A screening tool for detecting eating disorder risk and diagnostic symptoms among college-age women

The Trajectories of Online Mental Health Information Seeking: Modeling Search Behavior Before and After Completion of Self-report Screens

There is an appreciable mental health treatment gap in the United States. Efforts to bridge this gap and improve resource accessibility have led to the provision of online, clinically-validated tools for mental health self-assessment. In theory, these screens serve as an invaluable component of information-seeking, representing the preparative and action-oriented stages of this process while altering or reinforcing the search content and language of individuals as they engage with information online. Accordingly, this work investigated the association of screen completion with mental health-related search behaviors. Three-year internet search histories from N=7,572 Microsoft Bing users were paired with their respective depression, anxiety, bipolar disorder, or psychosis online screen completion and sociodemographic data available through Mental Health America. Data was transformed into network representations to model queries as discrete steps with probabilities and times-to-transition from one search type to another. Search data subsequent to screen completion was also modeled using Markov chains to simulate likelihood trajectories of different search types through time. Differences in querying dynamics relative to screen completion were observed, with searches involving treatment, diagnosis, suicidal ideation, and suicidal intent commonly emerging as the highest probability behavioral information seeking endpoints. Moreover, results pointed to the association of low risk states of psychopathology with transitions to extreme clinical outcomes (i.e., active suicidal intent). Future research is required to draw definitive conclusions regarding causal relationships between screens and search behavior.

Measures of nutrition status and health for weight-inclusive patient care: A narrative review

In healthcare, weight is often equated to and used as a marker for health. In examining nutrition and health status, there are many more effective markers independent of weight. In this article, we review practical and emerging clinical applications of technologies and tools used to collect non-weight-related data in nutrition assessment, monitoring, and evaluation in the outpatient setting. The aim is to provide clinicians with new ideas about various types of data to evaluate and track in nutrition care.

Rates and correlates of study enrolment and use of a chatbot aimed to promote mental health services use for eating disorders following online screening

OBJECTIVE

We developed a chatbot aimed to facilitate mental health services use for eating disorders (EDs) and offered the opportunity to enrol in a research study and use the chatbot to all adult respondents to a publicly available online ED screen who screened positive for clinical/subclinical EDs and reported not currently being in treatment. We examined the rates and correlates of enrolment in the study and uptake of the chatbot.

METHOD

Following screening, eligible respondents (≥18 years, screened positive for a clinical/subclinical ED, not in treatment for an ED) were shown the study opportunity. Chi-square tests and logistic regressions explored differences in demographics, ED symptoms, suicidality, weight, and probable ED diagnoses between those who enroled and engaged with the chatbot versus those who did not.

RESULTS

6747 respondents were shown the opportunity (80.0% of all adult screens). 3.0% enroled, of whom 90.2% subsequently used the chatbot. Enrolment and chatbot uptake were more common among respondents aged ≥25 years old versus those aged 18-24 and less common among respondents who reported engaging in regular dietary restriction.

CONCLUSIONS

Overall enrolment was low, yet uptake was high among those that enroled and did not differ across most demographics and symptom presentations. Future directions include evaluating respondents' attitudes towards treatment-promoting tools and removing barriers to uptake.

Development and usability testing of an online platform for provider training and implementation of cognitive-behavioral therapy guided self-help for eating disorders

Background

Most individuals with eating disorders (EDs) do not receive treatment, and those who do receive care typically do not receive evidence-based treatment, partly due to lack of accessible provider training. This study developed a novel "all-in-one" online platform for disseminating training for mental health providers in cognitive-behavioral therapy guided self-help (CBTgsh) for EDs and supporting its implementation. The aim of the study was to obtain usability data from the online platform prior to evaluating its effects on provider training outcomes and patient ED symptom outcomes in an open pilot trial.

Methods

Nine mental health provider participants (n = 4 in Cycle 1; n = 5 in Cycle 2) and 9 patient participants (n = 4 in Cycle 1; n = 5 in Cycle 2) were enrolled over two cycles of usability testing. In Cycle 1, we recruited providers and patients separately to complete brief platform testing sessions. In Cycle 2, we recruited provider-patient dyads; providers completed training using the platform and subsequently delivered CBTgsh to a patient for three weeks. Usability was assessed using the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), and semi-structured interviews.

Results

Interview feedback converged on two themes for providers (applicability of program for real-world use, platform structure and function) and two themes for patients (barriers and facilitators to engagement, perceived treatment effects). SUS and USE scores were in the "average" to "good" ranges across cycles.

Conclusions

Findings from this study demonstrate preliminary feasibility and acceptability of the online platform. Data collected in this study will inform further refinements to the online platform. The platform's effects on provider training outcomes and patient ED symptom outcomes will be evaluated in an open pilot trial. Given the wide treatment gap for EDs and barriers to dissemination and implementation of evidence-based treatments, the online platform represents a scalable solution that could improve access to evidence-based care for EDs.

Introducing Diagnostic Classification Modeling as an Unsupervised Method for Screening Probable Eating Disorders

Screening for eating disorders (EDs) is an essential part of the prevention and intervention of EDs. Traditional screening methods mostly rely on predefined cutoff scores which have limitations of generalizability and may produce biased results when the cutoff scores are used in populations where the instruments or cutoff scores have not been validated. Compared to the traditional cutoff score approach, the diagnostic classification modeling (DCM) approach can provide psychometric and classification information simultaneously and has been used for diagnosing mental disorders. In the present study, we introduce DCM as an innovative and alternative approach to screening individuals at risk of EDs. To illustrate the practical utility of DCM, we provide two examples: one involving the application of DCM to examine probable ED status from the 12-item Short form of the Eating Disorder Examination-Questionnaire (EDE-QS) to screen probable thinness-oriented EDs and the Muscularity-Oriented Eating Test (MOET) to screen probable muscularity-oriented EDs.

The need for more inclusive measurement to advance equity in eating disorders prevention

Eating disorder (ED) research and practice have been shaped by prevailing stereotypes about who EDs are most likely to affect. Subsequently, the field has prioritized the needs and concerns of affluent, cisgender, heterosexual, white girls and women to the exclusion of others, especially people marginalized based on their race, ethnicity, sexual orientation, and/or gender identity. However, EDs exist across diverse groups and actually occur with elevated prevalence in several marginalized groups. Growing research points to differences in the drivers of EDs in such groups (e.g. desire to attain the curvy rather than thin ideal; dietary restraint due to food insecurity rather than weight/shape concerns), yet tools typically used for screening and intervention evaluation do not capture eating pathology driven by such factors. In this commentary, we describe gaps in existing ED assessment tools and argue these gaps likely underestimate EDs among marginalized groups, bias who is invited, participates in, and benefits from ED prevention programs, and obscure potential group differences in the efficacy of such programs. We also discuss the potential of these ramifications to exacerbate inequities in EDs. Finally, we outline recommendations to overcome existing gaps in measurement and, consequently, advance equity in the realm of ED prevention.

Eating disorder symptoms and comorbid mental health risk among teens recruited to a digital intervention research study via two online approaches

INTRODUCTION

It is crucial to identify and evaluate feasible, proactive ways to reach teens with eating disorders (EDs) who may not otherwise have access to screening or treatment. This study aimed to explore the feasibility of recruiting teens with EDs to a digital intervention study via social media and a publicly available online ED screen, and to compare the characteristics of teens recruited by each approach in an exploratory fashion.

METHOD

Teens aged 14-17 years old who screened positive for a clinical/subclinical ED or at risk for an ED and who were not currently in ED treatment completed a baseline survey to assess current ED symptoms, mental health comorbidities, and barriers to treatment. Bivariate analyses were conducted to examine differences between participants recruited via social media and those recruited after completion of a widely available online EDs screen (i.e., National Eating Disorders Association [NEDA] screen).

RESULTS

Recruitment of teens with EDs using the two online approaches was found to be feasible, with 934 screens completed and a total of 134 teens enrolled over 6 months: 77% (n = 103) via social media 23% (n = 31) via the NEDA screen. Mean age of participants (N = 134) was 16 years old, with 49% (n = 66) identifying as non-White, and 70% (n = 94) identifying as a gender and/or sexual minority. Teens from NEDA reported higher ED psychopathology scores (medium effect size) and more frequent self-induced vomiting and driven exercise (small effect sizes). Teens from NEDA also endorsed more barriers to treatment, including not feeling ready for treatment and not knowing where to find a counselor or other resources (small effect sizes).

