Self-help for bulimic disorders: a randomised controlled trial comparing minimal guidance with face-to-face or telephone guidance

Adaptive design trials in eating disorder research: A scoping review

OBJECTIVE

This scoping review sought to map the breadth of literature on the use of adaptive design trials in eating disorder research.

METHOD

A systematic literature search was conducted in Medline, Scopus, PsycInfo, Emcare, Econlit, CINAHL and ProQuest Dissertations and Theses. Articles were included if they reported on an intervention targeting any type of eating disorder (including anorexia nervosa, bulimia nervosa, binge-eating disorder, and other specified feeding or eating disorders), and employed the use of an adaptive design trial to evaluate the intervention. Two independent reviewers screened citations for inclusion, and data abstraction was performed by one reviewer and verified by a second.

RESULTS

We identified five adaptive design trials targeting anorexia nervosa, bulimia nervosa and binge-eating disorder conducted in the USA and Australia. All employed adaptive treatment arm switching based on early response to treatment and identified a priori stopping rules. None of the studies included value of information analysis to guide adaptive design decisions and none included lived experience perspectives.

DISCUSSION

The limited use of adaptive designs in eating disorder trials represents a missed opportunity to improve enrolment targets, attrition rates, treatment outcomes and trial efficiency. We outline the range of adaptive methodologies, how they could be applied to eating disorder research, and the specific operational and statistical considerations relevant to adaptive design trials.

PUBLIC SIGNIFICANCE

Adaptive design trials are increasingly employed as flexible, efficient alternatives to fixed trial designs, but they are not often used in eating disorder research. This first scoping review identified five adaptive design trials targeting anorexia nervosa, bulimia nervosa and binge-eating disorder that employed treatment arm switching adaptive methodology. We make recommendations on the use of adaptive design trials for future eating disorder trials.

Pharmacotherapy compared to placebo for people with Bulimia Nervosa: A systematic review and meta-analysis

Bulimia Nervosa is a disorder with high rates of psychiatric and medical comorbidity and substantial societal costs. Cognitive Behavioural Therapy is considered the preferred treatment, but access can be problematic. Pharmacotherapy is more accessible but remains significantly underutilised. We aimed to assess the efficacy, tolerability, and safety of all available forms of pharmacotherapy for the treatment of bulimia nervosa. We conducted a comprehensive search of PubMed, EMBASE, CENTRAL, ClinicalTrials.gov, and reference lists of relevant articles up until April 2023. The primary outcomes were remission and binge frequency. 52 randomised controlled trials (RCTs) involving 3313 participants were included in the meta-analysis. Overall, no significant difference was observed between drugs and placebo in terms of remission; however, the available data were limited. Notably, drugs, particularly antidepressants, demonstrated a significant reduction in the frequency of binge episodes compared to placebo. Antidepressants were also found to be more effective than placebo in terms of treatment response and other clinically meaningful outcomes. An important limitation is that few RCTs were available for individual drugs. Our findings provide evidence supporting the increased utilisation of pharmacotherapy in clinical practice and underscore the need for further research involving larger populations and a broader range of outcomes.

Low intensity psychological interventions for the treatment of feeding and eating disorders: a systematic review and meta-analysis

BACKGROUND

Feeding and eating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Low intensity psychological interventions have the potential to increase such access.

METHODS

A systematic review and meta-analysis were conducted on the use of low intensity psychological interventions for the treatment of feeding and eating disorders. Studies comparing low intensity psychological interventions against high intensity therapies and non-eating disorder specific psychological interventions were included, as well as those with waiting list control arms. There were three primary outcomes: eating disorder psychopathology, diagnostic and statistical manual of mental disorders (DSM) severity specifier-related outcomes and rates of remission/recovery.

RESULTS

Thirty-three studies met the inclusion criteria, comprising 3665 participants, and 30 studies were included in the meta-analysis. Compared to high intensity therapies, low intensity psychological interventions were equivalent on reducing eating disorder psychopathology (g = - 0.13), more effective at improving DSM severity specifier-related outcomes (g = - 0.15), but less likely to achieve remission/recovery (risk ratio (RR) = 0.70). Low intensity psychological interventions were superior to non-eating disorder specific psychological interventions and waiting list controls across all three primary outcomes.

CONCLUSION

Overall, findings suggest that low intensity psychological interventions can successfully treat eating disorder symptoms. Few potential moderators had a statistically significant effect on outcome. The number of studies for many comparisons was low and the methodological quality of the studies was poor, therefore results should be interpreted with caution. More research is needed to establish the effectiveness of low intensity psychological interventions for children and young people, as well as for individuals with anorexia nervosa, avoidant/restrictive food intake disorder, pica and rumination disorder.

Accessibility of Psychological Treatments for Bulimia Nervosa: A Review of Efficacy and Engagement in Online Self-Help Treatments

Bulimia nervosa is an eating disorder characterised by marked impairment to one's physical health and social functioning, as well as high rates of chronicity and comorbidity. This literature review aims to summarise existing academic research related to the symptom profile of BN, the costs and burden imposed by the illness, barriers to the receipt of care, and the evidence base for available psychological treatments. As a consequence of well-documented difficulties in accessing evidence-based treatments for eating disorders, efforts have been made towards developing innovative, diverse channels to deliver treatment, with several of these attempting to harness the potential of digital platforms. In response to the increasing number of trials investigating the utility of online treatments, this paper provides a critical review of previous attempts to examine digital interventions in the treatment of eating disorders. The results of a focused literature review are presented, including a detailed synthesis of a knowledgeable selection of high-quality articles with the aim of providing an update on the current state of research in the field. The results of the review highlight the potential for online self-help treatments to produce moderately sized reductions in core behavioural and cognitive symptoms of eating disorders. However, concern is raised regarding the methodological limitations of previous research in the field, as well as the high rates of dropout and poor adherence reported across most studies. The review suggests directions for future research, including the need to replicate previous findings using rigorous study design and methodology, as well as further investigation regarding the utility of clinician support and interactive digital features as potential mechanisms for offsetting low rates of engagement with online treatments.

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.

