Improving motivation to change amongst individuals with eating disorders: A systematic review

Individual differences in motivation to change in individuals with eating disorders: A systematic review

OBJECTIVE

Motivation to change has been suggested to significantly impact treatment outcomes in eating disorders (EDs). This review will investigate factors associated with motivation to change in EDs with the aim of supporting clinicians to be aware and sensitive to factors that might obstruct recovery and to inform motivation-based interventions.

METHOD

Using PRISMA guidelines, this article identified 24 studies through database searches meeting eligibility criteria. Only correlates of motivation were identified, limiting the ability of this review to identify causal relationships. Factors that changed alongside changes in motivation were identified from longitudinal studies.

RESULTS

This review identified factors such as individual characteristics, co-morbid psychopathology, lack of treatment autonomy and relationships with others to be associated with motivation to change in individuals with EDs. In addition, motivation to change significantly increased alongside self-esteem and identity re-negotiation when measured longitudinally.

DISCUSSION

Motivational interviewing can typically focus on exploring ambivalence to treatment, identifying goals and values, and increasing self-efficacy. However, this review identifies individual and relational factors to be particularly significant and may obstruct recovery from an ED. As such, evidence-based targets have been identified to inform clinicians and motivation-based interventions.

PUBLIC SIGNIFICANCE

Knowledge of factors associated with motivation to change in EDs is important to understand those who may have poorer treatment outcomes. Motivation may be improved by supporting individuals' relationship with others and tailoring interventions according to temperament and personality traits. Utilizing an individual's social support as they enter ED treatment may be effective in maximizing motivation to recover.

A randomized controlled trial of an online single session intervention for body image in individuals with recurrent binge eating

OBJECTIVE

Theoretical models highlight body image disturbances as central to the maintenance of eating disorders, with empirical evidence finding negative body image to be a robust predictor of treatment nonresponse, relapse and symptom persistence. Accessible, scalable, and inexpensive interventions that can effectively target negative body image across the eating disorders are needed. We developed an online single session intervention (SSI) for negative body image and evaluated its acceptability and efficacy in a randomized controlled trial in individuals with recurrent binge eating.

METHOD

Participants with recurrent binge eating were randomly assigned to the SSI (n = 99) or a waitlist (n = 101). Assessments were conducted at baseline, 4 week follow-up, and 8 week follow-up.

RESULTS

81% of participants accessed the SSI, demonstrating reasonable uptake. However, issues with attrition were apparent; a 32% study dropout rate was observed at posttest, while a 58% dropout rate was observed at follow-up. 87% of participants who completed satisfaction measures would recommend the SSI. SSI participants experienced greater improvements in negative body image at both 4 (d = -0.65) and 8 week (d = -0.74) follow-up. Significant between-group effects were also observed on most other secondary symptom measures, though no differences were found for motivations and help-seeking beliefs and intentions.

CONCLUSION

Body image-focused self-guided SSIs for recurrent binge are largely accepted by those who are retained in the trial, but are associated with significant attrition. Although SSIs are not intended to replace standard treatment, they may help with short-term symptom management and could play an important role in eating disorder care.

PUBLIC SIGNIFICANCE

Single session interventions (SSI) are a potentially accessible, scalable, and cost-effective way to deliver evidence-based treatment content to people with eating disorders. This study shows that an online (SSI) designed to target body image among people with recurrent binge eating is accepted and produced short-term symptom relief.

Assessing motivation for treatment in eating disorders: psychometric validation of the Italian version of the Autonomous and Controlled Motivation for Treatment Questionnaire (ACMTQ-ITA)

PURPOSE

Treatment resistance is a significant challenge in addressing eating disorders (EDs). The Autonomous and Controlled Motivation for Treatment Questionnaire (ACMTQ) has been previously validated in ED populations to assess patients' motivation for treatment. This study aimed to validate the ACMTQ in the Italian language (ACMTQ-ITA) and evaluate its psychometric properties.

