Social support for young people with eating disorders-An integrative review.

Eating disorder treatment should be underpinned by a recovery-oriented approach, be therapeutic, personalised and trauma informed. Within such models of care, social support is an important factor to explore in terms of its influence in supporting hope for recovery, reducing stigma, and mitigating life stressors. Limited research has been conducted to understand the types of social support that are available to young people formally diagnosed with an eating disorder, their feasibility and acceptability and the positive outcomes. This integrative review sought to explore the positive outcomes of social support or social support programs for young people with eating disorders. An integrative review was conducted based on a search of five electronic databases from inception to 31 March 2023. Methodological quality was assessed using the Joanna Briggs Institute Critical Appraisal Tools and findings have been narratively synthesised and presented in accordance with the review's aims and questions. Seven studies (total 429 individuals, range 3-160) published between 2001 and 2023 were included in the final synthesis. Overall social support interventions showed promising preliminary evidence as a feasible and acceptable adjunct to treatment for young people with an eating disorder motivated to change, with some clinical improvements in psychopathology. Social support augmented existing relationships, providing a human element of open dialogue, friendship and a sense of hope for recovery. Despite the small number and heterogeneity of the studies, this review has highlighted some promising preliminary benefits. Future treatment for eating disorders should embrace adjunct modalities that enhance psychosocial recovery for young people with eating disorders.

Functional Connectivity Mechanisms Underlying Symptom Reduction Following Lisdexamfetamine Treatment in Binge-Eating Disorder: A Clinical Trial.

Background: Speculation exists as to whether lisdexamfetamine dimesylate (LDX) acts on the functional connectivity (FC) of brain networks that modulate appetite, reward, or inhibitory control in binge-eating disorder (BED). Better insights into its action may help guide the development of more targeted therapeutics and identify who will benefit most from this medication. Here, we use a comprehensive data-driven approach to investigate the brain FC changes that underlie the therapeutic action of LDX in patients with BED. Methods: Forty-six participants with moderate to severe BED received LDX titrated to 50 or 70 mg for an 8-week period. Twenty age-matched healthy control participants were also recruited. Resting-state functional magnetic resonance imaging was used to probe changes in brain FC pre- and post treatment and correlated with change in clinical measures. Results: Ninety-seven percent of trial completers (n = 31) experienced remission or a reduction to mild BED during the 8-week LDX trial. Widespread neural FC changes occurred, with changes in default mode to limbic, executive control to subcortical, and default mode to executive control networks associated with improvements in clinical outcomes. These connections were not distinct from control participants at pretreatment but were different from control participants following LDX treatment. Pretreatment connectivity did not predict treatment response. Conclusions: FC between networks associated with self-referential processing, executive function, and reward seem to underlie the therapeutic effect of LDX in BED. This suggests that LDX activates change via multiple systems, with most changes in compensatory networks rather than in those characterizing the BED diagnosis.

A three-arm randomised controlled trial of a telehealth intervention targeting improvement in addictive eating for Australian adults (the TRACE program).

There is a substantial research base for addictive eating with development of interventions. The current 3-arm RCT aimed to investigate the efficacy of the TRACE (Targeted Research for Addictive and Compulsive Eating) program to decrease addictive eating symptoms and improve mental health. Participants (18-85 yrs) endorsing ≥3 addictive eating symptoms were randomly allocated to 1) active intervention, 2) passive intervention, or 3) control group. Primary outcome was change in addictive eating symptoms 3-months post-baseline measured by the Yale Food Addiction Scale. Depression, anxiety and stress were also assessed. A total of 175 individuals were randomised. Using Linear Mixed Models, from baseline to 3-months, there was significant improvement in symptom scores in all groups with mean decrease of 4.7 (95% CI: -5.8, -3.6; p < 0.001), 3.8 (95% CI: -5.2, -2.4; p < 0.001) and 1.5 (95% CI: -2.6, -0.4; p = 0.01) respectively. Compared with the control group, participants in the active intervention were five times more likely to achieve a clinically significant change in symptom scores. There was a significant reduction in depression scores in the active and passive intervention groups, but not control group [-2.9 (95% CI: -4.5, -1.3); -2.3 (95% CI: -4.3, -0.3); 0.5 (95% CI: -1.1, 2.1), respectively]; a significant reduction in stress scores within the active group, but not passive intervention or control groups [-1.3 (95% CI: -2.2, -0.5); -1.0 (95% CI: -2.1, 0.1); 0.4 (95% CI: -0.5, 1.2), respectively]; and the reduction in anxiety scores over time was similar for all groups. A dietitian-led telehealth intervention for addictive eating in adults was more effective than a passive or control condition in reducing addictive eating scores from baseline to 6 months. Trial registration: Australia New Zealand Clinical Trial Registry ACTRN12621001079831.