Challenges and opportunities for enhanced cognitive behaviour therapy (CBT-E) in light of COVID-19

In the past few weeks, coronavirus disease 2019 (COVID-19) has dramatically expanded across the world. To limit the spread of COVID-19 and its negative consequences, many countries have applied strict social distancing rules. In this dramatic situation, people with eating disorders are at risk of their disorder becoming more severe or relapsing. The risk comes from multiple sources including fears of infection and the effects of social isolation, as well as the limited availability of adequate psychological and psychiatric treatments. A potential practical solution to address some of these problems is to deliver enhanced cognitive behaviour therapy (CBT-E), an evidence-based treatment for all eating disorders, remotely. In this guidance we address three main topics. First, we suggest that CBT-E is suitable for remote delivery and we consider the challenges and advantages of delivering it in this way. Second, we discuss new problems that patients with eating disorders may face in this period. We also highlight potential opportunities for adapting some aspects of CBT-E to address them. Finally, we provide guidelines about how to adapt the various stages, strategies and procedures of CBT-E for teletherapy use in the particular circumstances of COVID-19.

Effectiveness of a Self Help Cognitive Behavioural Treatment Program for Problem Gamblers: A Randomised Controlled Trial

The study aimed to strengthen the scarce literature on self-help treatments for Problem Gambling (PG) by comparing the effectiveness of a Self-Help Cognitive Behavioral Treatment (SHCBT) program (n = 23) with a 6-week Waitlist condition (n = 32) in problem gamblers. Participants were community volunteers with gambling problems and were randomly allocated to the Waitlist and treatment conditions. Results showed significant improvements at post-treatment in gambling behaviors including frequency of gambling, average amount gambled per day and PG symptoms as well as a number of gambling correlates including psychological states (e.g., depression, anxiety and stress), gambling cognitions, gambling urges, gambling related self-efficacy, satisfaction with life, and quality of life among those who completed the SHCBT program, when compared with the waitlist condition. The effect size (partial η ²) ranged from .25 to .57 for all assessed outcomes that showed significant improvement from pre- to post-treatment. It was concluded that a self-help CBT program can be beneficial for treating community problem gamblers.

Telephone-based CBT and the therapeutic relationship: The views and experiences of IAPT practitioners in a low-intensity service

WHAT IS KNOWN ON THE SUBJECT

There is a move towards the use of new ways of delivering mental health care, particularly via an increased use of telephone therapies. Although some studies have noted the advantages of telephone-delivered therapies (e.g., removing access barriers) and reported on equivalent therapeutic effects when compared to face-to-face, there are concerns about how telephone-based therapy adversely affects the therapeutic relationship.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

It contributes new knowledge regarding psychological practitioners' experience and views about using telephone-based therapies and how this affects the therapeutic relationship.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This paper provides data about the new practitioner workforce (IAPT Psychological Wellbeing Practitioners) and adds to a growing area of research regarding their clinical role. It has relevance for mental health nursing, because health services internationally and across the professions are exploring how telehealth can improve health care. This paper suggests that mental health services need to focus on what type of therapeutic relationship their practice facilitates and on offering transparency to service users. It concludes that telephone work in IAPT can accommodate a working alliance, but not other types of therapeutic relationship, which practitioners and service users hoped for. Services need to focus on what facilitates and inhibits deeper therapeutic closeness and connection.

ABSTRACT

Introduction Over-the-telephone (OTT)-delivered psychological therapies as an alternative method to face-to-face (F2F) are becoming more prevalent in mental health care. Research suggests a range of benefits of OTT use in therapy, but there are growing concerns about its consequences for the therapeutic relationship. This paper presents new knowledge regarding psychological practitioners' experience and views of OTT work and its potential effects on the therapeutic relationship in the context of the UK's Increasing Access to Psychological Therapy (IAPT) programme. Aim This paper presents IAPT practitioners' experiences and views of OTT work and its potential effects on the therapeutic relationship. Methods Completed questionnaires (exploring OTT versus F2F work) which were distributed to IAPT practitioners revealed a concern about the therapeutic relationship in OTT. To explore this further, nine in-depth semi-structured interviews with PWPs were conducted and the findings from this qualitative study are reported here. Results Practitioners noted OTT use facilitated access and flexibility for service users; however, they expressed some concern over the adverse effect of OTT on the therapeutic relationship. Discussion Although a working alliance was possible OTT, this research suggests the type of therapeutic relationship formed OTT in a "low contact-high volume" service such as IAPT needs to be better defined. By addressing this, dissonance which might arise between practitioner aims and the aims of IAPT can be reduced. This research also contributes to wider debates regarding mental health care and its provision in the UK. Implications for practice This paper concludes that mental health services need to focus on what type of therapeutic relationship their practice facilitates and to offer transparency to service users. The findings suggest that telephone work in IAPT can accommodate a working alliance, but not other types of therapeutic relationship, which practitioners and service users hoped for. Services need to offer a more nuanced understanding of the concept of a therapeutic relationship and focus on what facilitates and inhibits deeper therapeutic closeness and connection.

Management of bulimia nervosa and other binge eating problems

Binge eating occurs across the entire range of eating disorders. It is required for a diagnosis of bulimia nervosa but it is also seen in some cases of anorexia nervosa and in many cases of eating disorder not otherwise specified (usually referred to as eating disorder NOS or atypical eating disorder). This article focuses on the management of those eating disorders in which binge eating is a prominent feature.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

The Role of Regular Eating and Self-Monitoring in the Treatment of Bulimia Nervosa: A Pilot Study of an Online Guided Self-Help CBT Program

Background: Despite cognitive behavioural therapy (CBT) being regarded as the first-line treatment option for bulimia nervosa (BN), barriers such as its time-consuming and expensive nature limit patient access. In order to broaden treatment availability and affordability, the efficacy and convenience of CBT could be improved through the use of online treatments and selective emphasis on its most 'potent' components of which behavioural techniques form the focus. Method: Twenty-six individuals with BN were enrolled in an online CBT-based self-help programme and 17 completed four weeks of regular eating and food-monitoring using the online Food Diary tool. Participants were contacted for a weekly check-in phone call and had their bulimic symptom severity assessed at five time points (baseline and weeks 1-4). Results: There was a significant decrease in the frequency of self-reported objective binge episodes, associated loss of control and objective binge days reported between pre- and post-treatment measures. Significant improvements were also observed in most subscales of the Eating Disorder Examination-Questionnaire. Conclusion: This study provides encouraging preliminary evidence of the potential of behavioural techniques of online CBT in the treatment of BN. Online therapy with this focus is potentially a viable and practical form of treatment delivery in this illness group. These preliminary findings support the need for larger studies using control groups.

