The Efficacy of eHealth Interventions for the Treatment of Adults Diagnosed With Full or Subthreshold Binge Eating Disorder: Systematic Review and Meta-analysis

Assessing Discriminant Validity through Structural Equation Modeling: The Case of Eating Compulsivity

Food addiction (FA) and disordered eating behaviors related to obesity are gaining attention in clinical and research fields. The modified Yale Food Addiction Scale 2.0 (mYFAS2.0) is the gold standard questionnaire to measure FA, while another tool is the Measure of Eating Compulsivity 10 (MEC10). Discriminant validity is present when two measures of similar but distinct constructs show a correlation that is low enough for the factors to be regarded as distinct. However, the discriminant validity of these measures has never been tested. Through a cross-sectional study design, 717 inpatients (females: 56.20%, age: 53.681 ± 12.74) with severe obesity completed the MEC10, Binge Eating Scale (BES), and mYFAS2.0. A structural equation model (SEM) was fitted, freely estimating latent correlations with 95% confidence intervals (95% CI). The results confirmed the scales' excellent psychometric properties. Importantly, latent factor correlations between MEC10 and mYFAS2.0 (est = 0.783, 95% CI [0.76, 0.80]) supported their discriminant validity. In contrast, the latent correlation of MEC10 and BES (est = 0.86, 95% CI [0.84, 0.87]) exceeded the recommended thresholds, indicating the absence of discriminant validity and suggesting a potential overlap, consistent with previous evidence. In conclusion, MEC10 demonstrates excellent psychometric properties but is more a measure of BED and not FA.

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.

The acceptability, feasibility, and preliminary efficacy of a supported online self-help treatment program for binge-eating disorder

Introduction

Studies in transdiagnostic eating disorder (ED) samples suggest supported online self-help programs (eTherapies) are effective and may improve access to treatment; however, their evaluation in those with binge-eating disorder (BED) is limited. Given BED's high prevalence and low levels of treatment uptake, further eTherapy evaluation is needed to broaden access to effective, evidence-based treatment options. The aim of this study was to investigate the acceptability, feasibility, and preliminary efficacy of a supported eTherapy for those with BED or subthreshold BED, and to examine symptom change across the duration of therapy.

Method

Nineteen women with BED completed a supported, 10-session Cognitive Behavioural Therapy-based eTherapy in an uncontrolled, pre-post, and 3 months follow up intervention study. Key outcomes were assessed by the Eating Disorder Examination Questionnaire (EDE-Q): objective binge episode (OBE) frequency and ED psychopathology. Feasibility was evaluated via program adherence and dropout, whilst acceptability was assessed through participant feedback post-treatment. Weekly symptom change (ED psychopathology) during treatment was assessed by the Eating Disorder Examination - Questionnaire Short (EDE-QS).

Results

Generalised estimating equations showed statistically and clinically significant reductions in OBEs and ED psychopathology (large effects) post-treatment, with these decreases maintained at follow up. Across weekly assessment, a marked slowing in the rate of change in ED psychopathology was observed after four sessions of the program. Program feasibility was high (i.e., 84% of content completed), as was program acceptability (i.e., 93% of participants expressed high levels of satisfaction).

Discussion

These results support the acceptability, feasibility, and preliminary efficacy of a supported eTherapy program for those with BED and suggest the variability of symptom change across the duration of therapy. Future research should further investigate findings in an adequately powered randomised controlled trial.

Needs and demands for mHealth cardiac health promotion among individuals with cardiac diseases: a patient-centred design approach

Aims

Cardiovascular diseases are one of the main contributors to disability and mortality worldwide. Meanwhile, risk factors can be modified by lifestyle changes. mHealth is an innovative and effective way to deliver cardiac health promotion. This study aims to examine the needs and demands regarding the design and contents of an mHealth intervention for cardiac health promotion among individuals with cardiac diseases. Different clusters were determined and analysed in terms of the intention to use an mHealth intervention.

