Efficacy of an Internet- and Mobile-Based Intervention for Subclinical Anxiety and Depression (ICare Prevent) with Two Guidance Formats: Results from a Three-Armed Randomized Controlled Trial.

INTRODUCTION: Limited research exists on intervention efficacy for comorbid subclinical anxiety and depressive disorders, despite their common co-occurrence. Internet- and mobile-based interventions (IMIs) are promising to reach individuals facing subclinical symptoms. OBJECTIVE: This study aimed to evaluate the efficacy of a transdiagnostic and self-tailored IMI in reducing subclinical anxiety and depressive symptom severity with either individualized (IG-IMI) or automated (AG-IMI) guidance compared to a waitlist control group with care-as-usual access (WLC). METHODS: Participants included 566 adults with subclinical anxiety (GAD-7 ≥ 5) and/or depressive (CES-D ≥16) symptoms, who did not meet criteria for a full-syndrome depressive or anxiety disorder. In a three-arm randomized clinical trial, participants were randomized to a cognitive behavioral 7-session IMI plus booster session with IG-IMI (n = 186) or AG-IMI (n = 189) or WLC (n = 191). Primary outcomes included observer-rated anxiety (HAM-A) and depressive (QIDS) symptom severity 8 weeks after randomization assessed by blinded raters via telephone. Follow-up outcomes at 6 and 12 months are reported. RESULTS: Symptom severity was significantly lower with small to medium effects in IG-IMI (anxiety: d = 0.45, depression: d = 0.43) and AG-IMI (anxiety: d = 0.31, depression: d = 0.32) compared to WLC. No significant differences emerged between guidance formats in primary outcomes. There was a significant effect in HAM-A after 6 months favoring AG-IMI. On average, participants completed 85.38% of IG-IMI and 77.38% of AG-IMI. CONCLUSIONS: A transdiagnostic, self-tailored IMI can reduce subclinical anxiety and depressive symptom severity, but 12-month long-term effects were absent. Automated guidance holds promise for enhancing the scalability of IMIs in broad prevention initiatives.

Nurturing innovation, catalyzing change: Honoring the legacy of Dr. C. Barr Taylor in the eating disorders field.

This Virtual Issue of the International Journal of Eating Disorders honors the legacy of the late Dr. C. Barr Taylor in the eating disorders (EDs) field. For decades, Dr. Taylor led the way in not only conducting the research needed to achieve the ultimate goal of making affordable, accessible, and evidence-based care for EDs available to all, but also nurturing the next generation of scientific leaders and innovators. Articles included in this Virtual Issue are a selection of Dr. Taylor's published works in the Journal in the past decade, spanning original research, ideas worth researching, commentaries, and a systematic review. We hope this Virtual Issue will inspire the next generation of research in EDs, and equally, if not more importantly, the next generation of young investigators in the field. We urge the field to continue and build upon Dr. Taylor's vision-to increase access to targeted prevention and intervention for EDs in innovative and forward-thinking ways-while embracing his unique and powerful mentorship style to lift up early career investigators and create a community of leaders to address and solve our field's biggest challenges.

A pilot randomized controlled trial of a cognitive-behavioral therapy guided self-help mobile app for the post-acute treatment of anorexia nervosa: A registered report.

INTRODUCTION: Relapse following acute treatment for anorexia nervosa (AN) is common. Evidence suggests cognitive-behavioral therapy (CBT) may be useful in the post-acute period, but few patients have access to trained providers. mHealth technologies have potential to increase access to high-quality care for AN, including in the post-acute period. The aim of this study is to estimate the preliminary feasibility and effectiveness of a CBT-based mobile intervention plus treatment as usual (TAU), offered with and without an accompanying social networking feature. METHOD: In the current pilot randomized controlled trial, women with AN who have been discharged from acute treatment in the past 2 months (N = 90) will be randomly assigned to a CBT-based mobile intervention plus treatment as usual (TAU), a CBT-based mobile intervention including social networking plus TAU, or TAU alone. We will examine feasibility, acceptability, and preliminary effectiveness of the three conditions in terms of reducing eating disorder psychopathology, reducing frequency of eating disorder behaviors, achieving weight maintenance, reducing depression and suicidal ideation, and reducing clinical impairment. We will examine rehospitalization and full recovery rates in an exploratory fashion. We will also examine whether the mobile intervention and social networking feature change the proposed targets and whether changes in targets are associated with benefit, as well as conduct exploratory analyses to identify within-mobile intervention predictors and moderators of outcome. DISCUSSION: Ultimately, this research may lead to increased access to evidence-based treatment for individuals with AN and prevention of the extreme negative consequences that can result from this serious disorder. PUBLIC SIGNIFICANCE: Relapse after acute treatment for anorexia nervosa is common, and few patients have access to trained providers to support them following acute care. This study will pilot a coached mobile app, including a social networking component, for this population. If ultimately successful, our approach could greatly increase access to evidence-based treatment for individuals with anorexia nervosa and ultimately prevent the extreme negative consequences that can result from this serious disorder.

