The potential of technology-based psychological interventions for anorexia and bulimia nervosa: a systematic review and recommendations for future research

Adolescents' perspectives on a novel digital treatment targeting eating disorders: a qualitative study

BACKGROUND

Eating disorders in adolescence are associated with high psychological distress, impaired function and high comorbidity. Despite the severity, eating disorders remain highly underdiagnosed and untreated. Digital technology provides promising opportunities for treatment, however studies focusing on digital treatments for adolescents with eating disorders are lacking. The main aim of this study was to explore the perspectives of adolescents with lived experience of eating disorders on factors they deemed to be relevant in the development of a novel digital treatment.

METHODS

A qualitative intervention development study using semi-structured individual interviews. Data collection, coding and analysis were conducted using the principles of reflexive thematic analysis. Participants were adolescents aged 16-19 years, with a self-reported diagnosis of anorexia nervosa, bulimia nervosa or binge eating disorder, currently in the final phase or completed psychological treatment for an eating disorder within the last five years.

RESULTS

A total of 16 adolescents participated in the study, all females. Mean age was 17 ½ years (SD = 1.01). An in-depth understanding of the adolescents' perspectives was developed into three themes: Facilitating self-awareness and readiness to change; Strengthening interpersonal relationships and decreasing social isolation; Ensuring feeling seen and motivating regular use.

CONCLUSIONS

This study provides a unique insight into the perspectives of adolescents with lived experience of eating disorders. The uptake and engagement can be optimized in a novel digital treatment for eating disorders by taking the adolescents perspectives into consideration.

Effectiveness of a Web-Based Cognitive Behavioral Self-Help Intervention for Binge Eating Disorder: A Randomized Clinical Trial

Importance

Binge eating disorder (BED) is one of the most frequent eating pathologies and imposes substantial emotional and physical distress, yet insufficient health care resources limit access to specialized treatment. Web-based self-help interventions emerge as a promising solution, offering more accessible care.

Objective

To examine the effectiveness of a web-based cognitive behavioral self-help intervention for individuals with BED.

Design, Setting, and Participants

This 2-arm, parallel-group randomized clinical trial conducted from January 15, 2021, to August 3, 2022, in Germany and other German-speaking countries enrolled patients aged 18 to 65 years who met the diagnostic criteria for BED (according to the Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]). Data analysis occurred between January 27 and September 4, 2023, following our statistical analysis plan.

Interventions

Participants were randomized to a web-based self-help intervention or a waiting-list control condition.

Main Outcomes and Measures

The primary outcome was a change in objective binge eating episodes from baseline to after treatment. Secondary outcomes included global eating pathology, clinical impairment, work capacity, well-being, comorbid psychopathology, self-esteem, and emotion regulation.

Results

A total of 1602 patients were screened, of whom 154 (mean [SD] age, 35.93 [10.59] years; 148 female [96.10%]) fulfilled the criteria for BED and were randomized (77 each to the intervention and control groups). The web-based intervention led to significant improvements in binge eating episodes (Cohen d, -0.79 [95% CI, -1.17 to -0.42]; P < .001), global eating psychopathology (Cohen d, -0.71 [95% CI, -1.07 to -0.35]; P < .001), weekly binge eating (Cohen d, -0.49 [95% CI, -0.74 to -0.24]; P < .001), clinical impairment (Cohen d, -0.75 [95% CI, -1.13 to -0.37]; P < .001), well-being (Cohen d, 0.38 [95% CI, 0.01 to 0.75]; P = .047), depression (Cohen d, -0.49 [95% CI, -0.86 to -0.12]; P = .01), anxiety (Cohen d, -0.37 [95% CI, -0.67 to -0.07]; P = .02), self-esteem (Cohen d, 0.36 [95% CI, 0.13 to 0.59]; P = .003), and emotion regulation (difficulties: Cohen d, -0.36 [95% CI, -0.65 to -0.07]; P = .01 and repertoire: Cohen d, 0.52 [95% CI, 0.19 to 0.84]; P = .003).

Conclusion and Relevance

In this randomized clinical trial of a web-based self-help intervention for patients with BED, the findings confirmed its effectiveness in reducing binge eating episodes and improving various mental health outcomes, highlighting a scalable solution to bridge the treatment gap for this condition.

Trial Registration

ClinicalTrials.gov Identifier: NCT04876183.

Predictors, mediators, and moderators of response to digital interventions for eating disorders: A systematic review

OBJECTIVE

Digital interventions show promise as an effective prevention or self-management option for eating disorders (EDs). However, it remains unclear how, for whom, and through what mechanisms they work in this population, as a synthesis of outcome predictors, moderators, and mediators is lacking. This systematic review synthesized empirical research investigating predictors, mediators, and moderators of response to digital interventions for EDs.

METHOD

Six databases were searched (PROSPERO CRD42022295565) for studies that assessed predictors, moderators, or mediators of response (i.e., uptake, drop-out, engagement, and symptom level change) to a digital prevention or treatment program for EDs. Variables were grouped into several overarching categories (demographic, symptom severity, psychological, etc.) and were synthesized qualitatively across samples without a formally diagnosed ED (typically prevention-focused) and samples with a formally diagnosed ED (typically treatment-focused).

RESULTS

Eighty-six studies were included. For studies recruiting samples without a formal diagnosis (n = 70 studies), most predictors explored were statistically unrelated to outcome, although participant age, baseline symptom severity, confidence to change, motivation, and program engagement showed preliminary evidence of prognostic potential. No robust moderators or mediators were identified. Few studies recruiting samples with a formal diagnosis emerged (n = 16), of which no reliable predictors, moderators, or mediators were identified.

DISCUSSION

It remains unclear how, for whom, and under what circumstances digital programs targeting EDs work. We offer several recommendations for future research with the aim of advancing understanding of client characteristics and intervention elements that signal success from this intervention modality.

PUBLIC SIGNIFICANCE

Digital interventions have shown potential as an effective, scalable, and accessible intervention option for EDs. However, responsiveness varies, so advancing understanding of predictors, mediators, and moderators of outcome to digital interventions for EDs is needed. Such knowledge is important for enabling safe and efficient treatment matching, and for informing future development of effective digital interventions.