Methods and results

A cross-sectional study was conducted via a web-based survey. Three hundred and four individuals with coronary artery diseases (CADs) and/or congestive heart failure (CHF) were included in the data analysis. Descriptive statistics were applied to evaluate needs and demands regarding an mHealth intervention. A k-medoids cluster analysis was performed. Individuals with CAD and CHF favoured an mHealth intervention that supports its users permanently and is easily integrated into everyday life. Handheld devices and content formats that involve active user participation and regular updates were preferred. Three clusters were observed and labelled high, moderate, and low burden, according to their psychometric properties. The high burden cluster indicated higher behavioural intention towards use of an mHealth intervention than the other clusters.

Conclusion

The results of the study are a valuable foundation for the development of an mHealth intervention for cardiac health promotion following a user-centred design approach. Individuals with cardiac diseases report positive attitudes in the form of high usage intention regarding mHealth. Highly burdened individuals report a high intention to use such interventions.

Binge-Eating Disorder Interventions: Review, Current Status, and Implications

PURPOSE OF REVIEW

Binge-eating disorder (BED) is a serious psychiatric problem associated with substantial morbidity that, unfortunately, frequently goes unrecognized and untreated. This review summarizes the current status of behavioral, psychological, pharmacological, and combined treatments for BED in adults with a particular focus on recent findings and advances.

RECENT FINDINGS

Certain specific psychological treatments, notably CBT and IPT, and to some extent DBT, have demonstrated efficacy and are associated with durable benefits after treatment. Certain specific lower-cost scalable interventions, notably CBTgsh, have demonstrated efficacy and have potential for broader uptake. An important advance is the emerging RCT data indicating that BWL, a generalist and available behavioral lifestyle intervention, has effectiveness that approximates that of CBT for reducing binge eating and eating-disorder psychopathology but with the advantage of also producing modest weight loss. There exists only one pharmacological agent (LDX) with approval by the FDA for "moderate-to-severe" BED. Research with other "off label" medications has yielded modest and mixed outcomes with a few medications statistically superior to placebo over the short-term and almost no longer-term data. Nearly all research combining medications and psychological treatments has failed to enhance outcomes (combined appears superior to pharmacotherapy-only but not to psychotherapy-only). Many people with BED suffer in silence and shame, go untreated, and rarely receive evidence-based treatments. Patients and practitioners need to recognize that research has identified several effective interventions for BED, and these can work quickly for many patients. Future research should identify treatments for those who do not derive benefit from initial interventions, identify additional pharmacological options, test agents with relevant mechanisms of action, and utilize innovative adaptative "SMART" designs to identify treatments to enhance outcomes among initial responders and to test alternative treatments to assist initial non-responders.

Psychological and Medical Treatments for Binge-Eating Disorder: A Research Update

Binge-eating disorder (BED), characterized by recurrent binge eating in the absence of regular weight-compensatory behaviors, is the most common eating disorder, associated with pronounced mental and physical sequelae. An increasing body of research documents the efficacy of diverse approaches to the treatment of this disorder, summarized in meta-analyses. This research update narratively reviewed randomized-controlled trials (RCTs) on the psychological and medical treatment of BED published between January 2018 to November 2022, identified through a systematic literature search. A total of 16 new RCTs and 3 studies on previous RCTs providing efficacy- and safety-related data were included. Regarding psychotherapy, confirmatory evidence supported the use of integrative-cognitive therapy and, with lower effects, brief emotion regulation skills training for binge eating and associated psychopathology. Behavioral weight loss treatment was revealed to be efficacious for binge eating, weight loss, and psychopathology, but its combination with naltrexone-bupropion did not augment efficacy. New treatment approaches were explored, including e-mental-health and brain-directed treatments, mostly targeting emotion and self-regulation. Additionally, different therapeutic approaches were evaluated in complex stepped-care models. In light of these advances, future research is necessary to further optimize effects of evidence-based treatments for BED, through improvement of existing or development of new treatments, based on mechanistic and/or interventional research, and/or tailoring treatments to personal characteristics in a precision medicine approach.

