E-Health Interventions for Eating Disorders: Emerging Findings, Issues, and Opportunities

A co-designed intervention to support people living with achalasia to eat in a social setting: a feasibility study

BACKGROUND

Achalasia is a rare oesophageal condition that can affect eating behaviours. This study aimed to evaluate the feasibility of recruitment and assess the acceptability of a co-designed, workbook-based intervention targeting one of the most challenging eating behaviours, which was eating in a social setting.

METHODS

A mixed-method approach was employed, which involved pre- and post-intervention questionnaires and semi-structured interviews. The Achalasia Action group, a UK-based support group, facilitated participant recruitment. The intervention was a workbook designed collaboratively by the researchers and people living with achalasia, with strategies built on the COM-B model (Capability, Opportunity, Motivation-Behaviour). Outcome measures were based on recruitment and retention rates, the APEASE criteria for usability and acceptability, self-reported changes in eating behaviours, and qualitative feedback from participant interviews.

RESULTS

The study aimed to recruit 20 participants, and this target was achieved, resulting in a 100% recruitment rate. However, the post-intervention questionnaires were completed by only 10 participants, indicating a 50% retention rate from baseline. No issues were raised with completing the pre- and post-questionnaires, from completers. The quantitative feedback from participants indicated that they found the workbook activities clear, easy to understand, and complete, with the majority reporting positive experiences. Qualitative feedback on the intervention described enhanced social support and improved symptom management of achalasia in a social setting. Furthermore, the intervention met the APEASE criteria, indicating its usability and acceptability.

CONCLUSIONS

This study explored the feasibility of recruiting and retaining people living with achalasia in intervention research, highlighting the acceptability of the co-designed intervention to improve social eating experiences. However, with a retention rate of only 50% at follow-up, it is evident that future studies should explore the reason behind this and also consider recruiting a larger baseline sample to ensure the target is achieved. The positive outcomes of the co-designed intervention underscore the importance of user involvement in developing interventions. The intervention demonstrated the potential to support people living with achalasia in eating in a social setting. The co-designed intervention has significant practical implications by providing healthcare professionals and support groups with a feasible, potentially effective method to enhance the social eating experience of people living with achalasia, potentially improving their overall quality of life.

Adapting an Online Guided Self-Help CBT Programme Targeting Disordered Eating for Students in Aotearoa New Zealand: A Qualitative Study

Disordered eating is a significant issue in university student populations. Currently, access to interventions is limited. Online interventions present an innovative way to increase accessibility to treatment for those in need. The current study explored how an online intervention for disordered eating (everyBody) could be modified to suit the needs of university students in Aotearoa New Zealand. Aotearoa New Zealand is a unique cultural context, with an indigenous population that has a high incidence rate of disordered eating, highlighting the need to adapt everyBody to the local context. Individual interviews were conducted with nine students currently at university in Aotearoa New Zealand, aged between 18 and 33 years old (five females, four males). Three first-order themes were identified using template analysis. The themes indicate that participants perceived the programme as acceptable and feasible for use with Aotearoa New Zealand's university student population. Furthermore, the themes provide insight into potential adaptions to the programme to facilitate engagement and uptake. The suggested changes were largely consistent with previous research on E-therapy design (e.g., content length, therapeutic alliance), and also highlight changes specific to fit Aotearoa New Zealand's cultural context. The findings have implications for universities and other funders deciding on services for students with disordered eating and eating disorders.

Outcomes for binge eating disorder in a remote weight-inclusive treatment program: a case report

BACKGROUND

There are no known published reports on outcomes for medically and psychiatrically compromised patients with binge eating disorder (BED) treated remotely in higher level of care settings. This case report presents outcomes of an intentionally remote weight-inclusive partial hospitalization and intensive outpatient program based on Health at Every Size® and intuitive eating principles.

CASE PRESENTATION

The patient presented with an extensive trauma background and long history of disturbed eating and body image. She was diagnosed with BED along with several comorbidities, most notably major depressive disorder with suicidality and non-insulin dependent diabetes mellitus. She completed a total of 186 days in the comprehensive, multidisciplinary treatment program encompassing individual and group therapy, as well as other supportive services such as meal support and in vivo exposure sessions. Upon discharge, her BED was in remission, her major depressive disorder was in partial remission, and she no longer exhibited signs of suicidality. Overall, she showed decreases in eating disorder, depressive, and anxiety symptoms as well as increases in quality of life and intuitive eating throughout treatment, which were largely maintained after one year.

CONCLUSIONS

This case highlights the potential of remote treatment as an option for individuals with BED, especially in cases where access to higher levels of care might be limited. These findings exemplify how a weight-inclusive approach can be effectively applied when working with this population.

Realizing the untapped promise of single-session interventions for eating disorders

OBJECTIVE

Multilevel treatment barriers prevent up to 80% of individuals experiencing eating disorders (EDs) from accessing care. This treatment gap creates a critical need to identify interventions that are accessible, easily completable, and optimized for effectiveness by targeting core mechanisms linked to ED onset and maintenance. We propose single-session interventions (SSIs) as a promising path toward catalyzing innovation in the development of accessible, effective ED interventions. SSIs are structured programs that intentionally involve one encounter with a program or provider; they may serve as stand-alone or adjunctive clinical supports. All SSIs are built to acknowledge that any session might be someone's last-and that any single session can nonetheless yield meaningful clinical benefit.

METHOD

We define SSIs, summarize research supporting their utility for ED symptoms and other mental health problems, and recommend future directions for work in this domain.

RESULTS

Single-session interventions may hold promise to reduce some ED symptoms and risk factors, including restrictive eating and negative body image. Steps toward realizing this promise include (1) testing whether existing evidence-based SSIs (e.g., for depression) can also reduce EDs, risk factors, and symptoms; (2) developing novel SSIs that target modifiable ED risk factors and symptoms largely unaddressed by SSIs, such as purging and binge eating; (3) studying diverse implementation pathways; (4) capitalizing on SSIs' transdiagnostic utility to broaden funding opportunities; and (5) educating ED researchers and clinicians about SSIs.

DISCUSSION

Understanding the strengths and limits of mechanism-targeted SSIs for ED-related problems could be a low-risk, high-reward avenue toward reducing EDs at scale.

PUBLIC SIGNIFICANCE

Most individuals experiencing EDs never access any form of treatment, creating an urgent need to identify ED interventions built to overcome barriers to engaging with care. This Forum article introduces SSIs as a promising path to rapidly developing and testing accessible, evidence-based ED supports; supplementing existing ED treatment models; and reducing the individual, familial, and societal burdens of EDs at scale.

Canadian pediatric eating disorder programs and virtual care during the COVID-19 pandemic: a mixed-methods approach to understanding clinicians' perspectives

BACKGROUND

As a result of the public health measures put in place during the COVID-19 pandemic in Canada, many health services, including those for the treatment of eating disorders, were provided at a distance. This study aims to describe the adaptations made in specialized pediatric eating disorder programs in Canada and the impact of these adaptations on health professionals' experience of providing care.

METHODS

A mixed-methods design was used to survey healthcare professionals working in specialized pediatric eating disorder programs about adaptations to treatment made during the pandemic and the impact of these adaptations on their experience of providing care. Data were collected between October 2021 and March 2022 using a cross-sectional survey comprising 25 questions and via semi-structured interviews. Quantitative data were summarized using descriptive statistics and qualitative data were interpreted using qualitative content analysis.

RESULTS

Eighteen healthcare professionals in Canada completed the online survey, of whom six also participated in the semi-structured interviews. The cross-sectional survey confirmed that, unlike in pre-pandemic times, the majority of participants provided medical care (15/18) and mental health care (17/18) at a distance during the pandemic, with most participants using telephone (17/18) and videoconferencing (17/18). Most (16/18) health professionals indicated that virtual care would continue to be used as a tool in pediatric ED treatment after the pandemic. Participants used a combination of virtual and in-person care, with most reporting weighing patients both in clinic (16/18) and virtually (15/18). Qualitative content analysis generated five themes: (1) responding to increased demand with insufficient resources; (2) adapting to changes in care due to the COVID-19 pandemic; (3) dealing with uncertainty and apprehension; (4) virtual care as an acceptable and useful clinical tool, and (5) optimal conditions and future expectations. Most interview participants (5/6) had globally positive views of virtual care.