Efficacy of a therapist-guided smartphone-based intervention to support recovery from bulimia nervosa: Study protocol of a randomized controlled multi-centre trial

OBJECTIVE

Although inpatient treatment is highly effective for patients with bulimia nervosa (BN), some patients show a resurgence of symptoms and relapse after discharge. Therefore, the aim of this study is to evaluate the efficacy of a guided smartphone-based aftercare intervention following inpatient treatment to support recovery.

METHOD

172 female patients with BN (DSM-5: 307.51) will be randomized to receive a 16-week smartphone-based aftercare intervention (German version of 'Recovery Record') with therapist feedback as an add-on element to treatment as usual (TAU) or TAU alone. Assessments will take place at baseline (discharge, T0), during the intervention (after 4 weeks, T1), post-intervention (after 16 weeks, T2) and at 6-month follow-up (T3). Primary outcome will be remission at T2. Moderator and mediator analyses will investigate for whom the aftercare intervention suits best and how it works.

CONCLUSIONS

This is the first randomized controlled trial to examine a guided smartphone-based aftercare intervention following inpatient treatment of patients with BN. We expect that this innovative aftercare intervention is highly accepted by the patients and that it has the potential to support recovery after inpatient treatment and thereby could contribute to improving aftercare for patients with BN.

Internet-based cognitive behaviour therapy for the prevention, treatment and relapse prevention of eating disorders: A systematic review and meta-analysis

Eating disorders (EDs) are undertreated worldwide. In the UK the lag between recognition of symptoms and treatment ranges from about 15 months to in excess of 2 years. Internet-based cognitive behaviour therapy (ICBT) could be a viable alternative to face-to-face cognitive behaviour therapy (CBT) that avoids the negative impacts of delayed interventions. Based on evidence from randomised controlled trials (RCTs), this systematic review investigated the efficacy of minimally guided self-help ICBT, without face-to-face therapy, for the prevention, treatment and relapse prevention of all types of EDs in adults. The electronic databases MEDLINE, PsychINFO, CENTRAL, Scopus, and Web of Science were searched between 1991 and 2021. Inclusion criteria specified RCTs with ICBT versus inactive comparison groups. The Cochrane Risk of Bias Tool-2 was used for quality assessments. Qualitative synthesis and meta-analyses were conducted. Findings typically showed medium significant beneficial effect sizes for prevention studies ranging from (-0.31 [95% CI: -0.57, -0.06] to -0.47 [95% CI: -0.82, -0.11]) and generally large effect sizes for the treatment studies ranging from (-0.30 [95% CI: -0.57, -0.03] to -1.11 [95% CI: -1.47, -0.75]). Relapse prevention studies yielded mainly small non-significant beneficial effects with significant effect sizes of (-0.29 [95% CI: -0.56, -0.03] and -0.43 [95% CI: -0.70, -0.16]). Only the treatment studies reached clinical significance and cognitive symptoms improved more than behavioural symptoms. ICBT appears to be efficacious for the prevention, treatment and relapse prevention of eating disorders with treatment interventions being the most beneficial. However, the evidence base is very small, particularly for treatment and relapse prevention, indicating the need for more high-quality RCTs.

A randomised controlled trial of clinician supported vs self-help delivery of online cognitive behaviour therapy for Bulimia Nervosa

High dropout rates and poor adherence associated with digital interventions have prompted research into modifications of these treatments to improve engagement and completion rates. This trial aimed to investigate the added benefit of clinician support when paired alongside a ten-session, online cognitive behaviour therapy (CBT) self-help intervention for bulimia nervosa (BN). As part of a three-arm, phase II randomised controlled trial, 114 participants (16 years or over) with full or subthreshold BN were randomly assigned to complete the intervention in a self-help mode (with administrative researcher contact; n = 38), with adjunct clinician support (weekly 30-minute videoconferencing sessions; n = 37), or a no-treatment waitlist control (WLC; n = 39). Baseline to post-treatment (12-weeks) decreases in objective binge episode frequency were significantly greater for clinician-supported participants as compared to WLC, but not for self-help when compared to WLC. However, due to continued improvements for self-help across follow-up (24-weeks), both arms outperformed WLC when analysed as an overall rate of change across three timepoints. Clinician-supported participants outperformed self-help in regards to laxative use and dietary restraint. Our results demonstrate that good clinical outcomes can be achieved with a relatively brief online CBT-based program even in the absence of structured clinical support, indicating a possible overreliance upon clinician support as a primary adherence-facilitating mechanism.

Psychotherapies for eating disorders: findings from a rapid review

BACKGROUND

Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development.

METHODS

The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper.

RESULTS

281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence.

CONCLUSIONS

Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.

Self-help application for obsessive-compulsive disorder based on exposure and response prevention technique with prototype design and usability evaluation: A cross-sectional study

Background and Aims

Obsessive-compulsive disorder (OCD) is a relatively common disorder that, due to its debilitating nature, significantly affects personal abilities, job performance, social adjustment, and interpersonal relationships. There are significant barriers to accessing evidence-based cognitive-behavioral therapy as a first-line treatment for obsessive-compulsive disorder. Mobile health applications (Apps) offer a promising way to improve access to evidence-based therapies while overcoming these barriers. The present study was to design and evaluate a prototype of a self-help application for people with OCD (the most common pattern of OCD) based on the exposure and response prevention (ERP) technique.

Methods

This work was developed in four different phases. (1) Needs assessment: a thorough literature review, reviewing existing related programs and apps, and interviewing patients and psychiatrists; (2) Creating a paper prototype: considering the functional features identified in the previous phase using wireframe sketcher software. (3) Creating a digital prototype: developing an actual prototype using Axure RP software based on the information obtained from an expert panel's evaluation of the paper prototype. (4) Prototype usability evaluation: through a heuristic evaluation with experts and usability testing with patients using the SUS questionnaire.

Results

After requirement analysis, requirements were defined in the areas of information and educational elements, and functional capabilities. Prototypes designed based on identified requirements include capabilities such as in-app online self-help groups, assessing the severity of the symptoms of the disorder, psychological training, supportive treatment strategies, setting personalized treatment plans, tracking treatment progress through weekly reports provided, anxiety assessment, and setting reminders.