Indicated Web-Based Prevention for Women With Anorexia Nervosa Symptoms: Randomized Controlled Efficacy Trial.

BACKGROUND: Although preventive interventions for eating disorders in general have shown promise, interventions specifically targeting individuals at risk for anorexia nervosa (AN) are lacking. OBJECTIVE: The aim of this study was to determine the efficacy of a guided, indicated web-based prevention program for women at risk for AN. METHODS: We conducted a randomized controlled efficacy trial for women at risk for AN. Assessments were carried out at baseline (before the intervention), after the intervention (10 weeks after baseline), and at 6- and 12-month follow-ups (FUs). A total of 168 women with low body weight (17.5 kg/m2≤BMI≤19 kg/m2) and high weight concerns or with normal body weight (19 kg/m2

Challenges in Recruiting University Students for Web-Based Indicated Prevention of Depression and Anxiety: Results From a Randomized Controlled Trial (ICare Prevent).

BACKGROUND: Depression and anxiety are common mental health conditions in college and university student populations. Offering transdiagnostic, web-based prevention programs such as ICare Prevent to those with subclinical complaints has the potential to reduce some barriers to receiving help (eg, availability of services, privacy considerations, and students' desire for autonomy). However, uptake of these interventions is often low, and accounts of recruitment challenges are needed to complement available effectiveness research in student populations. OBJECTIVE: The aims of this study were to describe recruitment challenges together with effective recruitment strategies for ICare Prevent and provide basic information on the intervention's effectiveness. METHODS: A 3-arm randomized controlled trial was conducted in a student sample with subclinical symptoms of depression and anxiety on the effectiveness of an individually guided (human support and feedback on exercises provided after each session, tailored to each participant) and automatically guided (computer-generated messages provided after each session, geared toward motivation) version of ICare Prevent, a web-based intervention with transdiagnostic components for the indicated prevention of depression and anxiety. The intervention was compared with care as usual. Descriptive statistics were used to outline recruitment challenges and effective web-based and offline strategies as well as students' use of the intervention. A basic analysis of intervention effects was conducted using a Bayesian linear mixed model, with Bayes factors reported as the effect size. RESULTS: Direct recruitment through students' email addresses via the central student administration was the most effective strategy. Data from 35 participants were analyzed (individually guided: n=14, 40%; automatically guided: n=8, 23%; care as usual: n=13, 37%). Use of the intervention was low, with an average of 3 out of 7 sessions (SD 2.9) completed. The analyses did not suggest any intervention effects other than anecdotal evidence (all Bayes factors10≤2.7). CONCLUSIONS: This report adds to the existing literature on recruitment challenges specific to the student population. Testing the feasibility of recruitment measures and the greater involvement of the target population in their design, as well as shifting from direct to indirect prevention, can potentially help future studies in the field. In addition, this report demonstrates an alternative basic analytical strategy for underpowered randomized controlled trials. TRIAL REGISTRATION: International Clinical Trials Registry Platform NTR6562; https://tinyurl.com/4rbexzrk. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-018-2477-y.

Stakeholder consultation to facilitate implementation of interventions for prevention and promotion in mental health in Europe: introducing the design of the ICare Stakeholder Survey.

