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.

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.

Facebook usage among those who have received treatment for an eating disorder in a group setting.

OBJECTIVE: This study explored Facebook use among individuals with a history of receiving treatment for an eating disorder (ED) in a group setting (e.g., inpatient, residential, outpatient group), focusing primarily on comparisons individuals make about their bodies, eating, or exercise to those of their peers from treatment on Facebook and the relation between these comparisons and ED pathology. METHOD: Individuals (N = 415; mean age 28.15 years ± 8.41; 98.1% female) who self-reported receipt of ED treatment in a group setting were recruited via e-mail and social media to complete an online survey. RESULTS: Participants reported having an average of 10-19 Facebook friends from treatment and spending up to 30 min per day interacting on Facebook with individuals from treatment or ED-related organizations. More comparison to treatment peers on Facebook was associated with greater ED psychopathology and ED-related impairment. Conversely, positive interaction with treatment peers on Facebook was associated with lower ED psychopathology and ED-related impairment. Individuals who had been in treatment longer, more times, and more recently had more Facebook friends from treatment and ED-related organizations as well as spent more time in ED groups' pages on Facebook. Few participants (19.5%) reported that a therapist asked about the impact of Facebook on pathology. DISCUSSION: Interactions on Facebook could affect patients' recovery and potential for relapse. It may be helpful for treatment providers to discuss Facebook use and its potential benefits and drawbacks with patients preparing for discharge from group treatment. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:764-777).

Higher vagal activity as related to survival in patients with advanced breast cancer: an analysis of autonomic dysregulation.

OBJECTIVE: High levels of high-frequency heart rate variability (HF-HRV), related to parasympathetic-nervous-system functioning, have been associated with longer survival in patients with myocardial infarction and acute trauma and in patients undergoing palliative care. From animal studies linking higher vagal activity with better immune system functioning and reduced metastases, we hypothesized that higher HF-HRV would predict longer survival in patients with metastatic or recurrent breast cancer (MRBC). METHODS: Eighty-seven patients with MRBC participated in a laboratory task including a 5-minute resting baseline electrocardiogram. HF-HRV was computed as the natural logarithm of the summed power spectral density of R-R intervals (0.15-0.50 Hz). In this secondary analysis of a study testing whether diurnal cortisol slope predicted survival, we tested the association between resting baseline HF-HRV on survival using Cox proportional hazards models. RESULTS: A total of 50 patients died during a median follow-up of 7.99 years. Higher baseline HF-HRV predicted significantly longer survival, with a hazard ratio of 0.75 (95% confidence interval = 0.60-0.92, p = .006). Visceral metastasis status and baseline heart rate were related to both HF-HRV and survival. However, a combination of HF-HRV and heart rate further improved survival prediction, with a hazard ratio of 0.64 (95% confidence interval = 0.48-0.85, p = .002). CONCLUSIONS: Vagal activity of patients with MRBC strongly predicted their survival, extending the known predictive window of HF-HRV in cancer beyond palliative care. Vagal activity can be altered by behavioral, pharmacological, and surgical interventions and may be a promising target for extending life expectancy in patients with metastasizing cancer.

Racial and Ethnic Disparities in Barriers to Mental Health Treatment Among U.S. College Students.

OBJECTIVE: Using a sample of U.S. college students, the authors evaluated whether barriers to mental health treatment varied by race and ethnicity. METHODS: Data were drawn from a large multicampus study conducted across 26 U.S. colleges and universities. The sample (N=5,841) included students who screened positive for at least one mental disorder and who were not currently receiving psychotherapy. RESULTS: The most prevalent barriers to treatment across the sample were a preference to deal with issues on one's own, lack of time, and financial difficulties. Black and Hispanic/Latine students reported a greater willingness to seek treatment than did White students. However, Black and Hispanic/Latine students faced more financial barriers to treatment, and Hispanic/Latine students also reported lower perceived importance of mental health. Asian American students also reported financial barriers and preferred to handle their issues on their own or with support from family or friends and had lower readiness, willingness, and intentionality to seek help than did White students. CONCLUSIONS: Disparities in unmet treatment needs may arise from both distinct and common barriers and point to the potential benefits of tailored interventions to address the specific needs of students of color from various racial and ethnic backgrounds. The findings further underscore the pressing need for low-cost and brief treatment models that can be used or accessed independently to address the most prevalent barriers for students.