Exploring Psychological Constructs in People Receiving Treatment for Addictive Eating Behaviours: "I Hate Loving Food as Much as I Do".

Research into the complexities of addictive eating behaviours continues to develop, as a deeper understanding of this construct beyond self-report diagnostic tools emerges. In this study, we undertook structured interviews with 40 participants engaged in a personality-based management program for addictive eating, to gain insight into what situations lead people with addictive eating behaviours to overeat, and how they believe their lives would be different if they had control over their eating. A phenomenological analysis to explore compulsion and control in the context of food experiences for participants was used to construct two main themes of the addictive eating paradox and striving to transition from 'other' to 'normal'. The addictive eating paradox identified multiple contradictory experiences of a situation, e.g., 'loving food' but 'hating food'. Striving to transition from 'other' to 'normal' encompassed the idea that participants envisaged that by gaining control over their eating they could become 'normal'. This study emphasises the need to provide support and strategies to help people navigate paradoxical thoughts and presents new ideas to increase the effectiveness of interventions for individuals struggling with the complex self-beliefs held by those with addictive eating behaviours.

Specific psychological therapies versus other therapies or no treatment for severe and enduring anorexia nervosa.

BACKGROUND: Anorexia nervosa is a psychological condition characterised by self-starvation and fear or wait gain or other body image disturbance. The first line of treatment is specific psychological therapy; however, there is no consensus on best practice for treating people who develop severe and enduring anorexia nervosa (SEAN). Notably, there is no universal definition of SEAN. OBJECTIVES: To evaluate the benefits and harms of specific psychological therapies for severe and enduring anorexia nervosa compared with other specific therapies, non-specific therapies, no treatment/waiting list, antidepressant medication, dietary counselling alone, or treatment as usual. SEARCH METHODS: We used standard, extensive Cochrane search methods. The last search date was 22 July 2022. SELECTION CRITERIA: We included parallel randomised controlled trials (RCTs) of people (any age) with anorexia nervosa of at least three years' duration. Eligible experimental interventions were any specific psychological therapy for improved physical and psychological health in anorexia nervosa, conducted in any treatment setting with no restrictions in terms of number of sessions, modality, or duration of therapy. Eligible comparator interventions included any other specific psychological therapy for anorexia nervosa, non-specific psychological therapy for mental health disorders, no treatment or waiting list, antipsychotic treatment (with or without psychological therapy), antidepressant treatment (with or without psychological therapy), dietary counselling, and treatment as usual as defined by the individual trials. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcomes were clinical improvement (weight restoration to within the normal weight range for participant sample) and treatment non-completion. Results were presented using the GRADE appraisal tool. MAIN RESULTS: We found two eligible studies, but only one study provided usable data. This was a parallel-group RCT of 63 adults with SEAN who had an illness duration of at least seven years. The trial compared outpatient cognitive behaviour therapy for SEAN (CBT-SEAN) with specialist supportive clinical management for SEAN (SSCM-SE) over eight months. It is unclear if there is any difference between the effect of CBT-SEAN versus SSCM-SE on clinical improvement at 12 months (risk ratio (RR) 1.42, 95% confidence interval (CI) 0.66 to 3.05) or treatment non-completion (RR 1.72, 95% CI 0.45 to 6.59). There were no reported data on adverse effects. The trial was at high risk of performance and detection bias. We rated the GRADE level of evidence as very low-certainty for both primary outcomes, downgrading for imprecision and risk of bias concerns. AUTHORS' CONCLUSIONS: This review reports evidence from one trial that evaluated CBT-SEAN versus SSCM-SE. There was very low-certainty evidence of little or no difference in clinical improvement and treatment non-completion between the two therapies. There is a need for larger high-quality trials to determine the benefits of specific psychological therapies for people with SEAN. These should take into account the duration of illness as well as participants' previous experience with evidence-based psychological therapy for anorexia nervosa.

Examining the efficacy of a telehealth intervention targeting addictive eating in Australian adults (the TRACE Programme): a randomised controlled trial protocol.

