CBT4BN: A Randomized Controlled Trial of Online Chat and Face-to-Face Group Therapy for Bulimia Nervosa.

OBJECTIVE: Although cognitive-behavioral therapy (CBT) represents the first-line evidence-based psychotherapy for bulimia nervosa (BN), most individuals seeking treatment do not have access to this specialized intervention. We compared an Internet-based manualized version of CBT group therapy for BN conducted via a therapeutic chat group (CBT4BN) to the same treatment conducted via a traditional face-to-face group therapy (CBTF2F). METHOD: In a two-site, randomized, controlled noninferiority trial, we tested the hypothesis that CBT4BN would not be inferior to CBTF2F. A total of 179 adult patients with BN (2.6% males) received up to 16 sessions of group CBT over 20 weeks in either CBT4BN or CBTF2F, and outcomes were compared at the end of treatment and at the 12-month follow-up. RESULTS: At the end of treatment, CBT4BN was inferior to CBTF2F in producing abstinence from binge eating and purging. However, by the 12-month follow-up, CBT4BN was mostly not inferior to CBTF2F. Participants in the CBT4BN condition, but not CBTF2F, continued to reduce their binge-eating and purging frequency from the end of treatment to the 12-month follow-up. CONCLUSIONS: CBT delivered online in a group chat format appears to be an efficacious treatment for BN, although the trajectory of recovery may be slower than face-to-face group therapy. Online chat groups may increase accessibility of treatment and represent a cost-effective approach to service delivery. However, barriers in service delivery such as state-specific license and ethical guidelines for online therapists need to be addressed.

Predictors of dropout in face-to-face and internet-based cognitive-behavioral therapy for bulimia nervosa in a randomized controlled trial.

OBJECTIVE: We sought to identify predictors and moderators of failure to engage (i.e., pretreatment attrition) and dropout in both Internet-based and traditional face-to-face cognitive-behavioral therapy (CBT) for bulimia nervosa. We also sought to determine if Internet-based treatment reduced failure to engage and dropout. METHOD: Participants (N = 191, 98% female) were randomized to Internet-based CBT (CBT4BN) or traditional face-to-face group CBT (CBTF2F). Sociodemographics, clinical history, eating disorder severity, comorbid psychopathology, health status and quality of life, personality and temperament, and treatment-related factors were investigated as predictors. RESULTS: Failure to engage was associated with lower perceived treatment credibility and expectancy (odds ratio [OR] = 0.91, 95% CI: 0.82, 0.97) and body mass index (BMI) (OR = 1.10; 95% CI: 1.03, 1.18). Dropout was predicted by not having a college degree (hazard ratio [HR] = 0.55; 95% CI: 0.37, 0.81), novelty seeking (HR = 1.02; 95% CI: 1.01, 1.03), previous CBT experience (HR = 1.77; 95% CI: 1.16, 2.71), and randomization to the individual's nonpreferred treatment format (HR = 1.95, 95% CI: 1.28, 2.96). DISCUSSION: Those most at risk of failure to engage had a higher BMI and perceived treatment as less credible and less likely to succeed. Dropout was associated with less education, higher novelty seeking, previous CBT experience, and a mismatch between preferred and assigned treatment. Contrary to expectations, Internet-based CBT did not reduce failure to engage or dropout. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:569-577).

Internet-Delivered Disease Management for Recurrent Depression: A Multicenter Randomized Controlled Trial.

BACKGROUND: Strategies to improve the life of patients suffering from recurrent major depression have a high relevance. This study examined the efficacy of 2 Internet-delivered augmentation strategies that aim to prolong symptom-free intervals. METHODS: Efficacy was tested in a 3-arm, multicenter, open-label, evaluator-blind, randomized controlled trial. Upon discharge from inpatient mental health care, 232 adults with 3 or more major depressive episodes were randomized to 1 of 2 intervention groups (SUMMIT or SUMMIT-PERSON) or to treatment as usual (TAU) alone. Over 12 months, participants in both intervention arms received, in addition to TAU, intense monitoring via e-mail or a smartphone, including signaling of upcoming crises, assistance with personal crisis management, and facilitation of early intervention. SUMMIT-PERSON additionally offered regular expert chats. The primary outcome was 'well weeks', i.e. weeks with at most mild symptoms assessed by the Longitudinal Interval Follow-Up Evaluation, during 24 months after the index treatment. RESULTS: SUMMIT compared to TAU reduced the time with an unwell status (OR 0.48; 95% CI 0.23-0.98) through faster transitions from unwell to well (OR 1.44; 95% CI 0.83-2.50) and slower transitions from well to unwell (OR 0.69; 95% CI 0.44-1.09). Contrary to the hypothesis, SUMMIT-PERSON was not superior to either SUMMIT (OR 0.77; 95% CI 0.38-1.56) or TAU (OR 0.62; 95% CI 0.31-1.24). The efficacy of SUMMIT was strongest 8 months after the intervention. CONCLUSIONS: The fully automated Internet-delivered augmentation strategy SUMMIT has the potential to improve TAU by reducing the lifelong burden of patients with recurrent depression. The fact that the effects wear off suggests a time-unlimited extension.

