Online counselling for eating disorders: reaching an underserved population?

Enhanced recovery support for people with eating disorders during the COVID-19 pandemic: quality improvement using a web-based, stepped-care programme in Canada

BACKGROUND

Throughout the COVID-19 pandemic, the number of individuals struggling with eating disorders (EDs) increased substantially. Body Brave (a not-for-profit) created and implemented a web-based stepped-care Recovery Support Programme (RSP) to improve access to community-based ED services. This quality improvement study describes the RSP and assesses its ability to deliver timely access to treatment and platform engagement.

METHODS

We conducted a retrospective cohort study comparing access to, and use of Body Brave services 6 months before and 12 months after implementation of the RSP platform (using 6-month increments for two postimplementation periods). Primary programme quality measures included registration requests, number of participants onboarded and time to access services; secondary measures included use of RSP action plans, attendance for recovery sessions and workshops, number of participants accessing treatment and text-based patient experience data.

RESULTS

A substantial increase in registration requests was observed during the first postimplementation period compared with the preimplementation period (176.5 vs 85.5; p=0.028). When compared with the preimplementation period, the second postimplementation observed a significantly larger percentage of successfully onboarded participants (76.6 vs 37.9; p<0.01) and a reduction in the number of days to access services (2 days vs 31 days; p<0.01). Although participant feedback rates were low, many users found the RSP helpful, easy to access, user-friendly and were satisfied overall. Users provided suggestions for improvement (eg, a platform instructional video, offer multiple times of day for live sessions and drop-in hours).

CONCLUSIONS

Although clinical benefit needs to be assessed, our findings demonstrate that the RSP enabled participants to quickly onboard and access initial services and have informed subsequent improvements. Understanding initial programme effects and usage will help assess the feasibility of adapting and expanding the RSP across Canada to address the urgent need for low-barrier, patient-centred ED care.

Patient-centered education in dyslipidemia management: a systematic review

Background

Dyslipidemia management is crucial to reduce mortality and morbidity from cardiovascular diseases (CVDs). Patients must be educated and empowered to enable them to manage their own diseases. Various methods of patient education, such as patient-centered education (PCE) or non-PCE (such as didactic education or any traditional form of education), have been implemented.

Objective

To review and determine the effectiveness of PCE for dyslipidemia management compared with usual care. The primary outcome chosen was cholesterol level. Other measures, such as psychosocial or cognitive, behavioral, and other relevant outcomes, were also extracted. Additionally, underlying theories and other contributing factors that may have led to the success of the intervention were also reviewed and discussed.

Methods

We conducted searches in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Google Scholar from inception until April 2021. All studies involving randomized controlled trials were included. Study quality was assessed using the Critical Appraisal Skills Program (CASP) checklist specifically for randomized controlled trials.

Results

The search identified 8,847 records. Of these, 20 studies were eligible for inclusion. Interventions using a PCE approach were largely successful. Contributing factors extracted from the included studies were underlying theories, instant reward system, dietary education, collaborative care, duration of intervention with systematic follow-ups, social support, adherence assessment method, and usage of e-health.

Conclusions

PCE is successful in achieving the desired outcomes in dyslipidemia management. Future studies may incorporate the elements of PCE to improve the management of dyslipidemia in hospital or community settings where appropriate.

Identifying key challenges and needs in digital mental health moderation practices supporting users exhibiting risk behaviours to develop responsible AI tools: the case study of Kooth

Digital platforms for mental health and wellbeing purposes have become increasingly common to help users exhibiting risk behaviours (e.g. self-harming, eating-related disorders) across all ages, opening new frontiers in supporting vulnerable users. This study stems from a larger project, which explores how responsible AI solutions can up-scale existing manual moderation approaches and better target interventions for young people who ask for help or engage in risk behaviours online. This research aims to better understand the challenges and needs of moderators and digital counsellors, i.e. the ‘behind the scenes’. Through this case study, the authors intend to contribute to the development of responsible AI tools that are fit for purpose and better understand the challenges. The key focus lies on Kooth.com, the UK’s leading free online confidential service offering counselling and emotional wellbeing support to young people in the UK through its online web-based and pseudo-anonymous digital platform.

