Cost-effectiveness of Internet Interventions Compared With Treatment as Usual for People With Mental Disorders: Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: The economic costs of mental disorders for society are huge. Internet-based interventions are often coined as cost-effective alternatives to usual care, but the evidence is mixed. OBJECTIVE: The aim was to review the literature on the cost-effectiveness of internet interventions for mental disorders compared with usual care and to provide an estimate of the monetary benefits of such interventions compared with usual care. METHODS: A systematic review and meta-analysis of randomized controlled trials was conducted, which included participants with symptoms of mental disorders; investigated a telephone- or internet-based intervention; included a control condition in the form of treatment as usual, psychological placebo, waiting list control, or bibliotherapy; reported outcomes on both quality of life and costs; and included articles published in English. Electronic databases such as PubMed (including MEDLINE), Embase, Emcare, PsycINFO, Web of Science, and the Cochrane Library were used. Data on risk of bias, quality of the economic evaluation, quality-adjusted life years, and costs were extracted from the included studies, and the incremental net benefit was calculated and pooled. RESULTS: The search yielded 6226 abstracts, and 37 studies with 14,946 participants were included. The quality of economic evaluations of the included studies was rated as moderate, and the risk of bias was high. A random-effects approach was maintained. Analyses suggested internet interventions were slightly more effective than usual care in terms of quality-adjusted life years gain (Hedges g=0.052, 95% CI 0.010-0.094; P=.02) and equally expensive (Hedges g=0.002, 95% CI -0.080 to 0.84; P=.96). The pooled incremental net benefit was US $255 (95% CI US $91 to US $419; P=.002), favoring internet interventions over usual care. The perspective of the economic evaluation and targeted mental disorder moderated the results. CONCLUSIONS: The findings indicate that the cost-effectiveness of internet interventions for mental disorders compared with a care-as-usual approach is likely, but generalizability to new studies is poor given the substantial heterogeneity. This is the first study in the field of mental health to pool cost-effectiveness outcomes in an aggregate data meta-analysis. TRIAL REGISTRATION: PROSPERO CRD42019141659; https://tinyurl.com/3cu99b34.

Social Media, Body Image and Resistance Training: Creating the Perfect 'Me' with Dietary Supplements, Anabolic Steroids and SARM's.

BACKGROUND: Few studies have assessed the use of dietary supplements, anabolic androgenic steroids (AAS) and selective androgen receptor modulators (SARM) in male gym users. The comparison of physical appearance with others on social media and the exposure to fitness-related content on social media (i.e., image-centric social media use) may have a profound role in using these compounds due to its role in creating negative body images in male gym users. OBJECTIVE: Provide contemporary data on the use of dietary supplements, AAS and SARM among young male gym users, and test the hypothesis that social media is associated with the use of dietary supplements, AAS and SARM, as a result of a negative body image. METHODS: In this cross-sectional study, conducted in the Netherlands, male gym users (N = 2269; 24 ± 6 years) completed an online questionnaire including self-reported measures regarding resistance training participation, image-centric social media use, dietary supplement intake, and body image. The prevalence of AAS and SARM use was assessed with randomized response, a technique to ask sensitive questions indirectly. RESULTS: Of all participants, 83% used ergogenic dietary supplements (mainly protein and creatine), and an estimated 9 versus 2.7% had ever used AAS versus SARM. Image-centric social media use was positively associated with the use of dietary supplements (r = .26; p < 0.01) and AAS (p < 0.05), but not SARM. Image-centric social media use was associated with a more dissatisfied body image (r = .34; p < 0.01). Body image did not mediate the relationship between image-centric social media use and the use of doping compounds. CONCLUSIONS: The use of dietary supplements in young male gym users is exorbitant, with the use of AAS and SARM being substantial. Image-centric social media use is positively associated with the use of dietary supplements and AAS.

Justified indulgence: self-licensing effects on caloric consumption.