BACKGROUND: Online interventions to prevent mental health problems have proven to be effective. However, knowledge about their implementation in real-world practice as well as for dissemination to the target groups in different settings is scarce. The goal of the 'ICare' network is to establish a comprehensive model of eMental-health service delivery in and across different European countries. Since implementation and dissemination are influenced by many contextual factors, in the first phase of ICare a stakeholder survey was conducted. The survey aim was to explore stakeholders' experiences, needs and attitudes regarding Internet-based prevention of mental health problems and hindering and fostering factors for implementation and dissemination. This article is part of a supplement and describes the design of the stakeholder survey. Survey results are published in separate articles in the same supplement. METHODS: Based on a literature review and the individual characteristics of the ICare interventions, stakeholder groups were identified in different settings across six European countries. The RE-AIM framework guided the development of the research questions and survey instruments. A concurrent mixed methods design was applied comprising focus groups with the intended target groups of ICare interventions, an online questionnaire with potential facilitators/delivery staff and semi-structured interviews with policy makers. CONCLUSION: The challenge was to develop a design that allowed flexibility but at the same did not jeopardize the validity of the study. Implications drawn from this survey are not restricted to specific preventive interventions but will provide general information on how online mental illness prevention can be best implemented in various settings.

A systematic review of reach, adoption, implementation and maintenance of Internet-based interventions to prevent eating disorders in adults.

BACKGROUND: There is a growing body of research and evidence for the efficacy of Internet-based eating disorder (ED) prevention interventions for adults. However, much less is known about the reach, adoption, implementation and maintenance of these interventions. The RE-AIM (reach, efficacy/effectiveness, adoption, implementation, maintenance) model provides a framework to systematically assess this information. METHODS: A literature search was conducted in PubMed, Web of Science and PsycINFO for articles published between 2000 and 2019. Additionally, reference lists of the studies included and existing reviews published until the end of 2020 were searched. Sixty original articles describing 54 individual studies fulfilled inclusion criteria. Data were extracted for a total of 43 RE-AIM indicators for each study. Fostering and hindering factors for reach, adoption, implementation and maintenance were assessed qualitatively. RESULTS: Overall reporting rates were best for the RE-AIM dimensions reach (62.6%), implementation (57.0%) and effectiveness (54.2%), while adoption (24.2%) and maintenance (21.5%) had comparatively low overall reporting rates. Reporting on indicators of internal validity, such as sample size, effects or description of interventions was better than indicators relevant for dissemination and implementation in real-world settings, e.g. characteristics of non-participants, characteristics and representativeness of settings, and data to estimate cost. CONCLUSIONS: Because most Internet-based ED prevention interventions are provided in a research-funded context, little is known about their public health impact. Better reporting of factors determining external validity is needed to inform dissemination and implementation of these interventions.

Stakeholders' perspectives on online interventions to improve mental health in eating disorder patients and carers in Germany.

BACKGROUND: Eating disorders are causing severe consequences for those affected as well as a high burden for their carers. Although there is a substantial need for psychological assistance, different factors are hindering access to support. Internet-based interventions can help to overcome these barriers. To date, there is only little knowledge on attitudes of potential users, facilitators (e.g. psychologists) and decision makers (e.g. health insurances) regarding these interventions. METHODS: We conducted focus groups with potential users (N = 30) and semi-structured interviews with potential decision makers (N = 4). Potential facilitators (N = 41) participated in an online survey. Stakeholders' experiences, attitudes, and their needs regarding Internet-based interventions for eating disorder patients and carers were assessed. Furthermore, hindering and fostering factors related to reach, adoption, implementation and maintenance were analyzed. RESULTS: About two-thirds of the participating facilitators have heard or read about Internet-based interventions in general. In contrast, the other stakeholders mentioned to have no or little experience with such interventions. Factors like anonymity, availability and cost-effectiveness were seen as major advantages. Also disadvantages, e.g. lack of personal contact, limitations by disease severity and concerns on data safety, were mentioned. Stakeholders stated the need for interventions which are usable, evidence-based, tailored and provide personal support. CONCLUSION: Stakeholders considered Internet-based programmes to have more advantages than disadvantages. Effort should be put in providing systematic education to address prejudices. When offering an online intervention, stakeholders' needs, as well as a continuous evaluation and adaptation, have to be taken into account.

Stakeholders' views on online interventions to prevent common mental health disorders in adults implemented into existing healthcare systems in Europe.

