Predictors and moderators of three online interventions for eating disorder symptoms in a randomized controlled trial

OBJECTIVE

To optimize treatment recommendations for eating disorders, it is important to investigate whether some individuals may benefit more (or less) from certain treatments. The current study explored predictors and moderators of an automated online self-help intervention "Featback" and online support from a recovered expert patient.

METHODS

Data were used from a randomized controlled trial. For a period of 8 weeks, participants aged 16 or older with at least mild eating disorder symptoms were randomized to four conditions: (1) Featback, (2) chat or e-mail support from an expert patient, (3) Featback with expert-patient support, and (4) a waitlist. A mixed-effects partitioning method was used to see if age, educational level, BMI, motivation to change, treatment history, duration of eating disorder, number of binge eating episodes in the past month, eating disorder pathology, self-efficacy, anxiety and depression, social support, or self-esteem predicted or moderated intervention outcomes in terms of eating disorder symptoms (primary outcome), and symptoms of anxiety and depression (secondary outcome).

RESULTS

Higher baseline social support predicted less eating disorder symptoms 8 weeks later, regardless of condition. No variables emerged as moderator for eating disorder symptoms. Participants in the three active conditions who had not received previous eating disorder treatment, experienced larger reductions in anxiety and depression symptoms.

DISCUSSION

The investigated online low-threshold interventions were especially beneficial for treatment-naïve individuals, but only in terms of secondary outcomes, making them well-suited for early intervention. The study results also highlight the importance of a supportive environment for individuals with eating disorder symptoms.

PUBLIC SIGNIFICANCE

To optimize treatment recommendations it is important to investigate what works for whom. For an internet-based intervention for eating disorders developed in the Netherlands, individuals who had never received eating disorder treatment seemed to benefit more from the intervention than those who had received eating disorder treatment, because they experienced larger reductions in symptoms of depression and anxiety. Stronger feelings of social support were related to less eating disorder symptoms in the future.

Cost-effectiveness of Internet Interventions Compared With Treatment as Usual for People With Mental Disorders: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

The economic costs of mental disorders for society are huge. Internet-based interventions are often coined as cost-effective alternatives to usual care, but the evidence is mixed.

OBJECTIVE

The aim was to review the literature on the cost-effectiveness of internet interventions for mental disorders compared with usual care and to provide an estimate of the monetary benefits of such interventions compared with usual care.

METHODS

A systematic review and meta-analysis of randomized controlled trials was conducted, which included participants with symptoms of mental disorders; investigated a telephone- or internet-based intervention; included a control condition in the form of treatment as usual, psychological placebo, waiting list control, or bibliotherapy; reported outcomes on both quality of life and costs; and included articles published in English. Electronic databases such as PubMed (including MEDLINE), Embase, Emcare, PsycINFO, Web of Science, and the Cochrane Library were used. Data on risk of bias, quality of the economic evaluation, quality-adjusted life years, and costs were extracted from the included studies, and the incremental net benefit was calculated and pooled.

RESULTS

The search yielded 6226 abstracts, and 37 studies with 14,946 participants were included. The quality of economic evaluations of the included studies was rated as moderate, and the risk of bias was high. A random-effects approach was maintained. Analyses suggested internet interventions were slightly more effective than usual care in terms of quality-adjusted life years gain (Hedges g=0.052, 95% CI 0.010-0.094; P=.02) and equally expensive (Hedges g=0.002, 95% CI -0.080 to 0.84; P=.96). The pooled incremental net benefit was US $255 (95% CI US $91 to US $419; P=.002), favoring internet interventions over usual care. The perspective of the economic evaluation and targeted mental disorder moderated the results.

CONCLUSIONS

The findings indicate that the cost-effectiveness of internet interventions for mental disorders compared with a care-as-usual approach is likely, but generalizability to new studies is poor given the substantial heterogeneity. This is the first study in the field of mental health to pool cost-effectiveness outcomes in an aggregate data meta-analysis.

TRIAL REGISTRATION

PROSPERO CRD42019141659; https://tinyurl.com/3cu99b34.

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.

The ICEpop Capability Measure for Adults Instrument for Capabilities: Development of a Tariff for the Dutch General Population

OBJECTIVES

The ICEpop Capability Measure for Adults (ICECAP-A) assesses 5 capabilities (stability, attachment, autonomy, achievement, and enjoyment) that are important to one's quality of life and might be an important addition to generic health questionnaires currently used in economic evaluations. This study aimed to develop a Dutch tariff of the Dutch translation of the ICECAP-A.

METHODS

The methods used are similar to those used in the development of the UK tariff. A profile case best-worst scaling task was presented to 1002 participants from the general Dutch population. A scale-adjusted latent class analysis was performed to test for preferences of ICECAP-A capabilities and scale heterogeneity.