INTRODUCTION: Approximately 15%-20% of the adult population self-report symptoms of addictive eating. There are currently limited options for management. Motivational interviewing-based interventions, containing personalised coping skills training, have been found to be effective for behaviour change in addictive disorders (eg, alcohol). This project builds upon foundations of an addictive eating feasibility study previously conducted and co-design process involving consumers. The primary aim of this study is to examine the efficacy of a telehealth intervention targeting addictive eating symptoms in Australian adults compared with passive intervention and control groups. METHODS AND ANALYSIS: This three-arm randomised controlled trial will recruit participants 18-85 years, endorsing ≥3 symptoms on the Yale Food Addiction Scale (YFAS) 2.0, with body mass index >18.5 kg/m2. Addictive eating symptoms are assessed at baseline (pre-intervention), 3 months (post-intervention) and 6 months. Other outcomes include dietary intake and quality, depression, anxiety, stress, quality of life, physical activity and sleep hygiene. Using a multicomponent clinician-led approach, the active intervention consists of five telehealth sessions (15-45 min each) delivered by a dietitian over 3 months. The intervention uses personalised feedback, skill-building exercises, reflective activities and goal setting. Participants are provided with a workbook and website access. The passive intervention group receives the intervention via a self-guided approach with access to the workbook and website (no telehealth). The control group receives personalised written dietary feedback at baseline and participants advised to follow their usual dietary pattern for 6 months. The control group will be offered the passive intervention after 6 months. The primary endpoint is YFAS symptom scores at 3 months. A cost-consequence analysis will determine intervention costs alongside mean change outcomes. ETHICS AND DISSEMINATION: Human Research Ethics Committee of University of Newcastle, Australia provided approval (H-2021-0100). Findings will be disseminated via publication in peer-reviewed journals, conference presentations, community presentations and student theses. TRIAL REGISTRATION NUMBER: Australia New Zealand Clinical Trials Registry (ACTRN12621001079831).

Current approaches in the recognition and management of eating disorders.

Eating disorders are now well acknowledged mental health problems that are common and present in people from diverse sociodemographic backgrounds. The past decade has seen a rapid expansion in research into eating disorder interventions. In response to the increasing burden of eating disorders, the Australian Government Department of Health and Aged Care has implemented significant policy changes to improve patient access to Medicare and inpatient treatment facilities. There are several international clinical practice guidelines and a robust evidence base particularly for first line care with specific psychological therapies, including guidelines for the management of eating disorders in individuals with a high weight. Medications play an important adjunct role in care, and novel neuromodulating treatments, such as psychostimulants, are under study. There is emerging evidence for increased person-centred care, with more choice in the form of alternatives to hospital inpatient programs and more respectful consideration of care for all who experience an eating disorder, including people with high weight.

Impulsivity and Its Relationship With Lisdexamfetamine Dimesylate Treatment in Binge Eating Disorder.

High trait impulsivity is thought to contribute to the sense of loss of control over eating and impulses to binge eat experienced by those with binge eating disorder (BED). Lisdexamfetamine dimesylate (LDX), a drug approved for treatment of moderate to severe BED, has been shown to decrease impulsive features of BED. However, the relationship between LDX-related reductions of binge eating (BE) episodes and impulsivity has not yet been explored. Forty-one adults aged 18-40years with moderate to severe BED completed questionnaires and tasks assessing impulsivity at baseline and after 8weeks of 50-70mg of LDX. Twenty age-matched healthy controls were also assessed at two timepoints for normative comparison. Data were analysed using linear mixed models. BED participants exhibited increased self-reported motor, non-planning, cognitive and food-related impulsivity relative to controls but no differences in objective task-based measures of impulsivity. Food-related and non-planning impulsivity was significantly reduced by LDX, but not to normative levels. Individuals with higher baseline levels of motor and non-planning impulsivity, and loss of control over eating scores experienced the greatest reduction in BE frequency after 8weeks of LDX. Further, there were significant associations between the degree to which subjective loss of control over eating, non-planning impulsivity and BE frequency reduced after 8weeks of LDX. These data suggest that specific subjective measures of impulsivity may be able to predict who will have the greatest benefit from LDX treatment and that reductions in BE frequency may be moderated by concurrent reductions in non-planning impulsivity.

The feasibility of acupuncture as an adjunct intervention for antenatal depression: a pragmatic randomised controlled trial.

BACKGROUND: Antenatal depression is common and associated with adverse consequences for mothers, babies, and future generations. Limitations with conventional approaches has resulted in additional therapies being considered. This study examined the feasibility and effectiveness of acupuncture for improving mental health. METHODS: Fifty-seven pregnant women with depressive symptomologies were randomised to acupuncture (n=19) plus treatment as usual (TAU), progressive muscle relaxation (PMR, n=19) plus TAU or TAU (n=19). Treatments were conducted from 24 to 31 weeks gestation. Clinical assessments were performed throughout the intervention, as well as at a six-week postnatal follow-up. The primary outcome measure was depression. Secondary outcome measurements were stress, anxiety, psychological distress, quality of life and adjustment to mothering. Intention to treat (ITT), Linear Mixed Model (LMM) repeated measures and per protocol (PP) analyses were conducted. RESULTS: At end-of-intervention there were significantly lower depression scores in the acupuncture group versus TAU and PMR respectively [ITT p<0.001, mean difference (MD) -5.84 (95% CI -9.10 to -2.58); MD -3.42 (95% CI -6.64 to -0.20)]. LMM repeated measures analysis (including postnatal follow-up) also demonstrated significantly lowered acupuncture group scores for stress (p=0.006) and psychological distress (p<0.001) when compared to PMR and TAU. Between group differences were not significant at six-weeks postnatal. No adverse events were reported. LIMITATIONS: Main limitations are small sample size and the use of self-reported outcome measures. CONCLUSION: Prenatal acupuncture reduced depression, stress and distress, whilst also being well-tolerated and free from adverse events. Further research is warranted.