Guided Self-help for Eating Disorders: A Systematic Review and Metaregression

BACKGROUND

Evidence-based self-help is a recommended first stage of treatment for mild-moderate eating disorders. The provision of guidance enhances outcome. The literature evaluating exclusively 'guided' self-help (GSH) has not been systematically reviewed.

METHODS

The aim was to establish the effectiveness of GSH for reducing global eating disorder psychopathology and abstinence from binge eating, compared with controls. Results were pooled using random effects meta-analysis and heterogeneity explored using metaregression.

RESULTS

Thirty randomised controlled trials met the inclusion criteria. Results showed an overall effect of GSH on global eating disorder psychopathology (-0.46) and binge abstinence (-0.20). There was strong evidence for an association between diagnosis of binge eating disorder and binge abstinence.

DISCUSSION

Current interventions need to be adapted to address features other than binge eating. Further research is required to help us understand the effectiveness of GSH in children and young people, invariably high dropout rates and how technology can enhance interventions. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Comparison of face-to-face versus email guided self-help for binge eating: study protocol for a randomised controlled trial

Background

Guided self-help is a recommended first-step treatment for bulimia nervosa, binge eating disorder and atypical variants of these disorders. Further research is needed to compare guided self-help that is delivered face-to-face versus via email.

Methods/Design

This clinical trial uses a randomised, controlled design to investigate the effectiveness of providing guided self-help either face-to-face or via e-mail, also using a delayed treatment control condition. At least 17 individuals are required per group, giving a minimum N of 51.

Discussion

Symptom outcomes will be assessed and estimates of cost-effectiveness made. Results are proposed to be disseminated locally and internationally (through submission to conferences and peer-reviewed journals), and will hopefully inform local service provision. The trial has been approved by an ethics review board and was registered with ClinicalTrials.gov NCT01832792 on 9 April 2013.

Understanding the 'guide' in guided self-help for disordered eating: a qualitative process study

OBJECTIVES

This study aimed to explore how guidance contributes to the outcome of self-help for disordered eating.

METHOD

A sample of guides and clients with a range of disordered eating was interviewed on completion of a randomized control trial and analysed using thematic framework analysis.

RESULTS

Four themes emerged; the necessity of having a guide as a facilitator, features of the therapeutic relationship in clients with positive outcomes, features of the therapeutic relationship in clients with poor outcomes, and client suitability.

CONCLUSIONS

These findings have implications for the delivery of guided self-help interventions for disordered eating. They suggest the value of assessing clients' readiness to change, working with clients with less severe and complex conditions, and the importance of guide qualities and skills.

PRACTITIONER POINTS

Guidance is a necessary adjunct to self-help approaches for the effective treatment of a range of disordered eating and can be delivered by trained non-eating disorder specialists. Guided self-help appears most appropriate for less severe, binge-related eating disorders, including eating disorders not otherwise specified (EDNOS), further work is needed for use with anorexic-type presentations. While it is important to establish and maintain a strong, open, and collaborative therapeutic relationship, client 'readiness' appears fundamental in the relationship and consequent treatment outcome.

Computerised therapy for depression with clinician vs. assistant and brief vs. extended phone support: study protocol for a randomised controlled trial

BACKGROUND

Computerised cognitive behaviour therapy (cCBT) involves standardised, automated, interactive self-help programmes delivered via a computer. Randomised controlled trials (RCTs) and observational studies have shown than cCBT reduces depressive symptoms as much as face-to-face therapy and more than waiting lists or treatment as usual. cCBT's efficacy and acceptability may be influenced by the "human" support offered as an adjunct to it, which can vary in duration and can be offered by people with different levels of training and expertise.

METHODS/DESIGN

This is a two-by-two factorial RCT investigating the effectiveness, cost-effectiveness and acceptability of cCBT supplemented with 12 weekly phone support sessions are either brief (5-10 min) or extended (20-30 min) and are offered by either an expert clinician or an assistant with no clinical training. Adults with non-suicidal depression in primary care can self-refer into the study by completing and posting to the research team a standardised questionnaire. Following an assessment interview, eligible referrals have access to an 8-session cCBT programme called Beating the Blues and are randomised to one of four types of support: brief-assistant, extended-assistant, brief-clinician or extended-clinician.A sample size of 35 per group (total 140) is sufficient to detect a moderate effect size with 90% power on our primary outcome measure (Work and Social Adjustment Scale); assuming a 30% attrition rate, 200 patients will be randomised. Secondary outcome measures include the Beck Depression and Anxiety Inventories and the PHQ-9 and GAD-7. Data on clinical outcomes, treatment usage and patient experiences are collected in three ways: by post via self-report questionnaires at week 0 (randomisation) and at weeks 12 and 24 post-randomisation; electronically by the cCBT system every time patients log-in; by phone during assessments, support sessions and exit interviews.

DISCUSSION

The study's factorial design increases its efficiency by allowing the concurrent investigation of two types of adjunct support for cCBT with a single sample of participants. Difficulties in recruitment, uptake and retention of participants are anticipated because of the nature of the targeted clinical problem (depression impairs motivation) and of the studied interventions (lack of face-to-face contact because referrals, assessments, interventions and data collection are completed by phone, computer or post).

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98677176.

How many therapists? Practical guidance on investigating therapist effects in randomized controlled trials for eating disorders

OBJECTIVE

An important question in implementation/dissemination research is whether the efficacy of a given treatment varies in part based on the therapist delivering the treatment. This study sought to provide practical guidance to researchers in the field of eating disorders for building measurement of therapist effects into the design of a typical, relatively small randomized controlled trial (RCT).

