Sensitivity to change in well-being and health-related quality of life in adults with eating disorder symptoms: ICECAP-A versus EQ-5D-5L.

OBJECTIVE: Economic evaluations of treatments help to inform decisions on allocating health care resources. These evaluations involve comparing costs and effectiveness in terms of quality of life. To calculate quality-adjusted life years, generic health related quality of life is often used, but is criticized for not being sensitive to change in mental health populations. Another approach, using experienced well-being measured through capabilities with the ICECAP-A, has been proposed as an alternative. The aim of this study was to investigate whether changes in individuals with eating disorder (ED) symptoms can be better captured using health related quality of life (EQ-5D-5L) or well-being (ICECAP-A). METHOD: Measurements at two time points with an interval of 1 year were used from a sample of 233 participants with self-reported ED symptoms. An analysis of variance was used to test whether the EQ-5D-5L and ICECAP-A differed in sensitivity to change over time. In order to compare the two questionnaires in terms of clinically significant outcome, the reliable change index and clinical cut-off score were calculated. RESULTS: The two questionnaires did not differ in sensitivity to change. More individuals had recovered but also more had deteriorated according to the EQ-5D-5L compared to the ICECAP. DISCUSSION: The present study revealed no differences in sensitivity to change in health-related quality of life or well-being in individuals with ED symptoms in the context of mild clinical change. Results corroborated the pervasiveness of low quality of life in this population, even after alleviation of ED symptoms. PUBLIC SIGNIFICANCE STATEMENT: Measuring treatment benefits in terms of improvements in quality of life is an integral part of economic evaluations in health care. It was expected that these treatment benefits would be better captured as changes in well-being (measured with the ICECAP-A) than as changes in health-related quality of life (measured with the EQ-5D-5L) for individuals with ED symptoms. Based on the results of this study, no preference for one of the two approaches was found.

Associations between disordered eating behaviour, diabetes distress and emotion regulation strategies in adults with type 1 diabetes: Results from a Dutch-Italian cross-sectional study.

AIMS: Disordered eating behaviour (DEB) and diabetes distress are prevalent in adults with type 1 diabetes (T1D). Emotion regulation strategies, such as cognitive reappraisal and expressive suppression, are associated with DEB and managing stress in general. Here we examine the associations between DEB, diabetes distress, and emotion regulation strategies in the context of T1D. METHODS: Adults with T1D in The Netherlands and Italy completed an online survey, covering DEB (DEPS-R), diabetes distress (PAID-5), and emotion regulation strategies (ERQ). Associations between DEB, diabetes distress, and emotion regulation strategies were examined using path analysis. RESULTS: N = 291 participants completed the survey (78.9% women, 39 ± 13 years, HbA1c : 55 ± 16 mmol/mol (7.2% [3.6%]); TIR: 66% ± 25). N = 79 participants (27.1%) reported DEB (DEPS-R ≥ 20) and n = 159 participants (54.6%) reported elevated diabetes distress (PAID-5 ≥ 8). The path analysis, with small-to-medium effect sizes, revealed that more diabetes distress was associated with more DEB (ß = 0.23, 95% CI [0.13, 0.34]). Less diabetes distress was associated with more use of cognitive reappraisal (ß = -0.24, 95% CI [-0.36, -0.12]). More DEB was associated with more use of expressive suppression (ß = 0.14, 95% CI [0.04, 0.24]). CONCLUSIONS: This cross-sectional study suggests an association between DEB and diabetes distress, between cognitive reappraisal and less diabetes distress and between expressive suppression and more DEB. The results suggest that it may prove beneficial to prioritize strengthening emotion regulation strategies in interventions for people with T1D and DEB. Future research should help clarify causality with regard to emotion regulation and DEB in adults with T1D.

Predictors and moderators of three online interventions for eating disorder symptoms in a randomized controlled trial.