[Efficacy of an internet-delivered aftercare program for patients with chronic back pain]. / Wirksamkeit eines Internet-gestützten Nachsorgeangebots für Patienten mit chronischen Rückenschmerzen.

Chronic back pain leads to high societal costs and severely decreased quality of life for the sufferers. Pain treatment aims at sustainable behaviour changes in order to positively affect pain development in the medium term. A multicenter, randomised control trial was conducted. Participants (N=334) were recruited at 6 German hospitals and randomly assigned to an Internet-based aftercare intervention or treatment-as-usual. Primary endpoint was 12 months after treatment termination, primary outcome was pain intensity, and secondary outcomes were physical functioning, quality of life, and ability to work.The intervention was well accepted by the participants. Its efficacy could not be demonstrated. Neither pain intensity nor the secondary outcomes differed between the 2 study groups.Possible reasons for disappointing efficacy and preconditions for Internet-based programs will be discussed.

Cost-effectiveness of an internet-based aftercare intervention after inpatient treatment in a psychosomatic hospital.

OBJECTIVE: The implementation of new interventions into routine care requires the demonstration of both their effectiveness and cost-effectiveness. METHOD: We explored the cost-effectiveness of an Internet-based aftercare program in addition to treatment as usual (CHAT) which was compared to treatment as usual (TAU) following inpatient treatment. Incremental cost-effectiveness ratios were calculated based on cost of the intervention, cost of outpatient treatment, and remission rates within 1 year after discharge from hospital. RESULTS: Assuming a willingness-to-pay of an additional 14.87 € per treatment for every additional percent of remission, CHAT was cost-effective against TAU at a 95% level of certainty. Cost per remission equaled 2664.84 € in TAU and 1752.75 € in CHAT (34.2% savings). CONCLUSIONS: This is the first evidence that Internet-based aftercare may enhance long-term treatment outcome in a cost-effective way.

[Internet- and media-assisted therapy]. / Internet- und mediengestützte Therapie.

With the Internet-hype around the turn of the millenium some pioneers started initiatives of what is called E-Mental Health today. Evidence is growing since then, that E-Mental Health can contribute to a better mental health care. Some approaches have proved in studies as beneficial, that transfer into clinical routine can be tried out. Others showed promising results, and again others indicate clearly that not all hopes will become true. In this paper we will present our experience in exploring the potential of E-Mental Health in various projects over the last 10 years and what we believe to have learnt from projects in nextdoor garden. We hope that our conclusions will initiate a discussion about the future role of E-Mental Health for mental health care and research.

[Eating disorders on the internet: an experimental study on the effects of pro-eating disorders websites and self-help websites]. / Essstörungen im Internet: Eine experimentelle Studie zu den Auswirkungen von Pro-Essstörungs- und Selbsthilfewebsites.

Pro-eating disorders (ED) websites are assumed to have a negative impact on internet users because these sites promote ED as a lifestyle, and present an extreme thin ideal as well as extreme weight loss measures. We tested the impact of reading pro-ED contents in a sample of 421 women. The participants were randomly assigned to one of 3 conditions in which they were exposed to either a pro-ED blog, a self-help blog, or a neutral control blog. Post-exposure negative affect was higher in participants of the pro-ED and the self-help conditions compared to the neutral blog condition. Participants with an elevated risk for developing an ED had a lower appearance self esteem after exposure to the pro-ED, or the self-help blog. According to the study, a subgroup of high risk individuals might be affected by ED-related internet content. The implications of this study are discussed in the context of the ongoing controversy around pro-ED websites.

The effectiveness of internet chat groups in relapse prevention after inpatient psychotherapy.

The majority of patients benefit from psychotherapeutic treatment. However, many fail to maintain their treatment gains following discharge. In a controlled study, we investigated the effectiveness of internet chat groups in preventing relapse following inpatient treatment. One hundred and fifty-two patients were assessed with the Longitudinal Follow-up Evaluation (LIFE) 1 year after discharge from the hospital. Kaplan Meier survival analyses showed that significantly fewer chat participants (22.2%) than control participants (46.5%) experienced a relapse. Additional analyses yielded a significant difference in the relapse rates of chat and control participants depending on their utilization of outpatient treatment after discharge. The results confirm that technology-enhanced interventions are effective in maintaining treatment gains. Implications of the findings for health care provision are discussed.