User profile of an online cognitive behavioral therapy self-help platform in Turkey

Online mental health self-help services are of societal importance and increasingly popular. Therefore, we have developed an online platform offering free self-help to the Turkish public with modules based on Cognitive Behavioral Therapy (CBT) targeting depression, anxiety, and stress respectively. The main purpose of this study is to describe the user profile of this platform. A pre-intervention self-report assessment including general demographic information and the Brief Symptom Inventory questionnaire during October 2020 until September 2022. 8331 participants completed the assessment and created an account out of the 11.228 users who registered during a two-year period, of which 8.331 (74%) completed the assessment and created an account. The majority of these users were female (76.17%), highly educated (82%), single (68%) and actively studying or working (84%). Slightly more than half (57%) of the platform user had not received psychological assistance before, while those who did receive previous assistance indicate to have benefitted from that (74%). The psychological symptoms of users are widely distributed, encompassing a broad range of user profiles. Approximately half of all users actively used the platform, while the other half did not complete any module. Among active users, the course "coping with depressive mood" was the most popular (41.45%), followed by "coping with anxiety" (37.25%) and "coping with stress" (21.30%). Offering a free online CBT self-help platform to the Turkish public seems feasible, with strong uptake among both man and woman struggling with a variety of psychological symptoms. Further research is needed to assess user satisfaction and change in symptoms over time during platform use by means of a feasibility trial.

Comparison of online and in-person cognitive behavioral therapy in individuals diagnosed with major depressive disorder: a non-randomized controlled trial

Objective

The increased prevalence of major depressive disorder (MDD) amid the COVID-19 pandemic has resulted in substantial growth in online mental health care delivery. Compared to its in-person counterpart, online cognitive behavioral therapy (e-CBT) is a time-flexible and cost-effective method of improving MDD symptoms. However, how its efficacy compares to in-person CBT is yet to be explored. Therefore, the current study compared the efficacy of a therapist-supported, electronically delivered e-CBT program to in-person therapy in individuals diagnosed with MDD.

Methods

Participants (n = 108) diagnosed with MDD selected either a 12 week in-person CBT or an asynchronous therapist-supported e-CBT program. E-CBT participants (n = 55) completed weekly interactive online modules delivered through a secure cloud-based online platform (Online Psychotherapy Tool; OPTT). These modules were followed by homework in which participants received personalized feedback from a trained therapist. Participants in the in-person CBT group (n = 53) discussed sessions and homework with their therapists during one-hour weekly meetings. Program efficacy was evaluated using clinically validated symptomatology and quality of life questionnaires.

Results

Both treatments yielded significant improvements in depressive symptoms and quality of life from baseline to post-treatment. Participants who opted for in-person therapy presented significantly higher baseline symptomatology scores than the e-CBT group. However, both treatments demonstrated comparable significant improvements in depressive symptoms and quality of life from baseline to post-treatment. e-CBT seems to afford higher participant compliance as dropouts in the e-CBT group completed more sessions on average than those in the in-person CBT group.

Conclusion

The findings support e-CBT with therapist guidance as a suitable option to treat MDD. Future studies should investigate how treatment accessibility is related to program completion rates in the e-CBT vs. in-person group.

Clinical Trial Registration

ClinicalTrials.Gov Protocol Registration and Results System (NCT04478058); clinicaltrials.gov/ct2/show/NCT04478058.

Psychotherapists’ perspective of the use of eHealth services to enhance positive mental health promotion

Objective

Keyes’s two-continua model of mental health proposes that mental illness and positive mental health are two separate, correlated, unipolar dimensions. eHealth services have been used to deliver mental health care, though the focus remained largely on symptom reduction and management of negative aspects of mental health. The potential of eHealth services to promote positive mental well-being, however, has not been tapped sufficiently. The present study aims to explore psychotherapists’ perspective on the feasibility of eHealth services to enhance positive mental health promotion.

Methods

Seven focus group discussions were conducted among professionals ( n = 38) who delivered psychotherapy to examine positive mental health in their practice. Responses related to the use of e-psychotherapy to promote mental well-being were extracted for use in a secondary analysis of data in this study. Thematic analysis of data via inductive approach was conducted to allow emergence of common themes.