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 COVID-19 pandemic and eating disorders in children, adolescents, and emerging adults: virtual care recommendations from the Canadian consensus panel during COVID-19 and beyond

OBJECTIVE

The COVID-19 pandemic has had detrimental effects on mental health. Literature on the impact on individuals with eating disorders is slowly emerging. While outpatient eating disorder services in Canada have attempted to transition to virtual care, guidelines related to optimal virtual care in this field are lacking. As such, the objective of our Canadian Consensus Panel was to develop clinical practice guidelines related to the provision of virtual care for children, adolescents, and emerging adults living with an eating disorder, as well as their caregivers, during the COVID-19 pandemic and beyond.

METHODS

Using scoping review methodology (with literature in databases from 2000 to 2020 and grey literature from 2010 to 2020), the Grading of Recommendations, Assessment, Development, and Evaluation system, the Appraisal of Guidelines, Research and Evaluation tool, and a panel of diverse stakeholders from across Canada, we developed high quality treatment guidelines that are focused on virtual interventions for children, adolescents, and emerging adults with eating disorders, and their caregivers.

RESULTS

Strong recommendations were supported specifically in favour of in-person medical evaluation when necessary for children, adolescents, and emerging adults, and that equity-seeking groups and marginalized youth should be provided equal access to treatment. For children and adolescents, weak recommendations were supported for telehealth family-based treatment (FBT) and online guided parental self-help FBT. For emerging adults, internet cognitive-behavioural therapy (CBT)-based guided self-help was strongly recommended. Weak recommendations for emerging adults included CBT-based group internet interventions as treatment adjuncts, internet-based relapse prevention Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) guided self-help, telehealth relapse prevention using MANTRA, and guided CBT-based smartphone apps as treatment adjuncts. For caregivers of children and adolescents, weak recommendations were supported for virtual parent meal support training, and moderated online caregiver forums and support groups. For caregivers of emerging adults, guided parental self-help CBT was strongly recommended, and unguided caregiver psychoeducation self-help was weakly recommended.

CONCLUSIONS

Several gaps for future work were identified including the impact of sex, gender, race, and socioeconomic status on virtual care among children, adolescents, and emerging adults with eating disorders, as well as research on more intensive services, such as virtual day hospitals.

Can an internet-based program for the prevention and early intervention in eating disorders facilitate access to conventional professional healthcare?

BACKGROUND

The majorities of individual suffering from eating disorders do not seek or receive adequate professional treatment. Internet-based approaches promise to facilitate access to conventional healthcare by providing an easy-access, low-threshold contact.

AIM

The current study investigated whether an Internet-based program for the prevention and early intervention for eating disorders (ProYouth) may contribute to the actual and intended uptake of professional care. Characteristics of individuals who seek help are explored as well as barriers to help-seeking.

METHOD

The sample included 453 ProYouth participants who were surveyed three months after registration. Actual help-seeking behavior, intended help-seeking, potential help-seeking, and barriers to help-seeking were assessed.

RESULTS

Within three months of participation, 43 individuals (9.5%) took up treatment, 32 (7.8%) intended to start treatment, and 163 (43.1%) of the remaining reported that they would seek professional help in case of need (potential help-seeking). Approximately 50% of (potential) help-seekers stated that participation in ProYouth has changed their attitude towards help-seeking. Mental health literacy and shame/stigma were the most frequently mentioned barriers.

CONCLUSIONS

This is the first study indicating that an online program for prevention and early intervention may serve as facilitator in accessing conventional healthcare.

Web-Based Cognitive Behavioral Therapy for Female Patients With Eating Disorders: Randomized Controlled Trial

Background

Many patients with eating disorders do not receive help for their symptoms, even though these disorders have severe morbidity. The Internet may offer alternative low-threshold treatment interventions.