Preventing symptom progression in women at risk for AN: results of a pilot study.

OBJECTIVE: Despite the need, no targeted (indicated) prevention programs for women at risk for anorexia nervosa (AN) or with restrictive eating and normal body weight are available. Therefore, our aim was to develop a prevention program specific for these risk groups and to assess its feasibility and effectiveness in a pilot study. METHODS: Thirty-six women selected by high weight and shape concerns, low BMI and/or high restrained eating participated in a 10-week Internet-based cognitive-behavioural prevention program for AN. RESULTS: Feasibility, adherence and acceptance were assessed at post-intervention; symptoms of disordered eating and associated psychopathology were assessed at pre-intervention, post-intervention, and at 6-month follow-up. The 32 women who finished the study completed 88% of the sessions. Satisfaction with the program was also high. AN-specific eating and associated psychopathology improved significantly and differentially in the three weight-related subgroups. CONCLUSIONS: Overall, the results of this pilot study are promising. The efficacy of this indicated preventive intervention should be tested in a larger randomized controlled trial.

Training, supervision, and experience of coaches offering digital guided self-help for mental health concerns.

Accessible, low-cost intervention options are necessary to address the rise in mental health problems among college students. Digital guided self-help, or coached, programs have been developed to provide such services, with many commercially available. As such, there are a large and growing number of individuals coaching these programs. However, an unmet need is to evaluate and assess best practices for training and supervising individuals in these positions. To this end, we describe how we recruited, trained, and supervised coaches as part of a large randomized controlled trial using a widely available digital commercial platform. Coaches were trained to provide digital guided self-help for depression, anxiety, and/or eating disorders for college students. Coaches initially attended three live training sessions over 2-3 weeks, viewed multiple training videos, and read a detailed coaching manual developed by our team. Thereafter, they attended weekly supervision. Following their term, coaches completed an exit survey to assess their supervision and training experiences. A total of 37 of 70 (53%) graduate-level student coaches completed the survey. The experience was reported as very positive (95%). In particular, the majority reported feeling well prepared, more confident, and felt they had developed useful skills for their own practice.

Effects of an Internet-based prevention programme for eating disorders in the USA and Germany--a meta-analytic review.

A cross-cultural comparison of a cognitive-behavioural, Internet-based, 8-week prevention programme for eating disorders (StudentBodies™) evaluated in the USA and in Germany was performed. Six US and four German randomized controlled trials with a total (N) of 990 female high school and college students were included in the review. Two of the US and two of the German trials explicitly addressed high risk samples in a selective prevention approach. Effect sizes for main outcomes (disordered eating, weight and shape concerns) were calculated at postintervention and at follow-up. The intervention was associated with moderate improvements in eating disorder-related attitudes, especially reductions of negative body image and the desire to be thin. The reported effects remained significant at follow-up. No clear differences between US and German samples could be found on any of the outcome measures at postintervention. In conclusion, StudentBodies™ seems equally suitable and effective for American and German students.

Pilot randomized trial of self-guided virtual reality exposure therapy for social anxiety disorder.

BACKGROUND: Virtual reality exposure therapy (VRE) has shown promising efficacy for the treatment of social anxiety disorder (SAD) and related comorbidities. However, most trials conducted to date were therapist-led, and little is known about the efficacy of self-guided VRE. Therefore, this randomized controlled trial (RCT) aimed to determine the efficacy of a self-directed VRE for SAD. METHOD: Forty-four community-dwelling or undergraduate adults diagnosed with SAD based on the Mini International Neuropsychiatric Interview were randomly assigned to VRE designed to last four sessions or more (n = 26) or waitlist (WL; n = 18). Self-reported SAD severity (Social Phobia Diagnostic Questionnaire and Social Interaction Anxiety Scale), job interview anxiety (Measure of Anxiety in Selection Interviews), trait worry (Penn State Worry Questionnaire), and depression symptoms (Patient Health Questionnaire-9) were administered at baseline, post-treatment, 3-month-follow-up (3MFU), and 6-month-follow-up (6MFU). Piecewise multilevel modeling analyses were conducted to manage clustering in the data. RESULTS: VRE vs. WL resulted in greater reductions in SAD symptom severity, job interview fear, and trait worry, with moderate-to-large effect sizes (Hedge's g = -0.54 to -1.11) from pre-to-post treatment. Although significant between-group differences did not emerge for change in depression, VRE led to change in depression, whereas waitlist did not. These gains were also maintained at 3MFU and 6MFU. Further, facets of presence increased during the course of VRE (g = 0.36-0.45), whereas cybersickness decreased (g = -0.43). DISCUSSION: Brief, self-guided VRE might ameliorate SAD and comorbid worry, for young-to-middle-aged adults with SAD. Other theoretical and practical implications were also discussed.