Understanding the neural mechanisms of lisdexamfetamine dimesylate (LDX) pharmacotherapy in Binge Eating Disorder (BED): a study protocol.

BACKGROUND: The efficacy and safety of Lisdexamfetamine dimesylate (LDX) in the treatment of moderate to severe binge eating disorder (BED) has been demonstrated in multiple randomised clinical trials. Despite this, little is known about how LDX acts to improve binge eating symptoms. This study aims to provide a comprehensive understanding of the neural mechanisms by which LDX improves symptoms of BED. We hypothesise that LDX will act by normalising connectivity within neural circuits responsible for reward and impulse control, and that this normalisation will correlate with reduced binge eating episodes. METHODS: This is an open-label Phase 4 clinical trial of LDX in adults with moderate to severe BED. Enrolment will include 40 adults with moderate to severe BED aged 18-40 years and Body Mass Index (BMI) of 20-45 kg/m2, and 22 healthy controls matched for age, gender and BMI. Clinical interview and validated scales are used to confirm diagnosis and screen for exclusion criteria, which include comorbid anorexia nervosa or bulimia nervosa, use of psychostimulants within the past 6 months, and current use of antipsychotics or noradrenaline reuptake inhibitors. Baseline assessments include clinical symptoms, multimodal neuroimaging, cognitive assessment of reward sensitivity and behavioural inhibition, and an (optional) genetic sample. A subset of these assessments are repeated after eight weeks of treatment with LDX titrated to either 50 or 70 mg. The primary outcome measures are resting-state intrinsic connectivity and the number of binge eating episodes. Analyses will be applied to resting-state fMRI data to characterise pharmacological effects across the functional connectome, and assess correlations with symptom measure changes. Comparison of neural measures between controls and those with BED post-treatment will also be performed to determine whether LDX normalises brain function. DISCUSSION: First enrolment was in May 2018, and is ongoing. This study is the first comprehensive investigation of the neurobiological changes that occur with LDX treatment in adults with moderate to severe BED. TRIAL REGISTRATION: ACTRN12618000623291, Australian and New Zealand Clinical Trials Registry URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374913&isReview=true. Date of Registration: 20 April 2018.

Inpatient versus outpatient care, partial hospitalisation and waiting list for people with eating disorders.

BACKGROUND: Clinical guidelines recommend outpatient care for the majority of people with an eating disorder. The optimal use of inpatient treatment or combination of inpatient and partial hospital care is disputed and practice varies widely. OBJECTIVES: To assess the effects of treatment setting (inpatient, partial hospitalisation, or outpatient) on the reduction of symptoms and increase in remission rates in people with:1. Anorexia nervosa and atypical anorexia nervosa;2. Bulimia nervosa and other eating disorders. SEARCH METHODS: We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 2 July 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 20 November 2015). We also searched the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (6 July 2018). We ran a forward citation search on the Web of Science to identify additional reports citing any of the included studies, and screened reference lists of included studies and relevant reviews identified during our searches. SELECTION CRITERIA: We included randomised controlled trials that tested the efficacy of inpatient, outpatient, or partial hospital settings for treatment of eating disorder in adults, adolescents, and children, whose diagnoses were determined according to the DSM-5, or other internationally accepted diagnostic criteria. We excluded trials of treatment setting for medical or psychiatric complications or comorbidities (e.g. hypokalaemia, depression) of an eating disorder. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane procedures to select studies, extract and analyse data, and interpret and present results. We extracted data according to the DSM-5 criteria. We used the Cochrane tool to assess risk of bias. We used the mean (MD) or standardised mean difference (SMD) for continuous data outcomes, and the risk ratio (RR) for binary outcomes. We included the 95% confidence interval (CI) with each result. We presented the quality of the evidence and estimate of effect for weight or body mass index (BMI) and acceptability (number who completed treatment), in a 'Summary of findings' table for the comparison for which we had sufficient data to conduct a meta-analysis. MAIN RESULTS: We included five trials in our review. Four trials included a total of 511 participants with anorexia nervosa, and one trial had 55 participants with bulimia nervosa. Three trials are awaiting classification, and may be included in future versions of this review. We assessed a risk of bias from lack of blinding of participants and therapists in all trials, and unclear risk for allocation concealment and randomisation in one study.We had planned four comparisons, and had data for meta-analyses for one. For anorexia nervosa, there may be little or no difference between specialist inpatient care and active outpatient or combined brief hospital and outpatient care in weight gain at 12 months after the start of treatment (standardised mean difference (SMD) -0.22, 95% CI -0.49 to 0.05; 2 trials, 232 participants; low-quality evidence). People may be more likely to complete treatment when randomised to outpatient care settings, but this finding is very uncertain (risk ratio (RR) 0.75, 95% CI 0.64 to 0.88; 3 trials, 319 participants; very low-quality evidence). We downgraded the quality of the evidence for these outcomes because of risks of bias, small numbers of participants and events, and variable level of specialist expertise and intensity of treatment.We had no data, or data from only one trial for the primary outcomes for each of the other three comparisons.No trials measured weight or acceptance of treatment for anorexia nervosa, when comparing inpatient care provided by a specialist eating disorder service and health professionals and a waiting list, no active treatment, or treatment as usual.There was no clear difference in weight gain between settings, and only slightly more acceptance for the partial hospital setting over specialist inpatient care for weight restoration in anorexia nervosa.There was no clear difference in weight gain or acceptability of treatment between specialist inpatient care and partial hospital care for bulimia nervosa, and other binge eating disorders. AUTHORS' CONCLUSIONS: There was insufficient evidence to conclude whether any treatment setting was superior for treating people with moderately severe (or less) anorexia nervosa, or other eating disorders.More research is needed for all comparisons of inpatient care versus alternate care.