BACKGROUND: Online preventive interventions can help to reduce the incidence of mental disorders. Whereas knowledge on stakeholders' attitudes and factors relevant for successfully integrating online treatment into existing healthcare systems is available, knowledge is scarce for online prevention. METHODS: Stakeholders from Germany, Switzerland, Austria and Spain were surveyed. Potential facilitators/delivery staff (e.g. psychologists, psychotherapists) completed an online questionnaire (n = 183), policy makers (i.e. from the governing sector or health insurance providers) participated in semi-structured interviews (n = 16) and target groups/potential users of mental illness prevention (n = 49) participated in ten focus groups. Thematic analysis was used to identify their experiences with and attitudes and needs regarding online programmes to prevent mental disorders. Additionally, it was examined which groups they consider underserved and which factors they consider as fostering and hindering for reach, adoption, implementation and maintenance (cf. RE-AIM model) when integrating online prevention into existing healthcare systems. RESULTS: Main advantages of online mental illness prevention are perceived in low structural and psychological barriers. Lack of personal contact, security, privacy and trust concerns were discussed as disadvantages. Relevant needs are high usability and target group appropriateness, evidence for effectiveness and the use of motivational tools. CONCLUSIONS: Positive attitudes among stakeholders are the key for successful integration of online mental illness prevention into existing healthcare systems. Potential facilitators/delivery staff must receive training and support to implement these programmes; the programmes must be attractive and continuously evaluated, updated and promoted to ensure ongoing reach; and existing infrastructure and contextual factors must be considered.

Online prevention programmes for university students: stakeholder perspectives from six European countries.

BACKGROUND: Students beginning university are at a heightened risk for developing mental health disorders. Online prevention and early intervention programmes targeting mental health have the potential to reduce this risk, however, previous research has shown uptake to be rather poor. Understanding university stakeholders' (e.g. governing level and delivery staff [DS] and students) views and attitudes towards such online prevention programmes could help with their development, implementation and dissemination within university settings. METHODS: Semi-structured interviews, focus groups and online surveys were completed with staff at a governing level, university students and DS (i.e. student health or teaching staff) from six European countries. They were asked about their experiences with, and needs and attitudes towards, online prevention programmes, as well as the factors that influence the translation of these programmes into real-world settings. Results were analyzed using thematic analysis. RESULTS: Participating stakeholders knew little about online prevention programmes for university settings; however, they viewed them as acceptable. The main themes to emerge were the basic conditions and content of the programmes, the awareness and engagement, the resources needed, the usability and the responsibility and ongoing efforts to increase reach. CONCLUSIONS: Overall, although these stakeholders had little knowledge about online prevention programmes, they were open to the idea of introducing them. They could see the potential benefits that these programmes might bring to a university setting as a whole and the individual students and staff members.

Efficacy of a Specialized Group Intervention for Compulsive Exercise in Inpatients with Anorexia Nervosa: A Randomized Controlled Trial.

INTRODUCTION: Treatment of compulsive exercise is recognized as a key unmet challenge in the treatment of anorexia nervosa (AN). To address this challenge, we developed the manualized group intervention "healthy exercise behavior" (HEB). This study evaluates the efficacy of HEB for the reduction of compulsive exercise as add-on to routine inpatient treatment (treatment as usual [TAU]) in a randomized controlled trial. METHODS: Two hundred and seven adolescent and adult female inpatients with (atypical) AN were randomly allocated to TAU or to additional participation in HEB (TAU + HEB). HEB integrates elements of exercise-based therapy into a cognitive-behavioral approach. Assessments took place at admission, pre-intervention, post-intervention, discharge, and 6 months follow-up. Primary outcome was the severity of compulsive exercise assessed by the Commitment to Exercise Scale between pre- and post-intervention; secondary outcomes were additional aspects of compulsive exercise, assessed by the Compulsive Exercise Test, weight gain, eating disorder and general psychopathology, and emotion regulation. RESULTS: In intention-to-treat analysis for the primary outcome, the TAU + HEB group showed significantly stronger reductions in the severity of compulsive exercise compared to the TAU group (z = -2.81; p = 0.005; effect size [ES] = -0.3). We also found significantly stronger reductions from admission to discharge (z= 2.62; p = 0.009; ES = -0.43), and from admission to follow-up (z = 2.1; p = 0.035; ES = -0.39). Regarding secondary outcomes, we found significant group differences between pre- and post-intervention in additional aspects of compulsive exercise (z = -2.55; p = 0.011; ES = -0.27). We did not find significant differences regarding weight gain, eating disorder and general psychopathology, and emotion regulation. CONCLUSIONS: Our intervention proved efficacious in reducing compulsive exercise in inpatients with (atypical) AN.