CONCLUSIONS

Providing virtual multidisciplinary treatment for children and adolescents with eating disorders seemed feasible and acceptable to professionals during the pandemic. Moving forward, focusing on health professionals' perspectives and providing appropriate training in virtual interventions is essential given their central role in successful implementation and continued use of virtual and hybrid care models.

Optimizing digital health technologies to improve therapeutic skill use and acquisition alongside enhanced cognitive-behavior therapy for binge-spectrum eating disorders: Protocol for a randomized controlled trial

OBJECTIVE

Adjunctive mobile health (mHealth) technologies offer promise for improving treatment response to enhanced cognitive-behavior therapy (CBT-E) among individuals with binge-spectrum eating disorders, but research on the key "active" components of these technologies has been very limited. The present study will use a full factorial design to (1) evaluate the optimal combination of complexity of two commonly used mHealth components (i.e., self-monitoring and microinterventions) alongside CBT-E and (2) test whether the optimal complexity level of these interventions is moderated by baseline self-regulation. Secondary aims of the present study include evaluating target engagement associated with each level of these intervention components and quantifying the component interaction effects (i.e., partially additive, fully additive, or synergistic effects).

METHOD

Two hundred and sixty-four participants with binge-spectrum eating disorders will be randomized to six treatment conditions determined by the combination of self-monitoring condition (i.e., standard self-monitoring or skills monitoring) and microinterventions condition (i.e., no microinterventions, automated microinterventions, or just-in-time adaptive interventions) as an augmentation to 16 sessions of CBT-E. Treatment outcomes will be measured using the Eating Disorder Examination and compared by treatment condition using multilevel models.

RESULTS

Results will clarify the "active" components in mHealth interventions for binge eating.

DISCUSSION

The present study will provide critical insight into the efficacy of commonly used digital intervention components (i.e., skills monitoring and microinterventions) alongside CBT-E. Furthermore, results of this study may inform personalization of digital intervention intensity based on patient profiles of self-regulation.

PUBLIC SIGNIFICANCE

This study will examine the relative effectiveness of commonly used components of application-based interventions as an augmentation to cognitive-behavioral therapy for binge eating. Findings from this study will inform the development of an optimized digital intervention for individuals with binge eating.

Cost-effectiveness of Internet Interventions Compared With Treatment as Usual for People With Mental Disorders: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

The economic costs of mental disorders for society are huge. Internet-based interventions are often coined as cost-effective alternatives to usual care, but the evidence is mixed.

OBJECTIVE

The aim was to review the literature on the cost-effectiveness of internet interventions for mental disorders compared with usual care and to provide an estimate of the monetary benefits of such interventions compared with usual care.

METHODS

A systematic review and meta-analysis of randomized controlled trials was conducted, which included participants with symptoms of mental disorders; investigated a telephone- or internet-based intervention; included a control condition in the form of treatment as usual, psychological placebo, waiting list control, or bibliotherapy; reported outcomes on both quality of life and costs; and included articles published in English. Electronic databases such as PubMed (including MEDLINE), Embase, Emcare, PsycINFO, Web of Science, and the Cochrane Library were used. Data on risk of bias, quality of the economic evaluation, quality-adjusted life years, and costs were extracted from the included studies, and the incremental net benefit was calculated and pooled.

RESULTS

The search yielded 6226 abstracts, and 37 studies with 14,946 participants were included. The quality of economic evaluations of the included studies was rated as moderate, and the risk of bias was high. A random-effects approach was maintained. Analyses suggested internet interventions were slightly more effective than usual care in terms of quality-adjusted life years gain (Hedges g=0.052, 95% CI 0.010-0.094; P=.02) and equally expensive (Hedges g=0.002, 95% CI -0.080 to 0.84; P=.96). The pooled incremental net benefit was US $255 (95% CI US $91 to US $419; P=.002), favoring internet interventions over usual care. The perspective of the economic evaluation and targeted mental disorder moderated the results.

CONCLUSIONS

The findings indicate that the cost-effectiveness of internet interventions for mental disorders compared with a care-as-usual approach is likely, but generalizability to new studies is poor given the substantial heterogeneity. This is the first study in the field of mental health to pool cost-effectiveness outcomes in an aggregate data meta-analysis.

TRIAL REGISTRATION

PROSPERO CRD42019141659; https://tinyurl.com/3cu99b34.

Internet-based cognitive behavioral therapy for bulimic eating disorders in a clinical setting: Results from a randomized trial with one-year follow-up

BACKGROUND

Those who suffer from eating disorders often experience serious impairment in quality of life and the majority never receive treatment. Treatment availability may be increased by implementing methods that demand less resources and are more easy accessible such as internet-based treatments, but knowledge about their effects is still insufficient. The study evaluated effects of two types of internet-based cognitive behavioral therapy and a structured day patient program, the latter being a standard treatment at an eating disorder clinic at the time for the study.

METHODS

150 participants with bulimic eating disorders randomized to two types of internet based treatments (one pure online treatment and one based on a self-help guide in book-format) or an intensive 16-week day patient program. The number of participants that started treatment was 120 of which 98 in internet treatment and 22 in the day program. Outcome assessments were carried out at baseline, post treatment, and at one-year follow-up.

RESULTS

All treatments were associated with significantly improved eating disorder pathology, self-image, and clinical impairment. Although the day program generally showed larger effects, only one significant difference found was in diagnostic remission post treatment; 51 % of the participant was in remission in internet treatment and 88 % in the day program. At one-year follow-up, participants in the internet treatments had continued to improve, whereas in the day patient program the effect sustained. Internet treatment had a 36 % drop out rate, there were no dropouts found in the day program.

CONCLUSIONS

All treatments were comparable in effect at follow-up, suggesting that internet treatment is a conceivable alternative to standard treatment. Internet treatment in a book-based format was also equally effective as a pure online format. Internet delivered cognitive behavioral treatment forms can make important contributions to achieve increased access to treatment for patients with bulimic eating disorders. Future research and clinical implications for internet delivered treatments in eating disorder services are discussed.

CLINICAL TRIAL REGISTRATION

ISRCTN registry https://www.isrctn.com/ISRCTN44999017. The study was registered retrospectively.

Internet-based cognitive behavior therapy for eating disorders - Development and feasibility evaluation

BACKGROUND

Eating disorders (ED) are severe psychiatric conditions, characterized by decreased quality of life and high mortality. However, only a minority of patients with ED seek care and very few receive treatment. Internet-delivered cognitive behavioral therapy (ICBT) has the potential to increase access to evidence-based treatments.

AIMS

The aims of the present study were to (1) develop and evaluate the usability of an Internet-delivered guided self-help treatment based on Enhanced Cognitive Behavioral Therapy (ICBT-E) for patients with full or subthreshold bulimia nervosa (BN) or binge eating disorder (BED) with a user centered design process, and (2) to evaluate its feasibility and preliminary outcome in a clinical environment.

METHOD

The study was undertaken in two stages. In Stage I, a user-centered design approach was applied with iterative phases of prototype development and evaluation. Participants were eight clinicians and 30 individuals with current or previous history of ED. In Stage II, 41 patients with full or subthreshold BN or BED were recruited to a single-group open trial to evaluate the feasibility and preliminary outcome of ICBT-E. Primary outcome variables were diagnostic status and self-rated ED symptoms.

RESULTS

The user-centered design process was instrumental in the development of the ICBT-E, by contributing to improvements of the program and to the content being adapted to the needs and preferences of end-users. The overall usability of the program was found to be good. ICBT-E targets key maintaining factors in ED by introducing healthy eating patterns and addressing over-evaluation of weight and shape. The results indicate that ICBT-E, delivered in a clinical setting, is a feasible and promising treatment for full or subthreshold BN or BED, with a high level of acceptability observed and treatment completion of 73.2 %. Participation in ICBT-E was associated with significant symptom reductions in core ED symptomology, functional impairment as well as depressive symptoms, and the results were maintained at the 3-month follow-up.