METHODS

We recruited a clinical sample of adults aged 18 or older, diagnosed with EDs, proficient in the Italian language, and providing written informed consent. Participants with psychiatric comorbidities such as schizophrenia, bipolar disorder, and substance use disorder were excluded from the study. Validity of the ACMTQ-ITA was assessed using reliability analysis with Cronbach's α and McDonald's ω estimates, and Confirmatory Factor Analysis (CFA).

RESULTS

Results from the reliability analysis confirmed the internal consistency of the Autonomous Motivation (AM) factor (α = 0.82, ω = 0.82), the Controlled Motivation (CM) factor (α = 0.76, ω = 0.77), and the ACMTQ-ITA overall score (α = 0.79). The CFA confirmed the two-factor solution (i.e., AM and CM) identified in the original validation of the ACMTQ (Comparative Fit Index = 0.92, Akaike Information Criterion = 3427.26, Bayesian Information Criterion = 3486.82; Root Mean Square Error of Approximation = 0.08, Standardized Root Mean Square Residual = 0.09).

CONCLUSION

The ACMTQ-ITA emerged as a valid and reliable tool for measuring motivation for treatment in individuals with EDs. Its implementation may facilitate the comprehension of treatment motivation, offering valuable clinical insights and implications for health management practices.

LEVEL OF EVIDENCE

Level V, descriptive studies.

The Role of Aesthetics in Intentions to Use Digital Health Interventions

Digital interventions are increasingly recognised as cost-effective treatment solutions for a number of health concerns, but adoption and use of these interventions can be low, affecting outcomes. This research sought to identify how individual aesthetic facets and perceived trust may influence perceptions toward and intentions to use an online health intervention by building on the Technology Acceptance Model, where perceived attractiveness, perceived usefulness, perceived ease of use and perceived enjoyment are thought to predict behavioural intentions towards a website. An online questionnaire study assessed perceptions of nine stimuli varying in four aesthetic facets (simplicity, diversity, colour & craftsmanship), utilising a quasi-experimental within-subjects design with a repetition among three different groups: individuals from the general population who were shown stimuli referring to general health (GP-H) (N = 257); individuals experiencing an eating disorder and shown stimuli referring to eating disorders (ED-ED) (N = 109); and individuals from the general population who were shown stimuli referring to eating disorders (GP-ED) (N = 235). Linear mixed models demonstrated that perceptions of simplicity and craftsmanship significantly influenced perceptions of usefulness, ease of use, enjoyment and trust, which in turn influenced behavioural intentions. This study demonstrates that developing the TAM model to add a further construct of perceived trust could be beneficial for digital health intervention developers. In this study, simplicity and craftsmanship were identified as the aesthetic facets with the greatest impact on user perceptions of digital health interventions.

Prevention and early intervention in eating disorders: findings from a rapid review

BACKGROUND

Eating disorders (EDs) are complex psychological disorders, with low rates of detection and early intervention. They can lead to significant mental and physical health complications, especially if intervention is delayed. Given high rates of morbidity and mortality, low treatment uptake, and significant rates of relapse, it is important to examine prevention, early intervention, and early recognition initiatives. The aim of this review is to identify and evaluate literature on preventative and early intervention programs in EDs.

METHODS

This paper is one of a series of Rapid Reviews, designed to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded, and released by the Australian Government. To provide a current and rigorous review, peer-reviewed articles between 2009 and 2021 published in English were searched across three databases: ScienceDirect, PubMed and Ovid/Medline. Priority was given to high-level evidence including meta-analyses, systematic reviews, Randomised Control Trials, and large population studies. Findings from selected studies pertaining to prevention and early intervention in EDs were evaluated and are presented in this review.

RESULTS

In total, 130 studies were identified in the current review, 72% relating to prevention and 28% to early intervention. Most programs were theory-driven and targeted one or more ED risk factors such as thin-ideal internalisation and/or body dissatisfaction. There is reasonable evidence to support prevention programs reducing risk factors, particularly as part of school or university-based programs, with established feasibility and relatively high acceptance among students. There is increasing evidence around the use of technology (to increase dissemination potential) and for use of mindfulness approaches (targeting emotional resilience). Few longitudinal studies assessing incident cases following participation in a prevention program exist.