OBJECTIVE: Research on self-licensing, i.e. employing justifications to give into temptation, largely consists of studies examining dichotomous food choices (healthy vs. unhealthy), while evidence for its effects on how much (unhealthy) food is consumed remains scarce. The present studies aimed to demonstrate self-licensing effects on caloric consumption in both lab (Study 1 & 2) and field setting (Study 3). DESIGN: In all studies, female student samples were recruited. They either received a justification cue (license condition) or not (control condition), after which they could eat freely from unhealthy snacks (Study 1, N = 85 and Study 2, N = 95) or choose a snack for direct consumption at a take-out lunch place (Study 3, N = 110). MAIN OUTCOME MEASURES: Caloric value of consumed snacks (Study 1 and 2) and chosen snack (Study 3). RESULTS: In all studies, caloric consumption was higher in the license condition compared to the control condition: Participants ate more of the provided unhealthy snacks (Study 1 and 2) and chose a snack of higher caloric value (Study 3). CONCLUSIONS: The present research corroborates self-licensing as an important factor in the consumption of unhealthy foods by employing more ecologically valid outcomes.

Introducing functional and dysfunctional self-licensing: Associations with indices of (un)successful dietary regulation.

OBJECTIVE: Giving in to food temptations is typically labeled as self-regulation failure. However, when indulgence stems from self-licensing processes, that is, relying on reasons to justify diet deviations, these instances might actually promote successful goal striving. This research aimed to theoretically define and test under what conditions self-licensing would be considered functional (e.g., when it ultimately serves the long-term goal of weight control) and dysfunctional (e.g., when it threatens successful goal striving). METHOD: First, a pool of items reflecting functional and dysfunctional ways of self-licensing was tested and representative items were selected (Study 1; N = 194). Next, their classification was corroborated by examining the associations with indices of (un)successful dietary regulation (Study 2; N = 147). Finally, it was tested whether (dys)functional self-licensing predicted unhealthy snack intake, by means of participants keeping an unhealthy snack diary (Study 3; N = 54). RESULTS: The theorized distinction was confirmed, and the obtained correlational patterns supported the proposed (dys)functionality of the two types of self-licensing. Importantly, results showed that dysfunctional self-licensing predicted higher snack intake, whereas functional self-licensing predicted lower snack intake. CONCLUSION: The present studies provide evidence for the existence of two types of self-licensing, and thereby contribute to theoretical development.

How highlighted utensils influence consumption in a dark setting.

OBJECTIVE: Previous research has shown that people consume less food in the dark compared to normal vision conditions. While this effect is commonly attributed to increased attention to internal cues, it could also be caused by increased difficulty to maneuver in a dark setting. This study investigated this potential alternative explanation. DESIGN: A 2 (dark versus normal vision setting) × 2 (highlighted versus non-highlighted utensils) between-subjects design was employed. MAIN OUTCOME MEASURES: Perceived difficulty of maneuvering and consumption of yoghurt were assessed as main outcome measures. RESULTS: Participants consumed marginally less in dark compared to normal vision conditions, and experienced higher difficulty of maneuvering. Importantly, both effects were qualified by a significant interaction with highlighting, which increased consumption and reduced perceived difficulty compared to no highlights. Difficulty of maneuvering did not mediate the interactive effect of vision and highlighting on consumption. CONCLUSION: Difficulty to maneuver should be considered when investigating eating behaviour under dark conditions. In line with an embodied cognition account, results also reveal the necessity of visual information for interaction with objects in the environment and imply that detail-deprived object information may be sufficient for activation of the motor system.

Feeling bad or feeling good, does emotion affect your consumption of food? A meta-analysis of the experimental evidence.

Whether emotions affect eating, and in whom, has remained unclear. This meta-analysis assessed the effect of emotions on eating in both healthy and eating disordered individuals. Fifty-six experimental studies investigating the causal effect of emotions on eating behavior were selected including 3670 participants. Separate meta-analyses (random models) were performed for negative and positive emotions. Among healthy people the moderating impact of individual differences in restrained and emotional eating and of being overweight or obese was assessed for negative emotions. RESULTS: Restrained eaters showed increased eating in response to negative emotions. Negative emotions did not affect eating in overweight or obese people, people with eating disorders or in self-assessed emotional eaters. Positive emotion resulted in increased eating across groups. Heterogeneity was high and could be explained by differences in emotion induction procedures, eating measures, and age of participants. These findings indicate that particularly restrained eaters are vulnerable to emotion-induced eating. Additional qualitatively good experiments are called for in combination with studies assessing emotion-eating links in people's naturalistic environment.

Does Self-Licensing Benefit Self-Regulation Over Time? An Ecological Momentary Assessment Study of Food Temptations.