Recruiting participants to an Internet-based eating disorder prevention trial: Impact of the recruitment strategy on symptom severity and program utilization.

OBJECTIVE: Using data from a randomized controlled trial, we examined two different strategies to recruit participants for an indicated preventive intervention (StudentBodies-AN) for women at risk for anorexia nervosa and compared symptom severity and program utilization in participants recruited through each strategy. METHOD: We recruited participants by announcing the study (a) in lectures at universities and handing out screening questionnaires (face-to-face recruitment) and (b) through different media channels, and the participants completed the screening questionnaire on our study website (media-based recruitment). We compared symptom severity and program utilization between the two groups. RESULTS: A total of 4,646 women (face-to-face: 3,741, media-based: 905) were screened and 168 women (face-to-face: 114, media-based: 54) were randomized to the intervention. We found a statistically and clinically significant association between recruitment strategy and symptom severity: Participants who were recruited through media were more likely to fulfill the inclusion criteria (40.6% vs. 13.3%; p < .001) and endorsed significantly more frequently core behaviors and attitudes of disordered eating (EDE global score: 2.72 vs. 2.17, p < .05; Weight Concerns Scale [WCS] score: 66.05 vs. 56.40, p < .05) at baseline than participants recruited face-to-face. Also, participants recruited through media were more likely to log onto the program (χ2 = 5.06; p = .029) and accessed more of the intervention. DISCUSSION: Recruitment through media seems both more feasible and suitable to reach individuals in need of indicative prevention, and should be part of a multimodal recruitment package. Future studies should be explicitly designed to investigate the impact of recruitment modality on reach and effectiveness including cost-effectiveness analyses.

Prevention of eating disorders at universities: A systematic review and meta-analysis.