DISCUSSION

Online recruitment approaches in this study reached a large number of teens with an interest in a digital intervention to support ED recovery, demonstrating the feasibility of these outreach methods. Both approaches reached teens with similar demographic characteristics; however, teens recruited from NEDA reported higher ED symptom severity and barriers to treatment. Findings suggest that proactive assessment and intervention methods should be developed and tailored to meet the needs of each of these groups.

PUBLIC SIGNIFICANCE

This study examined the feasibility of recruiting teens with EDs to a digital intervention research study via social media and NEDA's online screen, and demonstrated differences in ED symptoms among participants by recruitment approach.

Prevalence, characteristics, and correlates of probable avoidant/restrictive food intake disorder among adult respondents to the National Eating Disorders Association online screen: a cross-sectional study

BACKGROUND

Avoidant/restrictive food intake disorder (ARFID) is a serious, albeit under-researched, feeding or eating disorder. This exploratory study utilized data from adult respondents to the National Eating Disorders Association online eating disorder screen to validate items assessing the presence of ARFID and examine the prevalence, clinical characteristics, and correlates of a positive ARFID screen.

METHODS

Among 50,082 adult screen respondents between January 2022 and January 2023, the prevalence of a positive ARFID screen was calculated. Chi-square tests and t-tests compared demographics, eating disorder attitudes and behaviors, suicidal ideation, current eating disorder treatment status, and eating disorder treatment-seeking intentions between respondents with possible ARFID and other eating disorder diagnostic and risk categories. Clinical characteristics of respondents with possible ARFID were also examined.

RESULTS

2378 (4.7%) adult respondents screened positive for ARFID. Respondents with possible ARFID tended to be younger, male, and have lower household income, and were less likely to be White and more likely to be Hispanic/Latino than most other diagnostic/risk groups. They had lower weight/shape concerns and eating disorder behaviors than most other diagnoses and higher BMI than those with AN. 35% reported suicidal ideation, 47% reported intentions to seek treatment for an eating disorder, and 2% reported currently being in treatment. The most common clinical feature of ARFID was lack of interest in eating (80%), followed by food sensory avoidance (55%) and avoidance of food due to fear of aversive consequences (31%).

CONCLUSIONS

Findings from this study indicated that ARFID was prevalent among adult screen respondents and more common among individuals who were younger, male, non-White, Hispanic, and lower income relative to those with other eating disorders, at risk for an eating disorder, or at low risk. Individuals with possible ARFID frequently reported suicidal ideation and were rarely in treatment for an eating disorder. Further research is urgently needed to improve advances in the assessment and treatment of ARFID and improve access to care in order to prevent prolonged illness duration.

Preferred treatment focus among college students with eating disorders and comorbid mental health problems in a digital cognitive-behavioral guided self-help program

OBJECTIVE

To examine the mental health problems that college students with eating disorders (EDs) and comorbid depression and/or anxiety disorders preferred to target first in a digital treatment program and explore correlates of preferred treatment focus.

METHODS

Four hundred and eighty nine college student users of a digital cognitive-behavioral guided self-help program targeting common mental health problems (76.7% female, Mage  = 20.4 ± 4.4, 64.8% White) screened positive for an ED and ≥one other clinical mental health problem (i.e., depression, generalized anxiety disorder, social phobia, and/or panic disorder). Students also reported on insomnia, post-traumatic stress, alcohol use, and suicide risk. Before treatment, they indicated the mental health problem that they preferred to target first in treatment. Preferred treatment focus was characterized by diagnostic profile (i.e., ED + Depression, ED + Anxiety, ED + Depression + Anxiety), symptom severity, and demographics.

RESULTS

58% of students with ED + Anxiety, 47% of those with ED + Depression, and 27% of those with ED + Depression + Anxiety chose to target EDs first. Across diagnostic profiles, those who chose to target EDs first had more severe ED symptoms than those who chose to target anxiety or depression (ps < .05). Among students with ED + Depression + Anxiety, those who chose to target EDs first had lower depression symptoms than those who chose to target depression, lower generalized anxiety than those who chose to target anxiety, and lower suicidality than those who chose to target anxiety or depression (ps < .01).

CONCLUSIONS

Students with EDs and comorbid depression and/or anxiety disorders showed variable preferred treatment focus across diagnostic profiles. Research should explore specific symptom presentations associated with preferred treatment focus.

PUBLIC SIGNIFICANCE

Findings indicate that a sizable percentage of college students with depression/anxiety who also have EDs prefer to target EDs first in treatment, highlighting the importance of increasing availability of ED interventions to college students. Students with EDs and comorbid depression and/or anxiety disorders showed variable preferred treatment focus across diagnostic profiles, and preference to target EDs was associated with greater ED psychopathology across diagnostic profiles.

Classifying excessive exercise: Examining the relationship between compulsive exercise with obsessive-compulsive disorder symptoms and disordered eating symptoms

OBJECTIVE

There remains a lack of consensus around nosology for compulsive exercise (CE). Although widely observed in eating disorders (ED), CE shares theoretical overlap with obsessive-compulsive disorder (OCD), where exercise compulsions occur in response to obsessions. Yet, there is limited and mixed evidence of a relationship between CE with OCD. This study aims to explore the appropriate diagnostic classification of CE through examination of CE in relation to OCD, obsessional thinking, and ED symptoms.

METHOD

Two hundred and eighty one adults with mental health symptoms, dieting, and exercise behaviour completed measures of OCD, CE, and disordered eating symptoms. Regression and Receiver Operating Characteristic analyses examined relationships between dimensions of CE with OCD and ED symptoms, and the predictive ability of CE assessment for detecting threshold OCD and ED symptoms.

RESULTS

CE assessment was poor at predicting threshold OCD symptoms, probable Anorexia Nervosa, and Binge Eating Disorder and moderate at detecting probable disordered eating and Bulimia Nervosa. Associations between CE and OCD symptoms were not significant after adjustment for ED symptoms. Obsessional thinking was associated only with lack of exercise enjoyment.

CONCLUSIONS

Results indicate that excessive exercise might represent a distinct disorder, with some shared traits across CE, OCD and ED symptoms. Findings question the utility of adaptation of OCD diagnostic criteria for CE. Assessment and treatment implications are considered.

The relation of food insecurity to eating disorder characteristics and treatment-seeking among adult respondents to the National Eating Disorders Association online screen

BACKGROUND

Food insecurity (FI), characterized by limited or uncertain access to adequate food, has been associated with eating disorders (EDs). This study explored whether FI was associated with ED behaviors, ED diagnosis, current treatment status, and treatment-seeking intentions among adults who completed an online ED screen.

METHODS

Respondents to the National Eating Disorders Association online screening tool self-reported demographics, FI, height and weight, past 3-month ED behaviors, and current treatment status. Respondents were also asked an optional question about treatment-seeking intentions. Hierarchical regressions evaluated relations between FI and ED behaviors, treatment status, and treatment-seeking intentions. Logistic regressions explored differences in probable ED diagnosis by FI status.

RESULTS

Of 8714 respondents, 25 % screened at risk for FI. FI was associated with greater binge eating (R2Change = 0.006), laxative use (R2Change = 0.001), and presence of dietary restriction (R2Change = 0.001, OR: 1.32) (ps < .05). Having FI was associated with greater odds of screening positive for a probable ED or as high risk for an ED (ps < .05). FI was not associated with current treatment status or treatment-seeking intentions (ps > .05).

CONCLUSIONS

Findings add to existing literature supporting a relation between FI and EDs. Implications include a need to disseminate EDs screening and treatment resources to populations affected by FI and to tailor treatments to account for barriers caused by FI.

Evaluation of a combined, online intervention for binge-type eating disorders and high body weight in young adults

BACKGROUND

Binge-type eating disorders (EDs; i.e., bulimia nervosa, binge eating disorder) are common among young adults with high body weight, yet few interventions target both conditions. This study tested an online guided self-help intervention that provided cognitive behavioral therapy (CBT) tools for EDs and behavioral weight loss (BWL) content to young adults with binge-type EDs and high body weight.

METHOD

60 adults aged 18-39 with clinical/subclinical binge-type EDs and high body weight were randomized to a combined condition or a CBT-only condition. Participants received self-help content for 8 weeks and self-reported ED attitudes, frequency of binge eating and compensatory behaviors, and weight at baseline, 4-weeks, and 8-weeks. Linear mixed models and negative binomial models compared changes between conditions in ED attitudes, ED behaviors, and weight at each timepoint. Chi-square test and independent samples t-test compared program completion and session engagement between conditions.

RESULTS

No significant differences in weight change or ED symptom change emerged between the conditions. Both conditions achieved significant reductions in ED attitudes, binge episodes, and compensatory behaviors from baseline to 8-weeks (ps < .05). Neither condition demonstrated significant weight loss from baseline to 8-weeks. Program completion (47 %) and session engagement (57 %) were equally high across conditions.