CONCLUSIONS

Although several prevention and early intervention programs have been shown to significantly reduce risk factors, promote symptom recognition, and encourage help-seeking behaviour, most of these studies have been conducted in older adolescent and university aged students, past the age of peak ED onset. One of the most targeted risk factors, body dissatisfaction, is found in girls as young as 6 years old, indicating a need for further research implementing prevention initiatives at younger ages. Follow-up research is limited; thus, the long-term efficacy and effectiveness of studied programs is unknown. Greater attention should be paid to the implementation of prevention and early intervention programs in identified high-risk cohorts or diverse groups, where a more targeted approach may be necessary.

A psycho-educational intervention for the prevention of foot lesions in people with diabetes: Report of a clinical audit

BACKGROUND AND AIMS

Motivational approaches may help target the psychological aspects of self-care, improving adherence to good practices in individuals with diabetes. The present study was designed to test the feasibility and effectiveness of a psychoeducational program for diabetic foot prevention or disease progression.

METHODS AND RESULTS

Eighty-one subjects with or at high risk of foot ulcer development entered a program consisting of six 120-min group sessions, conducted by a podiatrist and an expert in psycho-education. Occurrence/recurrence of lesions in a 3-year follow-up was compared with 172 cases with similar risk score (IWGDF score 2019), receiving education at any 6-month podiatric visit (standard-of-care). Motivation to self-care and competence were assessed by specific questionnaires. The experimental program increased adherence to follow-up. The prevalence of foot lesions was higher at baseline and was remarkably reduced at any time-point in patients attending the psychoeducational program, whereas it remained relatively stable in standard care (around 10% of cases). The cumulative incidence was lower in the psychoeducational program (13.2, 95% CI 9.2-18.0 per 100 patient-year vs. 26.1; 95% CI 22.1-30.2); time to new lesions was increased (P = 0.022). Cox proportional hazard analysis confirmed an overall reduction of lesions in the psychoeducational program (HR 0.34; 95% CI 0.18-0.66; P < 0.001), after adjustment for confounders. The program was associated with significant changes in competence and motivation to self-care.

CONCLUSION

A psychoeducational approach is both feasible and effective to support patients with diabetes at high risk of first or recurrent foot lesions, increasing their adherence to self-care practices.

Experiencing eight psychotherapy approaches devoted to eating disorders in a single-day workshop increases insight and motivation to engage in care: a pilot study

PURPOSE

For patients with eating disorders (EDs), early engagement in care is usually considered a positive prognostic factor. The aim of the study was to investigate how a single-day intervention devoted to early, brief, experiential exposure to a variety of psychotherapy approaches might support commitment to change and the decision to engage in care in patients with EDs.

METHODS

One hundred and sixty-nine adult outpatients newly diagnosed with an ED took part in a single-day workshop for groups of up to ten patients, where they experienced eight psychotherapeutic approaches. Motivation to change care and level of insight were assessed at baseline and 10 days after the intervention.

RESULTS

Motivation and commitment to take active steps toward change (expressed by the "Committed Action" composite score) significantly improved after the intervention (p < 0.001), and a significant number of patients specifically moved from "contemplation" to "action" stage (p < 0.001). The improvement of motivation to change was significantly associated with an increase in insight capacity (p < 0.001), and this increase was observed for almost all related dimensions such as recognition of illness or awareness of need for psychological treatment.

CONCLUSION

A single-day session devoted to experiencing a range of group psychotherapies increased patients' insight and motivation to actively engage in care. To confirm potential longer-term benefits of this intervention, further studies are needed to explore the contribution of each approach and process specifically involved in patients' increased motivation for care, as well as the clinical characteristics of patients associated with better outcomes.

LEVEL OF EVIDENCE

V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Patient perspectives on premature termination of eating disorder treatment: a systematic review and qualitative synthesis

BACKGROUND

High rates of premature treatment termination are a well-reported issue in eating disorder treatment, and present a significant barrier for treatment effectiveness and longer term health outcomes of patients with eating disorders. Understanding patient perspectives on this phenomenon is essential in improving treatment completion rates and informing research and intervention development. The aim of this review is to synthesise qualitative literature on patient perspectives of premature termination of eating disorder treatment and to summarise the key issues leading to discontinuation of treatment.