METHOD

Using assumptions based on past trials of eating disorder treatments, Monte Carlo simulations were used to examine 12 different scenarios based on crossing the number of therapists (between two and five) and the estimated therapist effect size (small, medium, and large). Patient sample size and study design were held constant.

RESULTS

There was reasonable power (≥70%) to detect the therapist effect with three or four therapists and a large effect size.

DISCUSSION

Several practical implications for testing therapist effects in RCT are discussed.

Classification of feeding and eating disorders: review of evidence and proposals for ICD-11

Current classification of eating disorders is failing to classify most clinical presentations; ignores continuities between child, adolescent and adult manifestations; and requires frequent changes of diagnosis to accommodate the natural course of these disorders. The classification is divorced from clinical practice, and investigators of clinical trials have felt compelled to introduce unsystematic modifications. Classification of feeding and eating disorders in ICD-11 requires substantial changes to remediate the shortcomings. We review evidence on the developmental and cross-cultural differences and continuities, course and distinctive features of feeding and eating disorders. We make the following recommendations: a) feeding and eating disorders should be merged into a single grouping with categories applicable across age groups; b) the category of anorexia nervosa should be broadened through dropping the requirement for amenorrhoea, extending the weight criterion to any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant presentations; c) a severity qualifier "with dangerously low body weight" should distinguish the severe cases of anorexia nervosa that carry the riskiest prognosis; d) bulimia nervosa should be extended to include subjective binge eating; e) binge eating disorder should be included as a specific category defined by subjective or objective binge eating in the absence of regular compensatory behaviour; f) combined eating disorder should classify subjects who sequentially or concurrently fulfil criteria for both anorexia and bulimia nervosa; g) avoidant/restrictive food intake disorder should classify restricted food intake in children or adults that is not accompanied by body weight and shape related psychopathology; h) a uniform minimum duration criterion of four weeks should apply.

Who benefits most from guided self-help for binge eating? An investigation into the clinical features of completers and non-completers

Guided self-help (GSH) is a recommended first step in treatment for bulimia nervosa (BN) and binge eating disorder (BED) (NICE, 2004). It remains unclear what makes some individuals more likely to respond to this form of treatment than others. Forty-eight patients participated in this study using a GSH programme for binge eating. Profiles of treatment completers and non-completers are compared, and reasons for non-completion explored. Completion of treatment was associated with significant improvements in mood, general functioning and on measures of dietary restraint, frequency of objective binge eating (OBE), laxative misuse, self-induced vomiting (SIV) and driven exercise. Improvements were maintained at follow-up. Treatment non-completers reported significantly higher pre-treatment levels of depression and weight concern, and lower levels of general health and vitality. Reasons for discontinuing treatment were related to perceptions of the GSH programme; practicalities of the programme; and readiness to change. Whilst GSH can be effective for a sub-group of patients, factors such as pre-morbid level of depression, degree of weight concern, perceptions of the programme, and readiness to change may increase the likelihood of non-completion.

An open trial of self-help behaviours of clients with eating disorders in an online programme

AIM

The aim of this study was to evaluate the self-help behaviour of individuals with eating disorders in an Internet-based self-help programme developed in the Asia-Pacific region and to determine their compliance with the programme.

BACKGROUND

Eating disorders represent a growing health problem affecting both Western and Asian countries. Without timely and adequate treatment, individuals with eating disorders are at risk of premature death. Self-help approaches for treating eating disorders offer therapeutic promise.

DESIGN

An open trial design was used.

METHOD

This study, conducted from August 2006-July 2011, included 280 participants recruited from outpatient eating disorder clinics and treatment units and through a university student newspaper and Internet websites. This open trial evaluated an Internet-based self-help programme, which included components on healthy eating, family education, health assessment, motivation enhancement, self-help strategies, and psychological health promotion. The progress of participants was followed up via monthly e-mails. A tracking system was implemented to determine their compliance with the programme.

FINDINGS

A small majority of the participants (56·9%) were already undergoing treatment for their eating disorders. About 63% (n = 176) demonstrated self-help behaviour, as manifested by their completion of health assessment questionnaires, involvement in motivation enhancement exercises, or the use of self-help strategies such as monitoring, normalizing eating behaviour, and stress management. Improvements were observed in their eating disorder psychopathology, motivational stage of change and psychological health from baseline to the 1-month follow up.

CONCLUSION

Internet-based self-help programmes for eating disorders are helpful adjuncts to professional treatment.

Cognitive-behavioral guided self-help for eating disorders: effectiveness and scalability

Given the well-documented shortage of cognitive-behavioral therapy (CBT) for eating disorders, there is a compelling need for advances in dissemination. Guided self-help based on cognitive-behavioral principles (CBTgsh) provides a robust means of improving implementation and scalability of evidence-based treatment for eating disorders. It is a brief, cost-effective treatment that can be implemented by a wide range of mental health providers, including non-specialists, via face-to-face contact and internet-based technology. Controlled studies have shown that CBTgsh can be an effective treatment for binge eating disorder and bulimia nervosa, although it is contraindicated for anorexia nervosa. Several studies have shown that CBTgsh can be as effective as more complex specialty therapies and that it is not necessarily contraindicated for patients with comorbid conditions. Mental health providers with relatively minimal professional credentials have in some studies obtained results comparable to specialized clinicians. Establishing the nature of optimal "guidance" in CBTgsh and the level of expertise and training required for effective implementation is a research priority. Existing manuals used in CBTgsh are outdated and can be improved by incorporating the principles of enhanced transdiagnostic CBT. Obstacles to wider adoption of CBTgsh are identified.

Guided self-help as the first step for bulimic symptoms: implementation of a stepped-care model within specialized psychiatry

OBJECTIVE

This study describes the implementation and effectiveness of the first step, guided self-help (GSH), in a clinical setting, of a stepped-care model of cognitive behavior therapy for patients with bulimic symptoms.

METHOD

Eighty-nine patients participated.