DISCUSSION

Both conditions achieved ED symptom change; however, neither condition was associated with weight change. Research is needed to identify the types of strategies and doses of BWL that promote clinically significant weight and ED symptom change in young adults.

Psychotherapy utilization by United States college students

Objective: We studied current psychotherapy utilization rates among college students with mental health problems and identified characteristics associated with differential utilization. Participants: Nationwide online survey of students screening positive for at least one clinical mental health problem (N = 18,435). Methods: Rates and correlates of psychotherapy utilization were analyzed descriptively and with logistic regression. Results: Sample-wide, 19% reported receiving psychotherapy. Being male (vs. female), being Asian, Black or African American, or Multiracial (vs. White), greater financial difficulty, lower parent education, lower year in school, and attending a public (vs. private) institution were associated with lower utilization. Holding a gender minority (vs. female) identity and holding a sexual minority (vs. heterosexual) identity were associated with higher utilization. Utilization fell from Fall 2019 to Spring 2020, early during the COVID-19 pandemic, and subsequently rebounded. Conclusions: This study estimates current psychotherapy utilization among students with mental health problems and identifies possibly underserved populations.

Prevalence, Characteristics, and Correlates of Avoidant/Restrictive Food Intake Disorder among Adult Respondents to the National Eating Disorders Association Online Screen: A Cross-Sectional Study

Background

Avoidant/restrictive food intake disorder (ARFID) is a serious, albeit under-researched, feeding or eating disorder. This exploratory study utilized data from adult respondents to the National Eating Disorders Association (NEDA) online eating disorder screen to validate items assessing the presence of ARFID and examine the prevalence, clinical characteristics, and correlates of a positive ARFID screen compared to other probable eating disorder/risk categories.

Methods

Among 47,705 adult screen respondents between January 2022 and January 2023, the prevalence of a positive ARFID screen was calculated. Chi-square tests and t-tests compared demographics, eating disorder attitudes and behaviors, suicidal ideation, current eating disorder treatment status, and eating disorder treatment-seeking intentions between respondents with possible ARFID and other eating disorder diagnostic and risk categories. Clinical characteristics of respondents with possible ARFID were also examined.

Results

2,378 (5.0%) adult respondents screened positive for ARFID. Respondents with possible ARFID tended to be younger, male, and have lower household income, and were less likely to be White and more likely to be Hispanic/Latino than most other diagnostic/risk groups. They had lower weight/shape concerns and eating disorder behaviors than all other diagnoses but higher BMI than those with AN. 35% reported suicidal ideation, 47% reported intentions to seek treatment for an eating disorder, and 2% reported currently being in treatment. The most common clinical feature of ARFID was lack of interest in eating (80%), followed by food sensory avoidance (55%) and avoidance of food due to fear of aversive consequences (31%).

Conclusions

Findings from this study indicated that ARFID was prevalent among adult screen respondents and more common among individuals who were younger, male, non-White, Hispanic, and lower income relative to those with other eating disorders or at risk for an eating disorder. Individuals with possible ARFID frequently reported suicidal ideation and were rarely in treatment for an eating disorder. Further research is urgently needed to improve advances in the assessment and treatment of ARFID and improve access to care in order to prevent prolonged illness duration.

Current evidence for avoidant restrictive food intake disorder: Implications for clinical practice and future directions

Background

ARFID (avoidant restrictive food intake disorder) is a relatively new diagnostic term covering a number of well-recognised, clinically significant disturbances in eating behaviour unrelated to body weight/shape concerns. Its phenotypic heterogeneity combined with much about the condition remaining unknown, can contribute to uncertainties about best practice. While other reviews of the evidence base for ARFID exist, few specifically target health care professionals and implications for clinical practice.

Methods

A narrative review was conducted to synthesise the findings of ARFID papers in scientific journals focussing on four key areas relevant to clinical practice: prevalence, assessment and characterisation of clinical presentations, treatment, and service delivery. Freely available online databases were searched for case studies and series, research reports, review articles, and meta-analyses. Findings were reviewed and practice implications considered, resulting in proposed clinical recommendations and future research directions.

Results

We discuss what is currently known about the four key areas included in this review. Based on available evidence as well as gaps identified in the literature, recommendations for clinical practice are derived and practice-related research priorities are proposed for each of the four of the areas explored.

Conclusion

Prevalence studies highlight the need for referral and care pathways to be embedded across a range of health care services. While research into ARFID is increasing, further studies across all areas of ARFID are required and there remains a pressing need for guidance on systematic assessment, evidence-based management, and optimal service delivery models. Informed clinical practice is currently predominantly reliant on expert consensus and small-scale studies, with ongoing routine clinical data capture, robust treatment trials and evaluation of clinical pathways all required. Despite this, a number a positive practice points emerge.

Moderators and mediators of a digital cognitive behavior therapy-guided self-help intervention for eating disorders: Informing future design efforts

OBJECTIVE

The Student Bodies-Eating Disorders intervention (SB-ED), a digital cognitive behavior therapy-guided self-help intervention for college women with an eating disorder, is effective for reducing eating disorder psychopathology. The purpose of this study was to evaluate moderators and mediators of the SB-ED intervention. To our knowledge, this is the first evaluation of clinical mediators of a digital intervention for women with eating disorders.

METHOD

This is an exploratory secondary analysis of a cluster randomized trial comparing the SB-ED intervention to referral to usual care among 690 women at 27 United States colleges. Moderators included body mass index (BMI), race, ethnicity, weight/shape concerns, eating disorder impairment, thin ideal internalization, depression, anxiety, and motivation for treatment, assessed at baseline. Thin ideal internalization and depressive symptoms were tested as predictors at postintervention and mediators at 2-year follow-up. Outcome was change in global eating disorder psychopathology.

RESULTS

BMI moderated the effect of the intervention at follow-up (but not posttreatment), with individuals with a lower BMI experiencing more continued improvements in eating disorder psychopathology following the intervention than individuals with a higher BMI. Thin ideal internalization mediated the effect of the intervention at follow-up, and depression partially mediated the effect of the intervention at follow-up.

CONCLUSIONS

Results of the mediator analyses suggest that helping college women reduce inflated internalization of the thin ideal and improve depressive symptoms leads to improvements in eating disorder psychopathology. Results also suggest opportunities to optimize the intervention so individuals across the BMI spectrum experience ongoing improvements over time. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Change in body image flexibility and correspondence with outcomes in a digital early intervention for eating disorders based on acceptance and commitment therapy

Body image flexibility (BIF) has been suggested as a transdiagnostic process of change in eating disorder (ED) interventions, but data remain sparse. The current study examined the relationship between BIF and treatment effects in a randomized controlled trial comparing a digital ACT-based intervention to a waitlist control for early ED intervention. Women and girls with elevated Weight Concern Scale (WCS) scores were randomized to either the ACT intervention or a waitlist control. Linear regression models were used to examine the impact of treatment on WCS scores controlling for age and body-mass index and BIF was examined as a mediator of change. Change in BIF was also examined as a predictor of Eating Disorder Examination-Questionnaire (EDE-Q) global scores at 1-month in the ACT condition. ACT participants had greater reductions in WCS scores, an effect partially mediated by BIF and concentrated almost entirely in the ACT condition. Increased BIF from baseline to end-of-treatment also predicted lower EDE-Q scores at 1-month post-intervention. The current study suggests additional research exploring BIF as a process of change in EDs is warranted and could expand understanding of how treatment works or treatment options. Additional studies with more frequent, complete and concordant assessments between groups are needed.

A pilot randomized controlled trial of a cognitive-behavioral therapy guided self-help mobile app for the post-acute treatment of anorexia nervosa: A registered report

INTRODUCTION

Relapse following acute treatment for anorexia nervosa (AN) is common. Evidence suggests cognitive-behavioral therapy (CBT) may be useful in the post-acute period, but few patients have access to trained providers. mHealth technologies have potential to increase access to high-quality care for AN, including in the post-acute period. The aim of this study is to estimate the preliminary feasibility and effectiveness of a CBT-based mobile intervention plus treatment as usual (TAU), offered with and without an accompanying social networking feature.

METHOD

In the current pilot randomized controlled trial, women with AN who have been discharged from acute treatment in the past 2 months (N = 90) will be randomly assigned to a CBT-based mobile intervention plus treatment as usual (TAU), a CBT-based mobile intervention including social networking plus TAU, or TAU alone. We will examine feasibility, acceptability, and preliminary effectiveness of the three conditions in terms of reducing eating disorder psychopathology, reducing frequency of eating disorder behaviors, achieving weight maintenance, reducing depression and suicidal ideation, and reducing clinical impairment. We will examine rehospitalization and full recovery rates in an exploratory fashion. We will also examine whether the mobile intervention and social networking feature change the proposed targets and whether changes in targets are associated with benefit, as well as conduct exploratory analyses to identify within-mobile intervention predictors and moderators of outcome.