Self-licensing, employing reasons to justify indulgence, may help resolve the conflict between immediate temptations and long-term goals in favor of the former. It was hypothesized that this conflict-resolving potential of self-licensing may benefit self-regulation over time. With a momentary assessment design, we examined how self-licensing affects self-regulatory ability and the capacity to deal with subsequent self-regulatory conflicts. One hundred thirty-six female participants filled out surveys eight times per day for one week. Food temptation strength, conflict, resistance, and enactment were assessed, as well as license opportunity and perceived self-regulatory ability. When self-licensing opportunity was high (vs. low), a weaker association between temptation strength and conflict was observed. High license opportunity was associated with higher perceived self-regulatory ability for instances of low degrees of temptation enactment and predicted better handling of subsequent conflict after high degrees of prior temptation enactment. These results suggest that self-licensing can support self-regulation after initial failure.

Healthy diet: Health impact, prevalence, correlates, and interventions.

OBJECTIVE: To discuss healthy diet from a psychological perspective by considering definitions of healthy diet in terms of consumer understanding; the health effects of specific dietary elements in terms of overweight and (chronic) illness; the prevalence of healthy diet; the psychological and environmental determinants of healthy diet; and the psychological interventions that have been designed to promote healthy diet. DESIGN: A systematic review of the psychological literature on healthy diet. RESULTS: Our findings suggest that consumers have a relatively poor understanding of a healthy diet. The literature also demonstrates that there is poor evidence on the health protective effects of single foods or nutrients. We further show that low SES is the single consistent risk factor for not adhering to a healthy diet. Our review of the literature on determinants demonstrates that intentions, habits, self-regulatory skills, and the social and physical environment are the most important determinants of a healthy diet, which are in turn amenable to change by intervention strategies with varying levels of effectiveness. Educational interventions generally show a limited effect on practising a healthy diet whereas interventions targeting habitual behaviour and/or the physical environment seem more promising. CONCLUSIONS: In view of the large number of people who are concerned about their diets and make attempts to change their dietary patterns, we conclude that it is crucial to gain a better understanding of both the automatic and environmental influences that are responsible for people not acting upon their good intentions for diet change.

Influence of negative affect on decision making in women with restrictive and binge-purge type anorexia nervosa.

The present study aims to examine the influence of negative affect on decision making in women with anorexia nervosa (AN) compared to healthy control women and, secondly, to assess differences between the restrictive (ANR) and binge-purge (ANBP) subtypes. One hundred four women (32 with ANR, 32 with ANBP, and 40 healthy controls) participated. All women were asked to watch either a negative or a control film fragment, both followed by the Bechara Gambling Task (BGT). Before and after the fragments negative affect was measured. Additionally, relevant characteristics (e.g., overall depressive symptoms) were assessed. Differences in negative affect did not influence decision making performance. Independent of affective state, decision making was found to be impaired in women with ANBP (no learning effect on the BGT), but not in women with ANR. These findings highlight the importance of considering different AN subtypes when examining decision making processes. However, the role of negative affect on decision making remains uncertain. Since other affect related factors such as affect dysregulation may also play a role, future studies on decision making in AN should take the role of affect into account.

'I ate too much so I must have been sad': Emotions as a confabulated reason for overeating.

BACKGROUND: Emotional eating (i.e., overeating in response to negative affect) is a commonly accepted explanation for eating behaviors that are not in line with personal eating-norms. However, the empirical evidence for a causal link between self-reported emotional eating and overeating is mixed. The present study tested an alternative hypothesis stating that high emotional eating scores are indicative of a susceptibility to use negative affect as a confabulated, post-hoc reason to explain overeating. METHODS: Female students (N = 46) participated in a 'taste-test' and came back to the lab a day later to receive feedback that they either ate too much (norm-violation condition) or an acceptable amount of food (control condition), whereafter emotional eating was assessed. Negative affect was measured several times throughout the study. RESULTS: In the norm-violation condition, participants with high emotional eating scores retrospectively rated their affect prior to eating as more negative than participants with low emotional eating scores. In the control condition, no effect of emotional score on affect ratings was found. DISCUSSION: For some individuals emotional eating scores may represent a tendency to retrospectively attribute overeating to negative affect. This could explain the lack of consistent findings for a link between self-reported emotional eating and overeating.

Oops I Did it Again: Examining Self-Licensing Effects in a Subsequent Self-Regulation Dilemma.