RESULTS

In the intent to-treat analyses, the effect sizes were small to moderate (0.25-0.66). However, the effect sizes were substantially larger (0.44-1.66) for the patients who completed all the GSH sessions (45%). The majority of noncompleters stayed within psychiatric services. Supplementary treatments were mostly directed towards comorbid conditions, especially depression. Those discontinuing treatment in advance where characterized by more lifetime diagnoses and higher ratings on the restraint subscale of the EDE-Q.

DISCUSSION

GSH within specialized psychiatry might be effective for about 30% of the patients. There is no indication of patients losing their confidence in psychiatric services by being offered GSH as the first treatment.

A randomized controlled two-stage trial in the treatment of bulimia nervosa, comparing CBT versus motivational enhancement in Phase 1 followed by group versus individual CBT in Phase 2

OBJECTIVE

To conduct a randomized, controlled, two-stage trial in the treatment of bulimia nervosa, comparing cognitive-behavioral therapy (CBT) versus motivational enhancement in Phase 1 followed by group versus individual CBT in Phase 2.

METHODS

A total of 225 patients with bulimia nervosa or eating disorder not otherwise specified (EDNOS) were recruited into a randomized controlled trial lasting 12 weeks with follow-ups at 1 year and 2.5 years.

RESULTS

Patients improved significantly across all of the interventions with no differences in outcome or treatment adherence. Including motivational enhancement therapy rather than a CBT first phase of treatment did not affect outcome.

CONCLUSIONS

Outcome differences between individual and group CBT were minor, suggesting that group treatment prefaced by a short individual intervention may be a cost-effective alternative to purely individual treatment.

Psychological treatments for bulimia nervosa and binging

BACKGROUND

A specific manual-based form of cognitive behavioural therapy (CBT) has been developed for the treatment of bulimia nervosa (CBT-BN) and other common related syndromes such as binge eating disorder. Other psychotherapies and modifications of CBT are also used.

OBJECTIVES

To evaluate the efficacy of CBT, CBT-BN and other psychotherapies in the treatment of adults with bulimia nervosa or related syndromes of recurrent binge eating.

SEARCH STRATEGY

Handsearch of The International Journal of Eating Disorders since first issue; database searches of MEDLINE, EXTRAMED, EMBASE, PsycInfo, CURRENT CONTENTS, LILACS, SCISEARCH, CENTRAL and the The Cochrane Collaboration Depression, Anxiety & Neurosis Controlled Trials Register; citation list searching and personal approaches to authors were used. Search date June 2007.

SELECTION CRITERIA

Randomised controlled trials of psychotherapy for adults with bulimia nervosa, binge eating disorder and/or eating disorder not otherwise specified (EDNOS) of a bulimic type which applied a standardised outcome methodology and had less than 50% drop-out rate.

DATA COLLECTION AND ANALYSIS

Data were analysed using the Review Manager software program. Relative risks were calculated for binary outcome data. Standardised mean differences were calculated for continuous variable outcome data. A random effects model was applied.

MAIN RESULTS

48 studies (n = 3054 participants) were included. The review supported the efficacy of CBT and particularly CBT-BN in the treatment of people with bulimia nervosa and also (but less strongly due to the small number of trials) related eating disorder syndromes.Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals were promising. Exposure and Response Prevention did not enhance the efficacy of CBT.Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders.

AUTHORS' CONCLUSIONS

There is a small body of evidence for the efficacy of CBT in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small. More and larger trials are needed, particularly for binge eating disorder and other EDNOS syndromes. There is a need to develop more efficacious therapies for those with both a weight and an eating disorder.

Cognitive-behavioural therapy for adolescents with bulimic symptomatology: the acceptability and effectiveness of internet-based delivery

BACKGROUND

The evidence base for the treatment of adolescents with bulimia nervosa (BN) is limited.

AIMS

To assess the feasibility, acceptability, and clinical outcomes of a web-based cognitive-behavioural (CBT) intervention for adolescents with bulimic symptomatology.

METHOD

101 participants were recruited from eating disorders clinics or from beat, a UK-wide eating disorders charity. The programme consisted of online CBT sessions ('Overcoming Bulimia Online'), peer support via message boards, and email support from a clinician. Participants' bulimic symptomatology and service utilisation were assessed by interview at baseline and at three and six months. Participants' views of the treatment package were also determined.

RESULTS

There were significant improvements in eating disorder symptoms and service contacts from baseline to three months, which were maintained at six months. Participants' views of the intervention were positive.

CONCLUSIONS

The intervention has the potential for use as a first step in the treatment of adolescents with bulimic symptomatology.

Patient health outcomes in psychiatric mental health nursing

This integrative literature review examined evidence concerning the relationship between psychiatric mental health nursing interventions and patient-focused outcomes. Empirical studies, published between 1997 and 2007, were identified and gathered by searching relevant databases and specific data sources. Although 156 articles were critically appraised, only 25 of them met the inclusion criteria. Findings from this review showed that the most frequently used outcome instruments assessed psychiatric symptom severity. Most of the instruments targeted two symptom categories: altered thoughts/perceptions and altered mood. Other outcome instruments were categorized in the following domains: self-care, functioning, quality of life and satisfaction. The most important finding of this review is the lack of consistently strong evidence to support decisions concerning which outcome instrument or combination of instruments to recommend for routine use in practice. Based on this review, additional research to conceptualize, measure and examine the feasibility of outcome instruments sensitive to psychiatric mental health nursing interventions is recommended.

Randomised controlled trial of CD-ROM-based cognitive-behavioural self-care for bulimia nervosa

BACKGROUND

Cognitive-behavioural self-care is advocated as a first step in the treatment of bulimia nervosa.

AIMS

To examine the effectiveness of a CD-ROM-based cognitive-behavioural intervention in bulimia nervosa and eating disorder not otherwise specified (NOS) (bulimic type) in a routine setting.

METHOD

Ninety-seven people with bulimia nervosa or eating disorder NOS were randomised to either CD-ROM without support for 3 months followed by a flexible number of therapist sessions or to a 3-month waiting list followed by 15 sessions of therapist cognitive-behavioural therapy (CBT) (ISRCTN51564819). Clinical symptoms were assessed at pre-treatment, 3 months and 7 months.

