Assessing clinician competence in the delivery of cognitive-behavioural therapy for eating disorders: development of the Cognitive-Behavioural Therapy Scale for Eating Disorders (CBTS-ED).

Evidence-based cognitive-behaviour therapy for eating disorders (CBT-ED) differs from other forms of CBT for psychological disorders, making existing generic CBT measures of therapist competence inadequate for evaluating CBT-ED. This study developed and piloted the reliability of a novel measure of therapist competence in this domain-the Cognitive Behaviour Therapy Scale for Eating Disorders (CBTS-ED). Initially, a team of CBT-ED experts developed a 26-item measure, with general (i.e. present in every session) and specific (context- or case-dependent) items. To determine statistical properties of the measure, nine CBT-ED experts and eight non-experts independently observed six role-played mock CBT-ED therapy sessions, rating the therapists' performance using the CBTS-ED. The inter-item consistency (Cronbach's alpha and McDonald's omega) and inter-rater reliability (ICC) were assessed, as appropriate to the clustering of the items. The CBTS-ED demonstrated good internal consistency and moderate/good inter-rater reliability for the general items, at least comparable to existing generic CBT scales in other domains. An updated version is proposed, where five of the 16 "specific" items are reallocated to the general group. These preliminary results suggest that the CBTS-ED can be used effectively across both expert and non-expert raters, though less experienced raters might benefit from additional training in its use.

Fulfilling the promise: Commentary on Schleider et al. (2023).

In their paper on "Realizing the Untapped Promise of Single-Session Interventions for Eating Disorders" Schleider and colleagues suggest an innovative approach to addressing a much- discussed critical issue in the treatment of eating disorders-how we help more people quickly and with greater efficiency. While building on the feasibility and success of program-led approaches, they make a potentially transformative proposal for the use of single-session, "one-at-a-time" interventions freely accessible to those in need. We suggest that not only does this proposal have the potential to narrow the treatment gap, but its ability to generate informative data at scale may also contribute to improving treatment outcomes overall. We also note the need for further independent support for the claim that single sessions produce meaningful benefit especially in the field of the prevention and treatment of eating disorders. While Schleider and colleagues' proposal is potentially transformative and has heuristic value, some caution needs to be exercised. In our view, single-session interventions should not be regarded as displacing existing treatment provision. Rather they should be seen as complementary and a potential way of improving provision overall.

Cognitive behavioral therapy for eating disorders: A map of the systematic review evidence base.

OBJECTIVE: To map and examine the systematic review evidence base regarding the effects of cognitive-behavioral therapy (CBT) for eating disorders (EDs), especially against active interventions. METHOD: This systematic review is an extension of an overview of CBT for all health conditions (CBT-O). We identified ED-related systematic reviews from the CBT-O database and performed updated searches of EMBASE, MEDLINE, and PsychInfo in April 2021 and September 2022. RESULTS: The 44 systematic reviews included (21 meta-analyses) were of varying quality. They focused on "high intensity" CBT, delivered face-to-face by qualified clinicians, in BN, BED and mixed, not specifically low-weight samples. ED-specific outcomes were studied most, with little consensus on their operationalization. The, often insufficient, reporting of sample characteristics did not allow assessment of the generalizability of findings. The meta-analytic syntheses show that high intensity one-to-one CBT produces better short-term effects than a mix of active controls especially on ED-specific measures for BED, BN, and transdiagnostic samples. There is little evidence favoring group CBT or low intensity CBT against other active interventions. DISCUSSION: While this study found evidence consistent with current ED treatment recommendations, it highlighted notable gaps that need to be addressed. There were insufficient data to allow generalizations regarding sex and gender, age, culture and comorbidity and to support CBT in AN samples. The evidence for group CBT and low intensity CBT against active controls is limited, as it is for the longer-term effects of CBT. Our findings identify areas for future innovation and research within CBT. PUBLIC SIGNIFICANCE: This study provides a comprehensive mapping and quality assessment of the current large systematic review research base regarding the effects of cognitive behavioral therapy (CBT) for eating disorders (EDs), with a focus on comparisons to other active interventions. By transcending the more limited scope of individual systematic reviews, this overview highlights the gaps in the current evidence base, and thus provides guidance for future research and clinical innovation.