Conclusion

The results of the heuristic evaluation with experts made it possible to identify how to provide information and implement the capabilities in a way that is more appropriate and easier for the user.

Development of a transdiagnostic digital interactive application for eating disorders: psychometric properties, satisfaction, and perceptions on implementation in clinical practice

BACKGROUND

Given limited availability of informed treatments for people affected by eating disorders (EDs), there has been increasing interest in developing self-administered, technology-based ED interventions. However, many available interventions are limited to a specific ED diagnosis or assume that participants are ready to change. We developed a digital self-help application (called ASTrA) that was explicitly designed to be transdiagnostic and to help increase motivation for change. The aim of the present study was to describe the development and examine the psychometric properties, user satisfaction and rated potentials for practical use of our application.

METHODS

The content of our application was based on concepts derived from self-determination theory, the transtheoretical model of change, and cognitive theory. The application was developed by a multidisciplinary team of clinicians, researchers, staff members and individuals with lived ED experience, each being involved in all steps of the application's development. We tested validity, reliability, satisfaction and perceived feasibility for clinical implementation in an independent sample of 15 patients with an ED and 13 clinicians specialized in ED treatment. Psychometric properties were evaluated using descriptive statistics, correlations, content validity indices and intraclass coefficients. Differences in satisfaction ratings and perceived potential for clinical implementation of the application between clinicians and patients were examined using Mann-Whitney U tests.

RESULTS

The digital application showed excellent validity (mean i-CVI: .93, range: .86-.96) and internal reliability (all Cronbach alpha's > .88). Patients and clinicians both considered the application acceptable, appropriate, and feasible for use in clinical practice.

CONCLUSIONS

Findings suggest that our transdiagnostic interactive application has excellent psychometric properties. Furthermore, patients and clinicians alike were positive about the possible use of the application in clinical practice. The next step will be to investigate the application's effectiveness as an intervention to promote autonomous motivation and to facilitate remission in people on the waitlist for specialized ED treatment.

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.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

Not applicable.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

PUBLIC SIGNIFICANCE STATEMENT

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

Self-help Digital Interventions Targeted at Improving Psychological Well-being in Young People With Perceived or Clinically Diagnosed Reduced Well-being: Systematic Review

BACKGROUND

Levels of well-being are declining, whereas rates of mental health problems remain high in young people. The World Health Organization defines mental health as not merely the absence of mental disorder but also includes social and psychological well-being as integral to positive mental health, highlighting that mental health is applicable to young people with mental health conditions and those without a diagnosis of a mental health condition. Reduced mental well-being have been identified in studies of young people with clinical populations, as well as in populations consisting of nonclinical young people. Self-help digital interventions can be delivered at mass at a low cost and without the need for trained input, thereby facilitating access to support for well-being. Self-help interventions are effective in young people with mental health conditions, but systematic reviews of such studies have been limited to randomized controlled trials, have not included reduced well-being as an inclusion criterion, and do not consider engagement factors such as retention.

OBJECTIVE

The objective of this study was to systematically review all controlled studies of digitally delivered, self-administered interventions for young people aged 9 to 25 years, with perceived or clinically diagnosed reduced psychological well-being. Participant retention and effectiveness of the interventions were also explored.

METHODS

A systematic search of the PsycInfo, EMBASE, Cochrane, Scopus, and MEDLINE databases from inception to 2021, reference searches of relevant papers, and gray literature was carried out for digitally controlled studies conducted with young people with perceived or clinically diagnosed reduced well-being, aimed at improving psychological well-being. Data were extracted to identify the effectiveness and retention rates of the interventions and the quality of the studies.

RESULTS

Overall, 1.04% (12/1153) of studies met the inclusion criteria: 83% (10/12) of studies were randomized controlled trials and 17% (2/12) were controlled pre-post studies. Most (6/12, 50%) studies aimed to improve symptoms of depression; 3 interventions aimed at both anxiety and depressive symptoms and 2 studies aimed at improving social functioning difficulties. Owing to the high risk of bias across interventions and lack of similar outcome measures, a meta-analysis was not conducted. Retention rates across studies were regarded as good, with moderate to high retention. Overall, the findings indicated that predominantly self-administered self-help interventions improved well-being in the areas targeted by the intervention and identified additional areas of well-being that were positively affected by interventions. Few interventions supported psychological well-being that was different from those used by young people with a clinical diagnosis of mental illness or young people from neurodiverse backgrounds.

CONCLUSIONS

The findings, along with the advantages of self-help interventions, highlight the need for upscaling self-help interventions to better support vulnerable populations of young people who experience poor psychological well-being.

TRIAL REGISTRATION

PROSPERO CRD42019129321; https://tinyurl.com/4fb2t4fz.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Evaluation of Web-Based Health Information From the Perspective of Women With Eating Disorders: Thematic Analysis

Background

Users with experience of eating disorders use the internet as a source of information, whether for prorecovery activities (such as web-based treatment, looking for information, support, and sharing) or activities that promote eating disorder behavior as a desirable lifestyle choice (such as pro–eating disorder communities and reading and creating pro–eating disorder posts). Their assessment of web-based eating disorder–related information is crucial for understanding the context of the illness and for health professionals and their web-based interventions.

Objective

This study aimed to understand the criteria young women with the experience of eating disorders use in evaluating eating disorder–related web-based information and what eating disorder–related characteristics of these women are involved in their evaluation.

Methods

We analyzed 30 semistructured individual interviews with Czech women aged 16 to 28 years with past or present eating disorder experience using a qualitative approach. Thematic analysis was adopted as an analytical tool.

Results

The specifics of eating disorder phases (the disorder stage and the treatment process) emerged as important aspects in the process of information assessment. Other specific characteristics of respondents (eg, motivation, abilities, and resources) addressed how the respondents arrived at certain web-based information and how they evaluated it. In addition, the respondents described some content cues as features of information (eg, novelty and social information pooling). Another finding is that other users’ attitudes, experiences, activities, and personal features are involved in the information evaluation of these users and the information presented by them. Finally, the respondents evaluated the websites’ visual look and graphic components.