Effects of an Internet-based intervention for subthreshold eating disorders: a randomized controlled trial.

BACKGROUND: Women reporting initial eating disorder (ED) symptoms are at highest risk for the development of an eating disorder. Preventive interventions should, therefore, be specifically tailored for this subgroup. AIMS: To adapt and evaluate the effects of the Internet-based prevention program "Student Bodies™" for women with symptoms of disordered eating and/or subthreshold eating disorder (ED) syndromes. METHOD: 126 women, reporting subthreshold ED symptoms (high weight and shape concerns and below threshold bingeing, purging, chronic dieting or several of these symptoms) were randomly assigned to a Student Bodies™+ (SB+) intervention or a wait-list control group and assessed at pre-intervention, post-intervention, and 6-month follow-up. "Student Bodies™" was adapted to be suitable for subthreshold EDs. Main outcome measures were attitudes and symptoms of disordered eating. Pre-follow-up data were analyzed by ANCOVAS with mixed effects. RESULTS: At 6-month follow-up, compared to participants in the control group, participants in the intervention group showed significantly greater improvements on ED-related attitudes. Intervention participants also showed 67% (95% CI = 20-87%) greater reductions in combined rates of subjective and objective binges, and 86% (95% CI = 63-95%) greater reduction in purging episodes. Also, the rates of participants abstinent from all symptoms of disordered eating (restrictive eating, binge eating and any compensatory behavior) were significantly higher in the intervention group (45.1% vs. 26.9%). Post-hoc subgroup analyses revealed that for participants with binge eating the effect on EDE-Q scores was larger than in the pure restricting subgroup. CONCLUSION: The adapted "SB+" program represents an effective intervention for women with subthreshold EDs of the binge eating subtype.

An e-mail delivered CBT for sleep-health program for college students: effects on sleep quality and depression symptoms.

STUDY OBJECTIVES: We examined the effects of a cognitive behavioral self-help program (Refresh) to improve sleep, on sleep quality and symptoms of depression among first-year college students. METHODS: Students in one residence hall (n = 48) participated in Refresh and students in another residence hall (n = 53) participated in a program of equal length (Breathe) designed to improve mood and increase resilience to stress. Both programs were delivered by e-mail in 8 weekly PDF files. Of these, 19 Refresh program participants and 15 Breathe program participants reported poor sleep quality at baseline (scores ≥ 5 on the Pittsburgh Sleep Quality Index [PSQI]). Participants completed the PSQI and the Center for Epidemiological Studies-Depression Scale (CES-D) at baseline and post-intervention. RESULTS: Among students with poor sleep (PSQI > 5) at baseline, participation in Refresh was associated with greater improvements in sleep quality and greater reduction in depressive symptoms than participation in Breathe. Among students with high sleep quality at baseline there was no difference in baseline to post-intervention changes in sleep (PSQI) or depressive symptom severity (CES-D). CONCLUSIONS: A cognitive behavioral sleep improvement program delivered by e-mail may be a cost effective way for students with poor sleep quality to improve their sleep and reduce depressive symptoms. An important remaining question is whether improving sleep will also reduce risk for future depression.

Maintenance of internet-based prevention: a randomized controlled trial.

OBJECTIVE: Excessive weight or shape concerns and dieting are among the most important and well-established risk factors for the development of symptoms of disordered eating or full-syndrome eating disorders. Prevention programs should therefore target these factors in order to reduce the likelihood of developing an eating disorder. The aims of this study were to determine the short-term and maintenance effects of an internet-based prevention program for eating disorders. METHOD: One hundred female students at two German universities were randomly assigned to either an 8-week intervention or a waiting-list control condition and assessed at preintervention, postintervention, and 3-month follow-up. RESULTS: Compared with the control group, the intervention produced significant and sustained effects for high-risk women. CONCLUSION: Internet-based prevention is effective and can be successfully adapted to a different culture.