Group cognitive remediation therapy for adults with obesity prior to behavioural weight loss treatment: study protocol for a randomised controlled superiority study (CRT study).

INTRODUCTION: Individuals with obesity show deficits in executive functioning which have been implicated in decreased weight loss outcome. Preliminary evidence suggests that cognitive remediation therapy (CRT) improves executive functioning and weight loss in obesity. However, confirmatory support, especially for pre-weight loss use, is lacking. The CRT study aims at determining the efficacy of CRT versus no treatment control in patients with obesity before entering behavioural weight loss (BWL) treatment. It is hypothesised that individuals who receive CRT will show better weight loss outcome, improved executive functioning, greater weight loss-related behavioural changes and higher attendance of BWL treatment, 6 and 12 months after cessation of CRT. METHODS AND ANALYSIS: In a single-centre, assessor-blinded, randomised, two-armed parallel-group superiority trial, 260 adults with body mass index ≥35.0 kg/m2 are centrally randomised to 8-week group-based CRT versus no treatment, before entering BWL treatment. Primary outcome is the amount of weight loss (%) at 6-month follow-up, compared with pre-treatment, derived from measured body weight. Secondary outcomes include improvement in executive functioning post-treatment and in weight loss-related behaviour, mental and physical health, and attendance to BWL treatment at 6-month and 12-month follow-up. Maintenance of weight loss at 12-month follow-up will be determined. Mixed model analyses based on intent-to-treat will be used to compare the CRT and control groups with respect to differences in weight change between pre-treatment and 6-month follow-up. Similar models will be used for analysing 12-month follow-up data and secondary outcomes. Further analyses will include additional covariates to identify predictors of treatment outcome. ETHICS AND DISSEMINATION: The study was approved by the Ethical Committee of the University of Leipzig (256-15-13072015, version 'Final 1.0 from 28 May 2015). The study results will be disseminated through peer-reviewed publications. TRIAL REGISTRATION NUMBER: DRKS00009333; Pre-results.

Acupuncture for depression.

