinical treatment guidelines for all specific eating disorders.

RECENT FINDINGS

Nine evidence-based clinical treatment guidelines for eating disorders were located through a systematic search. The international comparison demonstrated notable commonalities and differences among these current clinical guidelines.

SUMMARY

Evidence-based clinical guidelines represent an important step toward the dissemination and implementation of evidence-based treatments into clinical practice. Despite advances in clinical research on eating disorders, a growing body of literature demonstrates that individuals with eating disorders often do not receive an evidence-based treatment for their disorder. Regarding the dissemination and implementation of evidence-based treatments, current guidelines do endorse the main empirically validated treatment approaches with considerable agreement, but additional recommendations are largely inconsistent. An increased evidence base is critical in offering clinically useful and reliable guidance for the treatment of eating disorders. Because developing and updating clinical guidelines is time-consuming and complex, an international coordination of guideline development, for example, across the European Union, would be desirable.

Using the Internet to Train Therapists: Randomized Comparison of Two Scalable Methods

Background

One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. The currently accepted method of training is not scalable. Recently, a scalable form of training, Web-centered training, has been shown to have promise.

Objective

The goal of our research was to conduct a randomized comparison of the relative effects of independent and supported Web-centered training on therapist competence and investigate the persistence of the effects.

Methods

Eligible therapists were recruited from across the United States and Canada. They were randomly assigned to 1 of 2 forms of training in enhanced cognitive behavior therapy (CBT-E), a multicomponent evidence-based psychological treatment for any form of eating disorder. Independent training was undertaken autonomously, while supported training was accompanied by support from a nonspecialist worker. Therapist competence was assessed using a validated competence measure before training, after 20 weeks of training, and 6 months after the completion of training.

Results

A total of 160 therapists expressed interest in the study, and 156 (97.5%) were randomized to the 2 forms of training (81 to supported training and 75 to independent training). Mixed effects analysis showed an increase in competence scores in both groups. There was no difference between the 2 forms of training, with mean difference for the supported versus independent group being –0.06 (95% Cl –1.29 to 1.16, P=.92). A total of 58 participants (58/114, 50.9%) scored above the competence threshold; three-quarters (43/58, 74%) had not met this threshold before training. There was no difference between the 2 groups in the odds of scoring over the competence threshold (odds ratio [OR] 1.02, 95% CI 0.52 to 1.99; P=.96). At follow-up, there was no significant difference between the 2 training groups (mean difference 0.19, 95% Cl –1.27 to 1.66, P=.80). Overall, change in competence score from end of training to follow-up was not significant (mean difference –0.70, 95% CI –1.52 to 0.11, P=.09). There was also no difference at follow-up between the training groups in the odds of scoring over the competence threshold (OR 0.95, 95% Cl 0.34 to 2.62; P=.92).

Conclusions

Web-centered training was equally effective whether undertaken independently or accompanied by support, and its effects were sustained. The independent form of Web-centered training is particularly attractive as it provides a means of training large numbers of geographically dispersed therapists at low cost, thereby overcoming several obstacles to the widespread dissemination of psychological treatments.

Psychotherapy for bulimia nervosa on symptoms of depression: A meta-analysis of randomized controlled trials

OBJECTIVE

Depressive symptoms are an important risk factor and consequence of binge eating and purging behavior in bulimia nervosa (BN). Although psychotherapy is effective in reducing symptoms of BN in the short- and long-term, it is unclear whether psychotherapy for BN is also effective in reducing depressive symptoms. This meta-analysis examined the efficacy of psychotherapy for BN on depressive symptoms in the short- and long-term.

METHOD

Randomized controlled trials (RCTs) on BN that assessed depressive symptoms as an outcome were identified. Twenty-six RCTs were included.

RESULTS

Psychotherapy was more efficacious at reducing symptoms of depression at post-treatment (g = 0.47) than wait-lists. This effect was strongest when studies delivered therapist-led, rather than guided self-help, treatment. No significant differences were observed between psychotherapy and antidepressants. There was no significant post-treatment difference between CBT and other active psychological comparisons at reducing symptoms of depression. However, when only therapist-led CBT was analyzed, therapist-led CBT was significantly more efficacious (g = 0.25) than active comparisons at reducing depressive symptoms. The magnitude of the improvement in depressive symptoms was predicted by the magnitude of the improvement in BN symptoms.

DISCUSSION

These findings suggest that psychotherapy is effective for reducing depressive symptoms in BN in the short-term. Whether these effects are sustained in the long-term is yet to be determined, as too few studies conducted follow-up assessments. Moreover, findings demonstrate that, in addition to being the front-running treatment for BN symptoms, CBT might also be the most effective psychotherapy for improving the symptoms of depression that commonly co-occur in BN.

The economic case for digital interventions for eating disorders among United States college students

OBJECTIVE

Eating disorders (EDs) are serious health problems affecting college students. This article aimed to estimate the costs, in United States (US) dollars, of a stepped care model for online prevention and treatment among US college students to inform meaningful decisions regarding resource allocation and adoption of efficient care delivery models for EDs on college campuses.

METHODS

Using a payer perspective, we estimated the costs of (1) delivering an online guided self-help (GSH) intervention to individuals with EDs, including the costs of "stepping up" the proportion expected to "fail"; (2) delivering an online preventive intervention compared to a "wait and treat" approach to individuals at ED risk; and (3) applying the stepped care model across a population of 1,000 students, compared to standard care.

RESULTS

Combining results for online GSH and preventive interventions, we estimated a stepped care model would cost less and result in fewer individuals needing in-person psychotherapy (after receiving less-intensive intervention) compared to standard care, assuming everyone in need received intervention.

CONCLUSIONS

A stepped care model was estimated to achieve modest cost savings compared to standard care, but these estimates need to be tested with sensitivity analyses. Model assumptions highlight the complexities of cost calculations to inform resource allocation, and considerations for a disseminable delivery model are presented. Efforts are needed to systematically measure the costs and benefits of a stepped care model for EDs on college campuses, improve the precision and efficacy of ED interventions, and apply these calculations to non-US care systems with different cost structures.