Binge frequency predicts outcome in guided self-care treatment of bulimia nervosa

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.

Supported online cognitive behavioural therapy for bulimia nervosa: a study protocol of a randomised controlled trial

BACKGROUND

Despite the availability of effective treatments for bulimia nervosa (BN), a number of barriers to accessibility exist. Examples include access to trained clinicians, the expense of treatment, geographical limitations, and personal limitations such as stigma regarding help seeking. Self-help interventions, delivered via a digital platform, have the potential to overcome treatment gaps by providing patients with standardised, evidence-based treatments that are easily accessible, cost-effective, and require minimal clinician support. Equally, it is important to examine the shortcomings of digital interventions when compared to traditional to face-to-face delivery (e.g., high dropout rates) in order to maximise the therapeutic effectiveness of online, self-help interventions.

METHODS

A three-arm, multisite randomised controlled trial will be conducted in Australia examining the effectiveness and cost-effectiveness of a newly developed online self-help intervention, Binge Eating eTherapy (BEeT), in a sample of patients with full or sub-threshold BN. The BEeT program consists of 10, multimedia sessions delivering the core components of cognitive behaviour therapy. Eligible participants will be randomised to one of three groups: independent completion of BEeT as a purely self-help program, completion of BEeT alongside clinician support (in the form of weekly telemedicine sessions), or waitlist control. Assessments will take place at baseline, weekly, post-intervention, and three-month follow up. The primary outcome is frequency of objective binge episodes. Secondary outcomes include frequency of other core eating disorder behavioural symptoms and beliefs, psychological distress, and quality of life. Statistical analyses will examine treatment effectiveness, feasibility, acceptability and cost effectiveness.

DISCUSSION

There is limited capacity within the mental health workforce in Australia to meet the demand of people seeking treatment for eating disorders. This imbalance has only worsened following outbreak of the COVID-19 pandemic. Further research is required into innovative digital modes of treatment delivery with the capacity to service mental health needs in an accessible and affordable manner. Self-help programs may also appeal to individuals who are more reluctant to engage in traditional face-to-face treatment formats. This study will provide rigorous evidence on how to diversify treatment options for individuals with BN, ensuring more people with the illness can access evidence-based treatment. The study has been registered with the Australia New Zealand Clinical Trials Registry (ANZCTR Registration Number: ACTRN12619000123145p). Registered 22 January 2019, https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619000123145 .

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

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

Participation and outcome in manualized self-help for bulimia nervosa and binge eating disorder - a systematic review and metaregression analysis

There is a growing body of research on manualized self-help interventions for bulimia nervosa (BN) and binge eating disorder (BED). Study and treatment dropout and adherence represent particular challenges in these studies. However, systematic investigations of the relationship between study, intervention and patient characteristics, participation, and intervention outcomes are lacking. We conducted a systematic literature review using electronic databases and hand searches of relevant journals. In metaregression analyses, we analyzed study dropout as well as more specific measures of treatment participation in manualized self-help interventions, their association with intervention characteristics (e.g. duration, guidance, intervention type [bibliotherapy, CD-ROM or Internet based intervention]) and their association with treatment outcomes. Seventy-three publications reporting on 50 different trials of manualized self-help interventions for binge eating and bulimia nervosa published through July 9th 2012 were identified. Across studies, dropout rates ranged from 1% to 88%. Study dropout rates were highest in CD-ROM interventions and lowest in Internet-based interventions. They were higher in samples of BN patients, samples of patients with higher degrees of dietary restraint at baseline, lower age, and lower body mass index. Between 6% and 88% of patients completed the intervention to which they had been assigned. None of the patient, study and intervention characteristics predicted intervention completion rates. Intervention outcomes were moderated by the provision of personal guidance by a health professional, the number of guidance sessions as well as participants' age, BMI, and eating disorder related attitudes (Restraint, Eating, Weight and Shape Concerns) at baseline (after adjusting for study dropout and intervention completion rates). Guidance particularly improved adherence and outcomes in samples of patients with bulimia nervosa; specialist guidance led to higher intervention completion rates and larger intervention effects on some outcomes than non-specialist guidance. Self-help interventions have a place in the treatment of BN and BED, especially if the features of their delivery and indications are considered carefully. To better determine who benefits most from what kind and "dosage" of self-help interventions, we recommend the use of consistent terminology as well as uniform standards for reporting adherence and participation in future self-help trials.

Self-efficacy as a robust predictor of outcome in guided self-help treatment for broadly defined bulimia nervosa

OBJECTIVE

To examine predictors of guided self-help (GSH) treatment outcome in bulimia nervosa (BN).

METHOD

Data were included from 87 individuals who participated in one of two randomized controlled trials evaluating GSH interventions for BN. Participants received eight sessions of GSH over a 6- to 8-week period and were assessed at baseline, pretreatment, posttreatment, and 6-month follow-up.

RESULTS

Motivation (confidence in ability to change) proved to be the most robust predictor of outcome, across three of the four outcome measures. Baseline measures of concern over mistakes perfectionism also uniquely predicted outcome at posttreatment. Posttreatment measures of stress, eating disorder-related automatic thoughts, and frequency of binge episodes predicted outcome at 6-month follow-up.

DISCUSSION

This study suggests that tackling motivation early in therapy, with a particular focus on confidence in succeeding in change, could be of benefit to outcome in BN treatment.

Time to remission for eating disorder patients: a 2(1/2)-year follow-up study of outcome and predictors

The aim of the present study was to analyse outcome, time to remission, and predictors of time to remission in a cohort of Danish eating disorder patients. Seventy-eight patients (35 anorexic, 30 bulimic and 13 unspecified eating disorder patients) were interviewed 2(1/2) years after initial assessment. Method of assessment was Eating Disorder Examination (EDE), Longitudinal Interval Follow-up Evaluation of Eating Disorders (LIFE-EAT-II), Eating Disorder Inventory (EDI), Symptom Check List (SCL-90R), Present State Examination (PSE) and the Structured Clinical Interview for DSM-III-R Axis-II (SCID-II). Method of analysis was Kaplan-Meier estimate of survival, Log Rank test and Cox regression analysis. In total 48.7% reached remission with mean time to remission at 27 months. A trend difference between the diagnostic groups when measuring time to remission was found, i.e. patients with unspecified eating disorders remitted faster than bulimic (BN) patients who in turn remitted faster than anorexic (AN) patients. Body mass index (BMI) at baseline was the best predictor of time to remission for the total sample. Predictors differed when looking at diagnostic groups separately. Final outcome was comparable with earlier studies while relapse frequency was low. Patients with AN remitted faster than found in earlier survival analysis studies, while the remission rate for BN patients was comparable with earlier studies. Despite the prognostic value of BMI for the total sample, predictor analysis implied more disorder diversity than homogeneity.

Matching patient variables to treatment intensity. The continuum of care

This article has reviewed what is currently known regarding the relationship between specific patient variables and treatment response in AN, BN, and BED. Matching patient variables to treatment intensity remains an important and fruitful area for future research. There is a need for established guidelines for clinicians regarding the choice of the appropriateness of treatment settings and type of interventions delivered in those settings. These guidelines should be evidence based, with clear clinical indicators for each of the recognized eating disorders and their subclinical variants.