METHODS

A systematic review of 1222 articles was conducted to identify studies using qualitative methods to investigate patient experiences of prematurely terminating eating disorder treatment. Ten articles were included in the review, with thematic synthesis used to analyse the primary research and develop overarching analytical themes.

RESULTS

Conflict around enmeshment of eating disorder with identity, and lack of support with reconstructing a sense of self without the eating disorder; challenges of managing pressures of social and clinical relationships while feeling unheard and misunderstood by both; expectations and disappointments around treatment; and dissatisfaction with progress were key themes behind premature termination of treatment.

CONCLUSIONS

The findings of this review demonstrate the key issues influencing the decision to end treatment early, highlighting the contribution of individual, environmental, and service-level factors. Implications of these factors are discussed and suggestions raised for future research and service development.

Investigating Service Users' Perspectives of Eating Disorder Services: A Meta-Synthesis

Objective

Despite a number of qualitative studies published from the perspective of eating disorder (ED) service users, there has been no attempt to exclusively synthesize their views to gain a fuller understanding of their ED service experiences. It is important to understand this perspective, since previous research highlights the difficulties ED healthcare professionals report when working with this client group.

Method

A systematic search of the literature was conducted to identify qualitative studies focusing on experiences of ED services from the perspective of service users. Twenty‐two studies met the inclusion criteria and underwent a quality appraisal check using the Critical Appraisal Skills Programme (CASP) tool for qualitative research. These were then synthesized using a meta‐synthesis approach.

Results

Four overarching themes were generated: “Treatment: Focus on physical vs. psychological symptoms”; “Service Environment: The role of control within services”; “Staff: Experiences with staff and the value of rapport”; and “Peer Influence: Camaraderie vs. comparison.” Service users expressed a desire for more psychological input to tackle underlying difficulties relating to their ED. A complex relationship with feelings of control was described, with some feeling over‐controlled by service providers, while others retrospectively recognized the need for control to be taken away. Staff values, knowledge and trust played a significant role in treatment and recovery. Peers with an ED were described to be a valuable source of understanding and empathy, but some found peer influence to perpetuate comparison and competitiveness.

Discussion

The results portray some of the conflicts and complexities that service users encounter in ED services. A running thread throughout is the perceived importance of adopting an individualized approach within these services.

Early development of treatment motivation predicts adherence and symptom reduction in an internet-based guided self-help program for binge eating disorder

OBJECTIVE

Lack of motivation is widely acknowledged as a significant factor in treatment discontinuity and poor treatment outcomes in eating disorders. Treatment adherence is lower in internet-based treatment. The current study aimed to assess the relationship between treatment motivation and treatment outcomes in an internet-based therapist-guided intervention for Binge Eating Disorder (BED).

METHOD

Adults (N = 153) with mild to moderate symptoms of BED participated in a 10-session internet-based treatment program. Baseline and between-session scores of "Readiness to change" and "Belief in change" were used to predict treatment completion and eating disorder symptom reduction (EDE-Q Global, BED-Q, and weekly number of binge eating episodes) at post-treatment.

RESULTS

Baseline treatment motivation could not predict treatment completion or symptom reduction. Early measures of treatment motivation (regression slope from sessions 1-5) significantly predicted both treatment completion and post-treatment symptom reduction. "Belief in change" was the strongest predictor for completing treatment (OR = 2.18, 95%-CI: 1.06, 4.46) and reducing symptoms (EDE-Q Global: B = -0.53, p = 0.001; number of weekly binge eating episodes: B = 0.81, p < 0.01).

DISCUSSION

The results indicated that patients entering online treatment for BED feel highly motivated. However, baseline treatment motivation could not significantly predict treatment completion, which contradicts previous research. The significant predictive ability of early measures of treatment motivation supports the clinical relevance of monitoring the development of early changes to tailor and optimize individual patient care. Further research is needed to examine treatment motivation in regard to internet-based treatment for BED with more validated measures.