BACKGROUND: Eating problems are highly prevalent among young adults. Universities could be an optimal setting to prevent the onset of eating disorders through psychological intervention. As part of the World Mental Health-International College Student initiative, this systematic review and meta-analysis synthesizes data on the efficacy of eating disorder prevention programs targeting university students. METHOD: A systematic literature search of bibliographical databases (CENTRAL, MEDLINE, PsycINFO) for randomized trials comparing psychological preventive interventions for eating disorders targeting university students with psychoeducation or inactive controls was performed on October 22, 2019. RESULTS: Twenty-seven studies were included. Thirteen (48.1%) were rated to have a low risk of bias. The relative risk of developing a subthreshold or full-blown eating disorder was incidence rate ratio = 0.62 (95% CI [0.44, 0.87], n c = 8, numbers-needed-to-treat [NNT] = 26.08; standardized clinical interviews only), indicating a 38% decrease in incidence in the intervention groups compared to controls. Small to moderate between-group effects at posttest were found on eating disorder symptoms (g = 0.35, 95% CI [0.24, 0.46], NNT = 5.10, n c = 26), dieting (g = 0.43, 95% CI [0.29, 0.57], NNT = 4.17, n c = 21), body dissatisfaction (g = 0.40, 95% CI [0.27, 0.53], NNT = 4.48, n c = 25), drive for thinness (g = 0.43, 95% CI [0.27, 0.59], NNT = 4.23, n c = 12), weight concerns (g = 0.33, 95% CI [0.10, 0.57], NNT = 5.35, n c = 13), and affective symptoms (g = 0.27, 95% CI [0.15, 0.38], NNT = 6.70, n c = 18). The effects on bulimia nervosa symptoms were not significant. Heterogeneity was moderate across comparisons. DISCUSSION: Eating disorder prevention on campus can have significant, small-to-moderate effects on eating disorder symptoms and risk factors. Results also suggest that the prevention of subthreshold and full-syndrome eating disorders is feasible using such interventions. More research is needed to identify ways to motivate students to use preventive eating disorder interventions. ANTECEDENTES: Los trastornos de la conducta alimentaria son altamente prevalentes entre los adultos jóvenes. Las universidades podrían ser un entorno óptimo para prevenir la aparición de trastornos alimentarios a través de la intervención psicológica. Como parte de la iniciativa World Mental Health-International College Student, esta revisión sistemática y meta-análisis sintetiza datos sobre la eficacia de los programas de prevención de trastornos alimentarios dirigidos a estudiantes universitarios. MÉTODO: Una búsqueda bibliográfica sistemática de datos bibliográficas (CENTRAL, MEDLINE, PsycINFO) para ensayos aleatorios que comparaban intervenciones preventivas psicológicas para trastornos alimentarios dirigidos a estudiantes universitarios con psicoeducación o controles inactivos fue realizada hasta el 22 de octubre de 2019. RESULTADOS: Se incluyeron 27 estudios. Trece (48,1%) fueron calificados como de bajo riesgo de sesgo. El riesgo relativo de desarrollar un trastorno de la conducta alimentaria subclínico (parcial) o completo fue IRR = 0.62 (95% CI [0.44, 0.87], nc = 8, NNT = 26.08; sólo entrevistas clínicas estandarizadas), lo que indica una disminución del 38% en la incidencia en los grupos de intervención en comparación con los controles. Se encontraron efectos pequeños a moderados entre los grupos en la post-prueba en los síntomas del trastorno alimentario (g = 0.35, 95% CI [0.24, 0.46], NNT = 5.10, nc = 26), dieta (g = 0.43, 95% CI [0.29, 0.57], NNT = 4.17, nc = 21), insatisfacción corporal (g = 0.40, 95% CI [0.27, 0.53], NNT = 4.48, nc = 25), impulso por delgadez (g = 0.43, 95% CI [0.27, 0.59], NNT = 4.23, nc = 12), problemas de peso (g = 0.33, 95% CI [0.10, 0.57], NNT = 5.35, nc = 13) y síntomas afectivos (g = 0.27, 95% CI [0.15, 0.38], NNT = 6.70, nc = 18). Los efectos sobre los síntomas de la bulimia nervosa no fueron significativos. La heterogeneidad fue moderada en las comparaciones. DISCUSIÓN: La prevención de los trastornos de la conducta alimentaria en el campus universitario puede tener efectos significativos, de pequeños a moderados, sobre los síntomas del trastorno alimentario y los factores de riesgo. Los resultados también sugieren que la prevención de los trastornos alimentarios subclínicos o parciales y síndromes completos es factible utilizando tales intervenciones. Se necesita más investigación para identificar formas de motivar a los estudiantes a usar intervenciones preventivas para los trastornos de la conducta alimentaria.

Using Digital Technology to Reduce the Prevalence of Mental Health Disorders in Populations: Time for a New Approach.

Digital technology, which includes the collection, analysis, and use of data from a variety of digital devices, has the potential to reduce the prevalence of disorders and improve mental health in populations. Among the many advantages of digital technology is that it allows preventive and clinical interventions, both of which are needed to reduce the prevalence of mental health disorders, to be feasibly integrated into health care and community delivery systems and delivered at scale. However, the use of digital technology also presents several challenges, including how systems can manage and implement interventions in a rapidly changing digital environment and handle critical issues that affect population-wide outcomes, including reaching the targeted population, obtaining meaningful levels of uptake and use of interventions, and achieving significant outcomes. We describe a possible solution, which is to have an outcome optimization team that focuses on the dynamic use of data to adapt interventions for populations, while at the same time, addressing the complex relationships among reach, uptake, use, and outcome. We use the example of eating disorders in young people to illustrate how this solution could be implemented at scale. We also discuss system, practitioner-related, and other issues related to the adaptation of such an approach. Digital technology has great potential for facilitating the reduction of mental illness rates in populations. However, achieving this goal will require the implementation of new approaches. As a solution, we argue for the need to create outcome optimization teams, tasked with integrating data from various sources and using advanced data analytics and new designs to develop interventions/strategies to increase reach, uptake, use/engagement, and outcomes for both preventive and treatment interventions.

A Framework for Applying Natural Language Processing in Digital Health Interventions.