RESULTS

A 3-preference class 2-scale class model with worst choice as scale predictor was considered optimal and was used to calculate the resulting tariff. Results indicated that the capabilities stability, attachment, and enjoyment were considered more important aspects of quality of life than autonomy and achievement. Additionally, improving capabilities from low to moderate levels had a larger effect on quality of life than improving capabilities that were already at a higher level.

CONCLUSIONS

The ICECAP-A tariffs found in this study could be used in economic evaluations of healthcare interventions in The Netherlands.

A randomized controlled trial of an Internet-based intervention for eating disorders and the added value of expert-patient support: study protocol

Background

E-mental health has become increasingly popular in interventions for individuals with eating disorders (EDs). It has the potential to offer low-threshold interventions and guide individuals to the needed care more promptly. Featback is such an Internet-based intervention and consists of psychoeducation and a fully automated monitoring and feedback system. Preliminary findings suggest Featback to be (cost-)effective in reducing ED symptomatology. Additionally, e-mail or chat support by a psychologist did not enhance the effectiveness of Featback. Support by an expert patient (someone with a lived experience of an ED) might be more effective, since that person can effectively model healthy behavior and enhance self-efficacy in individuals struggling with an ED. The present study aims to replicate and build on earlier findings by further investigating the (cost-)effectiveness of Featback and the added value of expert-patient support.

Methods

The study will be a randomized controlled trial with a two-by-two factorial design with repeated measures. The four conditions will be (1) Featback, in which participants receive automated feedback on a short monitoring questionnaire weekly, (2) Featback with weekly e-mail or chat support from an expert patient, (3) weekly support from an expert patient, and (4) a waiting list. Participants who are 16 years or older and have at least mild self-reported ED symptoms receive a baseline measure. Subsequently, they are randomized to one of the four conditions for 8 weeks. Participants will be assessed again post-intervention and at 3, 6, 9, and 12 months follow-up. The primary outcome measure will be ED psychopathology. Secondary outcome measures are experienced social support, self-efficacy, symptoms of anxiety and depression, user satisfaction, intervention usage, and help-seeking attitudes and behaviors.

Discussion

The current study is the first to investigate e-mental health in combination with expert-patient support for EDs and will add to the optimization of the delivery of Internet-based interventions and expert-patient support.

Trial registration

Netherlands Trial Register, NTR7065. Registered on 7 June 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3574-2) contains supplementary material, which is available to authorized users.

E-Health Interventions for Eating Disorders: Emerging Findings, Issues, and Opportunities

This study aimed to review the emerging findings regarding E-health interventions for eating disorders and to critically discuss emerging issues as well as challenges for future research. Internet-based cognitive behavioral therapy and guided self-help have demonstrated promising results in terms of reducing eating disorder psychopathology. Emerging findings also suggest that E-health interventions reach an underserved population and improve access to care. The use of smartphone applications is becoming increasingly popular and has much potential although their clinical utility and effectiveness is presently unknown and requires investigation. Important challenges include the diagnostic process in E-health interventions, the optimization of E-health within existing health care models, and the investigation and implementation of blended care. More high-quality research is needed to bring the field forward and to determine the place for E-health in our health care service delivery systems.

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.

An Internet-based intervention for eating disorders consisting of automated computer-tailored feedback with or without supplemented frequent or infrequent support from a coach: study protocol for a randomized controlled trial

Background

Several Internet-based interventions for eating disorders have shown their effectiveness. Still, there is a need to refine such interventions given that most existing programs seem to be limited by their static ‘one-size-fits-all’ approach. ‘Featback’, an Internet-based intervention for symptoms of eating disorders provides a more individualized approach. It consists of several components (psychoeducation, a fully automated monitoring and feedback system, and support from a coach), which can be matched to participants’ needs and preferences. Until now, it is unclear whether online self-help interventions for eating disorders with support are more effective than those without. The aims of the current study are i) to examine the relative effectiveness of (the different components of) Featback; ii) to examine predictors, moderators and mediators of intervention responses; iii) to report on practical experiences with Featback; and iv) to examine the cost-effectiveness of Featback.

Methods/design

Individuals aged 16 years or older, with mild to severe eating disorder symptoms will be randomized to one of the four study conditions. In condition one, participants receive the basic version of Featback, consisting of psychoeducation and a fully automated monitoring and feedback system. In conditions two and three, participants receive the basic version of Featback supplemented with the possibility of infrequent (weekly) or frequent (three times a week) e-mail, chat, or Skype support from a coach, respectively. The fourth condition is a waiting list control condition. Participants are assessed at baseline, post-intervention (8 weeks), and at 3- and 6-month follow-up (the latter except for participants in the waiting list control condition). Primary outcome measures are disordered eating behaviors and attitudes. Secondary outcome measures are (eating disorder-related) quality of life, self-stigma of seeking help, self-esteem, mastery and support, symptoms of depression and anxiety, repetitive negative thinking, motivation to change, user satisfaction, compliance, and help-seeking attitudes and behaviors.