CONCLUSIONS

ICBT-E was developed with end-users' preferences in mind, in accordance with the identified recommendations, and the program was perceived as usable by end-users. The study demonstrated the potential of ICBT-E, which marks a step forward in the effort to make powerful, empirically supported psychological interventions targeting ED more widely available and accessible.

The use of technology in the treatment of youth with eating disorders: A scoping review

BACKGROUND

Adolescence and young adulthood is a high-risk period for the development of eating disorders. In recent years, there has been an increase in use of technology-based interventions (TBIs) for the treatment of eating disorders. The objective of this study was to determine the types of technology used for eating disorder treatment in youth and their effectiveness.

METHODS

A scoping review was conducted according to PRISMA-ScR guidelines. Four databases were searched. Eligible articles included: (1) a TBI (2) participants with a mean age between 10- and 25-years and meeting DSM-IV or DSM-5 criteria for any eating disorder and (3) qualitative or quantitative designs. Quantitative and qualitative studies were assessed for quality.

RESULTS

The search identified 1621 articles. After screening of titles and abstracts, 130 articles were read in full and assessed for eligibility by two raters. Forty-nine (29 quantitative and 20 qualitative, observational, or mixed methods studies) met inclusion criteria. Quality ratings indicated that 78% of quantitative studies had a low risk of bias and 22% had a moderate risk. Technologies reviewed in our study included videoconference therapy, mobile applications, and online self-help. We considered interventions used both within sessions with clinicians as well as those used in between sessions by patients alone. Fifteen of 18 (83%) quantitative studies found that TBIs reduce eating disorder symptomatology, with nine of those reporting medium-to-large effect sizes. Qualitative data was of high quality and suggested that virtual interventions are acceptable in this population.

CONCLUSIONS

Although identified studies are of high quality, they are limited in number. More research is needed, particularly regarding videoconferencing and mobile applications. Nonetheless, TBIs show promise for the treatment of eating disorders in youth.

TRIAL REGISTRATION

Not applicable.

Effectiveness of an online self-help program, expert-patient support, and their combination for eating disorders: Results from a randomized controlled trial

OBJECTIVE

Many individuals with an eating disorder do not receive appropriate care. Low-threshold interventions could help bridge this treatment gap. The study aim was to evaluate the effectiveness of Featback, a fully automated online self-help intervention, online expert-patient support and their combination.

METHOD

A randomized controlled trial with a 12-month follow-up period was conducted. Participants aged 16 or older with at least mild eating disorder symptoms were randomized to four conditions: (1) Featback, a fully automated online self-help intervention, (2) chat or email support from a recovered expert patient, (3) Featback with expert-patient support and (4) a waiting list control condition. The intervention period was 8 weeks and there was a total of six online assessments. The main outcome constituted reduction of eating disorder symptoms over time.

RESULTS

Three hundred fifty five participants, of whom 43% had never received eating disorder treatment, were randomized. The three active interventions were superior to a waitlist in reducing eating disorder symptoms (d = -0.38), with no significant difference in effectiveness between the three interventions. Participants in conditions with expert-patient support were more satisfied with the intervention.

DISCUSSION

Internet-based self-help, expert-patient support and their combination were effective in reducing eating disorder symptoms compared to a waiting list control condition. Guidance improved satisfaction with the internet intervention but not its effectiveness. Low-threshold interventions such as Featback and expert-patient support can reduce eating disorder symptoms and reach the large group of underserved individuals, complementing existing forms of eating disorder treatment.

PUBLIC SIGNIFICANCE STATEMENT

Individuals with eating-related problems who received (1) a fully automated internet-based intervention, (2) chat and e-mail support by a recovered individual or (3) their combination, experienced stronger reductions in eating disorder symptoms than those who received (4) usual care. Such brief and easy-access interventions play an important role in reaching individuals who are currently not reached by other forms of treatment.

"That You Just Know You're Not Alone and Other People Have Gone through It Too." Eating Disorder Recovery Accounts on Instagram as a Chance for Self-Help? A Qualitative Interview Study among People Affected and Self-Help Experts

In addition to the professional treatment of eating disorders, the use of self-help groups has become increasingly important. Social media offers new possibilities for self-help, not only as online groups but also in increased access to recovery stories of people with similar diseases. People with eating disorders use the internet and social media depending on their motivation in different ways. Eating disorder recovery stories on social media have not yet been systematically used in treatment as appropriate guidelines are still lacking. This study provides an initial insight into the possibilities of using social media for self-help for eating disorders. Due to the exploratory nature, a qualitative design was used, combining interviews with people who have a recovery account on Instagram (n = 6) and self-help experts (n = 2). The results show that recovery stories on Instagram could serve as door openers for further treatment, motivation for therapy, a first step towards behaviour change, and support for existing therapies. If affected people can cope with the self-protection strategies, they can use Instagram positively for themselves and their disease. Nevertheless, there is a risk of negative influence as well as a risk of content and time overload. Therapeutic personnel can use these results to improve existing support services.

Effectiveness of recruitment strategies for a social media literacy E-intervention for young adults with body dissatisfaction: cost, time, diversity, and completion

Digital interventions are becoming increasingly popular for the treatment of body dissatisfaction and eating disorders. However, participant recruitment to online interventions poses a challenge. This study examined differences between a variety of recruitment strategies to a digital intervention in terms of number of participants recruited, cost, study personnel time, completion rates, and demographic characteristics of participants.Participants (N = 395) aged 18-25 years (79.5% women) were recruited to take part in an online body image intervention and asked how they heard about the program (e.g., through Facebook, a flyer on a university campus). Strategies of recruitment, including researcher time required and cost were recorded throughout the project. Cost and time effectiveness, study and intervention completion rates, and participant demographics for each recruitment approach were explored.Facebook paid advertising recruited n = 241 participants (78.0% women), with $29.81 cost per completer, and researcher time per completer at 2.41 minutes. Facebook unpaid advertising was also effective, recruiting n = 130 participants (78.5% women), with $0.00 external cost per completer, and time per completer at 20.43 minutes. Other strategies, both online and face-to-face, were far less effective in recruiting participants. Men proved difficult to recruit using any strategy.Facebook advertising was an effective tool for recruiting young adults to this online intervention, although further research should identify effective strategies to recruit men for similar interventions.

Retention, engagement, and binge-eating outcomes: Evaluating feasibility of the Binge-Eating Genetics Initiative study

OBJECTIVE

Using preliminary data from the Binge-Eating Genetics Initiative (BEGIN), we evaluated the feasibility of delivering an eating disorder digital app, Recovery Record, through smartphone and wearable technology for individuals with binge-type eating disorders.

METHODS

Participants (n = 170; 96% female) between 18 and 45 years old with lived experience of binge-eating disorder or bulimia nervosa and current binge-eating episodes were recruited through the Recovery Record app. They were randomized into a Watch (first-generation Apple Watch + iPhone) or iPhone group; they engaged with the app over 30 days and completed baseline and endpoint surveys. Retention, engagement, and associations between severity of illness and engagement were evaluated.

RESULTS

Significantly more participants in the Watch group completed the study (p = .045); this group had greater engagement than the iPhone group (p's < .05; pseudo-R2 McFadden effect size = .01-.34). Overall, binge-eating episodes, reported for the previous 28 days, were significantly reduced from baseline (mean = 12.3) to endpoint (mean = 6.4): most participants in the Watch (60%) and iPhone (66%) groups reported reduced binge-eating episodes from baseline to endpoint. There were no significant group differences across measures of binge eating. In the Watch group, participants with fewer episodes of binge eating at baseline were more engaged (p's < .05; pseudo-R2 McFadden  = .01-.02). Engagement did not significantly predict binge eating at endpoint nor change in binge-eating episodes from baseline to endpoint for both the Watch and iPhone groups.

DISCUSSION

Using wearable technology alongside iPhones to deliver an eating disorder app may improve study completion and app engagement compared with using iPhones alone.

Cost-effectiveness of three internet-based interventions for eating disorders: A randomized controlled trial

OBJECTIVE

The primary aim was assessing the cost-effectiveness of an internet-based self-help program, expert-patient support, and the combination of both compared to a care-as-usual condition.