OBJETIVO: Mapear y examinar la base de evidencia de la revisión sistemática con respecto a los efectos de la terapia cognitivo-conductual (TCC) para los trastornos de la conducta alimentaria (TCA), especialmente contra las intervenciones activas. MÉTODO: Esta revisión sistemática es una extensión de una visión general de la TCC para todas las afecciones de salud (TCC-O, Fordham et al., 2021a). Se identificaron revisiones sistemáticas relacionadas con los TCA a partir de la base de datos TCC-O y se realizaron búsquedas actualizadas en EMBASE, MEDLINE y PsychInfo en abril de 2021 y septiembre de 2022. RESULTADOS: Las 44 revisiones sistemáticas incluidas (21 metanálisis) fueron de calidad variable. Se centraron en la TCC de "alta intensidad", administrada cara a cara por clínicos calificados, en BN, TpA y muestras mixtas, no específicamente de bajo peso. Los resultados específicos de los TCA fueron los más estudiados, con poco consenso sobre su operacionalización. El informe, a menudo insuficiente, de las características de la muestra no permitió evaluar la generalización de los hallazgos. Las síntesis metaanalíticas muestran que la TCC uno a uno de alta intensidad produce mejores efectos a corto plazo que una combinación de controles activos, especialmente en medidas específicas de TCA para TpA, BN y muestras transdiagnósticas. Hay poca evidencia a favor de la TCC grupal o la TCC de baja intensidad frente a otras intervenciones activas. DISCUSIÓN: Si bien este estudio encontró evidencia consistente con las recomendaciones actuales de tratamiento de los TCA, también destacó las brechas notables que deben abordarse. No hubo datos suficientes para permitir generalizaciones con respecto al sexo y el género, la edad, la cultura y la comorbilidad y para apoyar la TCC en las muestras de AN. La evidencia para la TCC grupal y la TCC de baja intensidad contra los controles activos es limitada, al igual que para los efectos a más largo plazo de la TCC. Nuestros hallazgos identifican áreas para la innovación y la investigación futuras dentro de la TCC.

Developing a protocol to address co-occurring mental health conditions in the treatment of eating disorders.

OBJECTIVE: While co-occurring mental health conditions are the norm in eating disorders, no testable protocol addresses management of these in psychotherapy. METHOD: The literature on managing mental health conditions that co-occur with eating disorders is outlined and reviewed. RESULTS: In the absence of clear evidence to inform managing co-occurring mental health conditions, we advocate for use of an iterative, session-by-session measurement to guide practice and research. We identify three data-driven treatment approaches (focus solely on the eating disorder; multiple sequential interventions either before or after the eating disorder is addressed; integrated interventions), and the indications for their use. Where a co-occurring mental health condition/s impede effective treatment of the eating disorder, and an integrated intervention is required, we outline a four-step protocol for three broad intervention approaches (alternate, modular, transdiagnostic). A research program is suggested to test the usefulness of the protocol. DISCUSSION: Guidelines that provide a starting point to improving outcomes for people with eating disorders that can be evaluated/researched are offered in the current paper. These guidelines require further elaboration with reference to: (1) whether any difference in approach is required where the co-occurring mental health condition is a comorbid symptom or condition; (2) the place of biological treatments within these guidelines; (3) precise guidelines for selecting among the three broad intervention approaches when adapting care for co-occurring conditions; (4) optimal approaches to involving consumer input into identifying the most relevant co-occurring conditions; (5) detailed specification on how to determine which adjuncts to add. PUBLIC SIGNIFICANCE: Most people with an eating disorder also have another diagnosis or an underlying trait (e.g., perfectionism). Currently no clear guidelines exist to guide treatment in this situation, which often results in a drift away from evidence-based techniques. This paper outlines data-driven strategies for treating eating disorders and the accompanying comorbid conditions and a research program that can test the usefulness of the different approaches suggested.