Objective

This study evaluated the effects of a Web-based cognitive behavioral therapy (CBT) intervention using intensive asynchronous therapeutic support to improve eating disorder psychopathology, and to reduce body dissatisfaction and related health problems among patients with eating disorders.

Methods

A two-arm open randomized controlled trial comparing a Web-based CBT intervention to a waiting list control condition (WL) was carried out among female patients with bulimia nervosa (BN), binge eating disorder (BED), and eating disorders not otherwise specified (EDNOS). The eating disorder diagnosis was in accordance with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, and was established based on participants’ self-report. Participants were recruited from an open-access website, and the intervention consisted of a structured two-part program within a secure Web-based application. The aim of the first part was to analyze participant’s eating attitudes and behaviors, while the second part focused on behavioral change. Participants had asynchronous contact with a personal therapist twice a week, solely via the Internet. Self-report measures of eating disorder psychopathology (primary outcome), body dissatisfaction, physical health, mental health, self-esteem, quality of life, and social functioning were completed at baseline and posttest.

Results

A total of 214 participants were randomized to either the Web-based CBT group (n=108) or to the WL group (n=106) stratified by type of eating disorder (BN: n=44; BED: n=85; EDNOS: n=85). Study attrition was low with 94% of the participants completing the posttest assignment. Overall, Web-based CBT showed a significant improvement over time for eating disorder psychopathology (F₉₇=63.07, P<.001, d=.82) and all secondary outcome measures (effect sizes between d=.34 to d=.49), except for Body Mass Index. WL participants also improved on most outcomes; however, effects were smaller in this group with significant between-group effects for eating disorder psychopathology (F₂₀₁=9.42, P=.002, d=.44), body dissatisfaction (F₂₀₁=13.16, P<.001, d=.42), physical health (F₂₀₀=12.55, P<.001, d=.28), mental health (F₂₀₃=4.88, P=.028, d=.24), self-esteem (F₂₀₂=5.06, P=.026, d=.20), and social functioning (F₂₀₅=7.93, P=.005, d=.29). Analyses for the individual subgroups BN, BED, and EDNOS showed that eating disorder psychopathology improved significantly over time among Web-based CBT participants in all three subgroups; however, the between-group effect was significant only for participants with BED (F₇₈=4.25, P=.043, d=.61).

Conclusions

Web-based CBT proved to be effective in improving eating disorder psychopathology and related health among female patients with eating disorders.

Trial Registration

Nederlands Trial Register (NTR): NTR2415; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2415 (Archived by WebCite at http://www.webcitation.org/6T2io3DnJ).

Internet-based preventive intervention for reducing eating disorder risk: A randomized controlled trial comparing guided with unguided self-help

Student Bodies, an internet-based intervention, has successfully reduced weight/shape concerns and prevented eating disorders in a subset of college-age women at highest risk for an eating disorder. Student Bodies includes an online, guided discussion group; however, the clinical utility of this component is unclear. This study investigated whether the guided discussion group improves program efficacy in reducing weight/shape concerns in women at high risk for an eating disorder. Exploratory analyses examined whether baseline variables predicted who benefitted most. Women with high weight/shape concerns (N = 151) were randomized to Student Bodies with a guided discussion group (n = 74) or no discussion group (n = 77). Regression analyses showed weight/shape concerns were reduced significantly more among guided discussion group than no discussion group participants (p = 0.002; d = 0.52); guided discussion group participants had 67% lower odds of having high-risk weight/shape concerns post-intervention (p = 0.02). There were no differences in binge eating at post-intervention between the two groups, and no moderators emerged as significant. Results suggest the guided discussion group improves the efficacy of Student Bodies in reducing weight/shape concerns in college students at high risk for an eating disorder.

A randomized controlled trial of an internet-based posttreatment care for patients with eating disorders

BACKGROUND

Despite effective treatment approaches, relapses are frequent in eating disorders. Posttreatment care is essential to enhance continuous recovery and prevent deterioration. This study evaluated the effects of an Internet-based intervention following routine care.