Study Protocol for "Psilocybin as a Treatment for Anorexia Nervosa: A Pilot Study"

Background: Anorexia nervosa (AN) is a serious and life-threatening psychiatric condition. With a paucity of approved treatments, there is a desperate need for novel treatment avenues to be explored. Here, we present (1) an overview of the ways through which Public Patient Involvement (PPI) has informed a trial of psilocybin-assisted therapy for AN and (2) a protocol for a pilot study of psilocybin-assisted therapy in AN currently underway at Imperial College London. The study aims to assess the feasibility, brain mechanisms and preliminary outcomes of treating anorexia nervosa with psilocybin. Methods: (1) PPI: Across two online focus groups, eleven individuals with lived experience of AN were presented with an overview of the protocol. Their feedback not only identified solutions to possible barriers for future participants, but also helped the research team to better understand the concept of "recovery" from the perspective of those with lived experience. (2) Protocol: Twenty female participants [21-65 years old, body mass index (BMI) 15 kg/m2 or above] will receive three oral doses of psilocybin (up to 25 mg) over a 6-week period delivered in a therapeutic environment and enveloped by psychological preparation and integration. We will work with participant support networks (care teams and an identified support person) throughout and there will be an extended remote follow-up period of 12 months. Our two-fold primary outcomes are (1) psychopathology (Eating Disorder Examination) across the 6-month follow-up and (2) readiness and motivation to engage in recovery (Readiness and Motivation Questionnaire) across the 6-week trial period. Neurophysiological outcome measures will be: (1) functional magnetic resonance imaging (fMRI) brain changes from baseline to 6-week endpoint and (2) post-acute changes in electroencephalography (EEG) activity, including an electrophysiological marker of neuronal plasticity. Discussion: The results of this pilot study will not only shed light on the acceptability, brain mechanisms, and impression of the potential efficacy of psilocybin as an adjunct treatment for AN but will be essential in shaping a subsequent Randomised Control Trial (RCT) that would test this treatment against a suitable control condition. Clinical Trial Registration: identifier: NCT04505189.

Smartphone application for adolescents with anorexia nervosa: an initial acceptability and user experience evaluation

BACKGROUND

Anorexia Nervosa (AN) is a key target for E-Health programs considering the many barriers hindering patients' access to care and the disorder's severity. Although these programs have become more common and effective, they often have low adherence, especially among youth. This can hinder their implementation and effectiveness in real-world settings. User experience partly overlaps with the acceptability field and may provide insight into factors affecting adherence and adoption of E-Health programs. This study aimed to explore early acceptability and user experience of a companion app prototype for adolescents with AN using user-centered design methods.

METHODS

We developed a prototype containing self-help material and emotions and behaviors evaluation and management features. Then we conducted a mixed evaluation combining semi structured focus group interviews and questionnaires in a clinician group and an AN patient group. We analyzed data using thematic analysis and descriptive statistics.

RESULTS

The app's overall appeal was adequate. The user experience questionnaire revealed the weakest dimensions, including novelty, dependability, and efficiency versus stimulation (i.e., ability to induce motivation to use the product) and perspicuity (i.e., easy to understand, to get familiar with). The qualitative data analysis revealed three central axes: acceptability, features, and use. We identified acceptability barriers and facilitators such as the importance of design and customization, especially for adolescents. Psychoeducation was a major feature for participants, as patients highlighted the difficulties they encountered when seeking disorders-related information.

CONCLUSIONS

This study shows the importance of including users in the different stages of an e-health intervention development, in order to identify their needs, general use and compliance patterns, to improve adherence and adoption of the program and its effectiveness.

Cognitive remediation therapy for anorexia nervosa as a rolling group intervention: Data from a longitudinal study in an eating disorders specialized inpatient unit

Objective

Cognitive remediation therapy (CRT) has been proposed as an add‐on treatment approach that could increase the engagement in treatment of anorexia nervosa (AN) patients and reduce maintaining factors, but prior studies have evaluated CRT in individual and group settings, difficult protocols for rehabilitation settings. Our aim is to evaluate the CRT rolling protocol implementation in an inpatient specialised unit.

Methods

A historical longitudinal controlled study was designed to include 31 AN patients for the CRT program, and 28 AN patients treated as usual. The CRT rolling group was implemented in a multidisciplinary inpatient rehabilitation ward with both adolescent and adult patients and an 8‐weeks protocol. To evaluate the treatment implementation effect, different self‐administered questionnaires were used.