BACKGROUND: Depression is recognised as a major public health problem that has a substantial impact on individuals and on society. People with depression may consider using complementary therapies such as acupuncture, and an increasing body of research has been undertaken to assess the effectiveness of acupuncture for treatment of individuals with depression. This is the second update of this review. OBJECTIVES: To examine the effectiveness and adverse effects of acupuncture for treatment of individuals with depression.To determine:• Whether acupuncture is more effective than treatment as usual/no treatment/wait list control for treating and improving quality of life for individuals with depression.• Whether acupuncture is more effective than control acupuncture for treating and improving quality of life for individuals with depression.• Whether acupuncture is more effective than pharmacological therapies for treating and improving quality of life for individuals with depression.• Whether acupuncture plus pharmacological therapy is more effective than pharmacological therapy alone for treating and improving quality of life for individuals with depression.• Whether acupuncture is more effective than psychological therapies for treating and improving quality of life for individuals with depression.• Adverse effects of acupuncture compared with treatment as usual/no treatment/wait list control, control acupuncture, pharmacological therapies, and psychological therapies for treatment of individuals with depression. SEARCH METHODS: We searched the following databases to June 2016: Cochrane Common Mental Disorders Group Controlled Trials Register (CCMD-CTR), Korean Studies Information Service System (KISS), DBPIA (Korean article database website), Korea Institute of Science and Technology Information, Research Information Service System (RISS), Korea Med, Korean Medical Database (KM base), and Oriental Medicine Advanced Searching Integrated System (OASIS), as well as several Korean medical journals. SELECTION CRITERIA: Review criteria called for inclusion of all published and unpublished randomised controlled trials comparing acupuncture versus control acupuncture, no treatment, medication, other structured psychotherapies (cognitive-behavioural therapy, psychotherapy, or counselling), or standard care. Modes of treatment included acupuncture, electro-acupuncture, and laser acupuncture. Participants included adult men and women with depression diagnosed by Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV), Research Diagnostic Criteria (RDC), International Statistical Classification of Diseases and Related Health Problems (ICD), or Chinese Classification of Mental Disorders Third Edition Revised (CCMD-3-R). If necessary, we used trial authors' definitions of depressive disorder. DATA COLLECTION AND ANALYSIS: We performed meta-analyses using risk ratios (RRs) for dichotomous outcomes and standardised mean differences (SMDs) for continuous outcomes, with 95% confidence intervals (CIs). Primary outcomes were reduction in the severity of depression, measured by self-rating scales or by clinician-rated scales, and improvement in depression, defined as remission versus no remission. We assessed evidence quality using the GRADE method. MAIN RESULTS: This review is an update of previous versions and includes 64 studies (7104 participants). Most studies were at high risk of performance bias, at high or unclear risk of detection bias, and at low or unclear risk of selection bias, attrition bias, reporting bias, and other bias.Acupuncture versus no treatment/wait list/treatment as usualWe found low-quality evidence suggesting that acupuncture (manual and electro-) may moderately reduce the severity of depression by end of treatment (SMD -0.66, 95% CI -1.06 to -0.25, five trials, 488 participants). It is unclear whether data show differences between groups in the risk of adverse events (RR 0.89, 95% CI 0.35 to 2.24, one trial, 302 participants; low-quality evidence).Acupuncture versus control acupuncture (invasive, non-invasive sham controls)Acupuncture may be associated with a small reduction in the severity of depression of 1.69 points on the Hamilton Depression Rating Scale (HAMD) by end of treatment (95% CI -3.33 to -0.05, 14 trials, 841 participants; low-quality evidence). It is unclear whether data show differences between groups in the risk of adverse events (RR 1.63, 95% CI 0.93 to 2.86, five trials, 300 participants; moderate-quality evidence).Acupuncture versus medicationWe found very low-quality evidence suggesting that acupuncture may confer small benefit in reducing the severity of depression by end of treatment (SMD -0.23, 95% CI -0.40 to -0.05, 31 trials, 3127 participants). Studies show substantial variation resulting from use of different classes of medications and different modes of acupuncture stimulation. Very low-quality evidence suggests lower ratings of adverse events following acupuncture compared with medication alone, as measured by the Montgomery-Asberg Depression Rating Scale (MADRS) (mean difference (MD) -4.32, 95% CI -7.41 to -1.23, three trials, 481 participants).Acupuncture plus medication versus medication aloneWe found very low-quality evidence suggesting that acupuncture is highly beneficial in reducing the severity of depression by end of treatment (SMD -1.15, 95% CI -1.63 to -0.66, 11 trials, 775 participants). Studies show substantial variation resulting from use of different modes of acupuncture stimulation. It is unclear whether differences in adverse events are associated with different modes of acupuncture (SMD -1.32, 95% CI -2.86 to 0.23, three trials, 200 participants; very low-quality evidence).Acupuncture versus psychological therapyIt is unclear whether data show differences between acupuncture and psychological therapy in the severity of depression by end of treatment (SMD -0.5, 95% CI -1.33 to 0.33, two trials, 497 participants; low-quality evidence). Low-quality evidence suggests no differences between groups in rates of adverse events (RR 0.62, 95% CI 0.29 to 1.33, one trial, 452 participants). AUTHORS' CONCLUSIONS: The reduction in severity of depression was less when acupuncture was compared with control acupuncture than when acupuncture was compared with no treatment control, although in both cases, results were rated as providing low-quality evidence. The reduction in severity of depression with acupuncture given alone or in conjunction with medication versus medication alone is uncertain owing to the very low quality of evidence. The effect of acupuncture compared with psychological therapy is unclear. The risk of adverse events with acupuncture is also unclear, as most trials did not report adverse events adequately. Few studies included follow-up periods or assessed important outcomes such as quality of life. High-quality randomised controlled trials are urgently needed to examine the clinical efficacy and acceptability of acupuncture, as well as its effectiveness, compared with acupuncture controls, medication, or psychological therapies.

Evaluation of an antenatal acupuncture intervention as an adjunct therapy for antenatal depression (AcuAnteDep): study protocol for a pragmatic randomised controlled trial.

