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.

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.

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.

'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.

"Because I am worth it": a theoretical framework and empirical review of a justification-based account of self-regulation failure.

Self-regulation failure is often explained as being overwhelmed by impulse. The present article proposes a novel pathway, presenting a theoretical framework and empirical review of a justification-based account of self-regulation failure. With justification we refer to making excuses for one's discrepant behavior, so that when experiencing a self-regulation dilemma between immediate impulses and long-term intentions, people resolve the conflict by developing and employing justifications that allow violations of the goal they endorse. Accordingly, rather than inhibiting motivations from the impulsive system, the reflective system can also facilitate them, leading to self-regulation failure. We bring together empirical evidence from various domains demonstrating that justifications can instigate self-regulation failure and rule out alternative accounts. Having established that justification processes contribute to self-regulation failure, we then propose several mechanisms that may fuel the effect. Finally, routes for future research and the conceptual and practical implications of these novel insights for self-regulation are discussed.

Who diets? Most people and especially when they worry about food.

Dieting is generally not effective in establishing weight loss and research has focused on documenting these negative consequences of dieting. Much less is known about why people diet. The present study employed a large and representative community sample to determine the demographic and psychological correlates of dieting and to examine the hypothesis that food concerns are associated with considering oneself a dieter. Participants from a community sample (n = 1113) completed an internet survey on dieting (restraint scale of the DEBQ) and its demographic and psychological correlates, with a specific focus on food concerns. In addition, they completed a 7-day snack diary to determine their food intake. According to sex-specific norm scores, 63.2% of the men and 62.7% of the women qualified as a dieter, defined as having elevated scores on the DEBQ restraint scale. Women and older people more often reported to diet, as did people with higher weights. In line with our hypothesis, food concerns (weight concerns and concerns about the diet-health link) were most strongly associated with dieting. Considering oneself as a dieter was weakly related to actual snack consumption whereas food concerns were unrelated to the consumption of snacks. Considering oneself as a dieter in terms of endorsing items on a restraint scale is an expression of food concerns that is virtually unaccompanied by changes in food intake. These findings suggest a reinterpretation of the dieting concept in terms of a strategy for coping with food concerns which need consideration in future research.

Good mood food. Positive emotion as a neglected trigger for food intake.

UNLABELLED: Research on emotions as a trigger for food intake has mainly been focused on the role of negative emotions. In the present studies the role of positive emotions as a trigger for food intake is investigated in a sample of healthy participants with a normal weight. Two laboratory studies were conducted in which positive emotions or no emotions were induced (Study 1) or in addition negative emotions were induced (Study 2) after which unhealthy food intake was assessed by bogus taste tests. In Study 3, food intake was assessed by registering snack intake in a 7-day diary study together with the emotions accompanying each snacking episode to provide a more ecologically valid test of our hypothesis. Studies 1 and 2 showed that positive emotions, compared to the control conditions, evoked more caloric intake. Dietary restraint did not moderate this effect. Study 2 additionally showed that positive emotions evoked caloric intake to the same extent as negative emotions. Study 3 showed that snack intake in daily life was reported to result from positive emotions more frequently than from negative emotions. CONCLUSIONS: Positive emotions serve as an important but under-investigated trigger for unhealthy food intake that deserves further scrutiny. Future research should further investigate whether food intake results from emotional arousal in general, or from emotional valence in particular.

Coping under pressure: employing emotion regulation strategies to enhance performance under pressure.

Performing under high pressure is an emotional experience. Hence, the use of emotion regulation strategies may prove to be highly effective in preventing choking under pressure. Using a golf putting task, we investigated the role of arousal on declined sport performance under pressure (pilot study) and the effectiveness of emotion regulation strategies in alleviating choking under pressure (main study). The pilot study showed that pressure resulted in decreased performance and this effect was partially mediated by increased arousal. The main study, a field study, showed that whereas the choking effect was observed in the control condition, reappraisal and, particularly, distraction were effective emotion regulation strategies in helping people to cope instead of choke under pressure. These findings suggest that interventions that aim to prevent choking under pressure could benefit from including emotion regulation strategies.

A double burden: emotional eating and lack of cognitive reappraisal in eating disordered women.