BACKGROUND: Previous studies have mainly examined the immediate effects of self-licensing on self-regulation failure. The present vignette studies examined what happens when a second self-regulation dilemma is encountered. METHODS: In Studies 1 (N = 52) and 2 (N = 166), participants read a vignette in which the protagonist chooses to buy a treat while being on a diet, which was preceded by a license (License condition) or not (Control condition). The self-reported likelihood of indulging again when a second dilemma was presented in the same situation served as the dependent variable. Study 2 included measures of self-regulatory ability (motivation and self-efficacy) and also presented the dilemma in a new situation. RESULTS: Study 1 showed that participants were more likely to indulge again after an initial indulgent choice with a license. This was replicated in Study 2, which also showed that self-licensing had no effect on goal re-engagement in a new situation. A marginally significant positive effect of self-licensing was found for self-efficacy. CONCLUSIONS: The results obtained suggest that self-licensing negatively affects goal re-engagement in the same situation, but not in a new situation. Whether self-licensing maintains or increases feelings of self-efficacy needs to be validated in future studies.

Defying Food - How Distance Determines Monkeys' Ability to Inhibit Reaching for Food.

Objects, such as food, in the environment automatically activate and facilitate affordances, the possibilities for motoric movements in interaction with the objects. Previous research has shown that affordance activation is contingent upon the distance of the object with only proximal objects activating potential movements. However, the effect of affordance-activating proximal objects on the ability to inhibit movements has been unaddressed. The current study addressed this question with two experiments on long-tailed macaques. In both experiments monkeys were situated behind a Plexiglass screen that prevented direct access to food placed right behind the screen. The food could only be reached via a detour through one of two holes on the sides of the screen. It was assessed whether monkeys' ability to inhibit the unsuccessful immediate reaching movement forward toward the food depended on the distance at which the food was presented. Results of both Experiments revealed that monkeys reached for the proximally positioned food significantly more than for the distally positioned food, despite this Plexiglass screen preventing successful obtainment of the food. The findings reveal the effect of proximal, affordance-activating objects on the ability to resist movements involved in interacting with the objects. Implications for humans, living in environments in which proximal, or accessible food is constantly available are discussed. The findings can contribute to an understanding of why resisting accessible food in the environment is often unsuccessful.

Bedtime procrastination: A self-regulation perspective on sleep insufficiency in the general population.

Getting insufficient sleep has serious consequences in terms of mental and physical health. The current study is the first to approach insufficient sleep from a self-regulation perspective by investigating the phenomenon of bedtime procrastination: going to bed later than intended, without having external reasons for doing so. Data from a representative sample of Dutch adults (N = 2431) revealed that a large proportion of the general population experiences getting insufficient sleep and regularly goes to bed later than they would like to. Most importantly, a relationship between self-regulation and experienced insufficient sleep was found, which was mediated by bedtime procrastination.

Investigating sex differences in psychological predictors of snack intake among a large representative sample.

OBJECTIVE: It is often assumed that there are substantial sex differences in eating behaviour (e.g. women are more likely to be dieters or emotional eaters than men). The present study investigates this assumption in a large representative community sample while incorporating a comprehensive set of psychological eating-related variables. DESIGN: A community sample was employed to: (i) determine sex differences in (un)healthy snack consumption and psychological eating-related variables (e.g. emotional eating, intention to eat healthily); (ii) examine whether sex predicts energy intake from (un)healthy snacks over and above psychological variables; and (iii) investigate the relationship between psychological variables and snack intake for men and women separately. Snack consumption was assessed with a 7d snack diary; the psychological eating-related variables with questionnaires. SETTING: Participants were members of an Internet survey panel that is based on a true probability sample of households in the Netherlands. SUBJECTS: Men and women (n 1292; 45 % male), with a mean age of 51·23 (sd 16·78) years and a mean BMI of 25·62 (sd 4·75) kg/m2. RESULTS: Results revealed that women consumed more healthy and less unhealthy snacks than men and they scored higher than men on emotional and restrained eating. Women also more often reported appearance and health-related concerns about their eating behaviour, but men and women did not differ with regard to external eating or their intentions to eat more healthily. The relationships between psychological eating-related variables and snack intake were similar for men and women, indicating that snack intake is predicted by the same variables for men and women. CONCLUSIONS: It is concluded that some small sex differences in psychological eating-related variables exist, but based on the present data there is no need for interventions aimed at promoting healthy eating to target different predictors according to sex.