Discussion

This study aims to provide more insight into the (cost-) effectiveness of Internet-based interventions for eating disorders, particularly those with and without professional support, as well as different levels of support.

Trial registration

NTR3646

Treating eating disorders over the internet: a systematic review and future research directions

OBJECTIVE

To review the literature regarding internet-based treatment of eating disorders (ED).

METHOD

Relevant studies were identified by searching electronic databases (including Medline, Embase, PsycInfo, and Web of Science). Eligible studies evaluated an internet-based treatment for ED, or an ED treatment that included at least one internet-based component.

RESULTS

Twenty-one studies were included. Methodological quality varied. Internet-based treatments were superior to waiting lists in reducing ED psychopathology, frequency of binge eating and purging, and in improving (ED-related) quality of life. Internet-based treatment was more effective for individuals with less comorbid psychopathology, binge eating as opposed to restrictive problems, and individuals with binge eating disorder as opposed to bulimia nervosa. Higher levels of compliance were related to more improvements in ED symptoms. Study dropout ranged from 5.3 to 76.8%. Inclusion of face-to-face assessments and therapist support seemed to enhance study compliance. Overall, the internet can be considered an acceptable vehicle for delivering ED treatment.

DISCUSSION

Future research should determine the utility of internet-based treatment by comparing them to face-to-face treatment. Research should furthermore focus on unraveling predictors and mediators of treatment outcome, compliance, and dropout, respectively. Studies with good methodological quality are needed with reports according to CONSORT guidelines.

Correlates and associations between weight suppression and binge eating symptomatology in a population-based sample

Weight suppression (WS), the discrepancy between a person's highest ever and current body weight, has been found in a number of studies to be associated with the onset and maintenance of bulimia nervosa (BN). The current theories on the working mechanism hypothesize that individuals with BN might be caught in a (psycho)biobehavioral bind and suggest a circle of weight loss, weight suppression, weight gain, and binge eating that in theory should also apply to a broad spectrum of binge eating symptomatology. This study was intended to test the hypothesis that WS predicts current binge eating with a loss of control (BE+LOC) in a population-based sample. We used a population-sample of participants (N=3,512) who responded to a survey in a women's magazine. In a logistic regression analysis, WS did not predict current BE+LOC, in contrast to high diet activity in the past year. Possible explanations for the lack of association are discussed. Future studies are needed to specify the specific active ingredients in the relation between WS and BN.

Norms and discriminative validity of the Eating Disorder Examination Questionnaire (EDE-Q)

The first aim of this study was to provide norms for the Eating Disorder Examination Questionnaire (EDE-Q) in a diverse and large clinical sample of individuals with an eating disorder (ED), and a general population sample without an ED. Norms for individuals with obesity without an ED were also provided, as a more relevant comparison group for individuals with binge eating disorder. The second aim was to investigate the discriminative validity of the EDE-Q. A sample of females with an ED (N=935), women from the general population without an ED (N=235), and obese females without an ED (N=321) completed the EDE-Q. Explorative factor analyses did not support the theorized four subscales of the EDE-Q. Norms for EDE-Q global scores were provided for each of the three samples. Within the ED sample, norms were provided separately for patients with different ED diagnoses. Receiver operating characteristic analyses showed the EDE-Q global score to be highly accurate in discriminating individuals with an ED from those without, and moderately accurate in discriminating individuals with binge eating disorder from those with obesity. The presented norms contribute to a more accurate interpretation of EDE-Q scores, providing an index of the severity level of ED psychopathology. Furthermore, these norms can be used to assess clinical significant change during treatment. In addition, this study demonstrates that the EDE-Q, when using its global score, is a valid instrument to assess levels of ED psychopathology.

Coping strategies and recovery in patients with a severe eating disorder

A longitudinal prospective design was used to investigate whether recovery from a severe eating disorder is associated with differences in coping strategies and whether coping strategies predict recovery. Subjects were 146 patients who had received intensive day or inpatient treatment. Recovery is associated with less Avoiding, less Passive Reacting, more Active Tackling, and more Seeking of Social Support. Passive Reacting emerged as a robust predictor of recovery. Seeking Social Support predicted bulimic symptomatology and global functioning. Building coping skills in eating disorder patients may start early in treatment and may make patients less vulnerable for relapse.