MATERIALS AND METHODS

One hundred five women who received treatment for bulimia nervosa and related eating disorders not otherwise specified were randomly assigned either to an immediate Internet-based support program (EDINA) over 4 months or to a 4-month waiting-list treatment as usual (TAU) control condition. The primary outcome was eating disorder-related attitudes at baseline and after 4 months assessed by the Eating Disorder Examination Questionnaire (EDE-Q).

RESULTS

The program proved feasible and was well accepted. A significant reduction in eating disorder-related attitudes could be shown for both groups at the end of the 4 months. There was a tendency for participants of the aftercare intervention to show better results on all outcome measures. In total, 40.6% (13/32) of the EDINA participants and 24.4% (10/41) of the TAU participants showed statistically reliable improvement on the EDE-Q total score by the end of the intervention period [χ(2)(1)=2.195, p=0.138].

CONCLUSIONS

The Internet-based support program was feasible and well accepted but did not prove efficacious in a heterogeneous sample of patients following routine care.

Internet and patient empowerment in individuals with symptoms of an eating disorder: a cross-sectional investigation of a pro-recovery focused e-community

INTRODUCTION

Many individuals with eating disorder problems seek information and support online. There are however numerous websites that promote eating disordered behaviors. The website and e-community 'Proud2Bme' was developed as a healthy alternative for pro-eating disorder websites, providing a safe, positive, and pro-recovery focused environment. It offers a wide array of information and personal stories, as well as platforms for interaction such as a forum and chat. The first aim of this study was to investigate whether, and to what extent, empowering processes and outcomes are experienced by participants on Proud2Bme. The second aim was to examine correlates of empowering processes and outcomes.

METHODS

Participants (n=311) were recruited via an online survey on Proud2Bme. Correlations were examined and T-tests and ANOVAs were conducted.

RESULTS

Exchanging information, finding recognition, and sharing experiences were the empowering processes most often reported by participants. The most pronounced empowering outcome was feeling better informed. To a smaller degree, increased help-seeking behavior, increased optimism and control over the future, and increased confidence in treatment and the relationship with the therapist were reported. Lower levels of general empowerment, younger age, and more interactive usage patterns of the website were positively associated with the experience of empowering processes and outcomes.

DISCUSSION

Offering a platform where individuals can share their experiences and find recognition might be one of the most important ingredients for successful e-health initiatives aimed at improving patient empowerment. Moreover, in the field of eating disorders specifically, such initiatives offer a healthy alternative to the harmful and negative effects of pro-eating disorder websites.

Internet-based relapse prevention for anorexia nervosa: nine- month follow-up

BACKGROUND

To study the longer term effects of an internet-based CBT intervention for relapse prevention (RP) in anorexia nervosa.

METHODS

210 women randomized to the RP intervention group (full and partial completers) or the control group were assessed for eating and general psychopathology. Multiple regression analysis identified predictors of favorable course concerning Body Mass Index (BMI). Logistic regression analysis identified predictors of adherence to the RP program.

RESULTS

Most variables assessed showed more improvement for the RP than for the control group. However, only some scales reached statistical significance (bulimic behavior and menstrual function, assessed by expert interviewers blind to treatment condition). Very good results (BMI) were seen for the subgroup of "full completers" who participated in all nine monthly RP internet-based intervention sessions. "Partial completers" and controls (the latter non-significantly) underwent more weeks of inpatient treatment during the study period than "full completers", indicating better health and less need for additional treatment among the "full completers". Main long-term predictors for favorable course were adherence to RP, more spontaneity, and more ineffectiveness. Main predictors of good adherence to RP were remission from lifetime mood and lifetime anxiety disorder, a shorter duration of eating disorder, and additional inpatient treatment during RP.

CONCLUSIONS

Considering the high chronicity of AN, internet-based relapse prevention following intensive treatment appears to be promising.