Results

The study found greater improvements of the CRT group in clinical symptomatology (p = 0.039), flexibility (p = 0.003), self‐confidence about the ability to change (p < 0.001), and less short‐term focus (p < 0.001), with no differences between restrictive and binge‐purging patients.

Conclusion

This study demonstrates that CRT rolling group protocol is feasible in an inpatient treatment setting and may improve a rehabilitation program's outcome. Our results have shown how CRT can influence cognitive styles considered AN maintenance factors, positively affecting both restrictive and binge‐purge type.

Cognitive remediation therapy (CRT) could be implemented in an inpatient setting with a rolling protocol

CRT improves flexibility, drive to change, and therapy engagement

No differences between restrictive or binge/purge subgroups

Both adolescent and adult patients improved their cognitive styles

Patient use of a self-monitoring app during eating disorder treatment: Naturalistic longitudinal cohort study

OBJECTIVE

To explore patients' use of the self-monitoring app Recovery Record during 26 weeks of naturalistic eating disorder treatment.

METHODS

Selected patient characteristics at baseline were explored as predictors of app use using linear regression. Patients were grouped according to diagnosis (anorexia versus bulimia), and mixed-effects analyses were used to explore differences in app use between diagnoses across four time periods (weeks 1-4; weeks 5-8; weeks 9-12; weeks 13-26).

RESULTS

Eighty-four patients were included of which 41 had anorexia and 43 had bulimia. The total number of logs varied greatly (mean (SD): 592 (628.50)), and patient app activity almost ceased at week 13. Increasing age and no previous eating disorder treatment predicted increased app activity (p = .007; p = .039, respectively). Patients with anorexia logged over four times more often than patients with bulimia in the last time period (median (CI): 4.27 (1.28;14.31); p = .018). Time predicted declining app use (all p ≤ .007).

CONCLUSION

Future research on long-term app engagement should investigate associations between patients' app use and changes in their eating disorder symptom severity over time.

Developments in the psychological treatment of anorexia nervosa and their implications for daily practice

PURPOSE OF REVIEW

Our aim is to give an overview of the recent literature on psychological treatment for young adults and adults with anorexia nervosa and to discuss the implications of the findings for clinical practice.

RECENT FINDINGS

Three systematic reviews and meta-analyses have recently been published on psychological treatments for anorexia nervosa. Treatment outcomes are still modest and mainly focus on weight outcome, although outcomes for eating disorder disease and quality of life have also been reported. Adhering to a treatment protocol might lead to faster and better results.

SUMMARY

For children and adolescents with anorexia nervosa, the major guidelines recommend a family-based treatment. The treatments of choice for young adults and adults with anorexia nervosa are the Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), Cognitive Behaviour Therapy-Enhanced (CBT-E) and Specialist Supportive Clinical Management (SSCM), but none of these treatments seem to be superior. In search of other ways to improve outcome, shared decision making may be a way to help patients become more involved in their treatment, enhance their motivation and consequently improve the outcome.

A randomised clinical trial to evaluate the acceptability and efficacy of an early phase, online, guided augmentation of outpatient care for adults with anorexia nervosa

BACKGROUND

Outpatient interventions for adult anorexia nervosa typically have a modest impact on weight and eating disorder symptomatology. This study examined whether adding a brief online intervention focused on enhancing motivation to change and the development of a recovery identity (RecoveryMANTRA) would improve outcomes in adults with anorexia nervosa.

METHODS

Participants with anorexia nervosa (n = 187) were recruited from 22 eating disorder outpatient services throughout the UK. They were randomised to receiving RecoveryMANTRA in addition to treatment as usual (TAU) (n = 99; experimental group) or TAU only (n = 88; control group). Outcomes were measured at end-of-intervention (6 weeks), 6 and 12 months.