DISCUSSION

Ultimately, this research may lead to increased access to evidence-based treatment for individuals with AN and prevention of the extreme negative consequences that can result from this serious disorder.

PUBLIC SIGNIFICANCE

Relapse after acute treatment for anorexia nervosa is common, and few patients have access to trained providers to support them following acute care. This study will pilot a coached mobile app, including a social networking component, for this population. If ultimately successful, our approach could greatly increase access to evidence-based treatment for individuals with anorexia nervosa and ultimately prevent the extreme negative consequences that can result from this serious disorder.

Screening for eating disorders across genders in college students: Initial validation of the brief assessment of stress and eating

Given that eating disorders (EDs) are relatively common in college populations, it is important to have reliable and valid tools to identify students so that they can be referred to evidence-based care. Although research supports the psychometric properties of existing ED screens for identifying cases of EDs, most studies have been conducted in samples of young white-majority women or have not reported the psychometric properties of the screening tool in men.

OBJECTIVE

The purpose of the current study was to validate a brief, 10-item screening tool for the identification of EDs-the brief assessment of stress and eating (BASE).

METHOD

Participants were college students (N = 596; 68.2% cisgender women) from a large Midwestern university who completed the BASE and SCOFF. The Eating Disorders Diagnostic Survey was used to generate DSM-5 ED diagnoses. We evaluated area under the curve (AUC) for both receiver operating curves (ROC) and precision-recall curves (PRC).

RESULTS

Both the BASE and SCOFF performed significantly better than chance at identifying probable EDs in cisgender women (BASE AUC: ROC = .787, PRC = .633, sensitivity = .733, specificity = .697; SCOFF AUC: ROC = .810, PRC = .684, sensitivity = .793, specificity = .701). However, the BASE (AUC: ROC = .821, PRC = .605, sensitivity = .966, specificity = .495) significantly outperformed the SCOFF (AUC: ROC = .710, PRC = .354, sensitivity = .828, specificity = .514) for identifying probable EDs in cisgender college men.

DISCUSSION

The BASE is appropriate for student healthcare and college research settings. Because the BASE outperforms the SCOFF in college men, results from the current study are expected to contribute to improved identification of EDs on college campuses.

PUBLIC SIGNIFICANCE

The BASE is a new screening tool to identify eating disorders. The BASE performed as well as, if not better than, the SCOFF (particularly in men). Given the need for brief, psychometrically strong, and unbiased ED screening tools in college students, the current study helps address an unmet student healthcare need that we expect will contribute to improved identification of EDs on college campuses.

Development and usability testing of a chatbot to promote mental health services use among individuals with eating disorders following screening

OBJECTIVE

A significant gap exists between those who need and those who receive care for eating disorders (EDs). Novel solutions are needed to encourage service use and address treatment barriers. This study developed and evaluated the usability of a chatbot designed for pairing with online ED screening. The tool aimed to promote mental health service utilization by improving motivation for treatment and self-efficacy among individuals with EDs.

METHODS

A chatbot prototype, Alex, was designed using decision trees and theoretically-informed components: psychoeducation, motivational interviewing, personalized recommendations, and repeated administration. Usability testing was conducted over four iterative cycles, with user feedback informing refinements to the next iteration. Post-testing, participants (N= 21) completed the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), and a semi-structured interview.

RESULTS

Interview feedback detailed chatbot aspects participants enjoyed and aspects necessitating improvement. Feedback converged on four themes: user experience, chatbot qualities, chatbot content, and ease of use. Following refinements, users described Alex as humanlike, supportive, and encouraging. Content was perceived as novel and personally relevant. USE scores across domains were generally above average (~5 out of 7), and SUS scores indicated "good" to "excellent" usability across cycles, with the final iteration receiving the highest average score.

DISCUSSION

Overall, participants generally reflected positively on interactions with Alex, including the initial version. Refinements between cycles further improved user experiences. This study provides preliminary evidence of the feasibility and acceptance of a chatbot designed to promote motivation for and use of services among individuals with EDs.

PUBLIC SIGNIFICANCE

Low rates of service utilization and treatment have been observed among individuals following online eating disorder screening. Tools are needed, including scalable, digital options, that can be easily paired with screening, to improve motivation for addressing eating disorders and promote service utilization.

Predictors of treatment seeking and uptake among respondents to a widely disseminated online eating disorders screen in the United States

OBJECTIVE

To explore predictors of treatment seeking and uptake among individuals following an online eating disorders (EDs) screen in the U.S. disseminated by the National Eating Disorders Association.

METHOD

Respondents who screened at risk or positive for a probable ED from 04/2019 to 05/2021 (N = 263,530) were eligible to complete a 2-month follow-up survey that assessed treatment seeking and uptake after being offered referral options following screening. Analyses were conducted using chi-square tests or logistic regressions.

RESULTS

Sixty thousand thirty-four respondents (22.8%) opted-in to the follow-up survey, of whom 2276 (3.8%) completed it. Of the final analytic sample (n = 1922), 35.7% of respondents reported seeking and 22.4% reported receiving treatment. Treatment seeking and uptake were more common among respondents who were female, White, or >24 years of age; uptake was more common among respondents who were non-Hispanic or higher income. Elevated shape/weight concerns were significantly, albeit modestly, associated with reduced likelihood to receive treatment.

DISCUSSION

Demographic differences in treatment seeking and uptake highlight the need to optimize ED screening tools/feedback to meet the needs of underserved groups and to address stereotypes and structural barriers that may interfere. Research is also needed to identify barriers to uptake among those with elevated shape/weight concerns.

PUBLIC SIGNIFICANCE

Relatively low rates of treatment seeking and uptake were observed, particularly among underserved groups, 2 months following a widely disseminated online eating disorders screen. Optimization of online eating disorder screening tools and delivery of feedback and referral information may be needed to increase health care utilization.

Sexual assault predicts unhealthy weight management among college women: A longitudinal, prospective study

Objective: To examine whether sexual assault prospectively predicts unhealthy weight management behaviors in college women. Method: Participants were female college students (N = 483) with monthly assessments across the first year, including the frequency and severity of sexual assault and unhealthy weight management behaviors. Results: Frequency of sexual assault prior to college predicted dieting, purging, and diet pill use, over the first year. Severity of those experiences predicted dieting and diet pill use. Frequency of sexual assault during the first semester predicted purging and diet pill use during the second semester. Severity predicted all three unhealthy weight management behaviors. Findings held consistently when controlling for socioeconomic status (SES), race/ethnicity, body mass index (BMI), and pre-college mood, anxiety, and eating disorders, as well as unhealthy weight management behaviors during the first semester in longitudinal analyses. Reverse models were non-significant. Conclusions: This research documents the detrimental effects of sexual assault on unhealthy weight management behaviors in college women, and highlights the importance of prevention and intervention.

Estimated prevalence of eating disorders in Malaysia based on a diagnostic screen

Eating disorders (EDs) are debilitating health conditions and common across cultures. Recent reports suggest that about 14.0% of university students in Malaysia are at risk for developing an ED, and that prevalence may differ by ethnicity and gender. However, less is known about the prevalence of EDs in nonuniversity populations.

OBJECTIVE

The current study seeks to (1) estimate the prevalence of EDs and ED risk status among adults in Malaysia using an established diagnostic screen; (2) examine gender and ethnic differences between ED diagnostic/risk status groups; and (3) characterize the clinical profile of individuals who screen positive for an ED.

METHOD

We administered the Stanford-Washington University Eating Disorder Screen, an online ED screening tool, to adults in Malaysia in September 2020.

RESULTS

ED risk/diagnostic categories were assigned to 818 participants (ages 18-73 years) of which, 0.8% screened positive for anorexia nervosa, 1.4% for bulimia nervosa, 0.1% for binge-ED, 51.4% for other specified feeding or ED, and 4.8% for avoidant/restrictive food intake disorder. There was gender parity in the high risk and the overall ED categories. The point prevalence of positive eating pathology screening among Malays was significantly higher than Chinese but no different from Indians.

DISCUSSION

This is the first study to estimate the prevalence of EDs using a diagnostic screen in a population-based sample of Malaysians. It is concerning that over 50% of Malaysians reported symptoms of EDs. This study highlights the need to invest more resources in understanding and managing eating pathology in Malaysia.