OBJECTIVE: To examine the influence of emotional eating and lack of cognitive reappraisal on eating pathology in women with binge-purge and restricting type eating disorders. METHOD: Women with a diagnosis of anorexia or bulimia nervosa according to the DSM-IV-tr (n = 50) and non-clinical women without eating disorders (n = 52) were asked about emotional eating tendencies, adaptive emotion regulation strategies (cognitive reappraisal) and eating pathology symptoms. RESULTS: In binge-purging women, emotional eating with limited use of cognitive reappraisal predicted level of eating pathology but not in the restricting and non-clinical women. DISCUSSION: Emotional eating tendencies in combination with a low tendency to use cognitive reappraisal may influence the severity of eating pathology in individuals with binge-purge behaviours. Evidently, patients with these characteristics require a therapy that addresses adaptive emotion regulation skills.

The Eating Disorder Diagnostic Scale: psychometric features within a clinical population and a cut-off point to differentiate clinical patients from healthy controls.

The Eating Disorder Diagnostic Scale (EDDS) is a brief self-report measure for diagnosing anorexia nervosa, bulimia nervosa and binge eating disorder. Research has provided evidence of the reliability and validity of this scale in non-clinical populations. Our study is the first to examine the psychometric features of the EDDS in a clinical population of eating disordered patients. We identified a cut-off point that differentiates clinical patients from healthy controls. A clinical group of 59 Dutch female eating disordered patients and a control group of 45 Dutch students completed the EDDS, the Eating Disorder Examination Interview, the Body Attitude Test and the Beck Depression Inventory--II. The EDDS showed good test-retest reliability, internal consistency, criterion validity and convergent validity with other scales assessing eating and general pathology. An overall symptom composite cut-off score of 16.5 accurately distinguished clinical patients from healthy controls. The EDDS may be a useful instrument in clinical settings and in aetiologic, prevention and treatment research.

The shaping role of hunger on self-reported external eating status.

As people are relatively incompetent in assessing the impact of visceral states on their behavior, two studies tested the hypothesis that hunger affects the extent to which people assess themselves as external eaters. In Study 1 participants' current self-reported hunger states were linked to their scores on an external eating scale. Hungrier participants perceived themselves more strongly as external eaters. In Study 2 hunger was experimentally manipulated, after which self-reported external eating was assessed. Hunger was found to affect people's self-reported external eating status, such that hungry participants scored higher and above the average norm score on external eating compared to satiated participants, who scored below this average norm score. The key implications of these findings are discussed.

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.

How chocolate keeps you slim. The effect of food temptations on weight watching goal importance, intentions, and eating behavior.

In the Western rich food environment, people are constantly confronted with palatable but unhealthy food products. For those who would like to watch their weight, the appeal of immediate satisfaction is in conflict with their long-term weight watching goal, constituting a classic self-control dilemma. The current studies were designed to test the effect of food temptations on self-regulation mechanisms. Hypotheses were based on counteractive control theory stating that temptations trigger goal-directed behavior, thereby forming an adaptive self-regulation mechanism. Two experimental studies showed that exposure to food temptations, compared to a control condition, yielded enhanced goal importance (Study 1), goal intentions, and goal-directed behavior (i.e., healthy eating; Study 2). It is concluded that confrontation with temptations is not always undermining self-control and may even be beneficial for long-term goal pursuit.

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.

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.

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.

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.

How to bite your tongue without blowing your top: implicit evaluation of emotion regulation predicts affective responding to anger provocation.

People frequently have to control their emotions to function in life. However, mounting evidence suggests that deliberate emotion regulation often is costly. This presents a dilemma: Is it better to let emotions go or to pay the price of exerting costly control? In two studies, the authors explore whether emotion regulatory processes associated with implicit positive evaluation of emotion regulation might provide the benefits of successful emotion regulation without the costs. In Study 1, the authors introduce a measure of implicit evaluation of emotion regulation (ER-IAT). Study 2 examined whether this measure is associated with actual emotional responses to an anger provocation. It was found that greater ER-IAT scores were associated with lesser anger experience, fewer negative thoughts, lessened self-reported effortful emotion regulation, and an adaptive pattern of cardiovascular responding. These findings suggest that implicit positive evaluation of emotion regulation is associated with successful, automatic, and physiologically adaptive down-regulation of anger.

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.