METHOD

An economic evaluation from a societal perspective was conducted alongside a randomized controlled trial. Participants aged 16 or older with at least mild eating disorder symptoms were randomly assigned to four conditions: (1) Featback, an online unguided self-help program, (2) chat or e-mail support from a recovered expert patient, (3) Featback with expert-patient support, and (4) care-as-usual. After a baseline assessment and intervention period of 8 weeks, five online assessments were conducted over 12 months of follow-up. The main result constituted cost-utility acceptability curves with quality-of-life adjusted life years (QALYs) and societal costs over the entire study duration.

RESULTS

No significant differences between the conditions were found regarding QALYs, health care costs and societal costs. Nonsignificant differences in QALYs were in favor of the Featback conditions and the lowest societal costs per participant were observed in the Featback only condition (€16,741) while the highest costs were seen in the care-as-usual condition (€28,479). The Featback only condition had the highest probability of being efficient compared to the alternatives for all acceptable willingness-to-pay values.

DISCUSSION

Featback, an internet-based unguided self-help intervention, was likely to be efficient compared to Featback with guidance from an expert patient, guidance alone and a care-as-usual condition. Results suggest that scalable interventions such as Featback may reduce health care costs and help individuals with eating disorders that are currently not reached by other forms of treatment.

PUBLIC SIGNIFICANCE STATEMENT

Internet-based interventions for eating disorders might reach individuals in society who currently do not receive appropriate treatment at low costs. Featback, an online automated self-help program for eating disorders, was found to improve quality of life slightly while reducing costs for society, compared to a do-nothing approach. Consequently, implementing internet-based interventions such as Featback likely benefits both individuals suffering from an eating disorder and society as a whole.

What Topics Do Members of the Eating Disorder Online Community Discuss and Empathize with? An Application of Big Data Analytics

Given the stigma of eating disorders (EDs), anonymous online communities of individuals with EDs can play a critical role in their treatment. In our study, we aimed to identify prevalent topics related to EDs in one community. To discover latent topics in an online community dedicated to EDs, we applied an automated text-mining approach to topic modeling after collecting data from Reddit created between January 2011 and September 2020. As a result of topic modeling, topics regarding emotional support, informational support, and inquiries about EDs were discovered. In frequently asked questions and advice about EDs in the online community, community members empathized more with topics soliciting emotional support rather than informational support. Despite the importance of online communities, studies on this topic, especially those analyzing online conversations, have remained limited. By demonstrating the role of online communities in supplementary interventions, our findings can support clinicians in caring for patients with EDs.

Evaluating a motivational and psycho-educational self-help intervention for athletes with mild eating disorder symptoms: A mixed methods feasibility study

OBJECTIVE

The primary aim was to assess the feasibility of undertaking a study evaluating the novel Motivational and Psycho-Educational Self-Help Programme for Athletes with Mild Eating Disorder Symptoms (MOPED-A). A mixed-methods approach was adopted to explore the feasibility of recruiting and retaining participants, and to evaluate the acceptability of measures, procedures and the intervention. A secondary aim was to explore the potential efficacy of MOPED-A in reducing athletes' eating disorder symptoms.

METHOD

Thirty-five athletes were recruited. Participation involved completing MOPED-A over a 6-week period and completing self-report measures at baseline (T1), post-intervention (T2) and 4-week follow-up (T3). A subsample (n = 15) completed an interview at T2.

RESULTS

Retention was good throughout the study (n = 28; 80%). Quantitative and qualitative feedback suggested the format, delivery, content and dosage of MOPED-A were acceptable. Athletes valued that the intervention was tailored to them, and this facilitated both participation and completion. Over a third of participants reported disclosing their eating difficulties and deciding to seek further support. Large reductions in eating disorder symptoms were detected at T2 and sustained at T3.

CONCLUSIONS

The MOPED-A intervention can be feasibly implemented, is acceptable to participants, and demonstrates potential for reducing symptoms in athletes. A larger, controlled trial is warranted.

Feasibility and Acceptability of a Guided Self-Help, Text-Messaging Intervention to Promote Positive Body Image of Emerging Adult Women

The predominant approach of existing eating disorder prevention programs targets risk factors for development; furthermore, burgeoning evidence suggests that promotion of protective factors against eating disorders (e.g., positive body image) is also a worthy avenue for prevention efforts. The present study considered existing literature gaps in the design of an 8-week guided self-help intervention meant to address the risk for disordered eating through the improvement of positive body image and enhancement of current adaptive functioning. The intervention incorporated elements of weight-inclusive health promotion (e.g., Health at Every Size; HAES) alongside positive psychology and third-wave behavioral interventions [e.g., self-compassion, mindful eating, Acceptance and Commitment Therapy (ACT)] to promote engagement in mindful-self-care. This mixed-methods study evaluated the feasibility and acceptability of the text-messaging based intervention in a diverse sample of cisgender college women (N = 30; 30% Black; 30% bisexual) at risk for disordered eating. Results indicated a high level of engagement and satisfaction with the intervention. Proof of concept was preliminarily supported by the observed significant changes in variables of interest (i.e., body appreciation, positive embodiment, mindful self-care, intuitive eating, self-compassion, disordered eating, and body image dissatisfaction) across the intervention. Overall, results of this study suggest that the use of a guided self-help program based in technology which seeks to reduce risk factors for disordered eating while also supporting adaptive functioning may be indicated for emerging adult women. This article will discuss how the present study provides the groundwork for continued development of innovative and remotely accessible interventions which promote positive body image.

Applying a web-based self-help intervention for bulimia nervosa in routine care: Study protocol for a randomized controlled trial

BACKGROUND

Individuals with bulimia nervosa (BN) experience persistent episodes of binge eating and inappropriate compensatory behavior associated with impaired physical and mental health. Despite the existence of effective treatments, many individuals with BN remain untreated, leading to a high burden and an increased risk of chronicity. Web-based interventions may help facilitate access to evidence-based treatments for BN by reducing barriers to the health care system.

METHODS

The present study will investigate the effectiveness of a web-based self-help intervention for BN in a two-armed randomized controlled trial. Individuals diagnosed with BN (N = 152) will be randomly assigned to either (1) an intervention group receiving a 12-week web-based intervention or (2) a waitlist control group with delayed access to the intervention. Further assessments will be scheduled 6 (mid-treatment) and 12 (post-treatment) weeks after baseline. Changes in the number of binge eating episodes and compensatory behaviors will be examined as primary outcomes. Secondary outcomes include global eating pathology, functional impairments, well-being, comorbid psychopathology, self-esteem, and emotion regulation abilities.

DISCUSSION

Adding web-based interventions into routine care is a promising approach to overcome the existing treatment gap for patients with BN. Therefore, the current study will test the effectiveness of a web-based intervention for BN under standard clinical care settings.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT04876196 (registered on May 6th, 2021).

Evaluation of the Effects of Telepsychotherapy in the Treatment and Prevention of Eating Disorders in Adolescents

According to the WHO definition, "telemedicine is the provision of health services, where distance is a critical factor, by all health professionals who use information and communication technologies for the exchange of valid information for the diagnosis, treatment and prevention of diseases, research and evaluation, and for the continuous training of health professionals, all in the interest of advancing the health of individuals and their communities". The purpose of our review work is specifically to investigate the effects of telemedicine in the treatment and prevention of eating disorders in adolescents. From June 2021 to (September 2021) in the databases of the Web of Science, EMBASE, PsycINFO and CINHAL, using search terms such as telehealth, eating disorder, adolescents, Internet/online treatments CBT and FB-T, anorexia nervosa, bulimia nervosa and binge eating disorder. The articles resulting from the search phases in the databases listed above produced a total of 176 items. Once the procedures for selecting the works were completed, only four studies were included in the review. Modern e-health psychological approaches in the treatment of eating disorders provide potential bases of continuous assistance that are decidedly less burdensome in the costs of territorial services in the case that they are not identified as necessary.

Efficacy of post-inpatient aftercare treatments for anorexia nervosa: a systematic review of randomized controlled trials

BACKGROUND

Early relapse after inpatient treatment is a serious problem in the management of anorexia nervosa (AN). Specialized aftercare interventions have the potential to bridge the gap between inpatient and outpatient care, to prevent relapse and to improve the long-term outcome for patients with AN.