RESULTS

Adherence rates to RecoveryMANTRA were 83% for the online guidance sessions and 77% for the use of self-help materials (workbook and/or short video clips). Group differences in body mass index at 6 weeks (primary outcome) were not significant. Group differences in eating disorder symptoms, psychological wellbeing and work and social adjustment (at 6 weeks and at follow-up) were not significant, except for a trend-level greater reduction in anxiety at 6 weeks in the RecoveryMANTRA group (p = 0.06). However, the RecoveryMANTRA group had significantly higher levels of confidence in own ability to change (p = 0.02) and alliance with the therapist at the outpatient service (p = 0.005) compared to the control group at 6 weeks.

CONCLUSIONS

Augmenting outpatient treatment for adult anorexia nervosa with a focus on recovery and motivation produced short-term reductions in anxiety and increased confidence to change and therapeutic alliance.

An uncontrolled pilot feasibility trial of an intuitive eating intervention for college women with disordered eating delivered through group and guided self-help modalities

OBJECTIVE

College women engage in high rates of disordered eating behaviors (DEBs), and most do not receive treatment. Campuses lack resources to meet this need, thus accessible and affordable treatment options are important. Intuitive eating (IE) is gaining mainstream interest, but intervention research is scarce, with no known clinical trials in college women. This uncontrolled pilot trial examined the feasibility, acceptability, and preliminary efficacy of an eight-week IE intervention delivered through two potentially accessible and affordable modalities: group and guided self-help (GSH).

METHOD

Racially and ethnically diverse college women (N = 71; <50% White) were recruited from a large public Mid-Atlantic university and randomized to group (n = 40) or GSH (n = 31). Assessments occurred at 0 (pre-test), 8 (post-test), and 16 weeks (follow-up). Group participants attended eight weekly 1.5-hour sessions. GSH participants engaged in self-study and had eight weekly 20-minute phone calls.

RESULTS

Both conditions demonstrated feasibility, with superior retention and attendance in GSH. Over 90% of those attending at least one session in either condition were retained through follow-up. Both conditions were highly acceptable, and produced medium to large reductions in DEBs, body dissatisfaction, and weight-bias internalization, and improvements in body appreciation, IE, and satisfaction with life from pre- to post-test, which were maintained at follow-up.

DISCUSSION

Results of this pilot are encouraging and support the development of a larger randomized controlled trial. Avenues for refinement include strategies to improve feasibility of the group condition, and conducting longer-term follow-up to examine maintenance of effects and the intervention's eating disorder prevention potential.

To contemplate or not to contemplate evaluating a preliminary intervention proposal in an outpatient setting: the contemplation therapy group

PURPOSE

The concept for the contemplation group intervention was derived from motivational interviewing (MI) to support people suffering from an eating disorder who are reluctant to engage with treatment. This evaluation focuses on the contemplation group run by the eating disorder services in the Cardiff and Vale area between 2012 and 2016 to investigate the outcomes for participants and implications for working with people suffering from an eating disorder who are ambivalent about change.

METHOD

Quantitative measures were used to assess eating disorder symptomatology, motivation to change and location within the stages of change model. A brief qualitative evaluation of client experiences was also included.

RESULTS

While dropout was high, a number of patients displayed increased readiness for treatment at the end of the group or even started to engage in change-focussed therapy. Participants who completed the group described it as challenging but helpful.

CONCLUSIONS

This evaluation shows that explorative contemplation of their ambivalence towards their eating disorder and treatment was helpful for the participants of the group and supported them in achieving more clarity and decisiveness regarding whether to engage in treatment or not. Further research is needed to evaluate long-term outcomes for patients who feel ambivalent towards treatment, and to explore what interventions can be used to help them.

EVIDENCE LEVEL

Level IV: Evidence obtained from multiple time series with or without the intervention.