PUBLIC SIGNIFICANCE

This study estimates the prevalence of EDs among adults in Malaysia using an online EDs screen. Over 50% of Malaysians report symptoms of EDs. The study highlights the need for more resources and funding to address this important public health issue through surveillance, prevention, and treatment of EDs in Malaysia.

Screening for Eating Disorders in Adolescents and Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Eating disorders are associated with adverse health and social outcomes.

OBJECTIVE

To review the evidence on screening for eating disorders in adolescents and adults to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, Cochrane Library, PsycINFO, and trial registries through December 19, 2020; surveillance through January 1, 2022.

STUDY SELECTION

English-language studies of screening test accuracy, randomized clinical trials (RCTs) of screening or interventions for eating disorders in populations with screen-detected or previously untreated eating disorders (trials limited to populations who are underweight were ineligible).

DATA EXTRACTION AND SYNTHESIS

Dual review of abstracts, full-text articles, and study quality. Meta-analysis of test accuracy studies and intervention trials.

MAIN OUTCOMES AND MEASURES

Test accuracy, eating disorder symptom severity, quality of life, depression, and harms.

RESULTS

Fifty-seven studies were included (N = 10 773); 3 (n = 1073) limited to adolescents (mean or median age, 14-15 years). No study directly evaluated the benefits and harms of screening. Seventeen studies (n = 6804) evaluated screening test accuracy. The SCOFF questionnaire (cut point ≥2) had a pooled sensitivity of 84% (95% CI, 74% to 90%) and pooled specificity of 80% (95% CI, 65% to 89%) in adults (10 studies, n = 3684). Forty RCTs (n = 3969) evaluated interventions for eating disorders; none enrolled a screen-detected population. Lisdexamfetamine for binge eating disorder (4 RCTs; n = 900) was associated with larger reductions in eating disorder symptom severity on the Yale-Brown Obsessive Compulsive Scale modified for binge eating (YBOCS-BE) than placebo (pooled mean difference, -5.75 [95% CI, -8.32 to -3.17]). Two RCTs (n = 465) of topiramate for binge eating disorder found larger reductions in YBOCS-BE scores associated with topiramate than placebo, from -6.40 (95% CI, -8.16 to -4.64) to -2.55 (95% CI, -4.22 to -0.88). Nine pharmacotherapy trials (n = 2006) reported on harms. Compared with placebo, lisdexamfetamine was associated with higher rates of dry mouth, headache, and insomnia, and topiramate was associated with higher rates of paresthesia, taste perversion, confusion, and concentration difficulty. Twenty-four trials (n = 1644) assessed psychological interventions. Guided self-help for binge eating disorder improved eating disorder symptom severity more than control (pooled standardized mean difference, -0.96 [95% CI, -1.26 to -0.67]) (5 studies, n = 391). Evidence on other interventions was limited.

CONCLUSIONS AND RELEVANCE

No studies directly assessed the benefits and harms of screening. The SCOFF questionnaire had adequate accuracy for detecting eating disorders among adults. No treatment trials enrolled screen-detected populations; guided self-help, lisdexamfetamine, and topiramate were effective for reducing eating disorder symptom severity among referred populations with binge eating disorder, but pharmacotherapies were also associated with harms.

Effectiveness of a chatbot for eating disorders prevention: A randomized clinical trial

OBJECTIVE

Prevention of eating disorders (EDs) is of high importance. However, digital programs with human moderation are unlikely to be disseminated widely. The aim of this study was to test whether a chatbot (i.e., computer program simulating human conversation) would significantly reduce ED risk factors (i.e., weight/shape concerns, thin-ideal internalization) in women at high risk for an ED, compared to waitlist control, as well as whether it would significantly reduce overall ED psychopathology, depression, and anxiety and prevent ED onset.

METHOD

Women who screened as high risk for an ED were randomized (N = 700) to (1) chatbot based on the StudentBodies© program; or (2) waitlist control. Participants were followed for 6 months.

RESULTS

For weight/shape concerns, there was a significantly greater reduction in intervention versus control at 3- (d = -0.20; p = .03) and 6-m-follow-up (d = -0.19; p = .04). There were no differences in change in thin-ideal internalization. The intervention was associated with significantly greater reductions than control in overall ED psychopathology at 3- (d = -0.29; p = .003) but not 6-month follow-up. There were no differences in change in depression or anxiety. The odds of remaining nonclinical for EDs were significantly higher in intervention versus control at both 3- (OR = 2.37, 95% CI [1.37, 4.11]) and 6-month follow-ups (OR = 2.13, 95% CI [1.26, 3.59]).

DISCUSSION

Findings provide support for the use of a chatbot-based EDs prevention program in reducing weight/shape concerns through 6-month follow-up, as well as in reducing overall ED psychopathology, at least in the shorter-term. Results also suggest the intervention may reduce ED onset.

PUBLIC SIGNIFICANCE

We found that a chatbot, or a computer program simulating human conversation, based on an established, cognitive-behavioral therapy-based eating disorders prevention program, was successful in reducing women's concerns about weight and shape through 6-month follow-up and that it may actually reduce eating disorder onset. These findings are important because this intervention, which uses a rather simple text-based approach, can easily be disseminated in order to prevent these deadly illnesses.

TRIAL REGISTRATION

OSF Registries; https://osf.io/7zmbv.

Concerns and recommendations for using Amazon MTurk for eating disorder research

OBJECTIVE

Our original aim was to validate and norm common eating disorder (ED) symptom measures in a large, representative community sample of transgender adults in the United States. We recruited via Amazon Mechanical Turk (MTurk), a popular online recruitment and data collection platform both within and outside of the ED field. We present an overview of our experience using MTurk.

METHOD

Recruitment began in Spring 2020; our original target N was 2,250 transgender adults stratified evenly across the United States. Measures included a demographics questionnaire, the Eating Disorder Examination-Questionnaire, and the Eating Attitudes Test-26. Consistent with current literature recommendations, we implemented a comprehensive set of attention and validity measures to reduce and identify bot responding, data farming, and participant misrepresentation.

RESULTS

Recommended validity and attention checks failed to identify the majority of likely invalid responses. Our collection of two similar ED measures, thorough weight history assessment, and gender identity experiences allowed us to examine response concordance and identify impossible and improbable responses, which revealed glaring discrepancies and invalid data. Furthermore, qualitative data (e.g., emails received from MTurk workers) raised concerns about economic conditions facing MTurk workers that could compel misrepresentation.

DISCUSSION

Our results strongly suggest most of our data were invalid, and call into question results of recently published MTurk studies. We assert that caution and rigor must be applied when using MTurk as a recruitment tool for ED research, and offer several suggestions for ED researchers to mitigate and identify invalid data.

The Challenges in Designing a Prevention Chatbot for Eating Disorders: Observational Study

BACKGROUND

Chatbots have the potential to provide cost-effective mental health prevention programs at scale and increase interactivity, ease of use, and accessibility of intervention programs.

OBJECTIVE

The development of chatbot prevention for eating disorders (EDs) is still in its infancy. Our aim is to present examples of and solutions to challenges in designing and refining a rule-based prevention chatbot program for EDs, targeted at adult women at risk for developing an ED.

METHODS

Participants were 2409 individuals who at least began to use an EDs prevention chatbot in response to social media advertising. Over 6 months, the research team reviewed up to 52,129 comments from these users to identify inappropriate responses that negatively impacted users' experience and technical glitches. Problems identified by reviewers were then presented to the entire research team, who then generated possible solutions and implemented new responses.

RESULTS

The most common problem with the chatbot was a general limitation in understanding and responding appropriately to unanticipated user responses. We developed several workarounds to limit these problems while retaining some interactivity.

CONCLUSIONS

Rule-based chatbots have the potential to reach large populations at low cost but are limited in understanding and responding appropriately to unanticipated user responses. They can be most effective in providing information and simple conversations. Workarounds can reduce conversation errors.

Eating disorder behaviors and treatment seeking in self-identified military personnel and veterans: Results of the National Eating Disorders Association online screening

OBJECTIVE

To characterize disordered eating behaviors, eating disorder (ED) risk and diagnosis, and treatment seeking behaviors in active-duty military personnel/veterans compared with civilians.

METHOD

Self-selecting participants (n = 113,388; 1744 were military personnel/veterans) 18+ years old completed the National Eating Disorders Association's online screen. Engagement in and frequencies of disordered eating behaviors were compared across military/veteran and civilian groups and were stratified by gender. ED risk and diagnosis and treatment seeking behaviors were also compared.