BACKGROUND: Depressed pregnant women face difficulty navigating a course between the potentially serious consequences of leaving depression untreated and significant limitations associated with conventional therapies, such as foetal toxicity and teratogenicity. Preliminary evidence is suggestive that acupuncture may provide a safe and effective alternative treatment option for antenatal depression; however, additional research is required. The purpose of this study is to further investigate this treatment possibility, with an additional examination of a potential biomechanistic acupuncture effect. METHODS/DESIGN: In this pragmatic randomised controlled trial, we will compare individually tailored, flexible antenatal depression-oriented acupuncture with equivalent attention progressive muscle relaxation and routine antenatal depression hospital care. Eligible women at 24 weeks of gestation with Edinburgh Postnatal Depression Scale scores of 13 or more will be recruited from 2 antenatal clinics in South Western Sydney, Australia. The recruitment goal of 96 is powered to demonstrate a significant difference in Edinburgh Postnatal Depression Scale score severity between acupuncture and usual care, with intervention groups receiving weekly 1-h treatments for 8 weeks from 24 to 31 weeks of gestation. Mental health and quality-of-life assessments will occur at study commencement, intervention weeks 4 and 8 and 6 weeks post-natally via the collection of completed Edinburgh Postnatal Depression Scale scores, Depression, Stress and Anxiety Scale scores and World Health Organisation Quality of Life Scale scores. Adjustment to mothering will also be evaluated at 6 weeks post-natally using the Being a Mother Scale. A putative biomechanistic effect of acupuncture on the oxytocinergic system will additionally be examined by comparing baseline salivary hormone levels with those measured at intervention weeks 4 and 8, as well as leucocyte oxytocin receptor expression at baseline and intervention week 8. DISCUSSION: Ethical approval was received in February 2015, and recruitment is underway and expected to be completed in July 2016. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615000250538, Registered on 19 March 2015.

Identifying Persuasive Public Health Messages to Change Community Knowledge and Attitudes About Bulimia Nervosa.

Addressing stigma through social marketing campaigns has the potential to enhance currently low rates of treatment seeking and improve the well-being of individuals with the eating disorder bulimia nervosa. This study aimed to evaluate the persuasiveness of health messages designed to reduce stigma and improve mental health literacy about this disorder. A community sample of 1,936 adults (48.2% male, 51.8% female) from Victoria, Australia, provided (a) self-report information on knowledge and stigma about bulimia nervosa and (b) ratings of the persuasiveness of 9 brief health messages on dimensions of convincingness and likelihood of changing attitudes. Messages were rated moderately to very convincing and a little to moderately likely to change attitudes toward bulimia nervosa. The most persuasive messages were those that emphasized that bulimia nervosa is a serious mental illness and is not attributable to personal failings. Higher ratings of convincingness were associated with being female, with having more knowledge about bulimia nervosa, and with lower levels of stigma about bulimia nervosa. Higher ratings for likelihood of changing attitudes were associated with being female and with ratings of the convincingness of the corresponding message. This study provides direction for persuasive content to be included in social marketing campaigns to reduce stigma toward bulimia nervosa.

Comparing symptomatic and functional outcomes over 5 years in two nonclinical cohorts characterized by binge eating with and without objectively large episodes.

OBJECTIVE: The aim was to compare symptomatic and functional outcomes over 5 years in women with regular subjective (SBEs), objective (OBEs), and no regular binge eating episodes. METHOD: Data were derived from two cohorts of 330 women with high levels of eating disorders symptoms followed over 5 years. Three groups were formed: (a) regular SBEs but no regular OBEs (N = 68), (b) regular OBEs with or without regular SBEs (N = 154), and (c) with no regular binge eating episodes (N = 108). RESULTS: At baseline, the groups did not differ significantly in restraint scores and quality of life. People in the OBE group scored higher than those in the SBE group in body mass index (BMI). Those who had no regular binge eating had lower global Eating Disorder Examination Questionnaire (EDE-Q) and weight and shape concern scores than those with regular SBEs, and lower eating concern scores than either binge eating groups. Across the follow-up, there were no significant effects of being in either binge eating or the nonbinge eating group on the rates of change in BMI, general psychological distress, quality of life, or EDE-Q scores with the exception that OBE group had a significantly different rate of change in eating concern and psychological distress compared to the group without regular binge eating. DISCUSSION: Individuals that report regular SBEs without regular OBEs represent a group with similar mental hardship and outcomes to those with regular OBEs. The findings support inclusion of regular SBEs in criteria for eating disorder diagnostic categories characterized by recurrent binge eating.

Individual psychological therapy in the outpatient treatment of adults with anorexia nervosa.