Conclusions

This study shows that web-based information evaluation reported by women with experience of eating disorders is a complex process. The assessment is influenced by current personal characteristics related to the illness (mainly the motivation for maintaining or curing the eating disorder) using cues associated with information content, other users, and website look. The study findings have important implications for health professionals, who should ask their clients questions about web-based communities and their needs to understand what information and sources they choose.

Alliance matters: but how much? A systematic review on therapeutic alliance and outcome in patients with anorexia nervosa and bulimia nervosa

PURPOSE

Patients with eating disorders (ED) pose a high-risk group regarding relapse. The understanding of factors contributing to a better outcome is much-needed. Therapeutic alliance (TA) is one important, pantheoretical variable in the treatment process, which has shown to be connected with outcome. This review looks into a possible predictive effect of TA on outcome as well as related variables.

METHODS

A systematic review with pre-determined inclusion criteria following the PRISMA guidelines was conducted for studies published since 2014. Three previous reviews including studies up until 2014 were analyzed for studies matching our inclusion criteria. A total of 26 studies were included.

RESULTS

The results were heterogeneous between different patient groups. Regarding the predictive effect of TA, in adolescent samples, the TA of either the patients or their parents seems to impact outcome as well as completion. For adults, results are mixed, with a tendency to a greater impact of TA for anorexia nervosa (AN) patients, while some samples of adult bulimia nervosa (BN) patients did not find any relation between TA and outcome.

CONCLUSION

The effect of TA on clinical outcome depends on the patient group. TA has a greater impact on adolescents, irrespective of diagnosis, and on adults with AN. The examined studies have different limitations which include small sample sizes and questionable study design. The examination of motivation as a potential influencing factor is recommended.

LEVEL OF EVIDENCE

Level I, systematic review.

Use of Telehealth in the Management of Adolescent Eating Disorders: Patient Perspectives and Future Directions Suggested from the COVID-19 Pandemic

Efforts to increase accessibility of eating disorder (ED) treatment via telemedicine have been ongoing for the past decades. However, there has been a recent surge in research focused on remote delivery of interventions since the onset of the novel coronavirus pandemic (COVID-19) in 2020, the related lockdowns, and an exponential increase in ED symptoms in youth secondary to the pandemic worldwide. In the current review, we provide a focused summary of existing literature regarding telehealth for the treatment of EDs in adolescents using a frame of past, present, and future work. Specifically, we begin with a brief overview of research in remote delivery for EDs in youth prior to 2020. Then, we detail more recent studies in this domain, with a focus on research conducted during the COVID-19 pandemic. We close by outlining limitations of the existing data and future steps necessary to expand the rigor and impact of this work. Overall, there are considerable limitations associated with research conducted during the pandemic, but an increase in the acceptability of remote delivery methods and interest in hybrid care appears to be feasible, and likely to be lasting. Future work must replicate more recent research in non-pandemic contexts and prioritize evaluation of factors that will aid in matching patients to the most efficient and effective modalities of care moving forward.

Feasibility of guided internet-based cognitive behavioral therapy for patients with anorexia nervosa

OBJECTIVE

The objective of the present study was to investigate the feasibility of guided internet cognitive behavioral therapy (ICBT) for anorexia nervosa.

METHODS

We conducted a prospective single-arm study between January 2020 and March 2021. The intervention was built using videos, web programs, and chat tools. The intervention program was largely based on metacognitive training. Participants performed the self-help program once a week for 12 consecutive weeks. The primary outcome was the global Eating Disorder Examination Questionnaire (EDE-Q) score. Secondary outcomes included clinical symptoms of eating disorders, metacognitive function, body mass index, depression, and generalized anxiety. The main statistical analysis examined whether the EDE-Q score and other outcomes at the end of the intervention differed from the baseline.

RESULTS

Fourteen participants underwent the trial treatment, and 13 completed the intervention. There was a significant reduction in the global EDE-Q score from 3.48 (SD = 1.4) to 2.54 (SD = 1.5, p = 0.02, Cohen's d = 0.75) from baseline to post-intervention. Some EDE-Q subscales and body checking questionnaire scale demonstrated statistically significant improvements, with moderate to large effect sizes. Although there was no significant improvement in body mass index, metacognitive function, or depressive symptoms, there was a significant improvement in the severity of generalized anxiety (M = -4.0, p = 0.01, Cohen's d = 0.95). No adverse events were observed.

DISCUSSION

Our findings suggest that guided ICBT for anorexia nervosa is well accepted by female patients and practical as a telemedicine approach that improves symptoms. In the future, tightly controlled randomized controlled trials should be conducted for efficacy verification.

App-based food-specific inhibitory control training as an adjunct to treatment as usual in binge-type eating disorders: A feasibility trial

Current treatments for binge eating disorder (BED) and bulimia nervosa (BN) only show moderate efficacy, warranting the need for novel interventions. Impairments in food-related inhibitory control contribute to BED/BN and could be targeted by food-specific inhibitory control training (ICT). The aim of this study was to establish the feasibility and acceptability of augmenting treatment for individuals with BN/BED with an ICT app (FoodT), which targets motor inhibition to food stimuli using a go/no-go paradigm. Eighty patients with BED/BN receiving psychological and/or pharmacological treatment were randomly allocated to a treatment-as-usual group (TAU; n = 40) or TAU augmented with the 5-min FoodT app daily (n = 40) for 4 weeks. This mixed-methods study assessed feasibility outcomes, effect sizes of clinical change, and acceptability using self-report measures. Pre-registered cut-offs for recruitment, retention, and adherence were met, with 100% of the targeted sample size (n = 80) recruited within 12 months, 85% of participants retained at 4 weeks, and 80% of the FoodT + TAU group completing ≤8 sessions. The reduction in binge eating did not differ between groups. However, moderate reductions in secondary outcomes (eating disorder psychopathology: SES = -0.57, 95% CI [-1.12, -0.03]; valuation of high energy-dense foods: SES = -0.61, 95% CI [-0.87, -0.05]) were found in the FoodT group compared to TAU. Furthermore, small greater reductions in food addiction (SES = -0.46, 95% CI [-1.14, 0.22]) and lack of premeditation (SES = -0.42, 95% CI [-0.77, -0.07]) were found in the FoodT group when compared to TAU. The focus groups revealed acceptability of FoodT. Participants discussed personal barriers (e.g. distractions) and suggested changes to the app (e.g. adding a meditation exercise). Augmenting treatment for BED/BN with a food-specific ICT app is feasible, acceptable, and may reduce clinical symptomatology with high reach and wide dissemination.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

BED-online: Acceptance and efficacy of an internet-based treatment for binge-eating disorder: A randomized clinical trial including waitlist conditions

Objective

Internet‐based guided self‐help (GSH) programs increase accessibility and utilization of evidence‐based treatments in binge‐eating disorder (BED). We evaluated acceptance and short as well as long‐term efficacy of our 8‐session internet‐based GSH program in a randomized clinical trial with an immediate treatment group, and two waitlist control groups, which differed with respect to whether patients received positive expectation induction during waiting or not.