UnAdulterated - children and adults' visual attention to healthy and unhealthy food.

OBJECTIVE: Visually attending to unhealthy food creates a desire to consume the food. To resist the temptation people have to employ self-regulation strategies, such as visual avoidance. Past research has shown that self-regulatory skills develop throughout childhood and adolescence, suggesting adults' superior self-regulation skills compared to children. METHODS: This study employed a novel method to investigate self-regulatory skills. Children and adults' initial (bottom-up) and maintained (top-down) visual attention to simultaneously presented healthy and unhealthy food were examined in an eye-tracking paradigm. RESULTS: Results showed that both children and adults initially attended most to the unhealthy food. Subsequently, adults self-regulated their visual attention away from the unhealthy food. Despite the children's high self-reported attempts to eat healthily and importance of eating healthily, children did not self-regulate visual attention away from unhealthy food. Children remained influenced by the attention-driven desire to consume the unhealthy food whereas adults visually attended more strongly to the healthy food thereby avoiding the desire to consume the unhealthy option. CONCLUSIONS: The findings emphasize the necessity of improving children's self-regulatory skills to support their desire to remain healthy and to protect children from the influences of the obesogenic environment.

Thinking before sinning: reasoning processes in hedonic consumption.

Whereas hedonic consumption is often labeled as impulsive, findings from self-licensing research suggest that people sometimes rely on reasons to justify hedonic consumption. Although the concept of self-licensing assumes the involvement of reasoning processes, this has not been demonstrated explicitly. Two studies investigated whether people indeed rely on reasons to allow themselves a guilty pleasure. Participants were exposed to a food temptation after which passive and active reasoning was assessed by asking participants to indicate the justifications that applied to them for indulging in that temptation (Study 1) or having them construe reasons to consume the hedonic product (Study 2). Regression analyses indicated that higher levels of temptation predicted the number of reasons employed and construed to justify consumption. By providing evidence for the involvement of reasoning processes, these findings support the assumption of self-licensing theory that temptations not only exert their influence by making us more impulsive, but can also facilitate gratification by triggering deliberative reasoning processes.

Always gamble on an empty stomach: hunger is associated with advantageous decision making.

Three experimental studies examined the counterintuitive hypothesis that hunger improves strategic decision making, arguing that people in a hot state are better able to make favorable decisions involving uncertain outcomes. Studies 1 and 2 demonstrated that participants with more hunger or greater appetite made more advantageous choices in the Iowa Gambling Task compared to sated participants or participants with a smaller appetite. Study 3 revealed that hungry participants were better able to appreciate future big rewards in a delay discounting task; and that, in spite of their perception of increased rewarding value of both food and monetary objects, hungry participants were not more inclined to take risks to get the object of their desire. Together, these studies for the first time provide evidence that hot states improve decision making under uncertain conditions, challenging the conventional conception of the detrimental role of impulsivity in decision making.

Bedtime procrastination: introducing a new area of procrastination.

BACKGROUND: Procrastination is a prevalent and problematic phenomenon that has mostly been studied in the domain of academic behavior. The current study shows that procrastination may also lead to harmful outcomes in the area of health behavior, introducing bedtime procrastination as an important factor related to getting insufficient sleep and consequently affecting individual well-being. Bedtime procrastination is defined as failing to go to bed at the intended time, while no external circumstances prevent a person from doing so. METHODS: To empirically support the conceptual introduction of bedtime procrastination, an online survey study was conducted among a community sample (N = 177). The relationship between bedtime procrastination and individual difference variables related to self-regulation and general procrastination was assessed. Moreover, it was investigated whether bedtime procrastination was a predictor of self-reported sleep outcomes (experienced insufficient sleep, hours of sleep, fatigue during the day). RESULTS: Bedtime procrastination was negatively associated with self-regulation: people who scored lower on self-regulation variables reported more bedtime procrastination. Moreover, self-reported bedtime procrastination was related to general reports of insufficient sleep above and beyond demographics and self-regulation. CONCLUSIONS: Introducing a novel domain in which procrastinators experience problems, bedtime procrastination appears to be a prevalent and relevant issue that is associated with getting insufficient sleep.