Breastfeeding and pumping as maladaptive weight control behaviors.

It is well recognized by the general public that breastfeeding expends calories. In our clinical practice, a number of postpartum women with a history of or a current eating disorder (ED) report using breastfeeding and/or pumping breast milk to influence their body shape and weight. This appears to be either a form of weight control behavior or, in some cases, a compensation for perceived overeating or binge eating. Breastfeeding and pumping have not generally been identified as maladaptive weight control behaviors, nor have they been a subject of research to date. We suggest that this practice should be investigated to determine how common it is, its potential role in maintaining EDs or contributing to relapse in the postpartum period, and to better understand other potential harms it may cause to both the mother and infant/child. PUBLIC SIGNIFICANCE: Breastfeeding and pumping may be used as maladaptive methods of weight control by women with EDs. This behavior is under-recognized in clinical practice and has received little research attention. We argue that maladaptive breastfeeding and pumping warrant further investigation, as the behaviors may play an important role in maintaining an ED or in contributing to relapse during the postpartum period and may also indirectly harm the infant/child.

Improving programme-led and focused interventions for eating disorders: An experts' consensus statement-A UK perspective.

OBJECTIVE: Eating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Greater use of programme-led and focused interventions that are less resource-intensive might be part of the solution to this demand-capacity mismatch. METHOD: In October 2022, a group of predominantly UK-based clinical and academic researchers, charity representatives and people with lived experience convened to consider ways to improve access to, and efficacy of, programme-led and focused interventions for eating disorders in an attempt to bridge the demand-capacity gap. RESULTS: Several key recommendations were made across areas of research, policy, and practice. Of particular importance is the view that programme-led and focused interventions are suitable for a range of different eating disorder presentations across all ages, providing medical and psychiatric risk are closely monitored. The terminology used for these interventions should be carefully considered, so as not to imply that the treatment is suboptimal. CONCLUSIONS: Programme-led and focused interventions are a viable option to close the demand-capacity gap for eating disorder treatment and are particularly needed for children and young people. Work is urgently needed across sectors to evaluate and implement such interventions as a clinical and research priority.

Adaptation and translation of a scalable measure for assessing health worker competence to deliver a brief psychological intervention: A case study from central India of its comparison to a performance-based measure.

Efforts to reduce the global burden of common mental disorders have focused on scaling up evidence-based training programs for non-specialist providers to deliver brief psychological interventions. To evaluate these provider training programs, appropriate and scalable assessments of competency need to be developed alongside them. We followed a systematic approach for the cultural adaptation and translation into Hindi of a valid, English, multiple-choice applied knowledge measure to assess non-specialists' competence to deliver a brief psychological intervention for depression in rural India. We then explored the relationship between the performance of 30 non-specialist providers on the same written measure compared with a structured performance-based measure consisting of two role-plays. The results of the multiple-choice assessment had an overall mean score of 37.40 (SD = 11.31) compared to the mean scores of role-play A (the easier role-play) of 43.25 (SD = 14.50) and role-play B (the more difficult role-play) of 43.25 (SD = 13.00). Role-play performance-based measures and written applied knowledge measures represent different approaches with unique strengths and challenges to measuring competence. Scaling up training programs requires the development of scalable methods for competency assessment. Exploring the relationship between these two measures, our team found no apparent differences between the two modes of assessment. Continued comparison of these approaches is needed to determine the consistency of outcomes across the two formats and to link the scores on these measures with clinical performance as reflected by the quality of care and patient outcomes.Trial Registration: ClinicalTrials.gov Identifier: NCT04157816; 8th November 2019.