Method

Sixty‐three patients (87% female, mean age 37.2 years) followed the eight‐session guided cognitive‐behavioural internet‐based program and three booster sessions in a randomized clinical trial design including an immediate treatment and two waitlist control conditions. Outcomes were treatment acceptance, number of weekly binge‐eating episodes, eating disorder pathology, depressiveness, and level of psychosocial functioning.

Results

Treatment satisfaction was high, even though 27% of all patients dropped out during the active treatment and 9.5% during the follow‐up period of 6 months. The treatment, in contrast to the waiting conditions, led to a significant reduction of weekly binge‐eating episodes from 3.4 to 1.7 with no apparent rebound effect during follow‐up. All other outcomes improved as well during active treatment. Email‐based positive expectation induction during waiting period prior to the treatment did not have an additional beneficial effect on the temporal course and thus treatment success, of binge episodes in this study.

Conclusion

This short internet‐based program was clearly accepted and highly effective regarding core features of BED. Dropout rates were higher in the active and lower in the follow‐up period. Positive expectations did not have an impact on treatment effects.

The present internet‐based guided self‐help program adds to the existing research regarding online treatment of binge‐eating disorder and is currently one of the two existing validated programs available in German language. It is based on an established cognitive‐behavioural treatment approach, shows high acceptance by patients and high efficacy after eight guided online sessions, thereby representing the shortest duration of currently evaluated treatments

During the internet‐based therapy, the number of weekly binge‐eating episodes, depressive symptoms, eating disorder pathology as well as impairments in psychosocial functioning all significantly decreased. These positive effects were maintained during follow‐up (6 months). Abstainer rate (no binge‐eating during last month) continued to increase during follow‐up with booster sessions

An email‐based pre‐treatment positive expectation induction did not alter the temporal course and thus treatment success, of binge episodes

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

Background

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

Methods

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

Results

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

Conclusions

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

Current state of scientific evidence on Internet-based interventions for the treatment of depression, anxiety, eating disorders and substance abuse: an overview of systematic reviews and meta-analyses

BACKGROUND

ICare represents a consortium of European Investigators examining the effects of online mental health care for a variety of common mental health disorders provided in a variety of settings. This article provides an overview of the evidence of effectiveness for Internet-based treatment for four common mental health disorders that are the focus of much of this work: depression, anxiety, substance abuse and eating disorders.

METHODS

The overview focused primarily on systematic reviews and meta-analyses identified through PubMed (Ovid) and other databases and published in English. Given the large number of reviews specific to depression, anxiety, substance abuse and/or eating disorders, we did not focus on reviews that examined the effects of Internet-based interventions on mental health disorders in general. Each article was reviewed and summarized by one of the senior authors, and this review was then reviewed by the other senior authors. We did not address issues of prevention, cost-effectiveness, implementation or dissemination, as these are addressed in other reviews in this supplement.

RESULTS

Across Internet-based intervention studies addressing depression, anxiety, substance abuse and eating disorders primarily among adults, almost all reviews and meta-analyses found that these interventions successfully reduce symptoms and are efficacious treatments. Generally, effect sizes for Internet-based interventions treating eating disorders and substance abuse are lower compared with interventions for depression and anxiety.

CONCLUSIONS

Given the effectiveness of Internet-based interventions to reduce symptoms of these common mental health disorders, efforts are needed to examine issues of how they can be best disseminated and implemented in a variety of health care and other settings.

A mixed-method systematic review of text-based telehealth interventions in eating disorder management

Purpose

Eating disorders (EDs) is a major health condition affecting 9% of the global population and 10% of those with EDs lost their lives as a result. Text-based telehealth interventions (TTIs) seem to provide a low-cost and convenient treatment option; however, the evidence is scarce. This study aimed to synthesize evidence relating to the use of TTIs for the management of EDs.

Design/methodology/approach

Five databases were searched published between January 2020 and May 2019. The authors used keywords relating to telehealth and EDs. The authors used Joanna Briggs Institute's (JBI's) critical appraisal instrument to assess the methodology quality of included studies.

Findings

Fifteen studies were included in this mix-method systematic review and assessed for methodology quality. Email, web-based texting, text-messaging and online chat room were used as mode for deliver healthcare for patients with EDs. In the treatment phase, all studies (nine studies; n = 860 participants) showed effectiveness (for RCTs) and usefulness (for non-RCT studies). In the aftercare phase (six studies; n = 364 participants), the results regarding the effectiveness of TTIs were mixed. Two studies showed effectiveness whilst four studies did not find statistically significant change of ED outcomes.

Research limitations/implications

The qualities of these studies varied; firstly, 66% (n = 10) of the studies were non-randomized studies (e.g. single-arm trial, case report) with small samples. Moreover, one-fourth (n = 4) of the studies did not use validated instruments or indicate the instrument. Also, half (n = 7) of the studies used TTIs as adjunct to face-to-face treatment or bigger online treatment, it is hard to make conclusion that the changes were due to TTIs' effect. In addition, follow-up rate is not satisfactory, thus results should be interpreted cautiously.

Practical implications

TTIs seem to be promising for management of EDs, particularly in the treatment phase. This provides an important treatment option for health practitioners and people with EDs as an alternative or in adjunct with face-to-face services.

Originality/value

This is the first review to synthesis the use of TTIs for ED management.