RESULTS

Individuals in the military/veteran group were more likely to engage in diuretic/laxative use and excessive exercise compared with civilians. Compared with civilians, the military/veteran group had a lower percentage who screened "at risk for an ED" and a higher percentage who screened for "no risk". Females in the military/veteran group were more likely to engage in diuretic/laxative use, excessive exercise, and fasting compared with female civilians; males in the military/veteran group were more likely to engage in excessive exercise and less likely to engage in vomiting than male civilians. Of the self-identified military personnel/veterans who screened positive for any ED, 86% had never received treatment, which did not differ significantly from civilians. Notably, 56.7% of those (54.1% of military/veteran group; 56.7% of civilians) who completed an optional item on intention to seek treatment (n = 5312) indicated they would not seek treatment.

CONCLUSIONS

Disordered eating and ED profiles, but not treatment seeking, may differ between military personnel/veterans and civilians who complete an online ED screen. Future work should emphasize treatment options and connecting respondents directly to tailored resources.

Assessment of avoidant restrictive food intake disorder, pica and rumination disorder: interview and questionnaire measures

PURPOSE OF REVIEW

This article reviews available assessment instruments for three of the feeding and eating disorder diagnostic categories: avoidant restrictive food intake disorder (ARFID), pica, and rumination disorder (RD). It includes an overview of the current status of screening tools, questionnaire measures, and diagnostic instruments.

RECENT FINDINGS

Screening instruments are available for all three disorders; however, for pica and RD, these typically include single screening items only and do not cover any specific features of these presentations. Only one questionnaire suitable for clinical populations is included, covering ARFID only. Standardized diagnostic interviews are limited to two covering both pica and RD, only one of which provides further clinical information. Of the five diagnostic instruments for ARFID described here, two include diagnostic items as well as allowing more detailed assessment of clinical features.

SUMMARY

There are a limited number of assessment measures available for all three disorders, with instruments for ARFID being the greatest in number and widest in terms of scope. A commonly encountered difficulty is that many assessment instruments do not adequately cover diagnostic exclusion criteria, which raises the likelihood of false positive findings. All currently available measures require further study to determine their reliability and validity.

Characterizing eating disorder diagnosis and related outcomes by sexual orientation and gender identity in a national sample of college students

OBJECTIVE

In a national sample of college students, the current study aimed to: 1) examine differences in probable diagnoses of EDs (i.e., anorexia nervosa (AN), clinical/subthreshold bulimia nervosa (BN), or binge eating disorder (BED)) and weight and shape concerns by sexual orientation and gender identity, and 2) examine differences in ED chronicity and probable comorbid psychiatric diagnoses by sexual orientation and gender identity.

METHOD

Students across nine U.S. universities completed an online screener for DSM-5 clinical or subthreshold ED diagnoses, comorbid depression and anxiety disorders, and self-reported ED chronicity. Self-reported sexual orientation and gender identity were also collected. Tukey-corrected logistic and linear regressions examined differences in outcomes separately by sexual orientation and gender identity, adjusting for age, race, and ethnicity.

RESULTS

A total of 8,531 students (24% sexually diverse (SD); 2.7% gender diverse (GD)) were studied. Students who identified as bisexual or other sexual orientation reported significantly greater odds of a probable ED diagnosis and greater elevations in weight and shape concerns compared to heterosexual students. Cisgender female students and GD students reported significantly greater odds of a probable ED diagnosis and greater elevations in weight and shape concerns compared to cisgender male students. Some SD students and GD students who met criteria for probable EDs were also more likely to report chronic ED symptoms and probable comorbid psychiatric diagnoses compared to heterosexual students and cisgender males, respectively.

DISCUSSION

Some SGD students may be at heightened risk for EDs, highlighting the need to identify mechanisms that contribute to disparities.

Exploring Social Media Recruitment Strategies and Preliminary Acceptability of an mHealth Tool for Teens with Eating Disorders

(1) Background: The current study leveraged social media to connect with teens with EDs to identify population specific characteristics and to gather feedback on an mHealth intervention. (2) Methods: We recruited teens with EDs from social media in two phases: (1) Discovery Group, (2) Testing Group. The Discovery Group (n = 14) participants were recruited from Facebook/Instagram and were asked to review the app for up to one week and provide qualitative feedback. After incorporating feedback from the Discovery Group, we refined our social media outreach methods to connect with 30 teens with EDs to pilot this mobile app. Recruitment from a variety of platforms on social media was successful, with the majority of enrolled participants in the Testing Group coming from Snapchat (60%) and a large percentage of participants belonging to gender and sexual minority groups (63%). (3) Results: Participants from both groups experienced extremely high rates of depression (100% Discovery, 90% Testing) and/or anxiety symptoms (100% Discovery, 93% Testing) in addition to ED symptoms, and noted this as a possible barrier to app engagement. (4) Conclusion: Use of social media for recruitment of teens with EDs is feasible and may connect with groups who may be more difficult to reach using traditional recruitment methods. Among the Discovery Group there was high acceptability of and interest in an app to support ED recovery, and characteristics of both groups demonstrated need for support in other mental health domains. Future studies should evaluate the preliminary efficacy of such tools among teens to determine the effects of such interventions on ED symptoms and other mental health outcomes.

College Mental Health Before and During the COVID-19 Pandemic: Results From a Nationwide Survey

Background

The COVID-19 pandemic could affect college students’ mental health. We examined screening rates for psychological disorders before and during the pandemic.

Methods

Undergraduates were surveyed before (n = 3643) or during the pandemic (n = 4970). Logistic regression adjusting for participant demographics was conducted.

Results

Frequencies of depression [OR 1.32, 95% CI (1.17, 1.48)], alcohol use disorder [OR 1.70, 95% CI (1.50, 1.93)], bulimia nervosa/binge-eating disorder [OR 1.54, 95% CI (1.28, 1.85)], and comorbidity [OR 1.19, 95% CI (1.04, 1.35)] were greater during (vs. before) the pandemic. Frequencies of posttraumatic stress disorder were lower during the pandemic [OR 0.86, 95% CI (0.75, 0.98)]. The upward trend in alcohol use disorder was stronger among women than men [OR 1.47, 95% CI (1.18, 1.83)]. The upward trend in depression was stronger among Black students than White students [OR 1.72, 95% CI (1.19, 2.49)]. Anxiety disorders, insomnia, anorexia nervosa, and suicidality showed no significant trends.

Conclusions

Depression, alcohol use disorder, bulimia nervosa/binge-eating disorder, and comorbidity were higher, whereas posttraumatic stress disorder was lower during the pandemic. Women and Black students could face especially heightened risk for alcohol use disorder and depression, respectively, during the pandemic.

Harnessing mobile technology to reduce mental health disorders in college populations: A randomized controlled trial study protocol

About a third of college students struggle with anxiety, depression, or an eating disorder, and only 20-40% of college students with mental disorders receive treatment. Inadequacies in mental health care delivery result in prolonged illness, disease progression, poorer prognosis, and greater likelihood of relapse, highlighting the need for a new approach to detect mental health problems and engage college students in services. We have developed a transdiagnostic, low-cost mobile mental health targeted prevention and intervention platform that uses population-level screening to engage college students in tailored services that address common mental health problems. We will test the impact of this mobile mental health platform for service delivery in a large-scale trial across 20+ colleges. Students who screen positive or at high-risk for clinical anxiety, depression, or an eating disorder and who are not currently engaged in mental health services (N = 7884) will be randomly assigned to: 1) intervention via the mobile mental health platform; or 2) referral to usual care (i.e., campus health or counseling center). We will test whether the mobile mental health platform, compared to referral, is associated with improved uptake, reduced clinical cases, disorder-specific symptoms, and improved quality of life and functioning. We will also test mediators, predictors, and moderators of improved mental health outcomes, as well as stakeholder-relevant outcomes, including cost-effectiveness and academic performance. This population-level approach to service engagement has the potential to improve mental health outcomes for the millions of students enrolled in U.S. colleges and universities.

Overweight and obesity are associated with increased eating disorder correlates and general psychopathology in university women with eating disorders

OBJECTIVE

Examine how eating disorder (ED) correlates, ED-related clinical impairment, general psychopathology, and ED diagnoses differ across weight statuses in a sample of university women with EDs.

METHOD

Participants were 690 women from 28 U.S. universities who screened positive for an ED (with the exception of anorexia nervosa [AN]) and participated in the Healthy Body Image Program study. ED correlates, ED-related clinical impairment, general psychopathology (i.e., depression and anxiety), and ED diagnoses were compared across weight statuses (i.e., healthy weight, overweight, obesity) using analyses of variance and chi-square tests.