Perspectives on Involuntary Treatment of Anorexia Nervosa

Involuntary treatment of anorexia nervosa is an option in cases in which the patient's life or other people's lives are at risk or, in some countries, to prevent the deterioration of the illness. Involuntary treatment is often regarded as controversial and has been intensely debated, although typically with few references to documented knowledge. This paper provides a research perspective of the topic by examine data in the field of the involuntary treatment of anorexia nervosa to pinpoint present knowledge as well as areas demanding clinical action or research attention. The prevalence of involuntary treatment in general as well as specific measures is described and possible early markers of patients at risk of involuntary treatment are discussed. Studies including patients' perspectives of involuntary treatment show the complexity of this treatment, its initiation, and its consequences. To qualify future discussions, improve current practice, and minimize involuntary treatment in general as well as on an individual level, at least four areas need attention: (i) the present specific symptoms of anorexia nervosa and their imminent consequences, (ii) illness history, (iii) overall psychiatric symptoms and general functioning, and (iv) contextual sphere of the patient. In particular, the last two require attention from both clinicians and researchers. Furthermore, critical evaluation of the attitudes of both patients and health care professionals toward each other and the treatment is recommended.

Clinical insight in anorexia nervosa: Associated and predictive factors

Clinical and cognitive factors associated with clinical insight regarding both baseline level and its time-related changes, in outpatients treated for anorexia nervosa. The 193 participants were recruited at 13 French centers specializing in eating disorders (FFAB network) and assessed for insight (SAI-ED), body mass index (BMI), eating disorder severity, symptoms of depression and anxiety, emotional state, silhouette, and functionality; two cognitive tests were also administered. The 137 patients were then re-assessed 18 weeks later. Minimum and ideal subjective BMI and premorbid intelligence were associated with poor baseline insight. Contrary to nearly all other clinical factors, the level of insight revealed no improvement after four months of care. Only the higher value of the minimum lifetime BMI was significantly predictive of increased insight. More positive emotions (PANAS), less symptoms of depression and anxiety (HADS scores), and fewer syndromes (HADS above threshold) were the only factors that covaried with the changes in the level of insight. In conclusion, poor insight has little time variability, contrary to nearly all clinical and cognitive factors. As increased insight is mainly accompanied by improvements in the emotional domain, the latter could represent potential targets for patients with lack of awareness about their eating disorder.

A Web-Based Intervention (MotivATE) to Increase Attendance at an Eating Disorder Service Assessment Appointment: Zelen Randomized Controlled Trial

BACKGROUND

Early assessment and treatment of eating disorder patients is important for patient outcomes. However, up to a third of people referred for treatment do not access services and 16.4% do not attend their first scheduled assessment appointment. MotivATE is a fully automated, novel, Web-based program intended to increase motivation to change eating disorder behaviors, designed for delivery at the point of invitation to an eating disorder service, with the aim of increasing service attendance.

OBJECTIVE

This paper assesses the impact of MotivATE on attendance at assessment when compared with treatment-as-usual.

METHODS

A Zelen randomized controlled design was used. All individuals referred to a specialist eating disorder service, Kimmeridge Court in Dorset, UK, over the course of a year (October 24, 2016-October 23, 2017) were randomized to treatment-as-usual only or treatment-as-usual plus an additional letter offering access to MotivATE. Attendance at the initial scheduled assessment appointment was documented. Logistic regression analysis assessed the impact of MotivATE on attendance at assessment. Additional analyses based on levels of engagement with MotivATE were also undertaken.

RESULTS

A total of 313 participants took part: 156 (49.8%) were randomized to treatment-as-usual and 157 (50.2%) were randomized to receive the additional offer to access MotivATE. Intention-to-treat analysis between conditions showed no impact of MotivATE on attendance at assessment (odds ratio [OR] 1.35, 95% CI 0.69-2.66, P=.38). Examination of the usage data indicated that only 53 of 157 participants (33.8%) in the MotivATE condition registered with the Web-based intervention. An analysis comparing those that registered with the intervention with those that did not found greater attendance at assessment in those that had registered (OR 9.46, 95% CI 1.22-73.38, P=.03).

CONCLUSIONS

Our primary analyses suggest no impact of MotivATE on attendance at the first scheduled assessment appointment, but secondary analyses revealed limited engagement with the program and improved attendance in those who did engage. It is unclear, however, if engagement with the program increased motivation and, in turn, attendance or if more motivated individuals were more likely to access the intervention. Further research is required to facilitate engagement with Web-based interventions and to understand the full value of MotivATE for users.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02777944; https://clinicaltrials.gov/ct2/show/NCT02777944 (Archived by WebCite at http://www.webcitation.org/75VDEFZZ4).