Results

Three main themes related to psychotherapists’ perspective on the feasibility of eHealth intervention in enhancing positive mental health were identified: (1) use of eHealth to educate and improve positive mental health; (2) concerns on incorporating psychotherapy into online services; (3) other factors that affect uptake or effectiveness of eHealth intervention for positive mental health.

Conclusions

The study generally found support among psychotherapists for the feasibility of eHealth intervention in promoting positive mental health among clients. Potential difficulties in implementation and practicality concerns were discussed.

Evaluating the feasibility and potential efficacy of a brief eTherapy for binge-eating disorder: A pilot study

OBJECTIVE

For those with binge-eating disorder (BED), access to evidence-based, face-to-face treatment is often constrained by clinician availability and high treatment costs. Emerging evidence suggests online therapy (eTherapy) may navigate these barriers and reduce binge-eating symptomatology; however, less evaluation has been done in those with BED, particularly with briefer programs targeting early change. This study investigated the feasibility and potential efficacy of a brief, supported eTherapy in those with BED or subthreshold BED.

METHOD

Participants were 19 women with BED who completed a four-session eTherapy. This was a single-arm, pre-post intervention study, with participants completing weekly content and attending telehealth sessions. Key outcomes were assessed by the Eating Disorder Examination Questionnaire-Short (EDE-QS): objective binge episode days, loss of control over eating days, and eating disorder (ED) psychopathology via a total EDE-QS score.

RESULTS

Generalized and linear mixed models showed significantly reduced loss of control over eating days and ED psychopathology. Program feasibility was high, with strong program adherence and a below average attrition rate.

DISCUSSION

Pilot results support the feasibility and potential efficacy of a brief, behavioral-focused eTherapy program in reducing ED pathology in those with BED. Future research should further investigate findings in an adequately powered randomized controlled trial.

PUBLIC SIGNIFICANCE

This study suggests that a brief, behavioral-focused online therapy, guided by non-expert clinicians, can be successfully administered to those with binge-eating disorder (BED) and may be efficacious at reducing eating disorder and other related symptomatology. Brief eTherapies that are effective, accessible, and rapidly available may facilitate earlier intervention in illness and improve treatment outcomes for individuals who experience this common and distressing disorder.

The impacts of COVID-19 on eating disorders and disordered eating: A mixed studies systematic review and implications

Purpose

The unique constraints to everyday life brought about by the COVID-19 pandemic have been suggested to negatively impact those with pre-existing mental health issues such as eating disorders. While individuals with eating disorders or disordered eating behaviors likely represent a vulnerable group to the COVID-19 pandemic, the impact of the pandemic is yet to be fully established.

Methods

We systematically examined the impact of the COVID-19 pandemic on eating disorders and disordered eating behaviors. We searched electronic databases MEDLINE, PsycINFO, CINAHL, and EMBASE for literature published until October 2021. Eligible studies were required to report on individuals with or without a diagnosed eating disorder or disordered eating behaviors who were exposed to the COVID-19 pandemic.

Findings

Seventy-two studies met eligibility criteria with the majority reporting an increase in eating disorder or disordered eating behaviors associated with the COVID-19 pandemic. Specifically, it appears children and adolescents and individuals with a diagnosed eating disorder may present vulnerable groups to the impacts of the COVID-19 pandemic.

Discussion

This mixed systematic review provides a timely insight into COVID-19 eating disorder literature and will assist in understanding possible future long-term impacts of the pandemic on eating disorder behaviors. It appears that the role of stress in the development and maintenance of eating disorders may have been intensified to cope with the uncertainty of the COVID-19 pandemic. Future research is needed among understudied and minority groups and to examine the long-term implications of the COVID-19 pandemic on eating disorders and disordered eating behaviors.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=284749, PROSPERO [CRD42021284749].

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.

Digital Health Interventions for Delivery of Mental Health Care: Systematic and Comprehensive Meta-Review

BACKGROUND

The COVID-19 pandemic has shifted mental health care delivery to digital platforms, videoconferencing, and other mobile communications. However, existing reviews of digital health interventions are narrow in scope and focus on a limited number of mental health conditions.