RESULTS

Women with EDs and overweight or obesity had higher levels of, perceived benefit of thinness, depressive symptoms, anxiety, and weight/shape concerns (obesity only) than those with healthy weight (ps ≤ .017). Compared to those with healthy weight, those with obesity had higher rates of clinical and sub-clinical binge eating disorder and lower rates of bulimia nervosa (p < .001).

DISCUSSION

Overweight and obesity in individuals with EDs, excluding AN, are associated with greater severity of ED correlates, ED-related clinical impairment, and co-morbid general psychopathology. The current study highlights the need to consider weight status in ED treatment and for optimization of ED treatments to address shared risk factors between EDs and overweight and obesity.

Comparing eating disorder characteristics and treatment in self-identified competitive athletes and non-athletes from the National Eating Disorders Association online screening tool

OBJECTIVE

We compared eating disorder (ED) characteristics and treatment seeking behaviors between self-identified competitive athletes and non-athletes in a large, community-based sample.

METHOD

During the 2018 National Eating Disorders Awareness Week, 23,920 respondents, 14.7% of whom identified as competitive athletes, completed the National Eating Disorders Association online screen. Data were collected on demographics, disordered eating behaviors, probable ED diagnosis/risk, treatment history, and intent to seek treatment.

RESULTS

The sample was predominantly White (81.8%), female (90.3%), and between 13 and 24 years (82.6%). Over 86% met criteria for an ED/subthreshold ED, and of those, only 2.5% were in treatment. Suicidal ideation was reported in over half of the sample. Athletes reported a significantly greater likelihood of engaging in and more frequent excessive exercise episodes than non-athletes. Athletes also reported a significantly lower likelihood of engaging in and less frequent binge-eating episodes compared with non-athletes. Athletes were more likely to screen positive for an ED/subthreshold ED than non-athletes, but percentages across all probable ED diagnoses were similar. No significant differences between athletes and non-athletes emerged on treatment history or intention to seek treatment post-screen (less than 30%).

DISCUSSION

Although the distribution of probable ED diagnoses was similar in athletes and non-athletes, symptom profiles related to disordered eating behavior engagement and frequency may differ. Athletes may be less likely to seek treatment due to stigma, accessibility, and sport-specific barriers. Future work should directly connect survey respondents to tailored treatment tools and increase motivation to seek treatment.

Estimated prevalence of eating disorders in Singapore

OBJECTIVE

There is a lack of research on the prevalence of eating disorders (EDs) in Singapore. The aims of our study were to (a) estimate the prevalence of EDs, risk status, and help-seeking behaviors among adults in Singapore, (b) examine gender differences between ED status groups, and (c) characterize clinical profiles of ED status groups.

METHOD

We administered a cross-sectional survey that included a validated EDs screening tool to adults in Singapore.

RESULTS

A total of 797 Singaporean adults ages 21-77 years completed the ED screen. The majority of participants screened positive for a current DSM-5 clinical ED (6.2%), other specified feeding or ED (37.0%) or at high risk of developing an ED (19.5%). Only 1.6% of those who screened positive for an ED reported currently being in treatment. The ratio of males to females who screened positive for an ED was nearly 1:1. The clinical profiles of ED groups were consistent with the clinical presentations found in Western nations.

DISCUSSION

This is the first study in Singapore to estimate the prevalence of EDs in a large sample of adults. Results highlight the urgent need for more ED research and expansion of prevention and treatment programs to address the high prevalence of ED psychopathology in Singapore.

Adolescents and young adults engaged with pro-eating disorder social media: eating disorder and comorbid psychopathology, health care utilization, treatment barriers, and opinions on harnessing technology for treatment

PURPOSE

The purpose of this study was to examine exposure (i.e., seeing, following, posting) to body image content emphasizing a thin ideal on various social media platforms and probable eating disorder (ED) diagnoses, ED-related quality of life, and psychiatric comorbidities (i.e., depression, anxiety) among adolescents and young adult females recruited via social media who endorsed viewing and/or posting pro-ED online content. We also investigated health care utilization, treatment barriers, and opinions on harnessing technology for treatment.

METHODS

Participants were 405 adolescent and young adult females engaged with pro-ED social media. We reported on study constructs for the sample as a whole, as well as on differences between age groups.

RESULTS

Eighty-four percent of participants' self-reported symptoms were consistent with a clinical/subclinical ED, and this was slightly more common among young adults. Participants endorsed reduced ED-related quality of life, as well as comorbid depression and anxiety. Among those with clinical/subclinical EDs, only 14% had received treatment. The most common treatment barriers were believing the problem was not serious enough and believing one should help themselves. The majority of participants approved of harnessing technology for treatment.

CONCLUSIONS

Results provide support for engagement with pro-ED online content serving as a potential indicator of ED symptoms and suggest promise for facilitating linkage from social media to technology-enhanced interventions.

LEVEL OF EVIDENCE

V, cross-sectional descriptive study.

The Relationship between Childhood Trauma, Eating Disorders, and Sleep Quality among Registered Hospital Nurses in South Korea

This cross-sectional study examined the relationship between childhood trauma, eating disorders, and sleep quality among registered hospital nurses in South Korea. Self-report questionnaires were answered by 279 nurses from six general hospitals. Factors affecting sleep quality were analyzed with a linear regression analysis. The factors that influenced sleep quality included age, alcohol consumption, chronic disease, BMI, and emotional abuse in childhood trauma. Hospital nurses need to increase their sleep health knowledge to maintain a healthy lifestyle while working as a nurse. Therefore, hospital and nursing managers should consider strategies to prevent and intervene in the sleep quality threats attributed to the adverse childhood experiences of hospital nurses.

Transitioning to digital first line intervention - validation of a brief online screener for early identification of a suspected eating disorder: study protocol

BACKGROUND

Only one in four people with eating disorders seeks treatment, and of those who do seek treatment, 20% go on to experience a chronic course. Early intervention has been associated with better prognosis, with those seeking specialised intervention in the early stages of their illness more than twice as likely to achieve remission. Current screening measures typically require expert administration and are rarely validated across a spectrum of DSM-5 eating disorder presentations or for online use. In light of COVID-19 and increasing reliance on telehealth technologies in the intervention and delivery of mental health services, online assessments suitable for self-referral are likely to be the first step to seeking care. InsideOut Institute has developed a 6-item online screening tool for the purposes of identifying eating disorder risk and symptomatology, aimed specifically at increasing help-seeking behaviour in subsyndromal and early presentations.

METHODS

This study investigates the reliability and validity of the InsideOut Institute Screener (IOI-S), using a cross-sectional survey research design. Participants aged 14 and over will complete an extensive baseline survey battery for evaluation. 50% of participants will be randomly selected for one follow-up re-test of the IOI-S only, 2 weeks post initial testing. The IOI-S will be analysed for statistical reliability on two parameters: internal consistency and test re-test reliability, and for statistical validity on four parameters: concurrent validity, sensitivity and specificity, convergent and discriminant validity.

DISCUSSION

The rapid and ongoing shift to digital intervention has highlighted gaps and opportunities in our pathways to care. Adequate screening for eating disorders is a major gap. This study aims to validate an online screening tool for use in telehealth early intervention, designed for users seeking information for a suspected eating disorder. The screener meets those at risk 'where they are' (i.e. online) and may improve timely referrals to relevant services. This is of particular salience as face-to-face healthcare and traditional frontline interventions are disrupted, and we are challenged to re-design our practices to deliver diagnostic and treatment services in highly adaptive digital contexts.

Eating disorder symptomatology, clinical impairment, and comorbid psychopathology in racially and ethnically diverse college women with eating disorders

OBJECTIVE

To examine eating disorder (ED) symptomatology, related clinical impairment, and comorbid psychopathology in college women with EDs across five racial and two ethnic groups.

METHOD

Participants were 690 women from 28 US universities who screened positive for an ED. Thirteen variables assessing ED symptoms, related clinical impairment, and comorbid psychopathology were compared across racial and ethnic groups using analyses of variance (ANOVAs) and independent samples t-tests.

RESULTS

Across racial groups, significant differences emerged in binge eating and laxative use. Asian women reported significantly more binge eating than White women (p < .01). Individuals self-identified as the "Other" racial group reported greater laxative use than Asian and White women (ps ≤ .01). No other significant differences emerged across all other variables (ps ≥ .13). Across ethnic groups, Hispanic women reported significantly more laxative use (p < .01), and more comorbid insomnia symptoms (p = .03) than non-Hispanic women. No other significant differences were observed (ps ≥ .24).

DISCUSSION

Findings suggest that binge eating, laxative use, and insomnia symptoms differ across racial and ethnic groups in US college women who screened positive for EDs. Findings can inform tailoring of ED screening to reduce current disparities in these underrepresented populations.