RESULTS

Only two-thirds of participants started treatment. Although there were significant group x time interactions for bingeing and vomiting, favouring the CD-ROM group at 3 months and the waiting-list group at 7 months, post hoc group comparisons at 3 and 7 months found no significant differences for bingeing or vomiting. CD-ROM-based delivery of this intervention, without support from a clinician, may not be the best way of exploiting its benefits.

The effectiveness of telemental health applications: a review

OBJECTIVE

To review the evidence of benefit from use of telemental health (TMH) in studies that reported clinical or administrative outcomes.

METHOD

Relevant publications were identified through computerized literature searches using several electronic databases. Included for review were scientifically valid articles that described controlled studies, comparing TMH with a non-TMH alternative, and uncontrolled studies that had no fewer than 20 participants. Quality of the evidence was assessed with an approach that considers both study performance and study design. Judgments were made on whether further data were needed to establish each TMH application as suitable for routine clinical use.

RESULTS

Included in the review were 72 papers that described 65 clinical studies; 32 (49%) studies were of high or good quality. Quality of evidence was higher for Internet- and telephone-based interventions than for video conferencing approaches. There was evidence of success with TMH in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorders, substance abuse, eating disorders, and smoking prevention. Evidence of success for general TMH programs and in the management of obsessive-compulsive disorder were less convincing. Further study was judged to be necessary or desirable in 53 (82%) of the studies.

CONCLUSION

Evidence of benefit from TMH applications is encouraging, though still limited. There is a need for more good-quality studies on the use of TMH in routine care. The emerging use of Internet-based applications is an important development that deserves further evaluation.

A randomised trial investigating guided self-help to reduce perfectionism and its impact on bulimia nervosa: a pilot study

AIM

The purpose of the present study was to evaluate reducing perfectionism as a potential treatment target for individuals with Bulimia Nervosa (BN).

METHOD

Forty-eight individuals meeting DSM-IV criteria for BN or eating disorder - not otherwise specified with binge eating [objective or subjective] or purging at least once per week were recruited. Participants were randomly assigned to receive 8 sessions of manual-based guided self-help (GSH) over a 6-week period that was focused on either cognitive behaviour therapy (CBT) for perfectionism, CBT for BN, or a placebo. Individuals were assessed at baseline, pre-treatment, post-treatment and at six-month follow-up on 12 outcome variables, including diagnostic criteria and psychological variables.

RESULTS

There was no significant change in any of the outcome variables over a 6-week no-treatment period but at post-treatment and 6-month follow-up there were significant main effects of time for 10 and 8 outcome variables respectively, suggesting that all groups reported significant reductions in bulimic symptomatology and related psychopathology at post-treatment and follow-up.

CONCLUSIONS

These findings show potential for the use of novel interventions in GSH for BN.

Evidence-based psychosocial treatments for eating problems and eating disorders

Eating disorders represent a significant source of psychological impairment among adolescents. However, most controlled treatment studies have focused on adult populations. This review provides a synthesis of existing data concerning the efficacy of various psychosocial interventions for eating disorders in adolescent samples. Modes of therapy examined in adolescent samples include family therapy, cognitive therapy, behavioral therapy, and cognitive behavioral therapy mostly in patients with anorexia nervosa. At this time, the evidence base is strongest for the Maudsley model of family therapy for anorexia nervosa. Evidence of efficacy for other treatments and other conditions is limited by several methodological factors including the small number of studies, failure to use appropriate control conditions or randomization procedures, and small sample sizes (i.e., fewer than 10 participants per treatment arm). Potential moderators and mediators of treatment effect are reviewed. Finally, results from adolescent studies are contrasted with those from adult studies of eating disorders treatment. Many studies of adult populations comprise late adolescent/young adult participants, suggesting that findings regarding the efficacy of cognitive behavioral therapy for bulimia nervosa in adults likely extend to older adolescent populations.

A critical evaluation of the efficacy of self-help interventions for the treatment of bulimia nervosa and binge-eating disorder

OBJECTIVE

Cognitive behavioral therapy (CBT) is efficacious for the treatment of bulimia nervosa (BN) and binge-eating disorder (BED). As a number of factors limit the availability of CBT, self-help manuals have been developed to make the treatment more widely available.

METHOD

Published studies evaluating the efficacy of self-help programs in the treatment of BN and BED were reviewed.

RESULTS

Controlled studies of self-help programs for BN and BED have often employed a waiting list control group, and indicate that self-help provides more benefit than remaining on a waiting list. However, fewer studies have utilized a more active control group, and these studies have not been as positive.

CONCLUSION

In general, open and wait-list trials indicate that self-help is helpful in treating BN and BED, but there is little evidence for the specific efficacy of self-help in comparison to other treatments. Additional studies of self-help are needed to determine the specific utility of self-help interventions for BN and BED.

Health service utilization for eating disorders: findings from a community-based study

BACKGROUND

Prior use of health services was examined in a community sample of women with bulimic-type eating disorders.

METHOD

Participants (n = 159) completed a structured interview for the assessment of eating disorder psychopathology as well as questions concerning treatment-seeking and type of treatment received.

RESULTS

Whereas a minority (40.3%) of participants had received treatment for an eating problem, most had received treatment for a general mental health problem (74.2%) and/or weight loss (72.8%), and all had used one or more self-help treatments. Where treatment was received for an eating or general mental health problem, this was from a primary care practitioner in the vast majority of cases. Only half of those participants who reported marked impairment associated with an eating problem had ever received treatment for such a problem and less than one in five had received such treatment from a mental health professional.

CONCLUSION

Women with bulimic-type eating disorders rarely receive treatment for an eating problem, but frequently receive treatment for a general mental health problem and/or for weight loss. The findings underscore the importance of programs designed to improve the detection and management of eating disorders in primary care.