The relationship between working alliance with peer mentors and eating psychopathology in a digital 6-week guided self-help intervention for anorexia nervosa

OBJECTIVE

The quality of working alliance (WA) is associated with treatment outcomes across several types of psychiatric disorders and psychological interventions. This study examined the role of WA with peer mentors (people with lived experience of illness) and student mentors (graduated psychology students) in a 6-week, digital, guided self-help (GSH) intervention for anorexia nervosa.

METHOD

Ninety-nine patients rated weekly, for 6 weeks: (a) eating psychopathology using the short version of the Eating Disorder Examination Questionnaire (EDE-QS) and (b) WA with a student mentor (n = 14) or a peer mentor (n = 10). WA was assessed by asking patients the extent to which they felt comfortable working with their mentor and the extent to which they agreed with them on the goals for support. WA with mentors and the association with eating psychopathology change were measured on a session-by-session basis. The analysis involved a random intercepts cross-lagged panel model.

RESULTS

WA with peer mentors was slightly higher than WA with students (ES = 0.3). Peer mentors' WA in the previous session was significantly associated with eating psychopathology ratings in the next session. No significant relationship was found between the previous session's EDE-QS scores and peer mentor alliance in the following session. In the student mentor group, there were no session-by-session associations between WA and eating psychopathology. However, greater WA with the student mentor across sessions was associated with less eating psychopathology.

DISCUSSION

These findings suggest that clinical outcomes are in part associated with the characteristics of the mentor delivering guidance in an online GSH for eating disorders.

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.

Does a Skills Intervention for Parents Have a Positive Impact on Adolescents' Anorexia Nervosa Outcome? Answers from a Quasi-Randomised Feasibility Trial of SUCCEAT

Skills trainings for caregivers of patients with anorexia nervosa (AN) have been proven to be effective in improving caregiver skills and reducing caregivers’ psychopathology. The effects on patients, especially adolescents, are largely unknown. The aim of this study was to evaluate the effectiveness of a caregivers’ skills training program (Supporting Carers of Children and Adolescents with Eating Disorders in Austria, SUCCEAT, workshop or online version) on adolescents with AN delivered as workshops (WS) or online (ONL). Outcomes are Body-Mass-Index (BMI) percentile, eating psychopathology (Eating Disorder Examination, EDE), attitudinal and behavioural dimensions of eating disorders (Eating Disorder Inventory-2), motivation to change (AN Stages of Change Questionnaire), emotional and behavioural problems (Youth Self-Report) and quality of life (KINDL). All outcome variables significantly improved across both SUCCEAT groups (WS and ONL) and were sustained at 12-month follow-up. The online and workshop delivery of SUCCEAT were equally effective. Most effect sizes were in the medium-to-high range. Full or partial remission was observed in 72% (WS) and 87% (ONL) of patients. Caregiver skills trainings, either delivered as workshops or online modules, are highly recommended to complement treatment as usual.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

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

UNIQUE CLINICAL TRIAL NUMBER

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

Psychological Impact of Pro-Anorexia and Pro-Eating Disorder Websites on Adolescent Females: A Systematic Review

(1) Background: Teenagers (in particular, females) suffering from eating disorders report being not satisfied with their physical aspect and they often perceive their body image in a wrong way; they report an excessive use of websites, defined as PRO-ANA and PRO-MIA, that promote an ideal of thinness, providing advice and suggestions about how to obtain super slim bodies. (2) Aim: The aim of this review is to explore the psychological impact of pro-ana and pro-mia websites on female teenagers. (3) Methods: We have carried out a systematic review of the literature on PubMed. The search terms that have been used are: "Pro" AND "Ana" OR "Blogging" AND "Mia". Initially, 161 publications were identified, but in total, in compliance with inclusion and exclusion criteria, 12 studies have been analyzed. (4) Results: The recent scientific literature has identified a growing number of Pro Ana and Pro Mia blogs which play an important role in the etiology of anorexia and bulimia, above all in female teenagers. The feelings of discomfort and dissatisfaction with their physical aspect, therefore, reduce their self-esteem. (5) Conclusion: These websites encourage anorexic and bulimic behaviors, in particular in female teenagers. Attention to healthy eating guidelines and policies during adolescence, focused on correcting eating behavioral aspects, is very important to prevent severe forms of psychopathology with more vulnerability in the perception of body image, social desirability, and negative emotional feedback.

Attitudes toward Technology-Based Cancer Support Programs Among Korean American Breast Cancer Survivors

Despite the increasing usages of technology-based programs, few technology-based support programs are currently available for racial/ethnic minority cancer survivors including Korean-American cancer survivors. The purpose of this study was to explore the attitudes toward technology-based cancer support programs among Korean-American cancer survivors from a feminist perspective. In-person focus group interviews were held with 17 Korean-American cancer survivors. All the interviews were recorded by writing memos. Then, the written memos were analyzed using a content analysis. Four major themes reflecting their attitudes toward technology-based cancer-support programs were identified: (a) "easy to access"; (b) "good for peer and family support," (c) "overcoming language barriers," and (d) "providing Korean-specific and personalized trustable information." Future technology-based cancer support groups for this specific population need to incorporate peer support, support for family members, Korean language, and Korea-specific information and intervention components.

Telemedicine for Acute Conditions During COVID-19: A Nationwide Survey Using Crowdsourcing

Background: COVID-19 has resulted in a rapid and significant adoption of telemedicine for acute conditions. Understanding whether patient demand will last after the pandemic helps providers and payers make informed decisions about whether to continue adopting telemedicine. Objective: We examine user experience as well as process and patient outcomes of using telemedicine for acute conditions during COVID-19 and assess how patient outcomes are affected by waiting times and demographics. Materials and Methods: A survey was conducted via Amazon Mechanical Turk during June 17-29, 2020. Inclusion criteria were: (1) ≥18 years old, (2) residing in the United States, (3) used telemedicine for acute conditions after January, and 4) a human intelligence task approval rate of >95%. Process outcomes included patient waiting time with patient outcomes being satisfaction and future use intention. Bivariate analysis and regressions of the data were performed. Results: On average, respondents reported appointment wait time of 2.76 days and virtual office wait time of 19.44 min. Overall, respondents reported moderate satisfaction (mean 5.08-5.35 of 7) and future use intention (mean 5.10-5.32 of 7). Over 72% of the respondents were satisfied and had future use intention. Females, heavier internet users, and those on the higher/lower ends of the education spectrum reported better patient outcomes. Patients "visiting" a doctor experiencing eye problems, vis-à-vis other ailments, reported lower satisfaction and intention. Waiting time negatively associates with satisfaction. Conclusions: Given the satisfactory outcomes, the high demand for telemedicine may continue after the COVID-19 pandemic. However, whether providers will continue to offer telemedicine visits may require more evidence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHOD

