User-centered design for technology-enabled services for eating disorders.

OBJECTIVE: Technology-enabled services frequently have limited reach and suboptimal engagement when implemented in real-world settings. One reason for these implementation failures is that technology-enabled services are not designed for the users and contexts in which they will be implemented. User-centered design is an approach to designing technologies and services that is grounded in information from the stakeholders who will be using or impacted by them, and the contexts for implementation. The purpose of this article is to present user-centered design methods that can be applied to technology-enabled services for eating disorders. METHOD: We provide an overview of the user-centered design process, which is iterative and involves stakeholders throughout. One model is presented that depicts six phases of a user-centered design process: investigate, ideate, prototype, evaluate, refine and develop, and validate. RESULTS: We then review how user-centered design approaches can be applied to designing technology-enabled services for patients with eating disorders, and we integrate a hypothetical case example that demonstrates the application of these techniques to designing a technology-enabled service for binge eating. Most of the user-centered design techniques can be implemented relatively quickly, allowing us to rapidly learn what stakeholders want and to identify problems before devoting time and resources to developing and delivering technologies and services. DISCUSSION: Through this work, we show how designing services that fit into the patterns and routines that stakeholders already are doing can ensure that services are relevant to stakeholders and meet their needs, potentially improving engagement and clinical impact. RESUMEN: Los servicios habilitados tecnológicamente frecuentemente tienen un alcance limitado y un involucramiento subóptimo cuando son implementados en escenarios del mundo real. Una razón para estas fallas de implementación es que los servicios habilitados tecnológicamente no están diseñados para los usuarios y contextos en los que serán implementados. El diseño centrado en el usuario es un abordaje para diseñar tecnologías y servicios que está basado en información de las partes interesadas que estarán haciendo uso o impactados por ellos, y los contextos para implementación. El propósito de este estudio es presentar métodos de diseños centrados en el usuario que pueden ser aplicados a servicios habilitados tecnológicamente para trastornos de la conducta alimentaria. Ofrecemos una visión general del proceso de diseño centrado en el usuario, que es iterative e involucra a las partes interesadas a lo largo de todo el proceso. Hemos presentado un modelo que describe seis fases de un proceso de diseño centrado en el usuario: investigar, idear, crear prototipos, evaluar, refinar y desarrollar, y validar. Luego revisamos cómo estos abordajes de diseño centrado en el usuario pueden ser aplicados para diseñar servicios habilitados tecnológicamente para pacientes con trastornos de la conducta alimentaria, e integramos un ejemplo de caso hipotético que demuestra la aplicación de estas técnicas para diseñar un servicio habilitado tecnológicamente para comer en atracones. Muchas de las técnicas de diseño centrado en el usuario pueden ser implementadas relativamente rápido, lo que nos permite aprender rápidamente lo que las partes interesadas quieren e identificar los problemas antes de dedicarles tiempo y recursos al desarrollo y entrega de tecnologías y servicios. A través de este trabajo, mostramos cómo el diseño de servicios que se ajustan a los patrones y rutinas que las partes interesadas ya están haciendo puede garantizar que los servicios sean relevantes para los interesados y que satisfagan sus necesidades, lo que podría mejorar la participación y el impacto clínico.

Validation of a six-item male body image concerns scale (MBICS).

Elevated body image concerns may be a risk factor for eating disorders among males and contribute to a range of other mental health problems. This study tested a 6-item measure of general male body image concerns in two studies with adolescent males ages 14-18 (total N = 122). The measure showed strong convergent validity, scale score reliability, and test-retest reliability, and was significantly correlated with the number of episodes of binge eating in the past month. A short scale will relieve participant burden and provide a useful research tool for studies with males at risk for or with eating disorders.

Adaptation and evaluation of an Internet-based prevention program for eating disorders in a sample of women with subclinical eating disorder symptoms: a pilot study.

OBJECTIVE: Women reporting subclinical eating disorder (ED) symptoms are at higher risk for the development of an ED. Preventive interventions should therefore be specifically tailored for this subgroup. Accordingly, the aim of this pilot study was to test the feasibility of the adapted Internet-based prevention program "Student Bodies™" for women with subclinical ED and to obtain effect size and sample size estimates for a subsequent randomized controlled trial. METHOD: Twenty-two women with subclinical ED participated in the 8-week intervention; pre-post data are available for 12 women. Measures of ED symptoms and established risk factors, such as weight and shape concerns, were assessed at preand post-intervention. RESULTS: Completers' adherence and appraisal of the program were good. At post-intervention, completers reported significantly fewer ED symptoms and reduced weight and shape concerns. Pre-post-effect sizes ranged from medium to large. CONCLUSION: The pilot study showed the feasibility of the adapted online intervention and gave indications for its effectiveness.