METHODS

Following the guidelines of the PRISMA statement, we conducted a systematic review, synthesizing the evidence from randomized-controlled trials (RCTs) investigating the efficacy of post-inpatient aftercare treatments for AN.

RESULTS

Our search resulted in seven RCTs and three registered ongoing trials. Pharmacotherapy and low-threshold guided self-help have limited uptake and high dropout. Novel mobile guided self-help approaches seem promising due to high patient satisfaction, but their efficacy has yet to be investigated in larger trials. Cognitive-behavior psychotherapy may be beneficial in delaying relapse, but evidence is based on a single study.

CONCLUSION

Only a limited number of RCTs investigating aftercare interventions for patients with AN is available. There is no clear evidence favoring any one specific approach for post-inpatient aftercare in adult patients with AN. The field faces many challenges which generally affect intervention research in AN. A specific issue is how to increase uptake of and reduce dropout from aftercare interventions. This calls for better tailoring of interventions to patient needs and the integration of patient perspectives into treatment. Intensified research and care efforts are needed to address the problem of recurrent relapse after intensive inpatient treatment for AN and to eventually improve prognosis for this eating disorder.

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.

Views on online self-help programmes from people with eating disorders and their carers in UK

Background

Digitalizing the healthcare system has been declared a priority by the UK government. People with eating disorders (EDs), especially those with bulimia nervosa (BN) or binge eating disorder (BED), and ED carers may benefit from online self-help programmes, due to the shame and stigma associated with EDs and barriers in accessing treatment, skills-training or support. Qualitative studies are needed to explore stakeholders’ needs, attitudes to and views about online self-help, to optimize intervention design and delivery.

Methods

Focus groups and telephone interviews were conducted with people with BN or BED, and carers of people with anorexia nervosa, between March and September 2018 in the UK.

Results

People with EDs and carers perceived online self-help positively in the context of barriers to seeking and accessing treatment and support, despite some seeing it as inferior to face-to-face support. Most reported little experience with online interventions. Participants thought the disadvantages of online interventions could be overcome by reminders, progress summaries, regular engagement and engaging with peers. Receiving guidance was seen as an important functionality in the intervention by people with EDs.

Conclusions

People with EDs and their carers are aware of the potential benefits of online self-help despite having little experience with this form of intervention. A stepped-care approach that utilizes technology-based interventions as a first step and makes such interventions available directly to the consumer may fit the attitudes and needs of stakeholders. The study provides a foundation for future research on design and delivery of ED online self-help.

A Review on Strategies for Data Collection, Reflection, and Communication in Eating Disorder Apps

Eating disorders (EDs) constitute a mental illness with the highest mortality. Today, mobile health apps provide promising means to ED patients for managing their condition. Apps enable users to monitor their eating habits, thoughts, and feelings, and offer analytic insights for behavior change. However, not only have scholars critiqued the clinical validity of these apps, their underlying design principles are not well understood. Through a review of 34 ED apps, we uncovered 11 different data types ED apps collect, and 9 strategies they employ to support collection and reflection. Drawing upon personal health informatics and visualization frameworks, we found that most apps did not adhere to best practices on what and how data should be collected from and reflected to users, or how data-driven insights should be communicated. Our review offers suggestions for improving the design of ED apps such that they can be useful and meaningful in ED recovery.

Therapist-guided smartphone-based aftercare for inpatients with severe anorexia nervosa (SMART-AN): Study protocol of a randomized controlled trial

OBJECTIVE

Inpatient treatment for patients with anorexia nervosa (AN) is recommended in extreme or severe cases after failure of outpatient treatment and is highly effective. However, a number of patients show symptom increase and relapse after discharge. The aim of this study is to evaluate the efficacy of a therapist-guided smartphone-based aftercare intervention for inpatients with AN to support symptom stabilization.

METHOD

A total of 186 female patients with a DSM-5 diagnosis of AN (307.1) will be randomized either to receive a 16-week smartphone-based aftercare intervention with therapist feedback as add-on to treatment as usual (TAU) or TAU alone. Data will be assessed at discharge (= baseline, T0), after 16 weeks (= end of the aftercare intervention, T1) and after 10 months (= 6-month follow-up, T2). Primary outcome will be overall eating disorder symptomatology (Eating Disorder Examination Global score). Secondary outcome measures will include body mass index, depression, motivation to change, self-efficacy, patient satisfaction with and adherence to the smartphone-based aftercare intervention as well as rehospitalization rate.

DISCUSSION

This study will be the first randomized controlled trial to examine a therapist-guided smartphone-based aftercare intervention for inpatients with AN. Results may reveal whether and to which extent this novel intervention can support symptom stabilization after inpatient treatment.

Family-based treatment via videoconference: Clinical recommendations for treatment providers during COVID-19 and beyond

The necessity to employ distance-based methods to deliver on-going eating disorder care due to the novel coronavirus (COVID-19) pandemic represents a dramatic and urgent shift in treatment delivery. Yet, TeleHealth treatments for eating disorders in youth have not been adequately researched or rigorously tested. Based on clinical experience within our clinic and research programs, we aim to highlight the common challenges clinicians may encounter in providing family-based treatment (FBT) via TeleHealth for children and adolescents with anorexia nervosa and bulimia nervosa. We also discuss possible solutions and offer practical considerations for providers delivering FBT in this format. Additional research in TeleHealth treatment for eating disorders in youth may lead to improved access, efficiency, and effectiveness of FBT delivered via videoconferencing.

Review of Randomized Controlled Trials Using e-Health Interventions for Patients With Eating Disorders

BACKGROUND

In a world of technological advancements, electronic devices and services seem to be a promising way to increase patients' engagement in treatment and to help manage their symptoms. Here, we identified and analyzed the current evidence of RCTs to evaluate the effectiveness and acceptability of e-health interventions in the eating disorder (ED) field.

METHODS

We screened an initial cluster of 581 papers. In the end, 12 RCTs in clinical ED cohorts were included.

RESULTS

Some studies were conceived as stand-alone interventions, while others were presented as add-ons to ED-specific treatments. Studies varied in the type of EDs under investigation and in the e-health intervention applied (with vs. without therapist support vs. blended interventions; smartphone- vs. web-based). Only four studies reported explicit acceptability measures. Out of those, two reported high acceptability, one reported low acceptability, and one reported no significant difference in acceptability between groups. Four studies reported higher effectiveness of the e-health intervention compared to the control condition, e.g., reduction in maladaptive eating behaviors. Regarding control groups, three used a wait list design and nine had another kind of intervention (e.g., face-to-face CBT, or treatment as usual) as control.

DISCUSSION

So far, the evidence for acceptability and effectiveness of e-health interventions in EDs is very limited. There is also a lack of studies in older patients, adolescents, men, sexual and ethnic minorities. Shame/stigma is discussed in the context of e-health interventions for EDs. It remains unclear how severity of EDs affects the effectiveness of e-health interventions, how patients can channel the knowledge they acquire from e-health interventions into their actual behaviors, and how such interventions can better fit the needs of the individual patient to increase acceptability and effectiveness.

The Feasibility of Using Guided Self-Help in Anorexia Nervosa: An Analysis of Drop-Out From the Study Protocol and Intervention Adherence

The implementation of online technologies to promote wellbeing is increasingly becoming a worldwide priority. This study includes secondary analyses of data and examined drop-out rates in an online guided self-help intervention for patients with anorexia nervosa. Specifically, rates of drop-out at end of treatment (i.e., 6 weeks assessment), as well as intervention adherence (minimum of four of six online guided sessions) and differences between completers and drop-outs were examined. Motivation to change and associated patient variables were assessed as predictors of drop-out using structural equation modeling. Ninety-nine patients were randomized to the intervention arm of the trial. Data were available for 82 individuals, 67 of whom completed the 6 weeks assessment and attended a minimum of four online sessions. No significant differences were found between completers and drop-outs at baseline. At the end of the first week of participation, drop-outs from the 6 weeks assessment or the intervention reported less satisfaction with their work with the mentor delivering online guidance. Greater confidence in own ability to change and higher controlled motivation (willingness to change due to pressure from others) predicted lower drop-out rates from the 6 weeks assessment. Stronger alliance with the therapist at the treatment center and lower psychological distress were associated with greater autonomous motivation (self-directed motivation) and importance and ability to change. Data demonstrate that a novel online guided self-help intervention for patients with anorexia nervosa is feasible. Early satisfaction with the program and external pressure to change have a protective role against drop-out rates.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT02336841.