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

DISCUSSION

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

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

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

Long-Term Efficacy of the Workshop Vs. Online SUCCEAT (Supporting Carers of Children and Adolescents with Eating Disorders) Intervention for Parents: A Quasi-Randomised Feasibility Trial

Interventions for main carers of adult patients with anorexia nervosa (AN) can reduce the caregiving burden and increase caregiver skills. However, the effectiveness and feasibility for carers of adolescent patients, the optimal form of the intervention and long-term outcomes are largely unknown. We evaluated the efficacy and feasibility of the "Supporting Carers of Children and Adolescents with Eating Disorders in Austria" (SUCCEAT) workshop vs. online intervention. Main caregivers (parents) of adolescent patients with AN were randomly allocated to a workshop (n = 50) or online version (n = 50). Participants were compared to a non-randomised comparison group (n = 49) receiving multi-family or systemic family therapy. Primary (General Health Questionnaire) and secondary outcomes were obtained at baseline, three-month and 12-month follow-up. Adherence was high for workshop and online participants (6.2 and 6.7 sessions completed out of 8). Intention-to-treat analyses revealed significant pre-post reductions in the primary outcome for the workshop (d = 0.87 (95%conficence interval (CI): 0.48; 1.26)) and online (d = 0.65 (95%CI: 0.31; 0.98)) intervention that were sustained at the 12-month follow-up. There was no significant group difference (p = 0.473). Parental psychopathology and burden decreased and caregiver skills increased in all groups; the improvement of caregiver skills was significantly higher in SUCCEAT participants than in the comparison group. Online interventions for parents of adolescents with AN were equally effective as workshops. The improvements remained stable over time.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

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

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

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

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Randomized Controlled Trial Comparing Health Coach-Delivered Smartphone-Guided Self-Help With Standard Care for Adults With Binge Eating

OBJECTIVE

Cognitive-behavioral therapy (CBT) has shown efficacy in the treatment of eating disorders. The authors conducted a randomized controlled telemedicine trial of CBT-guided self-help (CBT-GSH) assisted with a smartphone app, Noom Monitor, for binge eating with or without purging. They hypothesized that coach-delivered CBT-GSH telemedicine sessions plus Noom Monitor would yield greater reductions in symptoms of binge eating, purging, and eating disorders compared with standard care.

METHODS

Fifty-two-week outcomes for CBT-GSH plus Noom Monitor (N=114) were compared with outcomes for standard care (N=111) among members of an integrated health care system in the Pacific Northwest. Patients in the health system who met inclusion criteria were ≥18 years old, had a body mass index ≥18.5, met criteria for DSM-5 binge eating disorder or bulimia nervosa, had 12 months of continuous health care enrollment in Kaiser Permanente Northwest, and had a personal smartphone. Participants received eight CBT-GSH telemedicine sessions over 12 weeks administered by health coaches, and outcomes were assessed at baseline and at weeks 4, 8, 12, 26, and 52. The use of available treatment offered within the Kaiser Permanente health care system was permitted for participants assigned to standard care.

RESULTS

Participants who received CBT-GSH plus Noom Monitor reported significant reductions in objective binge-eating days (β=-0.66, 95% CI=-1.06, -0.25; Cohen's d=-1.46, 95% CI=-4.63, -1.09) and achieved higher rates of remission (56.7% compared with 30%; number needed to treat=3.74) at 52 weeks compared with participants in standard care, none of whom received any eating disorder treatment during the intervention period (baseline and weeks 1-12). Similar patterns emerged for compensatory behaviors (vomiting, use of laxatives, and excessive exercise; 76.3% compared with 56.8%; number needed to treat=5.11), eating disorder symptoms (body shape, weight, eating concerns, and dietary restraint), and clinical impairment (Cohen's d=-10.07, -2.15).

CONCLUSIONS

These results suggest that CBT-GSH plus Noom Monitor delivered via telemedicine by routine-practice health coaches in a nonacademic health care system yields reductions in symptoms and impairment over 52 weeks compared with standard care.

Knowledge, attitude, and use of mHealth technology among students in Ghana: A university-based survey

Background

Interest in mHealth interventions, defined as the use of mobile phones to access healthcare is increasingly becoming popular globally. Given its technology-based applications, university students may be key clients of the mHealth adoption but studies are rare in sub-Saharan Africa. This study provides a snapshot and baseline evidence on knowledge, attitude and use of mHealth among university students in Ghana.

Methods

Using a self-administered questionnaire, we collected data between April and June 2017 from 963 randomly sampled undergraduate students at the Kwame Nkrumah University of Science and Technology (KNUST). Pearson’s Chi-square (χ²) test assessed the differences between variables whilst  logistic regression models estimated the independent predictors of use of mHealth with p < 0.05 as significant.

Results

Knowledge on mHealth was moderately high. Specifically, more than half of the sample reported awareness of mHealth although the prevalence of use of mHealth stood at 51%. Logistic regressions revealed that mHealth use was positively associated with respondents’ year (second year: OR = 1.704, 95% CI: 1.185–2.452, and third year: OR = 1.528, 95% CI: 1.060–2.202), and monthly income (OR:3.112, 95%CI: 1.180-8.211). However, ethnicity [(OR = 0.761, 95% CI (0.580–0.997)] was negatively associated with the use of mHealth technology.

Conclusion

Findings suggest that knowledge of mHealth among university students is low. Policy and public health interventions for urgent awareness creation and promotion of use of mHealth as well as its possible integration into the mainstream healthcare system in Ghana are timely.