Sympathetic activation in broadly defined generalized anxiety disorder.

The definition of generalized anxiety disorder (GAD) has been narrowed in successive editions of DSM by emphasizing intrusive worry and deemphasizing somatic symptoms of hyperarousal. We tried to determine the clinical characteristics of more broadly defined chronically anxious patients, and whether they would show physiological signs of sympathetic activation. A group whose chief complaint was frequent, unpleasant tension over at least the last six weeks for which they desired treatment, was compared with a group who described themselves as calm. Participants were assessed with structured interviews and questionnaires. Finger skin conductance, motor activity, and ambient temperature were measured for 24h. Results show that during waking and in bed at night, runs of continuous minute-by-minute skin conductance level (SCL) declines were skewed towards being shorter in the tense group than in the calm group. In addition, during waking, distributions of minute SCLs were skewed towards higher levels in the tense group, although overall mean SCL did not differ. Thus, the tense group showed a failure to periodically reduce sympathetic tone, presumably a corollary of failure to relax. We conclude that broader GAD criteria include a substantial number of chronically anxious and hyperaroused patients who do not fall within standard criteria. Such patients deserve attention by clinicians and researchers.

Using digital interventions to improve the cardiometabolic health of populations: a meta-review of reporting quality.

OBJECTIVES: We conducted a meta-review to determine the reporting quality of user-centered digital interventions for the prevention and management of cardiometabolic conditions. MATERIALS AND METHODS: Using predetermined inclusion criteria, systematic reviews published between 2010 and 2015 were identified from 3 databases. To assess whether current evidence is sufficient to inform wider uptake and implementation of digital health programs, we assessed the quality of reporting of research findings using (1) endorsement of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, (2) a quality assessment framework (eg, Cochrane risk of bias assessment tool), and (3) 8 parameters of the Consolidated Standards of Reporting Trials of Electronic and Mobile HEalth Applications and onLine TeleHealth (CONSORT-eHEALTH) guidelines (developed in 2010). RESULTS: Of the 33 systematic reviews covering social media, Web-based programs, mobile health programs, and composite modalities, 6 reported using the recommended PRISMA guidelines. Seven did not report using a quality assessment framework. Applying the CONSORT-EHEALTH guidelines, reporting was of mild to moderate strength. DISCUSSION: To our knowledge, this is the first meta-review to provide a comprehensive analysis of the quality of reporting of research findings for a range of digital health interventions. Our findings suggest that the evidence base and quality of reporting in this rapidly developing field needs significant improvement in order to inform wider implementation and uptake. CONCLUSION: The inconsistent quality of reporting of digital health interventions for cardiometabolic outcomes may be a critical impediment to real-world implementation.

Anxiety and Related Disorders and Concealment in Sexual Minority Young Adults.

Sexual minorities face greater exposure to discrimination and rejection than heterosexuals. Given these threats, sexual minorities may engage in sexual orientation concealment in order to avoid danger. This social stigma and minority stress places sexual minorities at risk for anxiety and related disorders. Given that three fourths of anxiety disorder onset occurs before the age of 24, the current study investigated the symptoms of generalized anxiety disorder, social phobia, panic disorder, posttraumatic stress disorder, and depression in sexual minority young adults relative to their heterosexual peers. Secondarily, the study investigated sexual orientation concealment as a predictor of anxiety and related disorders. A sample of 157 sexual minority and 157 heterosexual young adults matched on age and gender completed self-report measures of the aforementioned disorders, and indicated their level of sexual orientation concealment. Results revealed that sexual minority young adults reported greater symptoms relative to heterosexuals across all outcome measures. There were no interactions between sexual minority status and gender, however, women had higher symptoms across all disorders. Sexual minority young women appeared to be at the most risk for clinical levels of anxiety and related disorders. In addition, concealment of sexual orientation significantly predicted symptoms of social phobia. Implications are offered for the cognitive and behavioral treatment of anxiety and related disorders in this population.

Non-suicidal self-injury and suicidal ideation in relation to eating and general psychopathology among college-age women.