Disordered eating in sexual minority post-9/11 United States veterans.

OBJECTIVE: It is well documented that sexual minority individuals are more likely to report disordered eating (DE) than those identifying as heterosexual. Although DE is prevalent in veterans, investigation of potential disparities in DE among sexual minority veterans is limited. This study examined rates of DE in post-9/11 United States (U.S.) veterans identifying as sexual minorities and explored their association with discrimination because of marginalized identities. METHODS: A national sample of recently separated post-9/11 U.S. veterans were recruited. Women (N = 805; heterosexual [n = 656]; lesbian [n = 51]; bisexual [n = 98]) and men (N = 558; heterosexual [n = 540]; gay [n = 11]; bisexual [n = 7]) completed a survey assessing eating behaviors, mental health, and military experiences. Weighted correlational and regression analyses were conducted. Analyses in men were exploratory. RESULTS: DE was prevalent across gender and sexual orientation identity groups. Women identifying as bisexual and men identifying as gay reported higher rates of DE and consequent impairment compared to veterans who identified as heterosexual. There were no differences in DE between heterosexual and lesbian female veterans, but lesbian women reported lower DE-related impairment. Experiencing any discrimination in the military was positively related to DE. DISCUSSION: This study found evidence of disparities in DE among sexual minority U.S. military veterans. While the factors contributing to these differences, such as the role of discrimination, are not completely understood, DE is a health concern for sexual minority veterans and requires continued investigation. PUBLIC SIGNIFICANCE: Sexual minority individuals experience disparities in disordered eating; yet, this has not been explored in military veterans. This study found that disordered eating is a significant health concerns for veteran women and men, especially among those identifying as sexual minorities. More research is needed to explore why these disparities exist, such as the role of minority stress, in order to address the unique healthcare needs of these veterans.

Posttraumatic stress disorder and eating disorders: maintaining mechanisms and treatment targets.

Many individuals with lifetime histories of eating disorders (EDs) report exposure to interpersonal trauma and posttraumatic stress disorder (PTSD). However, this relationship is not well-understood, and there are no established, evidence-based therapies for the concurrent treatment of EDs and PTSD. This review focuses on studies of the mechanisms associating trauma exposure and/or PTSD with EDs. Possible mechanisms of the trauma-ED association identified from the literature include self-criticism, low self-worth, guilt, shame, depression, anxiety, emotion dysregulation, anger, and impulsivity/compulsivity. ED behaviors may be used as coping strategies to manage PTSD symptoms and negative affect. Avoidance of hyperarousal symptoms by engaging in binge eating, purging, and/or restriction may serve to maintain both the ED as well as the PTSD. Given the evidence of the bidirectional relationship between EDs and PTSD, we describe an integrated cognitive behavioral theory that may account for the persistence of comorbid PTSD and EDs. The integrated model is based on the theoretical models that underpin existing evidence-based treatments for PTSD and ED and incorporates many of the potential mechanisms highlighted to date. The primary aim of the model is to identify potential treatment targets as well as elucidate future directions for research.

Mediators of change in cognitive behavior therapy and interpersonal psychotherapy for eating disorders: A secondary analysis of a transdiagnostic randomized controlled trial.