Internet-Based Cognitive Behavioral Therapy via Videoconference for Patients With Bulimia Nervosa and Binge-Eating Disorder: Pilot Prospective Single-Arm Feasibility Trial

Background

A major problem in providing mental health services is the lack of access to treatment, especially in remote areas. Thus far, no clinical studies have demonstrated the feasibility of internet-based cognitive behavioral therapy (ICBT) with real-time therapist support via videoconference for bulimia nervosa and binge-eating disorder in Japan.

Objective

The goal of the research was to evaluate the feasibility of ICBT via videoconference for patients with bulimia nervosa or binge-eating disorder.

Methods

Seven Japanese subjects (mean age 31.9 [SD 7.9] years) with bulimia nervosa and binge-eating disorder received 16 weekly sessions of individualized ICBT via videoconference with real-time therapist support. Treatment included CBT tailored specifically to the presenting diagnosis. The primary outcome was a reduction in the Eating Disorder Examination Edition 16.0D (EDE 16D) for bulimia nervosa and binge-eating disorder: the combined objective binge and purging episodes, objective binge episodes, and purging episodes. The secondary outcomes were the Eating Disorders Examination Questionnaire, Bulimic Investigatory Test, Edinburgh, body mass index for eating symptoms, Motivational Ruler for motivation to change, EuroQol-5 Dimension for quality of life, 9-item Patient Health Questionnaire for depression, 7-item Generalized Anxiety Disorder scale for anxiety, and Working Alliance Inventory–Short Form (WAI-SF). All outcomes were assessed at week 1 (baseline) and weeks 8 (midintervention) and 16 (postintervention) during therapy. Patients were asked about adverse events at each session. For the primary analysis, treatment-related changes were assessed by comparing participant scores and 95% confidence intervals using the paired t test.

Results

Although the mean combined objective binge and purging episodes improved from 47.60 to 13.60 (71% reduction) and showed a medium effect size (Cohen d=–0.76), there was no significant reduction in the combined episodes (EDE 16D –41; 95% CI –2.089 to 0.576; P=.17). There were no significant treatment-related changes in secondary outcomes. The WAI-SF scores remained consistently high (64.8 to 66.0) during treatment.

Conclusions

ICBT via videoconference is feasible in Japanese patients with bulimia nervosa and binge-eating disorder.

Trial Registration

UMIN Clinical Trials Registry UMIN000029426; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000033419

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Improving aftercare with technology for anorexia nervosa after intensive inpatient treatment: A pilot randomized controlled trial with a therapist-guided smartphone app

OBJECTIVE

To evaluate the feasibility, acceptability, and preliminary efficacy of an innovative therapist-guided smartphone-based aftercare intervention following inpatient treatment of patients with severe anorexia nervosa (AN).

METHOD

Forty female patients with AN (ICD-10: F50.0/F50.1) (aged: 15-36 years) were randomized either to an 8-week smartphone-based aftercare intervention (German version of "Recovery Record") with therapist feedback as an adjunct to treatment as usual (intervention group [IG]) or to treatment as usual alone (control group [CG]). Body mass index (BMI) and eating disorder (ED) symptoms were assessed at discharge (baseline), postintervention (after 8 weeks), and at 6-month follow-up. Additionally, patients' satisfaction, adherence to the smartphone-based intervention, and postdischarge health care utilization were evaluated.

RESULTS

Patients showed a high level of adherence and reported a very high acceptance of the app and the aftercare intervention. We found at postintervention nonsignificant small to moderate between-group effect sizes favoring the IG regarding BMI (d = -0.24; 95% confidence interval [CI] [-0.90, 0.41]) and ED symptoms (Eating Disorder Examination-Questionnaire global: d = 0.56; 95% CI [-0.10, 1.22]). At 6-month follow-up, effects wore off and no significant differences between the IG and CG were evident.

DISCUSSION

This was the first study to evaluate a therapist-guided smartphone-based aftercare intervention for discharged inpatients with AN. Results suggest that such an intervention is highly accepted by patients and that it could support symptom stabilization or continued improvement as an add-on therapy to treatment as usual. A larger scale randomized controlled trial is now planned to further evaluate the efficacy of this aftercare intervention for patients with AN.

Towards Scalable, Integrative Assessment of Children's Self-Regulatory Capabilities: New Applications of Digital Technology

The assessment of self-regulation in children is of significant interest to researchers within education, clinical and developmental psychology, and clinical neuroscience, given its importance to adaptive functioning across a wide range of social, educational, interpersonal, educational and health domains. Because self-regulation is a complex, multidimensional construct, a range of assessment approaches have been developed to assess its various components including behavioural, cognitive and emotional domains. In recent years, digital technology has been increasingly used to enhance or supplement existing measurement approaches; however, developments have predominantly focused on translating traditional testing paradigms into digital formats. There is a need for more innovation in digital psychological assessments that harness modern mechanisms such as game-based design and interactivity. Such approaches have potential for the development of scalable, adaptable universal approaches to screening and assessment of children's self-regulatory capabilities, to facilitate early identification of difficulties in individuals and also guide planning and decision-making at a population level. We highlight a novel, innovative digital assessment tool for children called Rumble's Quest, a new measure of children's socio-emotional functioning that shows promise as an integrative assessment of well-being and self-regulation, and which incorporates both self-report and direct assessment of cognitive self-regulation. This tool is scalable, can be integrated into normal classroom activities, and forms part of a comprehensive prevention support system that can be used to guide stakeholders' decision-making regarding early intervention and support at the individual, classroom, school and community level. We finish by discussing other innovative possibilities for psychological assessment with children, using new and emerging technologies and assessment approaches.

Self-Help Treatment of Eating Disorders

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

Clinician-Delivered Teletherapy for Eating Disorders

The delivery of teletherapy is an important advancement in clinical care for the treatment of eating disorders (EDs). Specifically, it seems to improve access to highly specialized ED treatment. Research on the application of videoconferencing-based psychotherapy services for EDs is minimal; however, results suggest that this treatment format leads to significant improvements in clinical symptoms and is well accepted by patients. General telemedicine guidelines and administrative and clinical recommendations specific to the treatment of ED patients have been identified. With careful planning and thoughtful application, Internet-based therapy seems to be a valuable resource for practitioners seeking to disseminate specialized ED treatments.