BACKGROUND: Digital health interventions (DHIs) are poised to reduce target symptoms in a scalable, affordable, and empirically supported way. DHIs that involve coaching or clinical support often collect text data from 2 sources: (1) open correspondence between users and the trained practitioners supporting them through a messaging system and (2) text data recorded during the intervention by users, such as diary entries. Natural language processing (NLP) offers methods for analyzing text, augmenting the understanding of intervention effects, and informing therapeutic decision making. OBJECTIVE: This study aimed to present a technical framework that supports the automated analysis of both types of text data often present in DHIs. This framework generates text features and helps to build statistical models to predict target variables, including user engagement, symptom change, and therapeutic outcomes. METHODS: We first discussed various NLP techniques and demonstrated how they are implemented in the presented framework. We then applied the framework in a case study of the Healthy Body Image Program, a Web-based intervention trial for eating disorders (EDs). A total of 372 participants who screened positive for an ED received a DHI aimed at reducing ED psychopathology (including binge eating and purging behaviors) and improving body image. These users generated 37,228 intervention text snippets and exchanged 4285 user-coach messages, which were analyzed using the proposed model. RESULTS: We applied the framework to predict binge eating behavior, resulting in an area under the curve between 0.57 (when applied to new users) and 0.72 (when applied to new symptom reports of known users). In addition, initial evidence indicated that specific text features predicted the therapeutic outcome of reducing ED symptoms. CONCLUSIONS: The case study demonstrates the usefulness of a structured approach to text data analytics. NLP techniques improve the prediction of symptom changes in DHIs. We present a technical framework that can be easily applied in other clinical trials and clinical presentations and encourage other groups to apply the framework in similar contexts.

Combining day treatment and outpatient treatment for eating disorders: findings from a naturalistic setting.

BACKGROUND: Day treatment programs for individuals with eating disorders (ED) have been the subject of research and are promoted as an alternative to inpatient treatment due to their therapeutic and economic advantages, but have not regularly been implemented in regular care. PURPOSE: We investigated the long-term effectiveness of a transdiagnostic combined eating disorder treatment program which consisted of an 8-week day treatment phase followed by an average of 19 sessions of outpatient treatment over an average of 39 weeks in a naturalistic setting. METHODS: We accepted 148 patients with different diagnoses of eating disorders into our combined treatment program. We assessed weight, behavioral eating disorder symptoms and eating disorder related cognitions and attitudes at the beginning and the end of the day treatment phase and after 6, 12 and 26 months. RESULTS: Over the course of the 8-week day treatment phase, patients with initial binge eating, purging and/or fasting behavior reduced these symptoms by 91%, 90% and, 86%. Patients who were underweight at baseline gained on average 1.05 BMI points (d = 0.76). In addition, eating disorder related cognitions and attitudes of all patients significantly improved with large effect sizes (d = 1.12). On average, all improvements remained stable during the follow-up period. CONCLUSIONS: Our findings add to the existing studies on day treatment and support previously found encouraging effects of treatment programs that combine day treatment and consecutive outpatient treatment for eating disorders. LEVEL OF EVIDENCE: Level III, longitudinal cohort study.

Optimizing eating disorder treatment outcomes for individuals identified via screening: An idea worth researching.

In recent years, online screens have been commonly used to identify individuals who may have eating disorders (EDs), many of whom may be interested in treatment. We describe a new empirical approach that takes advantage of current evidence on empirically supported, effective treatments, while at the same time, uses modern statistical frameworks and experimental designs, data-driven science, and user-centered design methods to study ways to expand the reach of programs, enhance our understanding of what works for whom, and improve outcomes, overall and in subpopulations. The research would focus on individuals with EDs identified through screening and would use continuously monitored data, and interactions of interventions/approaches to optimize reach, uptake, engagement, and outcome. Outcome would be assessed at the population, rather than individual level. The idea worth researching is to determine if an optimization outcome model produces significantly higher rates of clinical improvement at a population level than do current approaches, in which traditional interventions are only offered to the few people who are interested in and able to access them.

Adherence Reporting in Randomized Controlled Trials Examining Manualized Multisession Online Interventions: Systematic Review of Practices and Proposal for Reporting Standards.

