Treatment dropout in web-based cognitive behavioral therapy for patients with eating disorders

The acceptability, feasibility, and preliminary efficacy of a supported online self-help treatment program for binge-eating disorder

Introduction

Studies in transdiagnostic eating disorder (ED) samples suggest supported online self-help programs (eTherapies) are effective and may improve access to treatment; however, their evaluation in those with binge-eating disorder (BED) is limited. Given BED's high prevalence and low levels of treatment uptake, further eTherapy evaluation is needed to broaden access to effective, evidence-based treatment options. The aim of this study was to investigate the acceptability, feasibility, and preliminary efficacy of a supported eTherapy for those with BED or subthreshold BED, and to examine symptom change across the duration of therapy.

Method

Nineteen women with BED completed a supported, 10-session Cognitive Behavioural Therapy-based eTherapy in an uncontrolled, pre-post, and 3 months follow up intervention study. Key outcomes were assessed by the Eating Disorder Examination Questionnaire (EDE-Q): objective binge episode (OBE) frequency and ED psychopathology. Feasibility was evaluated via program adherence and dropout, whilst acceptability was assessed through participant feedback post-treatment. Weekly symptom change (ED psychopathology) during treatment was assessed by the Eating Disorder Examination - Questionnaire Short (EDE-QS).

Results

Generalised estimating equations showed statistically and clinically significant reductions in OBEs and ED psychopathology (large effects) post-treatment, with these decreases maintained at follow up. Across weekly assessment, a marked slowing in the rate of change in ED psychopathology was observed after four sessions of the program. Program feasibility was high (i.e., 84% of content completed), as was program acceptability (i.e., 93% of participants expressed high levels of satisfaction).

Discussion

These results support the acceptability, feasibility, and preliminary efficacy of a supported eTherapy program for those with BED and suggest the variability of symptom change across the duration of therapy. Future research should further investigate findings in an adequately powered randomised controlled trial.

Consulta remota a pessoas com transtornos alimentares durante a pandemia de COVID-19

RESUMO Objetivos: analisar as experiências subjetivas relacionadas à adaptação ao atendimento remoto por usuários com transtornos alimentares durante a pandemia de COVID-19. Métodos: estudo descritivo de abordagem qualitativa realizado com usuários de um ambulatório especializado em transtornos alimentares. Foi aplicada uma entrevista semiestruturada remota, utilizando-se o aplicativo Google Meet. Os dados foram submetidos à análise lexical por meio do software ALCESTE e discutidos à luz das evidências científicas. Resultados: a consulta remota é uma estratégia positiva, mas não substitutiva da modalidade presencial. Vantagens como economia financeira, maior contato com os profissionais e flexibilização de horários de atendimentos foram citadas. Dificuldade de avaliação clínica em relação ao peso, sinais vitais e pouco domínio da tecnologia foram apontados como limitações. Considerações Finais: o estudo induz a discussão sobre sistematização dos atendimentos remotos, os quais, durante a pandemia de COVID-19, foram responsáveis por fornecer maior sensação de suporte às pessoas com transtornos alimentares.

Remote consultation with people with eating disorders during the COVID-19 pandemic

ABSTRACT Objectives: to analyze subjective experiences related to adaptation to remote care by users with eating disorders during the COVID-19 pandemic. Methods: a descriptive study with a qualitative approach conducted with users of an eating disorders outpatient clinic. A semi-structured remote interview was applied using the Google Meet application. The data were submitted to lexical analysis using ALCESTE software and discussed in the light of scientific evidence. Results: the remote appointment is a positive strategy but not a substitute for the face-to-face modality. The research cited financial savings, closer contact with professionals, and flexibility of service schedules as advantages. It pointed out the difficulty in clinical evaluation concerning weight, vital signs, and poor mastery of technology as limitations. Final Considerations: the study induces discussion about the systematization of remote care, which, during the COVID-19 pandemic, were responsible for providing a greater sense of support to people with eating disorders.

Therapeutic Alliance in Web-Based Treatment for Eating Disorders: Secondary Analysis of a Randomized Controlled Trial

Background

In face-to-face therapy for eating disorders, therapeutic alliance (TA) is an important predictor of symptom reduction and treatment completion. To date, however, little is known about TA during web-based cognitive behavioral therapy (web-CBT) and its association with symptom reduction, treatment completion, and the perspectives of patients versus therapists.