Guided self-help versus pure self-help for perfectionism: A randomised controlled trial

Perfectionism is known to be a risk factor for the development and maintenance of obsessive-compulsive (OC) and depressive symptoms. The purpose of the present study was to test the effectiveness of a cognitive-behavioural self-help therapy for perfectionism, and to examine the effect of such treatment on OC and depressive symptomatology. The study compares the effectiveness of guided self-help (GSH, n=24) with pure self-help (PSH, n=25) therapy. Both GSH and PSH were found to be effective in reducing perfectionism, and also in reducing OC and depressive symptomatology. Overall, participants in the GSH condition experienced greater symptom improvement than participants in the PSH condition, and treatment gains for both groups were largely maintained at 3-month follow-up. Twenty percent of PSH participants experienced clinically significant increases in depressive symptoms over the treatment and follow-up period (compared to 0% in the GSH condition), suggesting that PSH may be a less suitable strategy than GSH in treating this population. Overall, the findings suggest that self-help for perfectionism is effective in reducing OC and depressive symptomatology in non-clinical individuals, with GSH being superior to PSH.

Remote treatment of bulimia nervosa and binge eating disorder: A randomized trial of Internet-assisted cognitive behavioural therapy

The present study investigated the efficacy of self-help based on cognitive behaviour therapy in combination with Internet support in the treatment of bulimia nervosa and binge eating disorder. After confirming the diagnosis with an in-person interview, 73 patients were randomly allocated to treatment or a waiting list control group. Treated individuals showed marked improvement after 12 weeks of self-help compared to the control group on both primary and secondary outcome measures. Intent-to-treat analyses revealed that 37% (46% among completers) had no binge eating or purging at the end of the treatment and a considerable number of patients achieved clinically significant improvement on most of the other measures as well. The results were maintained at the 6-month follow-up, and provide evidence to support the continued use and development of self-help programmes.

Treatment of bulimia nervosa: where are we and where are we going?

OBJECTIVE

The purpose of this article is to review the extant treatment literature on bulimia nervosa and to offer suggestions for future research directions.

METHOD

The available treatment studies regarding both pharmacotherapy and psychotherapy are reviewed.

RESULTS

Both pharmacotherapy and psychotherapy appear to play a role in the treatment of bulimia nervosa; however, available data suggest that cognitive behavioral therapy remains the treatment of choice.

CONCLUSION

Additional work is clearly indicated regarding assisted and unassisted self-help. An enhanced form of CBT and the integrative cognitive-affective therapy both deserve further study. New approaches need to be piloted. More research is needed on treatment modeling.

Systematic review of interventions delivered by UK mental health nurses

The effectiveness of mental health nurse interventions has not been generally established in the literature. In this systematic review, randomised controlled trials (RCTs) were identified, undertaken in the United Kingdom, where mental health interventions delivered by mental health nurses had been evaluated. The main online literature databases were searched, key journals were hand searched and contact was made with key authors, resulting in a total of 52 studies, involving at least 7172 service users. Data were extracted and then all identified trials were assessed for inclusion by two reviewers. The results showed that in the UK, mental health nurses are involved in the delivery of a wide range of interventions in a variety of clinical health settings, with broadly positive results.

Attrition and outcome in self-help treatment for bulimia nervosa and binge eating disorder: a constructive replication

The aim of the study was to assess the efficacy of a 12-week CBT-based pure and guided self-help among 29 patients with full and subthreshold bulimia nervosa, and binge eating disorder. In the intention-to-treat analyses, self-help had a moderately positive and sustained effect on the patients' eating problems. The patients reduced their mean number of objective bulimic episodes and purging behavior by 26% and 22% over the course of treatment. The corresponding reduction levels for the treatment completers (n=21) were 41% and 34%, respectively. As in the previous study, there were no significant differences between the pure and guided self-help mode in terms of outcome, and the results were sustained 6 months after the end of the treatment. The findings are discussed in relation to the shorter duration of the self-help, the lower rate of attrition, and the characteristics of the sample compared to the earlier trial.

Telephone administered cognitive behaviour therapy for treatment of obsessive compulsive disorder: randomised controlled non-inferiority trial

OBJECTIVES

To compare the effectiveness of cognitive behaviour therapy delivered by telephone with the same therapy given face to face in the treatment of obsessive compulsive disorder.

DESIGN

Randomised controlled non-inferiority trial.

SETTING

Two psychology outpatient departments in the United Kingdom.

PARTICIPANTS

72 patients with obsessive compulsive disorder.

INTERVENTION

10 weekly sessions of exposure therapy and response prevention delivered by telephone or face to face.

MAIN OUTCOME MEASURES

Yale Brown obsessive compulsive disorder scale, Beck depression inventory, and client satisfaction questionnaire.

RESULTS

Difference in the Yale Brown obsessive compulsive disorder checklist score between the two treatments at six months was -0.55 (95% confidence interval -4.26 to 3.15). Patient satisfaction was high for both forms of treatment.

CONCLUSION

The clinical outcome of cognitive behaviour therapy delivered by telephone was equivalent to treatment delivered face to face and similar levels of satisfaction were reported.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN500103984 [controlled-trials.com].

Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home

BACKGROUND

It is known that many patients encounter a variety of problems in the first weeks after they have been discharged from hospital to home. In recent years many projects have addressed discharge planning, with the aim of reducing problems after discharge. Telephone follow-up (TFU) is seen as a good means of exchanging information, providing health education and advice, managing symptoms, recognising complications early, giving reassurance and providing quality aftercare service. Some research has shown that telephone follow-up is feasible, and that patients appreciate such calls. However, at present it is not clear whether TFU is also effective in reducing postdischarge problems.

OBJECTIVES

To assess the effects of follow-up telephone calls in the first month post discharge, initiated by hospital-based health professionals, to patients discharged from hospital to home.