Adherence as a predictor of dropout in Internet-based guided self-help for adults with binge-eating disorder and overweight or obesity

OBJECTIVE

Internet-based guided self-help (GSH-I) is an efficacious treatment for adults with binge-eating disorder (BED) and overweight or obesity. Although broadly accessible, high dropout from GSH-I has been reported. However, little is known about the factors explaining dropout from GSH-I, including patients' adherence to treatment.

METHOD

Within a randomized trial on the treatment of BED, adherence to 4-month GSH-I was objectively assessed in N = 89 patients with BED and overweight or obesity. Objective adherence and subjective treatment evaluation were evaluated as predictors of dropout from GSH-I, defined as having accessed 5 or less of 11 modules. Cutoffs with optimal sensitivity and specificity were derived using Receiver Operating Characteristics curves analysis, and baseline sociodemographic and clinical correlates were determined.

RESULTS

According to our definition, n = 22 (24.7%) patients were defined as dropouts. Results of the full logistic regression model accounted for 72% of the variance in dropout and all objective adherence parameters (i.e., number of messages exchanged, days with a completed food diary, and days spent per module), but not patients' subjective GSH-I evaluation significantly predicted dropout. Specifically, not completing the food diary in week 7 had maximized sensitivity and specificity in predicting dropout. Patients' body mass index was positively associated with the number of messages exchanged between patients and coaches. No other associations between baseline variables and objective adherence were found.

DISCUSSION

Patients at risk for dropout from GSH-I can be reliably identified via monitoring of objective adherence and may be provided with additional interventions to prevent dropout.

Treatment delivery strategies for eating disorders

PURPOSE OF REVIEW

The traditional model of treatment delivery, based on a psychotherapeutic intervention delivered by a trained professional, in a one-to-one relationship, occurring in a treatment setting context (e.g., clinic, private office, and hospital), highly restricts access to the best standards of care to all of those in need.In this article, we will be focusing on treatment delivering methods for eating disorders that depart from the traditional mode of delivery. We will focus on the use of self-help strategies, both in a pure self-help format, and with external minimal support, guided self-help. We will additionally review the evidence on the use of internet and mobile technology (m-Health) for delivering treatment.

RECENT FINDINGS

Internet-based self-help interventions based on cognitive behavioral approaches have shown to be superior to no treatment for patients diagnosed with bulimia nervosa, binge eating disorder, and other specified feeding or eating disorders with binge/purge characteristics. Although face-to-face, traditional, interventions seem to be more effective than internet-based ones, the latter might have cost benefits and constitute a viable first line of treatment in a stepped care model, or as an alternative to a waitlist while treatment is not available. Other forms of mobile health (e.g., mobile apps) have experienced a surge but remain under researched.

SUMMARY

Mobile health and the internet are promising media for delivering eating disorder treatment. However, more research is needed to determine the utility of internet-based treatments by comparing them to traditional face-to-face treatments for eating disorders, and explore the moderators and mediators impacting adherence and outcome.

Experiences of computer-based and conventional self-help interventions for eating disorders: A systematic review and meta-synthesis of qualitative research

OBJECTIVE

Self-help interventions have been demonstrated to be effective in treating bulimic-type eating disorders (EDs). In particular, computer-based interventions have received increasing attention due to their potential to reach a wider population. This systematic review aimed to synthesize findings from qualitative studies on users' experiences of self-help interventions for EDs and to develop an exploratory framework.

METHOD

A systematic review and meta-synthesis on seven peer-reviewed qualitative studies on structured computer and book-based self-help interventions for EDs was conducted using Noblit and Hare's (1988) 7-phase meta-ethnography. Four of the selected studies investigated computer-based self-help programs, and three of the studies investigated book-based guided self-help programs.

RESULTS

Six concepts were synthesized. They included intervention-related factors (anonymity and privacy; accessibility and flexibility; guidance) and user-related factors (agency/autonomy; self-motivation; and expectations/attitudes). The study revealed the "machine-like" and relational properties of the computer; the expansion of treatment time and space in psychological interventions, the changing role of the medical health professional from a "therapist" to a "guide," and a change from understanding interventions as a conclusive treatment plan to a starting point or stepping stone toward recovery.

DISCUSSION

Computer-based self-help interventions should take advantage of the "machine-like" properties of a computer (neutrality, availability, etc.) as well as its ability to facilitate human interactions. Users should also be facilitated to have a realistic understanding of the purpose of self-help interventions and the place of self-help interventions in their broader treatment plans to moderate expectations and attitudes.

Moving beyond self-report data collection in the natural environment: A review of the past and future directions for ambulatory assessment in eating disorders

OBJECTIVE

In recent years, ecological momentary assessment (EMA) has been used to repeatedly assess eating disorder (ED) symptoms in naturalistic settings, which has allowed for increased understanding of temporal processes that potentiate ED behaviors. However, there remain notable limitations of self-report EMA, and with the rapid proliferation of technology there are ever-increasing possibilities to improve ambulatory assessment methods to further the understanding and treatment of EDs. Therefore, the purpose of this review was to (a) systematically review the studies in EDs that have utilized ambulatory assessment methods other than self-report, and (b) provide directions for future research and clinical applications.

METHOD

A systematic literature search of electronic databases was conducted, and data regarding study characteristics and methodological quality were extracted.

RESULTS

The search identified 17 studies that used ambulatory assessment methods to gather objective data, and focused primarily on autonomic functioning, physical activity, and cognitive processes in ED and control groups.

DISCUSSION

Together the literature demonstrates the promise of using a range of ecologically valid ambulatory assessment approaches in EDs, though there remains limited research that has utilized methods other than self-report (e.g., wearable sensors), particularly in recent years. Going forward, there are several technology-enhanced momentary assessment methods that have potential to improve the understanding and treatment of EDs.

A randomized controlled trial of an Internet-based intervention for eating disorders and the added value of expert-patient support: study protocol

Background

E-mental health has become increasingly popular in interventions for individuals with eating disorders (EDs). It has the potential to offer low-threshold interventions and guide individuals to the needed care more promptly. Featback is such an Internet-based intervention and consists of psychoeducation and a fully automated monitoring and feedback system. Preliminary findings suggest Featback to be (cost-)effective in reducing ED symptomatology. Additionally, e-mail or chat support by a psychologist did not enhance the effectiveness of Featback. Support by an expert patient (someone with a lived experience of an ED) might be more effective, since that person can effectively model healthy behavior and enhance self-efficacy in individuals struggling with an ED. The present study aims to replicate and build on earlier findings by further investigating the (cost-)effectiveness of Featback and the added value of expert-patient support.

Methods

The study will be a randomized controlled trial with a two-by-two factorial design with repeated measures. The four conditions will be (1) Featback, in which participants receive automated feedback on a short monitoring questionnaire weekly, (2) Featback with weekly e-mail or chat support from an expert patient, (3) weekly support from an expert patient, and (4) a waiting list. Participants who are 16 years or older and have at least mild self-reported ED symptoms receive a baseline measure. Subsequently, they are randomized to one of the four conditions for 8 weeks. Participants will be assessed again post-intervention and at 3, 6, 9, and 12 months follow-up. The primary outcome measure will be ED psychopathology. Secondary outcome measures are experienced social support, self-efficacy, symptoms of anxiety and depression, user satisfaction, intervention usage, and help-seeking attitudes and behaviors.

Discussion

The current study is the first to investigate e-mental health in combination with expert-patient support for EDs and will add to the optimization of the delivery of Internet-based interventions and expert-patient support.

Trial registration

Netherlands Trial Register, NTR7065. Registered on 7 June 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3574-2) contains supplementary material, which is available to authorized users.