Parental consent: A potential barrier for underage teens' participation in an mHealth mental health intervention

PURPOSE

We sought to examine whether underage adolescents displaying symptoms for a mental illness (i.e., an eating disorder) would be willing to obtain parental consent to participate in a study to test the efficacy of an evidence-based mobile mental health intervention targeting teens with eating disorders.

METHODS

The participants (n = 366) were 15 to 17 year-old English-speakers who post or follow social media accounts on Instagram that emphasize being thin as important or attractive. The participants were administered a survey through Qualtrics to assess eating disorder pathology, interest in trying an evidence-based mobile mental-health intervention, and comfort level with obtaining parental consent to partake in a research study about such an intervention.

RESULTS

About 85% of participants met clinical or subclinical criteria for an eating disorder; however, only 12% had received a treatment within the past six months. While 83% of participants were interested in trying a mobile health interventions app, only 35% indicated willingness to obtain parental consent to participate in a research study. The primary reasons presented for unwillingness to obtain consent included importance of retaining privacy and feeling that parents lack awareness or understanding about mental health issues.

CONCLUSIONS

While barriers exist to obtaining treatment for eating disorders, a mobile intervention app may close some of these gaps. Many underage participants indicated interest in obtaining such treatment, yet only a third were willing to obtain parental consent. Future studies should investigate how to reduce these barriers to obtaining parental consent to facilitate teen access to research and mobile mental health treatment.

Preliminary data on help-seeking intentions and behaviors of individuals completing a widely available online screen for eating disorders in the United States

OBJECTIVE

Scaling an online screen that provides referrals may be key in closing the treatment gap for eating disorders (EDs), but we need to understand respondents' help-seeking intentions and behaviors after receiving screen results. This study reported on these constructs among respondents to the National Eating Disorders Association online screen who screened positive or at high risk for an ED.

METHOD

Respondents completed the screen over 18 months (February 9, 2018-August 28, 2019). Those screening positive or at high risk for an ED (n = 343,072) had the option to provide data on help-seeking intentions (after screen completion) and behaviors (2-month follow-up).

RESULTS

Of eligible respondents, 4.8% (n = 16,396) provided data on help-seeking intentions, with only 33.7% of those reporting they would seek help. Only 7.6% of eligible respondents opted in to the 2-month follow-up, with 10.6% of those completing it (n = 2,765). Overall, 8.9% of respondents to the follow-up reported being in treatment when they took the screen, 15.5% subsequently initiated treatment, and 75.5% did not initiate/were not already in treatment.

DISCUSSION

Preliminary results suggest that among the small minority who provided data, only one-third expressed help-seeking intentions and 16% initiated treatment. Online screening should consider ways to increase respondents' motivation for and follow-through with care.

Predicting eating disorders from Internet activity

OBJECTIVE

Eating disorders (EDs) compromise the health and functioning of affected individuals, but it can often take them several years to acknowledge their illness and seek treatment. Early identification of individuals with EDs is a public health priority, and innovative approaches are needed for such identification and ultimate linkage with evidence-based interventions. This study examined whether Internet activity data can predict ED risk/diagnostic status, potentially informing timely interventions.

METHOD

Participants were 936 women who completed a clinically validated online survey for EDs, and 231 of them (24.7%) contributed their Internet browsing history. A machine learning algorithm used key attributes from participants' Internet activity histories to predict their ED status: clinical/subclinical ED, high risk for an ED, or no ED.

RESULTS

The algorithm reached an accuracy of 52.6% in predicting ED risk/diagnostic status, compared to random decision accuracy of 38.1%, a relative improvement of 38%. The most predictive Internet search history variables were the following: use of keywords related to ED symptoms and websites promoting ED content, participant age, median browsing events per day, and fraction of daily activity at noon.

DISCUSSION

ED risk or clinical status can be predicted via machine learning with moderate accuracy using Internet activity variables. This model, if replicated in larger samples where it demonstrates stronger predictive value, could identify populations where further assessment is merited. Future iterations could also inform tailored digital interventions, timed to be provided when target online behaviors occur, thereby potentially improving the well-being of many individuals who may otherwise remain undetected.

Longer-term follow-up of college students screening positive for anorexia nervosa: psychopathology, help seeking, and barriers to treatment

The purpose of this study was to conduct a longer-term (i.e., 9-month) follow-up of students identified with possible anorexia nervosa (AN) as part of the Healthy Body Image Program, an online platform for screening and delivering tailored feedback and interventions, offered at 36 US universities. Participants were 61 individuals who screened positive for AN and who completed the follow-up. Regarding results, some indices of ED pathology and psychiatric comorbidity decreased over time, while others did not. Participants most commonly endorsed feeling ashamed, nervous, validated, and sad in response to receiving the referral. One-third (33%) reported already being in treatment at the time they received the referral, 26% initiated treatment since that time, and 41% did not initiate treatment. The most common reasons for seeking treatment were emotional distress, concern with eating, and health concerns. The strongest treatment barriers were believing one should be able to help themselves, believing the problem was not serious enough to warrant treatment, and not having time. Findings highlight the high level of pathology in students identified with possible AN, even nine months after they were first identified and provided resources, and the relatively low rates of treatment utilization given the seriousness of these illnesses.

Effectiveness of a Digital Cognitive Behavior Therapy-Guided Self-Help Intervention for Eating Disorders in College Women: A Cluster Randomized Clinical Trial

Importance

Eating disorders (EDs) are common, serious psychiatric disorders on college campuses, yet most affected individuals do not receive treatment. Digital interventions have the potential to bridge this gap.

Objective

To determine whether a coached, digital, cognitive behavior therapy (CBT) intervention improves outcomes for college women with EDs compared with referral to usual care.

Design, Setting, and Participants

This cluster randomized trial was conducted from 2014 to 2018 at 27 US universities. Women with binge-purge EDs (with both threshold and subthreshold presentations) were recruited from enrolled universities. The 690 participants were followed up for up to 2 years after the intervention. Data analysis was performed from February to September 2019.

Interventions

Universities were randomized to the intervention, Student Bodies-Eating Disorders, a digital CBT-guided self-help program, or to referral to usual care.

Main Outcomes and Measures

The main outcome was change in overall ED psychopathology. Secondary outcomes were abstinence from binge eating and compensatory behaviors, as well as ED behavior frequencies, depression, anxiety, clinical impairment, academic impairment, and realized treatment access.

Results

A total of 690 women with EDs (mean [SD] age, 22.12 [4.85] years; 414 [60.0%] White; 120 [17.4%] Hispanic; 512 [74.2%] undergraduates) were included in the analyses. For ED psychopathology, there was a significantly greater reduction in the intervention group compared with the control group at the postintervention assessment (β [SE], -0.44 [0.10]; d = -0.40; t1387 = -4.23; P < .001), as well as over the follow-up period (β [SE], -0.39 [0.12]; d = -0.35; t1387 = -3.30; P < .001). There was not a significant difference in abstinence from any ED behaviors at the postintervention assessment (odds ratio, 1.48; 95% CI, 0.48-4.62; P = .50) or at follow-up (odds ratio, 1.51; 95% CI, 0.63-3.58; P = .36). Compared with the control group, the intervention group had significantly greater reductions in binge eating (rate ratio, 0.82; 95% CI, 0.70-0.96; P = .02), compensatory behaviors (rate ratio, 0.68; 95% CI, 0.54-0.86; P < .001), depression (β [SE], -1.34 [0.53]; d = -0.22; t1387 = -2.52; P = .01), and clinical impairment (β [SE], -2.33 [0.94]; d = -0.21; t1387 = -2.49; P = .01) at the postintervention assessment, with these gains sustained through follow-up for all outcomes except binge eating. Groups did not differ in terms of academic impairment. The majority of intervention participants (318 of 385 participants [83%]) began the intervention, whereas only 28% of control participants (76 of 271 participants with follow-up data available) sought treatment for their ED (odds ratio, 12.36; 95% CI, 8.73-17.51; P < .001).

Conclusions and Relevance

In this cluster randomized clinical trial comparing a coached, digital CBT intervention with referral to usual care, the intervention was effective in reducing ED psychopathology, compensatory behaviors, depression, and clinical impairment through long-term follow-up, as well as realizing treatment access. No difference was found between the intervention and control groups for abstinence for all ED behaviors or academic impairment. Given its scalability, a coached, digital, CBT intervention for college women with EDs has the potential to address the wide treatment gap for these disorders.

Trial Registration

ClinicalTrials.gov Identifier: NCT02076464.