SEARCH STRATEGY

We searched the following databases from their start date to July 2003, without limits as to date of publication or language: the Cochrane Consumers and Communication Review Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), PubMed, EMBASE (OVID), BiomedCentral, CINAHL, ERIC (OVID), INVERT (Dutch nursing literature index), LILACS, Picarta (Dutch library system), PsycINFO/PsycLIT (OVID), the Combined Social and Science Citation Index Expanded (SCI-E), SOCIOFILE. We searched for ongoing research in the following databases: National Research Register (http://www.update-software.com/nrr/); Controlled Clinical Trials (http://www.controlled-trials.com/); and Clinical Trials (http://clinicaltrials.gov/). We searched the reference lists of included studies and contacted researchers active in this area.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of TFU initiated by a hospital-based health professional, for patients discharged home from an acute hospital setting. The intervention was delivered within the first month after discharge; outcomes were measured within 3 months after discharge, and either the TFU was the only intervention, or its effect could be analysed separately.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and for methodological quality. The methodological quality of included studies was assessed using the criteria from the Cochrane Effective Practice and Organisation of Care Review Group. The data-extraction form was based on the template developed by the Cochrane Consumers and Communication Review Group. Data was extracted by one review author and checked by a second author. For as far it was considered that there was enough clinical homogeneity with regard to patient groups and measured outcomes, statistical pooling was planned using a random effects model and standardised mean differences for continuous scales and relative risks for dichotomous data, and tests for statistical heterogeneity were performed.

MAIN RESULTS

We included 33 studies involving 5110 patients. Predominantly, the studies were of low methodological quality. TFU has been applied in many patient groups. There is a large variety in the ways the TFU was performed (the health professionals who undertook the TFU, frequency, structure, duration, etc.). Many different outcomes have been measured, but only a few were measured across more than one study. Effects are not constant across studies, nor within patient groups. Due to methodological and clinical diversity, quantitative pooling could only be performed for a few outcomes. Of the eight meta-analyses in this review, five showed considerable statistical heterogeneity. Overall, there was inconclusive evidence about the effects of TFU.

AUTHORS' CONCLUSIONS

The low methodological quality of the included studies means that results must be considered with caution. No adverse effects were reported. Nevertheless, although some studies find that the intervention had favourable effects for some outcomes, overall the studies show clinically-equivalent results between TFU and control groups. In summary, we cannot conclude that TFU is an effective intervention.

Self-help and guided self-help for eating disorders

BACKGROUND

Anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS) are common and disabling disorders. Many patients experience difficulties accessing specialist psychological treatments. Pure self-help (PSH: self-help material only) or guided self-help (GSH: self-help material with therapist guidance), may bridge this gap.

MAIN OBJECTIVE

Evaluate evidence from randomised controlled trials (RCTs) / controlled clinical trials (CCTs) for the efficacy of PSH/GSH with respect to eating disorder symptoms, compared with waiting list or placebo/attention control, other psychological or pharmacological treatments (or combinations/augmentations) in people with eating disorders.

SECONDARY OBJECTIVE

Evaluate evidence for the efficacy of PSH/GSH regarding comorbid symptomatology and costs.

SEARCH STRATEGY

CCDANCTR-Studies and CCDANCTR-References were searched in November 2005, other electronic databases were searched, relevant journals and grey literature were checked, and personal approaches were made to authors.

SELECTION CRITERIA

Published/unpublished RCTs/CCTs evaluating PSH/GSH for any eating disorder.

DATA COLLECTION AND ANALYSIS

Data was extracted using a customized spreadsheet. Relative Risks (RR) were calculated from dichotomous data and weighted/standardized mean differences (WMD/SMD) from continuous data, using a random effects model.

MAIN RESULTS

Twelve RCTs and three CCTs were identified, all focusing on BN, BED, EDNOS or combinations of these, in adults, using manual-based PSH/GSH across various settings. Primary comparisons:At end of treatment, PSH/GSH did not significantly differ from waiting list in abstinence from bingeing (RR 0.72, 95% CI 0.47 to 1.09), or purging (RR 0.86, 95% CI 0.68 to 1.08), although these treatments produced greater improvement on other eating disorder symptoms, psychiatric symptomatology and interpersonal functioning but not depression. Compared to other formal psychological therapies, PSH/GSH did not differ significantly at end of treatment or follow-up in improvement on bingeing and purging (RR 0.99, 95% CI 0.75 to 1.31), other eating disorder symptoms, level of interpersonal functioning or depression. There were no significant differences in treatment dropout. Secondary comparisons:One small study in BED found that cognitive-behavioural GSH compared to a non-specific control treatment produced significantly greater improvements in abstinence from bingeing and other eating disorder symptoms. Studies comparing PSH with GSH found no significant differences between treatment groups at end of treatment or follow-up. Comparison between different types of PSH/GSH found significant differences on eating disorder symptoms but not on bingeing/purging abstinence rates.

AUTHORS' CONCLUSIONS

PSH/GSH may have some utility as a first step in treatment and may have potential as an alternative to formal therapist-delivered psychological therapy. Future research should focus on producing large well-conducted studies of self-help treatments in eating disorders including health economic evaluations, different types and modes of delivering self-help (e.g. computerised versus manual-based) and different populations and settings.

Does personalized feedback improve the outcome of cognitive-behavioural guided self-care in bulimia nervosa? A preliminary randomized controlled trial

OBJECTIVES

Feedback has long been a part of psychosocial and health behaviour interventions and with the advent of computerised assessment and treatment tools, is gaining greater importance. The aim of the present study was to evaluate the addition of personalized feedback to a guided cognitive-behavioural (CBT) self-help programme for patients with bulimia nervosa.

DESIGN

Randomised-controlled trial.

METHOD

61 patients with DSM-IV bulimia nervosa or eating disorder not otherwise specified (EDNOS) were randomly allocated to receive 14 sessions of cognitive behavioural guided self-care with or without added personalised feedback on current physical and psychological status, risk and problems, and variables facilitating or hindering change. Feedback to patients was delivered in a number of ways: (a) personalised letters after assessment and at the end of treatment, (b) a specially designed feedback form administered half-way through treatment, (c) computerised feedback about bulimic and other symptoms, such as anxiety, depression and interpersonal functioning repeated at intervals throughout treatment and follow-up.

RESULTS

Outcome was assessed using patient-rated measures of bulimic symptoms at the end of treatment and at 6-month follow-up. The data were analysed using maximum likelihood methods of assess group differences at the follow-up. Added feedback did not have an effect on take-up or drop-out from treatment. However, it improved outcome by reducing self-induced vomiting and dietary restriction more effectively.

CONCLUSIONS

The findings lend support to the notion that the addition of repeated personalised feedback improves outcome from guided CBT self-help treatment and deserves further study.