BACKGROUND: Adherence reflects the extent to which individuals experience or engage with the content of online interventions and poses a major challenge. Neglecting to examine and report adherence and its relation to outcomes can compromise the interpretation of research findings. OBJECTIVE: The aim of this systematic review is to analyze how adherence is accounted for in publications and to propose standards for measuring and reporting adherence to online interventions. METHODS: We performed a systematic review of randomized controlled trials on online interventions for the prevention and treatment of common mental disorders (depression, anxiety disorders, substance related disorders, and eating disorders) published between January 2006 and May 2018 and indexed in Medline and Web of Science. We included primary publications on manualized online treatments (more than 1 session and successive access to content) and examined how adherence was reported in these publications. RESULTS: We identified 216 publications that met our inclusion criteria. Adherence was addressed in 85% of full-text manuscripts, but only in 31% of abstracts. A median of three usage metrics were reported; the most frequently reported usage metric (61%) was intervention completion. Manuscripts published in specialized electronic health journals more frequently included information on the relation of adherence and outcomes. CONCLUSIONS: We found substantial variety in the reporting of adherence and the usage metrics used to operationalize adherence. This limits the comparability of results and impedes the integration of findings from different studies. Based on our findings, we propose reporting standards for future publications on online interventions.

[Finding the needles in the haystack: quality criteria for the use of internet-based self-management interventions in the prevention and treatment of mental disorders]. / Die Nadeln im Heuhaufen finden: Qualitätskriterien für den Einsatz von internetbasierten Selbstmanagement-Interventionen in Prävention und Behandlung psychischer Störungen.

Numerous self-management interventions have proven to be efficacious in the treatment of a number of mental disorders in randomized trials. However, these interventions have not yet reached clinical routine everywhere. Among other things, this is due to the fact that, in addition to the evidence-based interventions, other interventions are offered that have never been scientifically investigated, and in some cases, do not even rely on evidence-based methods of psychotherapy. The present quality criteria, developed by the two professional associations DGPs and DGPPN, are intended to help patients, practitioners and decision-makers in the health care sector to identify safe and efficacious interventions. The core quality criteria cover the following aspects: safety of patients and their data; ensuring therapeutic quality by using evidence-based psychotherapeutic methods and developing the intervention in liaison with licensed psychotherapists or medical specialists; the presence of proof of efficacy from at least one randomized trial; and transparency regarding key information, e. g., the cost of the intervention. We hope that these criteria can contribute to the inclusion of self-management interventions in the range of services covered by statutory health insurance companies.

Online prevention of disordered eating in at-risk young-adult women: a two-country pragmatic randomized controlled trial.

BACKGROUND: Disordered eating (DE) is a widespread, serious problem. Efficacious prevention programs that can be delivered at-scale are needed. METHODS: A pragmatic randomized controlled trial of two online programs was conducted. Participants were young-adult women from Australia and New Zealand seeking to improve their body image. Media Smart-Targeted (MS-T) and Student Bodies (SB) were both 9-module interventions released weekly, whilst control participants received positive body image information. Primary [Eating Disorder Examination-Questionnaire (EDE-Q) Global], secondary (DE risk factors) and tertiary (DE) outcome measures were completed at baseline, post-program, 6- and 12-month follow-up. RESULTS: Baseline was completed by 608 women (M age = 20.71 years); 33 were excluded leaving 575 randomized to: MS-T (N = 191); SB (N = 190) or control (N = 194). Only 66% of those randomized to MS-T or SB accessed the intervention and were included in analyses with controls; 78% of this sample completed measures subsequent to baseline. Primary intent-to-treat (ITT) analyses revealed no differences between groups, while measure completer analyses found MS-T had significantly lower EDE-Q Global than controls at 12-month follow-up. Secondary ITT analyses found MS-T participants reported significantly higher quality of life-mental relative to both SB and controls (6-month follow-up), while MS-T and controls had lower clinical impairment relative to SB (post-program). Amongst measure completers, MS-T scored significantly lower than controls and SB on 5 variables. Of those with baseline DE, MS-T participants were significantly less likely than controls to have DE at 12-month follow-up. CONCLUSIONS: Given both programs were not therapist-moderated, MS-T has potential to achieve reductions in DE risk at low implementation costs.