[Transparency and outcome orientation as means to improve psychotherapeutic services: a study to evaluate outpatient psychotherapy (TRANS-OP)]. / Mit Transparenz und Ergebnisorientierung zur Optimierung der psychotherapeutischen Versorgung: Eine Studie zur Evaluation ambulanter Psychotherapie.

BACKGROUND: There is clear evidence for the efficacy of psychotherapy. However, there is a lack of large-scale naturalistic studies on the course of psychological problems and its predictors in people in psychotherapeutic routine care. MATERIAL AND METHODS: Between September 1998 and February 2000, 627 insurees of the "Deutsche Krankenversicherung", a major German health insurance company, who received outpatient psychotherapy (psychodynamic psychotherapy, analytic psychotherapy, or cognitive behavioral treatment), gave informed consent to participate in this study. During a two-year period, participants' health status was comprehensively assessed using standardised instruments. Hierarchical linear models were used to estimate courses of improvement in and transitions between the phases before, during, and after treatment. RESULTS: Psychological, interpersonal and physical problems improved substantially in all 3 forms of treatment. However, courses of improvement also varied among domains and form of treatment. The helping alliance was an ubiquitous, but not very strong predictor of treatment outcome. CONCLUSIONS: These results could be used as the basis for comprehensive quality management in psychotherapeutic care.

[Utilization of outpatient psychotherapy and its implications for service provision]. / Dauer und Umfang ambulanter Psychotherapie und Implikationen für die Versorgungspraxis.

Time structure of outpatient psychotherapy is important for clinical practice, as well as for theoretical and cost-effectiveness reasons. In this paper, important time variables (session number and frequency, therapy duration, utilization of the allocated session contingent, extension of therapy) are studied in a sample of n=714 German insurees in outpatient psychotherapy over a four-year period. Session number and duration of therapy were modelled with survival analysis, Cox regression was used to study the influence of covariates assessed at the beginning of therapy. Results are reported separately for the three therapy approaches financed by the German health insurance system: psychoanalytic psychotherapy (AP), psychodynamically-oriented therapy (TP) and cognitive-behavioral therapy (VT). Results show median session numbers of 25 (VT), 42 (TP) and 101 (AP) and a therapy duration of 12.8 (VT), 16.7 (TP) and 23.5 (AP) months. Initial therapeutic alliance was negatively associated with therapy duration and session number in AP. In TP and VT, a negative association between age and treatment duration was observed. 72.5% of the total session contingent was utilized and 38.4% of the participants applied for additional therapy sessions. An extension of psychotherapy happened more frequently 1) in psychoanalytic treatments and 2) in participants with higher initial psychological distress. Results show that the utilization of therapeutic resources differs from both theoretical concepts and fixed contingents allocated by health insurances. Potential implications for the allocation of psychotherapeutic resources are discussed.

Inpatient treatment to online aftercare: e-mailing themes as a function of therapeutic outcomes.

The authors applied the meaning extraction method (MEM) to 4,241 e-mails written by 297 participants of an email-based aftercare program following inpatient psychotherapy. Principal-components analysis of the most frequently used nouns in the e-mails yielded nine components: life decisions and coping, relationship conflict, psychological and physical symptoms, family of origin, social and leisure activities, present family and household, treatment, exercise and diet, and work. Relative to men, women focused more on symptoms, exercise and diet, and family of origin, but less on work. Older participants were more likely to e-mail about their present family. Younger participants were more likely to e-mail about their family of origin and exercise and diet. Patients who showed no therapeutic gains during their prior treatment wrote more about symptoms than patients who had improved. The potentials and limitations of the MEM for the analysis of therapy corpora are discussed.

New prospects for process research in group therapy: Text-based process variables in psychotherapeutic Internet chat groups.

This study focuses on the operationalization and validation of text-based process variables in psychotherapeutic Internet chat groups. The process variables activity, outdegree (OD; i.e., the frequency at which a group member addresses others in the group), and indegree (ID; i.e., the frequency at which a group member's name is mentioned by other group members or by the therapist [IDT]) were operationalized. Using 1,046 session transcripts from 130 participants of an Internet chat aftercare program, the authors studied the concurrent and predictive validity of activity, OD, ID, and IDT and of 52 text-based variables comprising linguistic, emotional, and cognitive aspects. Results showed consistent correlations between psychometric group ratings and the text-based variables ID, OD, and activity. The predictive validity of the variables IDT, ID, and activity was rather low but as good as the predictive validity of the psychometric ratings. The clinical implications of the results are discussed.