Objective

This study aimed to investigate TA ratings measured at interim and after treatment, separately for patients and therapists; the degree of agreement between therapists and patients (treatment completers and noncompleters) for TA ratings; and associations between patient and therapist TA ratings and both eating disorder pathology and treatment completion.

Methods

A secondary analysis was performed on randomized controlled trial data of a web-CBT intervention for eating disorders. Participants were 170 females with bulimia nervosa (n=33), binge eating disorder (n=68), or eating disorder not otherwise specified (n=69); the mean age was 39.6 (SD 11.5) years. TA was operationalized using the Helping Alliance Questionnaire (HAQ). Paired t tests were conducted to assess the change in TA from interim to after treatment. Intraclass correlations were calculated to determine cross-informant agreement with regard to HAQ scores between patients and therapists. A total of 2 stepwise regressive procedures (at interim and after treatment) were used to examine which HAQ scores predicted eating disorder pathology and therapy completion.

Results

For treatment completers (128/170, 75.3%), the HAQ-total scores and HAQ-Helpfulness scores for both patients and therapists improved significantly from interim to post treatment. For noncompleters (42/170, 24.7%), all HAQ scores decreased significantly. For all HAQ scales, the agreement between patients and therapists was poor. However, the agreement was slightly better after treatment than at interim. Higher patient scores on the helpfulness subscale of the HAQ at interim and after treatment were associated with less eating disorder psychopathology. A positive association was found between the HAQ-total patient scores at interim and treatment completion. Finally, posttreatment HAQ-total patient scores and posttreatment HAQ-Helpfulness scores of therapists were positively associated with treatment completion.

Conclusions

Our study showed that TA in web-CBT is predictive of eating disorder pathology and treatment completion. Of particular importance is patients’ confidence in their abilities as measured with the HAQ-Helpfulness subscale when predicting posttreatment eating disorder pathology and treatment completion.

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.

The Promise of Digital Self-Management: A Reflection about the Effects of Patient-Targeted e-Health Tools on Self-Management and Wellbeing

Increasingly, people have direct access to e-Health resources such as health information on the Internet, personal health portals, and wearable self-management applications, which have the potential to reinforce the simultaneously growing focus on self-management and wellbeing. To examine these relationships, we searched using keywords self-management, patient-targeting e-Health tools, and health as wellbeing. Direct access to the health information on the Internet or diagnostic apps on a smartphone can help people to self-manage health issues, but also leads to uncertainty, stress, and avoidance. Uncertainties relate to the quality of information and to use and misuse of information. Most self-management support programs focus on medical management. The relationship between self-management and wellbeing is not straightforward. While the influence of stress and negative social emotions on self-management is recognized as an important cause of the negative spiral, empirical research on this topic is limited to health literacy studies. Evidence on health apps showed positive effects on specific actions and symptoms and potential for increasing awareness and ownership by people. Effects on more complex behaviors such as participation cannot be established. This review discovers relatively unknown and understudied angles and perspectives about the relationship between e-Health, self-management, and wellbeing.

Long-term effectiveness of web-based cognitive behavioral therapy for patients with eating disorders

PURPOSE

To evaluate the long-term effectiveness of a web-based therapist-delivered cognitive behavioral therapy (CBT) for patients with eating disorders (ED).

METHODS

We used follow-up data from a randomized controlled trial that evaluated a web-based CBT on ED psychopathology and related health, compared to a waiting list control (WL) condition. As participants of the WL condition started the intervention after their waiting period, follow-up data included participants from both groups. The primary outcome was change from baseline, at 3, 6, and 12-month intervals in ED psychopathology, analyzed using mixed models for repeated measures. Secondary outcomes included body dissatisfaction, BMI, physical health, mental health, self-esteem, quality of life, and social functioning.

RESULTS

The population comprised 212 participants in total, in three subgroups: bulimia nervosa (BN; n = 44), binge eating disorder (BED; n = 83), and ED not otherwise specified (EDNOS; n = 85). Treatment effects were sustained during follow-up, with generally large effect sizes for the reduction of ED psychopathology and body dissatisfaction, and small to moderate effect sizes for physical and mental health, self-esteem, social functioning, and quality of life. Most effects were found for all three subgroups, except for long-term improvements in self-esteem and quality of life among participants with BN and EDNOS.

CONCLUSION

This study showed long-term sustainability of treatment effects up to 1-year post-treatment of a web-based therapist-delivered CBT for patients with various ED.