OBJECTIVE: Understanding the mechanisms of action of psychological treatments is a key first step in refining and developing more effective treatments. The present study examined hypothesized mediators of change of enhanced cognitive behavior therapy (CBT-E) and interpersonal psychotherapy for eating disorders (IPT-ED). METHOD: A series of mediation studies were embedded in a randomized controlled trial (RCT) comparing 20 weeks of CBT-E and IPT-ED in a transdiagnostic, non-underweight sample of patients with eating disorders (N = 130) consecutively referred to the service. Three hypothesized mediators of change in CBT-E (regular eating, weighing frequency, and shape checking) and the key hypothesized mediator of IPT-ED (interpersonal problem severity) were studied. RESULTS: The data supported regular eating as being a mediator of the effect of CBT-E on binge-eating frequency. The findings were inconclusive regarding the role of the other putative mediators of the effects of CBT-E; and were similarly inconclusive for interpersonal problem severity as a mediator of the effect of IPT-ED. DISCUSSION: This research highlights the potential benefits of embedding mediation studies within RCTs to better understand how treatments work. The findings supported the role of regular eating in reducing patients' binge-eating frequency. Other key hypothesized mediators of CBT-E and IPT-ED were not supported, although the data were not inconsistent with them. Key methodological issues to address in future work include the need to capture both behavioral and cognitive processes of change in CBT-E, and identifying key time points for change in IPT-ED.

Controlling binge eating and weight: a treatment for binge eating disorder worth researching?

PURPOSE: The majority of those who seek treatment for binge eating disorder also have accompanying obesity or overweight. The best available psychological treatments for binge eating disorder produce good and lasting outcomes with regard to control over eating but virtually no weight loss, yet control over eating and weight loss are both important and valued goals of those who seek treatment. METHODS: We have devised a model of the processes maintaining both the binge eating and the overweight or obesity that occurs in many patients with binge eating disorder who seek treatment. The model draws on previous research findings to highlight and integrate the factors maintaining both the disordered eating and the accompanying overweight or obesity. RESULTS: We outline a new treatment based on the proposed model that explicitly addresses the twin goals of cessation of binge eating and weight loss in an integrated fashion. The proposed treatment incorporates and integrates elements from two previously tested evidence-based interventions, enhanced cognitive behavioural therapy for eating disorders shown to reduce binge eating and cognitive behaviour therapy of obesity, which produces weight loss. CONCLUSION: To meet a major challenge for the treatment of binge eating disorder (BED), we have proposed that an integrated treatment with the goals of addressing both binge eating and overweight or obesity is worth researching further. Should this treatment be successful, the goals of many patients who seek treatment for BED are more likely to be met. LEVEL OF EVIDENCE: This brief report proposes a new approach to clinical practice to be researched further. The evidence on the basis of which the case is made is derived from Level 1: evidence obtained from at least one properly designed randomized controlled trial; systematic reviews and meta-analyses; and experimental studies.

Increasing the Availability of Psychological Treatments: A Multinational Study of a Scalable Method for Training Therapists.

BACKGROUND: One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. A highly scalable form of Web-centered therapist training, undertaken without external support, has recently been shown to have promise in promoting therapist competence. OBJECTIVE: The aim of this study was to conduct an evaluation of the acceptability and effectiveness of a scalable independent form of Web-centered training in a multinational sample of therapists and investigate the characteristics of those most likely to benefit. METHODS: A cohort of eligible therapists was recruited internationally and offered access to Web-centered training in enhanced cognitive behavioral therapy, a multicomponent, evidence-based, psychological treatment for any form of eating disorder. No external support was provided during training. Therapist competence was assessed using a validated competence measure before training and after 20 weeks. RESULTS: A total of 806 therapists from 33 different countries expressed interest in the study, and 765 (94.9%) completed a pretraining assessment. The median number of training modules completed was 15 out of a possible 18 (interquartile range, IQR: 4-18), and 87.9% (531/604) reported that they treated at least one patient during training as recommended. Median pretraining competence score was 7 (IQR: 5-10, range: 0-19; N=765), and following training, it was 12 (IQR: 9-15, range: 0-20; N=577). The expected change in competence scores from pretraining to posttraining was 3.5 (95% CI 3.1-3.8; P<.001). After training, 52% (300/574) of therapists with complete competence data met or exceeded the competence threshold, and 45% (95% CI 41-50) of those who had not met this threshold before training did so after training. Compliance with training predicted both an increase in competence scores and meeting or exceeding the competence threshold. Expected change in competence score increased for each extra training module completed (0.19, 95% CI 0.13-0.25), and those who treated a suitable patient during training had an expected change in competence score 1.2 (95% CI 0.4-2.1) points higher than those who did not. Similarly, there was an association between meeting the competence threshold after training and the number of modules completed (odds ratio, OR=1.11, 95% CI 1.07-1.15), and treating at least one patient during training was associated with competence after training (OR=2.2, 95% CI 1.2-4.1). CONCLUSIONS: Independent Web-centered training can successfully train large numbers of therapists dispersed across a wide geographical area. This finding is of importance because the availability of a highly scalable method of training potentially increases the number of people who might receive effective psychological treatments.