From Ecological Momentary Assessment (EMA) to Ecological Momentary Intervention (EMI): Past and Future Directions for Ambulatory Assessment and Interventions in Eating Disorders

PURPOSE OF REVIEW

Ambulatory assessment methods, including ecological momentary assessment (EMA), have often been used in eating disorders (EDs) to assess the type, frequency, and temporal sequencing of ED symptoms occurring in naturalistic environments. Relatedly, growing research in EDs has explored the utility of ecological momentary interventions (EMIs) to target ED symptoms. The aims of the present review were to (1) synthesize recent literature pertaining to ambulatory assessment/EMA and EMI in EDs, and (2) identify relevant limitations and future directions in these domains.

RECENT FINDINGS

With respect to ambulatory assessment and EMA, there has been substantial growth in the expansion of constructs assessed with EMA, the exploration of state- vs. trait-level processes, integration of objective and passive assessment approaches, and consideration of methodological issues. The EMI literature in EDs also continues to grow, though most of the recent research focuses on mobile health (mHealth) technologies with relatively minimal EMI components that adapt to momentary contextual information. Despite these encouraging advances, there remain several promising areas of ambulatory assessment research and clinical applications in EDs going forward. These include integration of passive data collection, use of EMA in treatment evaluation and design, evaluation of dynamic system processes, inclusion of diverse samples, and development and evaluation of adaptive, tailored EMIs such as just-in-time adaptive interventions. While much remains to be learned in each of these domains, the continual growth in mobile technology has potential to facilitate and refine our understanding of the nature of ED psychopathology and ultimately improve intervention approaches.

Self-Help Treatment of Eating Disorders

The authors provide an overview of the current state of research on self-help interventions for eating disorders. The efficacy of different forms of self-help interventions for bulimia nervosa, binge eating disorder, and other eating disorders at various stages of the care pathway (from prevention to relapse prevention) is described. Cost-effectiveness studies are also presented. Moderators of outcome, such as guidance and adherence, are discussed. Overall, the findings are promising and support the use of self-help interventions in the treatment of bulimic disorders, across the stages of the care pathway. Less is known about the use of self-help in anorexia nervosa.

Mobile Health Adoption in Mental Health: User Experience of a Mobile Health App for Patients With an Eating Disorder

Background

Despite the worldwide growth in mobile health (mHealth) tools and the possible benefits for both patients and health care providers, the overall adoption levels of mHealth tools by health professionals remain relatively low.

Objective

This study aimed (1) to investigate attitudes of health care providers and mHealth experts toward mHealth tools in the health context in general, and this study aimed (2) to test the acceptability and feasibility of a specific mHealth tool for patients with an eating disorder (ED), called TCApp, among patients and ED specialists.

Methods

To this purpose, we conducted an explorative qualitative study with 4 in-depth group discussions with several groups of stakeholders: our first focus group was conducted with 11 experts on mHealth from the Catalan Association of Health Entities; the second focus group included 10 health care professionals from the Spanish College of Doctors of Barcelona; the third focus group involved 9 patients with an ED who had used the TCApp over a 12-week period, and the fourth and last focus group involved 8 ED specialists who had monitored such ED patients on the Web.

Results

The focus groups showed that health care providers and mHealth experts reported barriers for mHealth adoption more often than facilitators, indicating that mHealth techniques are difficult to obtain and use. Most barriers were attributed to external factors relating to the human or organizational environment (ie, lack of time because of workload, lack of direct interest on a legislative or political level) rather than being attributed to internal factors relating to individual obstacles. The results of the mHealth intervention study indicate that the TCApp was considered as easy to use and useful, although patients and the ED specialists monitoring them on the Web reported different adoption problems, such as the inability to personalize the app, a lack of motivational and interactive components, or difficulties in adhering to the study protocol.

Conclusions

In general, this paper indicates that both health professionals and patients foresee difficulties that need to be addressed before comprehensive adoption and usage of mHealth techniques can be effectively implemented. Such findings are in line with previous studies, suggesting that although they acknowledge their possible benefits and cost-effectiveness, health care providers are quite resistant and conservative about integrating mHealth technologies in their daily practice.

Dissemination of an Internet-Based Program for the Prevention and Early Intervention in Eating Disorders

Objective: Research on the dissemination of e-mental health interventions is in an early stage, so that little is known about the reach, costs, participant characteristics, and patterns of program utilization associated with different recruitment strategies and access paths. This study investigated differences between user groups informed about an Internet-based program for the prevention and early intervention in eating disorders via different recruitment channels. Method: Participant characteristics and user behavior of 3548 participants in the Internet-based program ProYouth were analyzed. Participants were informed about ProYouth via different channels (e. g., print materials, high school, Internet). Results: Results indicate significant relationships between access paths and both user characteristics and program utilization. Participants who were informed about ProYouth at their high schools were more likely to be male, younger, and at lower risk of developing eating disorders. In contrast, other recruitment channels (e. g., Internet, print materials) resulted in participants with significantly higher risk and symptom levels who used the program more frequently and with higher intensity. Conclusion: Efforts aimed at the dissemination of Internet-based interventions should consider the effects that different recruitment channels and access paths may have on sample composition and utilization of the intervention.

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.

A systematic review of reviews to identify key research opportunities within the field of eHealth implementation

INTRODUCTION

This paper is a systematic review of the relevant literature surrounding the implementation and utilisation of eHealth to identify key challenges and opportunities to future eHealth applications.

METHODS

NHS Evidence, PubMed, IEEE Explorer, Cochrane Library and JMIR Publications were all searched for reviews published between 1 January 2010 and 30 June 2017.

RESULTS

A total of 47 papers met the final inclusion criterion. The published literature focused on a wide array of challenges categorised into five areas, facing the implementation and utilisation of eHealth; from this, four areas of opportunity to advance eHealth were identified.

DISCUSSION

The five challenge areas are (C1) stakeholders and system users, (C2) technology and interoperability, (C3) cost-effectiveness and start-up costs, (C4) legal clarity and legal framework and (C5) local context and regional differences. The four opportunity areas are (O1) participation and contribution, (O2) foundation and sustainability, (O3) improvement and productivity and (O4) identification and application.

CONCLUSION

The literature analysed in this systematic review identifies design and implementation priorities that can guide the development and utilisation of future eHealth initiatives.

Using internet-based self-help to bridge waiting time for face-to-face outpatient treatment for Bulimia Nervosa, Binge Eating Disorder and related disorders: Study protocol of a randomized controlled trial

BACKGROUND

Eating disorders are serious conditions associated with an impaired health-related quality of life and increased healthcare utilization and costs. Despite the existence of evidence-based treatments, access to treatment is often delayed due to insufficient health care resources. Internet-based self-help interventions may have the potential to successfully bridge waiting time for face-to-face outpatient treatment and, thus, contribute to overcoming treatment gaps. However, little is known about the feasibility of implementing such interventions into routine healthcare. The aim of this study is to analyze the effects and feasibility of an Internet-based self-help intervention (everyBody Plus) specifically designed for patients with Bulimia Nervosa, Binge Eating Disorder and other specified feeding and eating disorders (OSFED) on a waiting list for outpatient face-to-face treatment. The aim of this paper is to describe the study protocol.

METHODS

A multi-country randomized controlled trial will be conducted in Germany and the UK. N = 275 female patients awaiting outpatient treatment will be randomly allocated either to the guided online self-help intervention "everyBody Plus" or a waitlist control group condition without access to the intervention. everyBody Plus comprises eight weekly sessions that cover topics related to eating and exercise patterns, coping with negative emotions and stress as well as improving body image. Participants will receive weekly individualized feedback based on their self-monitoring and journal entries. Assessments will take place at baseline, post-intervention as well as at 6- and 12-months follow up. In addition, all participants will be asked to monitor core eating disorder symptoms weekly to provide data on the primary outcome. The primary outcome will be number of weeks after randomization until a patient achieves a clinically relevant improvement in core symptoms (BMI, binge eating, compensatory behaviors) for the first time. Secondary outcomes include frequency of core symptoms and eating disorder related attitudes and behaviors, as well as associated psychopathology. Additional secondary outcomes will be the participating therapists' confidence in treating eating disorders as well as perceived benefits of everyBody Plus for patients.