LEVEL OF EVIDENCE

Level IV, evidence obtained from multiple time series analysis, with intervention.

UNIQUE CLINICAL TRIAL NUMBER

NTR2415-Dutch Trial Registry ( http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2415 ).

A Pilot Study of a Videoconferencing-Based Binge Eating Disorder Program in Overweight or Obese Females

Background: There has been increasing interest in using videoconferencing in health care, but limited research was conducted in Binge Eating Disorder (BED) patients. This 3-month pilot study aimed to assess the feasibility, acceptability, and preliminary efficacy of a videoconferencing (VC)-based treatment program in overweight and obese females with BED. Methods: Eighteen participants, aged 20-73, were diagnosed and randomized into either a face-to-face (F2F) group or a VC-based group. In the F2F group, participants received 12 one-on-one weekly counseling sessions from a Licensed Mental Health Counselor and Registered Dietitian Nutritionist. In the VC group, participants received the same counseling through an online telemedicine software. Measured outcomes include retention, adherence to treatment, and attitudinal and behavioral changes of participants. Results: In the end of study, of the 9 participants randomized into each group, 8 (88.9%) F2F participants and 4 (44.4%) VC participants completed the study. On average, F2F finishers attended 94.8% of sessions and completed 66.2% of dietary diaries. VC finishers attended 95.8% of sessions and completed 55.4% of diaries. No changes in weight and binge eating episode were observed in either group. F2F finishers had significant improvement on uncontrolled eating (p = 0.01), emotional eating (p = 0.004), food addiction diagnosis (p = 0.04), loss of control (p = 0.04), and clinical significance (p = 0.04). VC finishers observed significant improvements in eating disorder examination shape concern (p = 0.03) and global score (p = 0.03). Conclusion: VC-based treatment program is feasible and could be effective for BED patients. Long-term large-scale randomized clinical trials are warranted to further assess the efficacy.

Personality as predictor of outcome in internet-based treatment of bulimic eating disorders

Internet-based cognitive behavioral therapy (ICBT) for bulimic eating disorders has demonstrated clinical utility and cost efficiency, but is associated with low patient preference, low credibility, sizeable dropout and only moderate symptom reduction. To improve outcome it is imperative to learn more about who might benefit from internet-based interventions. To do this, the current study investigated the Five Factor Model of personality as predictor of outcome in patients with full or sub-threshold bulimia nervosa (n = 109). Patients in a randomized controlled trial of ICBT were assessed prior to and at the end of treatment. Patients showed significant symptom reduction over time (Cohen's d = 1.0, p < .001). Remission as well as overall symptom reduction was positively predicted by Openness to Experience and Conscientiousness. Binge eating cessation specifically, was positively predicted by Extraversion. The study supports the use of personality assessment for patient selection and outcome optimization in internet-based treatment of bulimic eating disorders.

Characteristics of patients in an eating disorder sample who dropped out: 2-year follow-up

OBJECTIVE

This manuscript explores the characteristics of individuals diagnosed with an eating disorder who dropped out of treatment, compared with those who completed it.

METHOD

The participants were 196 patients diagnosed with eating disorders (according to DSM-IV-TR criteria) who consecutively began treatment for the first time in an eating disorders unit. They were assessed at baseline with a set of questionnaires evaluating eating habits, temperament, and general psychopathology. During the follow-up period, patients who dropped out were re-assessed via a telephone interview.

RESULTS

In the course of a 2-year follow-up, a total of 80 (40.8%) patients were labeled as dropouts, and 116 (59.2%) remaining subjects were considered completers. High TCI scores in the character dimensions of Disorderliness (NS4) (p < .01) and total Novelty Seeking (NST), along with low scores in Dependency (RD4), were significantly associated with dropout in the course of 2 years. Once the results were submitted to logistic regression analysis, dropout only remained associated with high scores in Disorderliness (NS4) and, inversely, with an initial Anorexia Nervosa (AN) diagnosis (p < .05). Reasons for dropout stated by the patients included logistic difficulties, subjective improvement of their condition, and lack of motivation.

DISCUSSION

Clinicians should handle the first therapeutic intervention with particular care in order to enhance their understanding of clients and their ability to rapidly identify those who are at risk of dropping out of treatment.

LEVEL OF EVIDENCE

Level III: Cohort Study.