Scaling Up Psychological Treatments: A Countrywide Test of the Online Training of Therapists.

BACKGROUND: A major barrier to the widespread dissemination of psychological treatments is the way that therapists are trained. The current method is not scalable. OBJECTIVE: Our objective was to conduct a proof-of-concept study of Web-centered training, a scalable online method for training therapists. METHODS: The Irish Health Service Executive identified mental health professionals across the country whom it wanted to be trained in a specific psychological treatment for eating disorders. These therapists were given access to a Web-centered training program in transdiagnostic cognitive behavior therapy for eating disorders. The training was accompanied by a scalable form of support consisting of brief encouraging telephone calls from a nonspecialist. The trainee therapists completed a validated measure of therapist competence before and after the training. RESULTS: Of 102 therapists who embarked upon the training program, 86 (84.3%) completed it. There was a substantial increase in their competence scores following the training (mean difference 5.84, 95% Cl -6.62 to -5.05; P<.001) with 42.5% (34/80) scoring above a predetermined cut-point indicative of a good level of competence. CONCLUSIONS: Web-centered training proved feasible and acceptable and resulted in a marked increase in therapist competence scores. If these findings are replicated, Web-centered training would provide a means of simultaneously training large numbers of geographically dispersed trainees at low cost, thereby overcoming a major obstacle to the widespread dissemination of psychological treatments.

Using the Internet to Train Therapists: Randomized Comparison of Two Scalable Methods.

BACKGROUND: One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. The currently accepted method of training is not scalable. Recently, a scalable form of training, Web-centered training, has been shown to have promise. OBJECTIVE: The goal of our research was to conduct a randomized comparison of the relative effects of independent and supported Web-centered training on therapist competence and investigate the persistence of the effects. METHODS: Eligible therapists were recruited from across the United States and Canada. They were randomly assigned to 1 of 2 forms of training in enhanced cognitive behavior therapy (CBT-E), a multicomponent evidence-based psychological treatment for any form of eating disorder. Independent training was undertaken autonomously, while supported training was accompanied by support from a nonspecialist worker. Therapist competence was assessed using a validated competence measure before training, after 20 weeks of training, and 6 months after the completion of training. RESULTS: A total of 160 therapists expressed interest in the study, and 156 (97.5%) were randomized to the 2 forms of training (81 to supported training and 75 to independent training). Mixed effects analysis showed an increase in competence scores in both groups. There was no difference between the 2 forms of training, with mean difference for the supported versus independent group being -0.06 (95% Cl -1.29 to 1.16, P=.92). A total of 58 participants (58/114, 50.9%) scored above the competence threshold; three-quarters (43/58, 74%) had not met this threshold before training. There was no difference between the 2 groups in the odds of scoring over the competence threshold (odds ratio [OR] 1.02, 95% CI 0.52 to 1.99; P=.96). At follow-up, there was no significant difference between the 2 training groups (mean difference 0.19, 95% Cl -1.27 to 1.66, P=.80). Overall, change in competence score from end of training to follow-up was not significant (mean difference -0.70, 95% CI -1.52 to 0.11, P=.09). There was also no difference at follow-up between the training groups in the odds of scoring over the competence threshold (OR 0.95, 95% Cl 0.34 to 2.62; P=.92). CONCLUSIONS: Web-centered training was equally effective whether undertaken independently or accompanied by support, and its effects were sustained. The independent form of Web-centered training is particularly attractive as it provides a means of training large numbers of geographically dispersed therapists at low cost, thereby overcoming several obstacles to the widespread dissemination of psychological treatments.