DISCUSSION

To the best of our knowledge, this is the first randomized controlled trial examining the effects of Internet-based self-help for outpatients with eating disorders awaiting face-to-face outpatient treatment. If proven to be effective and successfully implemented, Internet-based self-help programs might be used as a first step of treatment within a stepped-care approach, thus reducing burden and cost for both patients and health care providers.

eHealth in Treatment of Offenders in Forensic Mental Health: A Review of the Current State

BACKGROUND

Treatment of offenders in forensic mental health is complex. Often, these in- or outpatients have low treatment motivation, suffer from multiple disorders, and have poor literacy skills. eHealth may be able to improve treatment outcomes because of its potential to increase motivation and engagement, and it can overcome the predominant one-size-fits-all approach by being tailored to individual patients.

OBJECTIVE

To examine its potential, this systematic review studies the way that eHealth has been used and studied in forensic mental health and identifies accompanying advantages and disadvantages for both patients and treatment, including effectiveness.

METHODS

A systematic search in Scopus, PsycINFO, and Web of Science was performed up until December 2017. Studies were included if they focused on technological interventions to improve the treatment of forensic psychiatric patients.

RESULTS

The search resulted in 50 studies in which eHealth was used for treatment purposes. Multiple types of studies and technologies were identified, such as virtual reality, web-based interventions, and videoconferencing. The results confirmed the benefits of technology, for example, the acquisition of unique information about offenders, effectiveness, and tailoring to specific characteristics, but indicated that these are not fully taken advantage of.

DISCUSSION

To overcome the barriers and obtain the benefits, eHealth has to have a good fit with patients and the forensic psychiatric context. It has to be seamlessly integrated in existing care and should not be added as an isolated element. To bridge the gap between the current situation and eHealth's potential, further research on development, implementation, and evaluation should be conducted.

Smartphone-Enhanced Low-Threshold Intervention for adolescents with Anorexia Nervosa (SELTIAN) waiting for outpatient psychotherapy: study protocol of a randomised controlled trial

INTRODUCTION

As smartphones are widely distributed nowadays, mental health apps seem to be a promising treatment tool. First self-help apps for eating disorders have been developed recently. However, studies assessing the efficacy of such apps are scarce. A smartphone app could prevent further weight reduction and increase commitment during waiting time for outpatient treatment, especially for adolescents with anorexia nervosa (AN). In this study protocol, a randomised controlled trial to assess the efficacy of a smartphone-enhanced low-threshold intervention for AN during waiting time is described.

METHODS AND ANALYSIS

30 adolescents with AN aged 12-19 years will be recruited at three child and adolescent psychiatry centres in Germany. All participants will be randomised to consultations only or consultations and the use of the Jourvie Research app. The app will be installed either on their own smartphone or on a research device. The participants will receive biweekly to monthly consultations for 3 months to review meal plans and weight management with a clinician. In addition, the Jourvie Research app for meal, behaviour and emotion protocolling will be provided to the intervention group. The protocols will be discussed with a clinician during the consultations. Dialectical behaviour therapy-informed skills for tension regulation to increase compliance with the meal plan will be taught in the intervention group and the app will remind the participant of a skill in a moment of need. The primary outcome is the age-adjusted and height-adjusted weight gain in standard deviation score after 3 months.

ETHICS AND DISSEMINATION

Results will be disseminated at conferences and through peer-reviewed publications. The trial was approved by the ethics review board of the local medical association, Mainz, Germany, under the reference number 837.338.15.

TRIAL REGISTRATION NUMBER

German clinical trials register, reference number DRKS00008946.

Evolution of cognitive-behavioral therapy for eating disorders

The evolution of cognitive-behavioral therapy (CBT) for the treatment of bulimic disorders is described in this review. The impacts of successive attempts to enhance CBT such as the addition of exposure and response prevention; the development of enhanced CBT; and broadening the treatment from bulimia nervosa to binge eating disorder are considered. In addition to developing advanced forms of CBT, shortening treatment to guided self-help was the first step in broadening access to treatment. The use of technology such as computer-based therapy and more recently the Internet, promises further broadening of access to self-help and to therapist guided treatment. Controlled studies in this area are reviewed, and the balance of risks and benefits that accompany the use of technology and lessened therapist input are considered. Looking into the future, more sophisticated forms of treatment delivered as mobile applications ("apps") may lead to more personalized and efficacious treatments for bulimic disorders, thus enhancing the delivery of treatments for eating disorders.

New Horizons in Measurement: a Review of Novel and Innovative Approaches to Eating-Disorder Assessment

PURPOSE OF REVIEW

Eating disorders are serious mental-health concerns that will affect over 30 million individuals in the USA at some point in their lives. Eating disorders occur across the lifespan, in a variety of ethnicities and races, in both men and women, and across the socioeconomic spectrum. Given the prevalence and severity of eating disorders, it is important that clinicians and researchers have access to appropriate assessment tools to aid in the early identification and treatment referral, differential diagnosis, treatment planning, and progress monitoring, and to ensure valid research findings. In this review, we describe novel and innovative assessment tools that were developed within the past 5 years for utilization in research and/or clinical practice with individuals with eating disorders.

RECENT FINDINGS

We identified six multidimensional assessments for eating disorders, all of which can be administered online (with some also offering paper-and-pencil versions). Strengths of the measures included good internal consistency, test-retest reliability, and convergent validity. However, in part, due to problematic scale construction methods, certain scales had poor discriminant validity and most were developed and validated in mostly female samples. There are promising new eating disorder measures from which to choose; however, many measures continue to be limited by poor discriminant validity and need additional validation prior to incorporation into routine research and clinical practice.

Addressing critical gaps in the treatment of eating disorders

Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.

Web-Based Fully Automated Self-Help With Different Levels of Therapist Support for Individuals With Eating Disorder Symptoms: A Randomized Controlled Trial

Background

Despite the disabling nature of eating disorders (EDs), many individuals with ED symptoms do not receive appropriate mental health care. Internet-based interventions have potential to reduce the unmet needs by providing easily accessible health care services.

Objective

This study aimed to investigate the effectiveness of an Internet-based intervention for individuals with ED symptoms, called “Featback.” In addition, the added value of different intensities of therapist support was investigated.

Methods

Participants (N=354) were aged 16 years or older with self-reported ED symptoms, including symptoms of anorexia nervosa, bulimia nervosa, and binge eating disorder. Participants were recruited via the website of Featback and the website of a Dutch pro-recovery–focused e-community for young women with ED problems. Participants were randomized to: (1) Featback, consisting of psychoeducation and a fully automated self-monitoring and feedback system, (2) Featback supplemented with low-intensity (weekly) digital therapist support, (3) Featback supplemented with high-intensity (3 times a week) digital therapist support, and (4) a waiting list control condition. Internet-administered self-report questionnaires were completed at baseline, post-intervention (ie, 8 weeks after baseline), and at 3- and 6-month follow-up. The primary outcome measure was ED psychopathology. Secondary outcome measures were symptoms of depression and anxiety, perseverative thinking, and ED-related quality of life. Statistical analyses were conducted according to an intent-to-treat approach using linear mixed models.

Results

The 3 Featback conditions were superior to a waiting list in reducing bulimic psychopathology (d=−0.16, 95% confidence interval (CI)=−0.31 to −0.01), symptoms of depression and anxiety (d=−0.28, 95% CI=−0.45 to −0.11), and perseverative thinking (d=−0.28, 95% CI=−0.45 to −0.11). No added value of therapist support was found in terms of symptom reduction although participants who received therapist support were significantly more satisfied with the intervention than those who did not receive supplemental therapist support. No significant differences between the Featback conditions supplemented with low- and high-intensity therapist support were found regarding the effectiveness and satisfaction with the intervention.

Conclusions

The fully automated Internet-based self-monitoring and feedback intervention Featback was effective in reducing ED and comorbid psychopathology. Supplemental therapist support enhanced satisfaction with the intervention but did not increase its effectiveness. Automated interventions such as Featback can provide widely disseminable and easily accessible care. Such interventions could be incorporated within a stepped-care approach in the treatment of EDs and help to bridge the gap between mental disorders and mental health care services.

Trial Registration

Netherlands Trial Registry: NTR3646; http://www.trialregister.nl/trialreg/admin/ rctview.asp?TC=3646 (Archived by WebCite at http://www.webcitation.org/6fgHTGKHE)