Estimating Determinants of Attrition in Eating Disorder Communities on Twitter: An Instrumental Variables Approach

BACKGROUND

The use of social media as a key health information source has increased steadily among people affected by eating disorders (EDs). Research has examined characteristics of individuals engaging in online communities, whereas little is known about discontinuation of engagement and the phenomenon of participants dropping out of these communities.

OBJECTIVE

This study aimed to investigate the characteristics of dropout behaviors among eating disordered individuals on Twitter and to estimate the causal effects of personal emotions and social networks on dropout behaviors.

METHODS

Using a snowball sampling method, we collected a set of individuals who self-identified with EDs in their Twitter profile descriptions, as well as their tweets and social networks, leading to 241,243,043 tweets from 208,063 users. Individuals' emotions are measured from their language use in tweets using an automatic sentiment analysis tool, and network centralities are measured from users' following networks. Dropout statuses of users are observed in a follow-up period 1.5 years later (from February 11, 2016 to August 17, 2017). Linear and survival regression instrumental variables models are used to estimate the effects of emotions and network centrality on dropout behaviors. The average levels of attributes among an individual's followees (ie, people who are followed by the individual) are used as instruments for the individual's attributes.

RESULTS

Eating disordered users have relatively short periods of activity on Twitter with one half of our sample dropping out at 6 months after account creation. Active users show more negative emotions and higher network centralities than dropped-out users. Active users tend to connect to other active users, whereas dropped-out users tend to cluster together. Estimation results suggest that users' emotions and network centralities have causal effects on their dropout behaviors on Twitter. More specifically, users with positive emotions are more likely to drop out and have shorter lasting periods of activity online than users with negative emotions, whereas central users in a social network have longer lasting participation than peripheral users. Findings on users' tweeting interests further show that users who attempt to recover from EDs are more likely to drop out than those who promote EDs as a lifestyle choice.

CONCLUSIONS

Presence in online communities is strongly determined by the individual's emotions and social networks, suggesting that studies analyzing and trying to draw condition and population characteristics through online health communities are likely to be biased. Future research needs to examine in more detail the links between individual characteristics and participation patterns if better understanding of the entire population is to be achieved. At the same time, such attrition dynamics need to be acknowledged and controlled when designing online interventions so as to accurately capture their intended populations.

Treatment dropout in a family-based partial hospitalization program for eating disorders

Treatment dropout is a significant challenge in the treatment of eating disorders. In day hospital/partial hospitalization program settings, little is known about factors associated with treatment dropout. The purpose of the present study was to assess factors associated with treatment dropout in a partial hospitalization program for adolescents and young adults with anorexia nervosa. Patients and parents completed self-report and interview-based measures at baseline and at end of treatment in the partial hospitalization program. Few factors were found that differentiated the two groups. Those who dropped out had lower body weight at end of treatment, were less likely to have purged in the previous month, and had fathers who scored higher on the criticism subscale of expressed emotion. Patients who are purging may be seen as having more severe symptoms, thus possibly reducing the chances of parents prematurely discontinuing treatment. Parental criticism is a potentially modifiable factor in treatment. Further research is needed to identify effective ways to reduce parental criticism, and to identify additional modifiable factors associated with treatment dropout to reduce dropout rates in this population.Level IV: Evidence obtained from multiple time series with or without the intervention, such as case studies.

Predictors of premature termination from psychotherapy for anorexia nervosa: Low treatment credibility, early therapy alliance, and self-transcendence

OBJECTIVE

Failure to complete treatment for anorexia nervosa (AN) is- common, clinically concerning but difficult to predict. This study examines whether therapy-related factors (patient-rated pretreatment credibility and early therapeutic alliance) predict subsequent premature termination of treatment (PTT) alongside self-transcendence (a previously identified clinical predictor) in women with AN.

METHODS

56 women aged 17-40 years participating in a randomized outpatient psychotherapy trial for AN. Treatment completion was defined as attending 15/20 planned sessions. Measures were the Treatment Credibility, Temperament and Character Inventory, Vanderbilt Therapeutic Alliance Scale and the Vanderbilt Psychotherapy Process Scale. Statistics were univariate tests, correlations, and logistic regression.

RESULTS

Treatment credibility and certain early patient and therapist alliance/process subscales predicted PTT. Lower self-transcendence and lower early process accounted for 33% of the variance in predicting PTT.

DISCUSSION

Routine assessment of treatment credibility and early process (comprehensively assessed from multiple perspectives) may help clinicians reduce PTT thereby enhancing treatment outcomes.