The Reliability and Validity of the Clinical Perfectionism Questionnaire in Eating Disorder and Community Samples.

BACKGROUND: Clinical perfectionism is a risk and maintaining factor for anxiety disorders, depression and eating disorders. AIMS: The aim was to examine the psychometric properties of the 12-item Clinical Perfectionism Questionnaire (CPQ). METHOD: The research involved two samples. Study 1 comprised a nonclinical sample (n = 206) recruited via the internet. Study 2 comprised individuals in treatment for an eating disorder (n = 129) and a community sample (n = 80). RESULTS: Study 1 factor analysis results indicated a two-factor structure. The CPQ had strong correlations with measures of perfectionism and psychopathology, acceptable internal consistency, and discriminative and incremental validity. The results of Study 2 suggested the same two-factor structure, acceptable internal consistency, and construct validity, with the CPQ discriminating between the eating disorder and control groups. Readability was assessed as a US grade 4 reading level (student age range 9-10 years). CONCLUSIONS: The findings provide evidence for the reliability and validity of the CPQ in a clinical eating disorder and two separate community samples. Although further research is required the CPQ has promising evidence as a reliable and valid measure of clinical perfectionism.

Disseminating evidence-based psychological treatments for eating disorders.

The research-practice gap is of concern in the treatment of eating disorders. Despite the existence of empirically supported treatments, few receive them. The barriers to wider dissemination and implementation of evidence-based treatment include clinician attitudes towards such treatments and the lack of sufficient numbers of suitably trained therapists to provide treatment. In this review we discuss these barriers in the context of the wider issue of the dissemination and implementation of psychological treatments and review the research with regard to the treatment of eating disorders. Particular emphasis is placed on examining recent efforts to expand the availability and reach of treatments by making treatment delivery and training more scalable. We highlight promising developments and areas where further research is needed.

Development and usability testing of an online platform for provider training and implementation of cognitive-behavioral therapy guided self-help for eating disorders.

Background: Most individuals with eating disorders (EDs) do not receive treatment, and those who do receive care typically do not receive evidence-based treatment, partly due to lack of accessible provider training. This study developed a novel "all-in-one" online platform for disseminating training for mental health providers in cognitive-behavioral therapy guided self-help (CBTgsh) for EDs and supporting its implementation. The aim of the study was to obtain usability data from the online platform prior to evaluating its effects on provider training outcomes and patient ED symptom outcomes in an open pilot trial. Methods: Nine mental health provider participants (n = 4 in Cycle 1; n = 5 in Cycle 2) and 9 patient participants (n = 4 in Cycle 1; n = 5 in Cycle 2) were enrolled over two cycles of usability testing. In Cycle 1, we recruited providers and patients separately to complete brief platform testing sessions. In Cycle 2, we recruited provider-patient dyads; providers completed training using the platform and subsequently delivered CBTgsh to a patient for three weeks. Usability was assessed using the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), and semi-structured interviews. Results: Interview feedback converged on two themes for providers (applicability of program for real-world use, platform structure and function) and two themes for patients (barriers and facilitators to engagement, perceived treatment effects). SUS and USE scores were in the "average" to "good" ranges across cycles. Conclusions: Findings from this study demonstrate preliminary feasibility and acceptability of the online platform. Data collected in this study will inform further refinements to the online platform. The platform's effects on provider training outcomes and patient ED symptom outcomes will be evaluated in an open pilot trial. Given the wide treatment gap for EDs and barriers to dissemination and implementation of evidence-based treatments, the online platform represents a scalable solution that could improve access to evidence-based care for EDs.