BACKGROUND: Anorexia nervosa is a disorder with high morbidity and significant mortality. It is most common in young adult women, in whom the incidence may be increasing. The focus of treatment has moved to an outpatient setting, and a number of differing psychological therapies are presently used in treatment. This is an update of a Cochrane review which was last published in 2008. OBJECTIVES: To assess the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents treated in an outpatient setting. SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR) (16 July 2014). This register includes relevant randomised controlled trials from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We screened reference lists of all included studies and sent letters to identified, notable researchers requesting information on unpublished or ongoing studies. SELECTION CRITERIA: All randomised controlled trials of one or more individual outpatient psychological therapies for adults with anorexia nervosa, as defined by DSM-5 or similar international criteria. DATA COLLECTION AND ANALYSIS: We selected a range of outcome variables, including physical state, severity of eating disorder attitudes and beliefs, interpersonal function, and general psychiatric symptom severity. Continuous outcome data comparisons used the mean or standardised mean difference (MD or SMD), and binary outcome comparisons used the risk ratio (RR). Two review authors (PH and AC or ST) extracted data independently. MAIN RESULTS: We identified 10 trials from the search, with a total of 599 anorexia nervosa participants, and included them in the review. Seven had been identified in the previous versions of this review and we now include three new trials. We now deem one previously identified ongoing trial to be ineligible, and six ongoing trials are new for this update. Two of the 10 trials included children. Trials tested diverse psychological therapies and comparability was poor. Risks of bias were mostly evident through lack of blinded outcome assessments (in 60% of studies) and incomplete data reporting (attrition bias).The results suggest that treatment as usual (TAU) when delivered by a non-eating-disorder specialist or similar may be less efficacious than focal psychodynamic therapy. This was suggested for a primary outcome of recovery by achievement of a good or intermediate outcome on the Morgan and Russell Scale (RR 0.70, 95% confidence interval (CI) 0.51 to 0.97; 1 RCT, 40 participants; very low-quality evidence). However there were no differences between cognitive analytic therapy and TAU for this outcome (RR 0.78, 95% CI 0.61 to 1.00; 2 RCTs, 71 participants; very low-quality evidence), nor for body mass index (BMI). There were no differences in overall dropout rates between individual psychological therapies and TAU.Two trials found a non-specific specialist therapy (Specialist Supportive Clinical Management) or an Optimised TAU delivered by therapists with eating disorder expertise was similar in outcomes to cognitive behaviour therapy (BMI MD -0.00, 95% CI -0.91 to 0.91; 197 participants, low-quality evidence). When comparing individual psychological therapies with each other, no specific treatment was consistently superior to any other specific approach. Dietary advice as a control arm had a 100% non-completion rate in one trial (35 participants). None of the trials identified any adverse effects. Insufficient power was problematic for the majority of trials. AUTHORS' CONCLUSIONS: There was a suggestion in one trial that focal psychodynamic therapy might be superior to TAU, but this is in the context of TAU performing poorly. An alternative control condition of dietary advice alone appeared to be unacceptable, but again this is based on just one trial. Owing to the risk of bias and limitations of studies, notably small sample sizes, we can draw no specific conclusions about the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents. Larger RCTs of longer treatment duration and follow-up are needed.

Bulimia nervosa: online interventions.

INTRODUCTION: Up to 1% of people in the community may have bulimia nervosa, characterised by an intense preoccupation with body weight, binge-eating episodes, and use of extreme measures to counteract the feared effects of overeating. People with bulimia nervosa are of normal weight or are overweight, making the condition distinct from anorexia nervosa. After 10 years, about half of people with bulimia nervosa will have recovered fully, one third will have made a partial recovery, and 10% to 20% will still have symptoms. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of online interventions for people with bulimia nervosa? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found eight studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: applications (apps) or online programmes used as an adjunct to face-to-face therapy, delivery of self-help online, and delivery of therapy online.

Stigmatizing attitudes and beliefs toward bulimia nervosa: the importance of knowledge and eating disorder symptoms.

Widely held stigmatizing attitudes and beliefs toward bulimic eating disorders may lead to self-blame and reduced treatment seeking. Knowledge and familiarity with mental disorders may help decrease associated stigma. However, these relationships are not well understood in bulimia nervosa (BN). A community sample of 1828 adults aged 18 to 70 years completed a survey assessing stigmatizing attitudes and beliefs toward BN, knowledge and familiarity with the disorder, as well as levels of eating disorder symptoms. Knowledge of BN was negatively associated with three dimensions of stigmatization, personal responsibility (ρ = -0.28), unreliability (ρ = -0.19), and advantages of BN (ρ = -0.23). Familiarity revealed no association with stigmatization. Both men and women with high levels of eating disorder symptoms perceived BN as less serious than the participants with low levels of symptoms. Increasing community knowledge about bulimia may help mitigate stigmatization and perceived barriers to treatment.