Group processes and process evaluations in a new treatment setting: inpatient group psychotherapy followed by internet-chat aftercare groups.

Little is known about processes characterizing therapeutic Internet-chat groups, which offer a novel way of providing group therapy over distances. In this study group processes and group evaluations were examined in a treatment setting where face-to-face inpatient groups are followed by chat aftercare groups. For a sample of 121 patients who participated in both treatment modalities, group processes and group evaluations were modeled using hierarchical linear modeling. The group evaluations followed a consistent upward course from the beginning of therapy until the end of chat aftercare. For the process measures Activity and Emotional Reactivity, the initial scores at the beginning of the chat groups were lower than at the end of the inpatient treatment, but higher than at admission. During chat aftercare, Activity and Emotional Reactivity scores increased less than during the inpatient phase, but on average Activity and Emotional Reactivity were higher during Internet-chat aftercare. The predictive value of the acquaintance of the therapist from inpatient treatment and the course of group evaluations during inpatient treatment on the course of group evaluations during chat aftercare were examined.

Course of improvement over 2 years in psychoanalytic and psychodynamic outpatient psychotherapy.

OBJECTIVE: To assess and predict the level and course of symptomatic improvement in psychoanalytic (PAP) and psychodynamic psychotherapy (PD). METHODS: In a comprehensive longitudinal study, the course of improvement of 116 patients in PAP and of 357 patients in PD was tracked over a period of 2 years and analysed via hierarchical linear models. RESULTS: At baseline, over 90% of the patients reported substantial psychological, physical or interpersonal distress. In both forms of treatment, the course of improvement could be adequately fitted by a linear model. Symptom distress decreased notably within 2 years, with an especially sharp decline before the first formally scheduled therapy session. No significant differences between forms of treatment as to level or pace of symptom improvement could be observed. Prediction of speed of improvement was poor, with initial symptom distress showing the strongest influence while initial helping alliance had no predictive value. When comparing patients who finished their treatment within the 2-year observation period with those with still ongoing treatments, the former showed quicker symptom improvement. DISCUSSION: Strategies for the optimal allocation of valuable therapeutic resources should be reconsidered. An adaptive, outcome-oriented allocation strategy of therapeutic resources is proposed.

The core symptoms of bulimia nervosa, anxiety, and depression: A network analysis.

Bulimia nervosa (BN) is characterized by symptoms of binge eating and compensatory behavior, and overevaluation of weight and shape, which often co-occur with symptoms of anxiety and depression. However, there is little research identifying which specific BN symptoms maintain BN psychopathology and how they are associated with symptoms of depression and anxiety. Network analyses represent an emerging method in psychopathology research to examine how symptoms interact and may become self-reinforcing. In the current study of adults with a Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV) diagnosis of BN (N = 196), we used network analysis to identify the central symptoms of BN, as well as symptoms that may bridge the association between BN symptoms and anxiety and depression symptoms. Results showed that fear of weight gain was central to BN psychopathology, whereas binge eating, purging, and restriction were less central in the symptom network. Symptoms related to sensitivity to physical sensations (e.g., changes in appetite, feeling dizzy, and wobbly) were identified as bridge symptoms between BN, and anxiety and depressive symptoms. We discuss our findings with respect to cognitive-behavioral treatment approaches for BN. These findings suggest that treatments for BN should focus on fear of weight gain, perhaps through exposure therapies. Further, interventions focusing on exposure to physical sensations may also address BN psychopathology, as well as co-occurring anxiety and depressive symptoms. (PsycINFO Database Record

Supportive monitoring and disease management through the internet: an internet-delivered intervention strategy for recurrent depression.

Major depression is a highly prevalent, disabling disorder associated with loss of quality of life and large economic burden for the society. Depressive disorders often follow a chronic or recurrent course. The risk of relapses increases with each additional episode. The internet-deliverable intervention strategy SUMMIT (SUpportive Monitoring and Disease Management over the InTernet) for patients with recurrent depression has been developed with the main objectives to prolong symptom-free phases and to shorten symptom-loaden phases. This paper describes the study design of a six-sites, three-arm, randomized clinical trial intended to evaluate the efficacy of this novel strategy compared to treatment as usual (TAU). Two hundred thirty six patients who had been treated for their (at least) third depressive episode in one of the six participating psychiatric centers were randomized into one of three groups: 1) TAU plus a twelve-month SUMMIT program participation with personal support or 2) TAU plus a twelve-month SUMMIT program participation without personal support, or 3) TAU alone. Primary outcome of this study is defined as the number of "well weeks" over 24months after index treatment assessed by blind evaluators based on the Longitudinal Interval Follow-Up Evaluation. If efficacious, the low monetary and nonmonetary expenditures of this automated, yet individualized intervention may open new avenues for providing an acceptable, convenient, and affordable long-term disease management strategy to people with a chronic mental condition such as recurrent depression.