A multi-center, randomized, parallel-group study to compare the efficacy of enhanced cognitive behavior therapy (CBT-E) with treatment as usual (TAU) for anorexia nervosa: study protocol.

BACKGROUND: The superiority of Enhanced Cognitive Behavior Therapy (CBT-E) with regard to weight gain and improvement of psychopathology of eating disorders for patients with anorexia nervosa (AN) over other psychotherapies and treatment as usual (TAU) has not been demonstrated in randomized controlled trials (RCTs). However, a previous RCT showed that patients with AN whose baseline body mass index (BMI) was less than 17.5 kg/m2 gained more weight when treated with CBT-E than with other psychotherapies. The aim of the study is to compare the efficacy of CBT-E and TAU for patients with AN. It was hypothesized that CBT-E would be superior to TAU, at least in terms of weight gain, as most patients with AN are likely to have a BMI lower than 17.5 kg/m2. METHODS/DESIGN: A randomized parallel-group multicenter trial will be conducted in three teaching hospitals in Japan between January 2023 and March 2026. Patients with DSM-5 AN, aged 16 years and older, with a BMI equal to or above 14.0 and below 18.5 will be eligible to participate. 56 patients will be randomly and evenly assigned to two intervention groups (CBT-E and TAU). Those assigned to CBT-E will be offered 25-40 sessions in accordance with their initial BMI. Patients assigned to TAU will have at least one session every 2 weeks, with the number of sessions and treatment period not fixed in advance. The primary outcome is BMI at 40 weeks after treatment initiation. The secondary outcomes are the results from the Japanese version of the Eating Disorder Examination Questionnaire and Clinical Impairment Assessment questionnaire to measure eating disorder psychopathology and psychological impairment. The follow-up assessment will be performed 6 months after the 40-week assessment. DISCUSSION: This multi-center randomized controlled study will probably evaluate the efficacy of CBT-E compared with TAU for patients with more severe AN than in previous studies since Japanese patients are likely to have a lower BMI than those in Western countries. While it may be difficult to generalize the results of a study conducted in Japan, it would be valuable to clarify the efficacy of CBT-E as a treatment package. TRIAL REGISTRATION: UMIN, UMIN000048847. Registered 12 Sep 2022.

Interpersonal psychotherapy for eating disorders.

Interpersonal psychotherapy (IPT) is a leading evidence-based treatment for those eating disorders in which binge eating is a feature. This article begins with a consideration of the rationale for using IPT to treat patients with eating disorders. This is followed by a review of the evidence supporting its use and a brief description of treatment including an illustrative clinical case vignette. The article closes with a discussion of possible future directions for research on IPT for eating disorders.

Associations between probable eating disorders and healthcare use among post-9/11 veteran men and women.

OBJECTIVE: Healthcare use is elevated among individuals with eating disorders (EDs); however, most people with EDs do not receive ED-specific care, likely due to factors such as the cost and availability of treatment as well as stigma. U.S. military veterans historically have been understudied in ED research. We investigated healthcare use and barriers to care among recently separated veteran men and women. METHOD: In this cross-sectional study, 1494 participants completed an online or paper survey assessing ED symptoms, healthcare use, and logistical and attitudinal barriers to care. We estimated logistic regression models to investigate the association of ED status with healthcare use variables and examined gender similarities and differences in barriers to care. RESULTS: Men and women with probable EDs reported low rates of ED treatment but greater healthcare use, during military service and since separating from service, compared to veterans without probable EDs (odds ratios = 1.57-7.05). Large proportions of participants reported that they did not know where to get help for EDs and that treatment is too costly. There were few gender differences in barriers to care (Cramer's V = 0.02-0.32). CONCLUSION: Veterans reported high healthcare use but low rates of ED treatment. Findings underscore the need to increase the reach and accessibility of ED treatment in potentially vulnerable groups.