Non-suicidal self-injury (NSSI) and suicidal ideation are potent risk factors for suicide and are associated with general and eating disorder-specific psychopathology. Limited research has examined the effects of combined NSSI+suicidal ideation thus concurrent examination is needed to understand potential differential effects on psychopathology. College-aged women (N=508) completed self-report measures of NSSI, suicidal ideation, general psychopathology, and Eating Disorder-specific psychopathology. MANOVAs determined whether the NSSI/SI status groups differed on general and eating disorder pathology measures as a set. Significant MANOVAs were followed up with univariate ANOVAs and posthoc tests. Thirteen women endorsed NSSI+Suicidal Ideation, 70 endorsed NSSI-only, 25 endorsed Suicidal Ideation-only, and 400 endorsed no NSSI/Suicidal Ideation. Both general and eating disorder-specific psychopathology differed across groups. NSSI+Suicidal Ideation and Suicidal Ideation-only groups typically endorsed higher general psychopathology than the no NSSI/Suicidal Ideation and NSSI-only groups. Regarding eating disorder pathology, the NSSI+Suicidal Ideation group was more pathological than no NSSI/Suicidal Ideation and NSSI-only, except on the weight concerns scale, where NSSI+Suicidal Ideation only differed from no NSSI/Suicidal Ideation. The NSSI+Suicidal Ideation group was only greater than Suicidal Ideation-only on measures of depression and eating concern. Results highlight the importance of screening for both NSSI and suicidal ideation, especially for individuals with eating disorder symptoms. Likewise, screening for eating disorder pathology may be beneficial for individuals presenting with NSSI and suicidal ideation.

Ambulatory heart rate changes during panic attacks.

Ten patients suffering from panic attacks were studied in an effort to test the feasibility of measuring panic attacks via 24-h ambulatory heart rate monitoring. Subjects were also asked to record their activity level, anxiety level, and level of panic at 15-min intervals. Seven of the 10 patients reported panic attacks during the 24-h recording period; one patient reported two panic attacks. Three of the eight panic episodes demonstrated significant heart rate increases relative to activity level. Results suggest that ambulatory monitoring of panic attacks may be most useful with patients who suffer from more frequent and severe panic attacks and who have high heart rates (greater than 110) during these attacks.

Severity of child maltreatment, pain complaints and medical utilization among women.

High medical utilization in adults has been linked to both reported history of childhood abuse and mental health problems. However, few studies have explored relationships between abuse severity and psychological distress to identify subgroups with unique utilization patterns and medical complaints. This study compared two groups of psychologically distressed, high utilizers. One group (DS) was comprised of those with psychological distress, who reported a history of child sexual abuse (CSA); the other group (DSP) consisted of those with psychological distress, who reported CSA plus a history of childhood physical abuse. The groups were compared on severity of sexual and nonsexual child maltreatment, medical complaints and medical utilization. From a convenience sample of 206 females age 20-63, recruited while waiting for a physician appointment in a primary care clinic, we compared 25 DSPs to 33 DSs. Compared with DSs, DSPs reported significantly more severe: (1) sexual abuse including completed intercourse; (2) emotional abuse; (3) emotional neglect; and (4) psychological distress. DSPs also showed a nonsignificant trend towards more severe physical neglect. In addition to being significantly higher on emergency room visits, DSPs were marginally higher than DSs on nonpsychiatric outpatient visits. DSPs had significantly more frequent chronic and acute pain complaints at emergency room (ER) visits. Headaches were the most frequently coded diagnosis at ER visits in this sample. DSPs accounted for 89% of these ER visits attributable to headaches. The interaction of psychological distress and reported severity of child maltreatment reveals subgroups with unique utilization patterns and medical complaints. Physicians should screen patients for child maltreatment severity and psychological distress and should be involved in mental health referral where necessary.

Training in and implementation of Acceptance and Commitment Therapy for depression in the Veterans Health Administration: therapist and patient outcomes.

OBJECTIVE: The U.S. Department of Veterans Affairs has implemented a national dissemination and training initiative to promote the availability of Acceptance and Commitment Therapy for depression (ACT-D). This paper reports on therapist and patient outcomes associated with competency-based training in and implementation of ACT-D. METHOD: Therapist and patient outcomes were assessed on eleven cohorts of therapists (n = 391) and their patients (n = 745). RESULTS: Three-hundred thirty four therapists successfully completed all requirements of the Training Program. Ninety-six percent of therapists achieved competency by the end of training, compared to 21% at the outset of training. Mixed effects model analysis indicated therapists' overall ACT-D competency scores increased from 76 to 112 (conditional SD = 6.6), p < 0.001. Moreover, training was associated with significantly increased therapist self-efficacy and positive attitudes toward ACT-D. Therapeutic alliance increased significantly over the course of therapy. Mixed effects model analysis revealed that mean BDI-II scores decreased from 30 at baseline assessment to 19 (conditional SD = 5.6) at final assessment, t(367) = -20.3, p < 0.001. Quality of life scores also increased. CONCLUSIONS: Training in and implementation of ACT-D in the treatment of Veterans is associated with significant increases in therapist competency and robust improvements in patient outcomes.