OBJECTIVE

To address this gap, we conducted a comprehensive systematic meta-review of the literature to assess the state of digital health interventions for the treatment of mental health conditions.

METHODS

We searched MEDLINE for secondary literature published between 2010 and 2021 on the use, efficacy, and appropriateness of digital health interventions for the delivery of mental health care.

RESULTS

Of the 3022 records identified, 466 proceeded to full-text review and 304 met the criteria for inclusion in this study. A majority (52%) of research involved the treatment of substance use disorders, 29% focused on mood, anxiety, and traumatic stress disorders, and >5% for each remaining mental health conditions. Synchronous and asynchronous communication, computerized therapy, and cognitive training appear to be effective but require further examination in understudied mental health conditions. Similarly, virtual reality, mobile apps, social media platforms, and web-based forums are novel technologies that have the potential to improve mental health but require higher quality evidence.

CONCLUSIONS

Digital health interventions offer promise in the treatment of mental health conditions. In the context of the COVID-19 pandemic, digital health interventions provide a safer alternative to face-to-face treatment. However, further research on the applications of digital interventions in understudied mental health conditions is needed. Additionally, evidence is needed on the effectiveness and appropriateness of digital health tools for patients who are marginalized and may lack access to digital health interventions.

Early development of treatment motivation predicts adherence and symptom reduction in an internet-based guided self-help program for binge eating disorder

OBJECTIVE

Lack of motivation is widely acknowledged as a significant factor in treatment discontinuity and poor treatment outcomes in eating disorders. Treatment adherence is lower in internet-based treatment. The current study aimed to assess the relationship between treatment motivation and treatment outcomes in an internet-based therapist-guided intervention for Binge Eating Disorder (BED).

METHOD

Adults (N = 153) with mild to moderate symptoms of BED participated in a 10-session internet-based treatment program. Baseline and between-session scores of "Readiness to change" and "Belief in change" were used to predict treatment completion and eating disorder symptom reduction (EDE-Q Global, BED-Q, and weekly number of binge eating episodes) at post-treatment.

RESULTS

Baseline treatment motivation could not predict treatment completion or symptom reduction. Early measures of treatment motivation (regression slope from sessions 1-5) significantly predicted both treatment completion and post-treatment symptom reduction. "Belief in change" was the strongest predictor for completing treatment (OR = 2.18, 95%-CI: 1.06, 4.46) and reducing symptoms (EDE-Q Global: B = -0.53, p = 0.001; number of weekly binge eating episodes: B = 0.81, p < 0.01).

DISCUSSION

The results indicated that patients entering online treatment for BED feel highly motivated. However, baseline treatment motivation could not significantly predict treatment completion, which contradicts previous research. The significant predictive ability of early measures of treatment motivation supports the clinical relevance of monitoring the development of early changes to tailor and optimize individual patient care. Further research is needed to examine treatment motivation in regard to internet-based treatment for BED with more validated measures.

Evaluation of the Effects of Telepsychotherapy in the Treatment and Prevention of Eating Disorders in Adolescents

According to the WHO definition, "telemedicine is the provision of health services, where distance is a critical factor, by all health professionals who use information and communication technologies for the exchange of valid information for the diagnosis, treatment and prevention of diseases, research and evaluation, and for the continuous training of health professionals, all in the interest of advancing the health of individuals and their communities". The purpose of our review work is specifically to investigate the effects of telemedicine in the treatment and prevention of eating disorders in adolescents. From June 2021 to (September 2021) in the databases of the Web of Science, EMBASE, PsycINFO and CINHAL, using search terms such as telehealth, eating disorder, adolescents, Internet/online treatments CBT and FB-T, anorexia nervosa, bulimia nervosa and binge eating disorder. The articles resulting from the search phases in the databases listed above produced a total of 176 items. Once the procedures for selecting the works were completed, only four studies were included in the review. Modern e-health psychological approaches in the treatment of eating disorders provide potential bases of continuous assistance that are decidedly less burdensome in the costs of territorial services in the case that they are not identified as necessary.