Technology-enhanced maintenance of treatment gains in eating disorders: efficacy of an intervention delivered via text messaging.

OBJECTIVE: Given the lack of maintenance interventions for eating disorders, a program delivered via the short message service (SMS) and text messaging was developed to support patients after their discharge from inpatient treatment. METHOD: The efficacy of the intervention was studied in a randomized controlled trial. Additionally, its impact on the utilization of outpatient treatment during follow-up was investigated. One hundred sixty-five female patients with bulimia nervosa or a related eating disorder not otherwise specified were randomly assigned to a control group (treatment as usual; TAU) or an intervention group (SMS-based maintenance intervention; SMS). After hospital discharge, participants in the intervention group submitted a weekly symptom report via text message for 16 weeks and received tailored feedback. Primary outcome was the rate of partial remission 8 months after discharge from inpatient treatment. RESULTS: The difference in remission rates reached significance in the intent-to-treat analyses (SMS = 51.2%; TAU = 36.1%), χ²(1) = 3.81, p = .05, and approached significance in the completer analysis (SMS = 59.2%; TAU = 43.5%), χ²(1) = 3.44, p = .06. There were no differences in the utilization of outpatient treatment. Remission rates between the intervention and control groups were not significantly different among patients who used outpatient treatment (63.2% vs. 55.6%), χ²(1) = 0.44, p = .51. A significant difference was found in those who did not utilize such treatment (54.5% vs. 30.3%), χ²(1) = 3.97, p = .046. CONCLUSION: The aftercare intervention was efficacious in enhancing treatment outcome after discharge from inpatient treatment.

Short message service reduces dropout in childhood obesity treatment: a randomized controlled trial.

OBJECTIVE: Lifestyle programs can reduce the level of overweight in children; however, maintenance results and adherence to treatment are difficult to achieve. New technologies, such as the Short Message Service (SMS), might be a promising tool for enhancing interventions. The effect of an SMS approach aimed at improving treatment results and reducing dropout rates in a pediatric lifestyle intervention, is explored. METHOD: Overweight and obese children (N = 141; age 7-12 years) participating in a lifestyle program were randomly assigned to an intervention group receiving an SMS Maintenance Treatment (SMSMT) for 38 weeks (n = 73) or to a control group receiving no SMSMT (n = 68). Children were asked to send weekly self-monitoring data on exercise, eating behavior, and emotional well-being. In return, they received tailored feedback messages. A differential decrease in BMI was analyzed with repeated measures ANOVA and dropout with logistic regression analysis. RESULTS: We found no significant difference in BMI decrease between the two groups after 12 months; however, we showed that the SMSMT group had 3.25 times less probability of dropping out after 1 year (p = .01) than controls. In the first 3 months of SMSMT, the SMSMT completers sent 0.80 SMSs per week, which reduced to 0.50 SMSs in the final 3 months. Younger children sent more SMSs (p = .03). CONCLUSIONS: These results indicate that SMSMT is effective in reducing dropout rates from a pediatric lifestyle intervention. Future research should examine the effectiveness of SMSMT on weight management and related psychosocial variables.

CBT4BN versus CBTF2F: comparison of online versus face-to-face treatment for bulimia nervosa.

Cognitive-behavioral therapy (CBT) is currently the "gold standard" for treatment of bulimia nervosa (BN), and is effective for approximately 40-60% of individuals receiving treatment; however, the majority of individuals in need of care do not have access to CBT. New strategies for service delivery of CBT and for maximizing maintenance of treatment benefits are critical for improving our ability to treat BN. This clinical trial is comparing an Internet-based version of CBT (CBT4BN) in which group intervention is conducted via therapeutic chat group with traditional group CBT (CBTF2F) for BN conducted via face-to-face therapy group. The purpose of the trial is to determine whether manualized CBT delivered via the Internet is not inferior to the gold standard of manualized group CBT. In this two-site randomized controlled trial, powered for non-inferiority analyses, 180 individuals with BN are being randomized to either CBT4BN or CBTF2F. We hypothesize that CBT4BN will not be inferior to CBTF2F and that participants will value the convenience of an online intervention. If not inferior, CBT4BN may be a cost-effective approach to service delivery for individuals requiring treatment for BN.