OBJECTIVE: To optimize treatment recommendations for eating disorders, it is important to investigate whether some individuals may benefit more (or less) from certain treatments. The current study explored predictors and moderators of an automated online self-help intervention "Featback" and online support from a recovered expert patient. METHODS: Data were used from a randomized controlled trial. For a period of 8 weeks, participants aged 16 or older with at least mild eating disorder symptoms were randomized to four conditions: (1) Featback, (2) chat or e-mail support from an expert patient, (3) Featback with expert-patient support, and (4) a waitlist. A mixed-effects partitioning method was used to see if age, educational level, BMI, motivation to change, treatment history, duration of eating disorder, number of binge eating episodes in the past month, eating disorder pathology, self-efficacy, anxiety and depression, social support, or self-esteem predicted or moderated intervention outcomes in terms of eating disorder symptoms (primary outcome), and symptoms of anxiety and depression (secondary outcome). RESULTS: Higher baseline social support predicted less eating disorder symptoms 8 weeks later, regardless of condition. No variables emerged as moderator for eating disorder symptoms. Participants in the three active conditions who had not received previous eating disorder treatment, experienced larger reductions in anxiety and depression symptoms. DISCUSSION: The investigated online low-threshold interventions were especially beneficial for treatment-naïve individuals, but only in terms of secondary outcomes, making them well-suited for early intervention. The study results also highlight the importance of a supportive environment for individuals with eating disorder symptoms. PUBLIC SIGNIFICANCE: To optimize treatment recommendations it is important to investigate what works for whom. For an internet-based intervention for eating disorders developed in the Netherlands, individuals who had never received eating disorder treatment seemed to benefit more from the intervention than those who had received eating disorder treatment, because they experienced larger reductions in symptoms of depression and anxiety. Stronger feelings of social support were related to less eating disorder symptoms in the future.

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.

The ICEpop Capability Measure for Adults Instrument for Capabilities: Development of a Tariff for the Dutch General Population.

OBJECTIVES: The ICEpop Capability Measure for Adults (ICECAP-A) assesses 5 capabilities (stability, attachment, autonomy, achievement, and enjoyment) that are important to one's quality of life and might be an important addition to generic health questionnaires currently used in economic evaluations. This study aimed to develop a Dutch tariff of the Dutch translation of the ICECAP-A. METHODS: The methods used are similar to those used in the development of the UK tariff. A profile case best-worst scaling task was presented to 1002 participants from the general Dutch population. A scale-adjusted latent class analysis was performed to test for preferences of ICECAP-A capabilities and scale heterogeneity. RESULTS: A 3-preference class 2-scale class model with worst choice as scale predictor was considered optimal and was used to calculate the resulting tariff. Results indicated that the capabilities stability, attachment, and enjoyment were considered more important aspects of quality of life than autonomy and achievement. Additionally, improving capabilities from low to moderate levels had a larger effect on quality of life than improving capabilities that were already at a higher level. CONCLUSIONS: The ICECAP-A tariffs found in this study could be used in economic evaluations of healthcare interventions in The Netherlands.

Effectiveness of an online self-help program, expert-patient support, and their combination for eating disorders: Results from a randomized controlled trial.

OBJECTIVE: Many individuals with an eating disorder do not receive appropriate care. Low-threshold interventions could help bridge this treatment gap. The study aim was to evaluate the effectiveness of Featback, a fully automated online self-help intervention, online expert-patient support and their combination. METHOD: A randomized controlled trial with a 12-month follow-up period was conducted. Participants aged 16 or older with at least mild eating disorder symptoms were randomized to four conditions: (1) Featback, a fully automated online self-help intervention, (2) chat or email support from a recovered expert patient, (3) Featback with expert-patient support and (4) a waiting list control condition. The intervention period was 8 weeks and there was a total of six online assessments. The main outcome constituted reduction of eating disorder symptoms over time. RESULTS: Three hundred fifty five participants, of whom 43% had never received eating disorder treatment, were randomized. The three active interventions were superior to a waitlist in reducing eating disorder symptoms (d = -0.38), with no significant difference in effectiveness between the three interventions. Participants in conditions with expert-patient support were more satisfied with the intervention. DISCUSSION: Internet-based self-help, expert-patient support and their combination were effective in reducing eating disorder symptoms compared to a waiting list control condition. Guidance improved satisfaction with the internet intervention but not its effectiveness. Low-threshold interventions such as Featback and expert-patient support can reduce eating disorder symptoms and reach the large group of underserved individuals, complementing existing forms of eating disorder treatment. PUBLIC SIGNIFICANCE STATEMENT: Individuals with eating-related problems who received (1) a fully automated internet-based intervention, (2) chat and e-mail support by a recovered individual or (3) their combination, experienced stronger reductions in eating disorder symptoms than those who received (4) usual care. Such brief and easy-access interventions play an important role in reaching individuals who are currently not reached by other forms of treatment.

Cost-effectiveness of three internet-based interventions for eating disorders: A randomized controlled trial.

OBJECTIVE: The primary aim was assessing the cost-effectiveness of an internet-based self-help program, expert-patient support, and the combination of both compared to a care-as-usual condition. METHOD: An economic evaluation from a societal perspective was conducted alongside a randomized controlled trial. Participants aged 16 or older with at least mild eating disorder symptoms were randomly assigned to four conditions: (1) Featback, an online unguided self-help program, (2) chat or e-mail support from a recovered expert patient, (3) Featback with expert-patient support, and (4) care-as-usual. After a baseline assessment and intervention period of 8 weeks, five online assessments were conducted over 12 months of follow-up. The main result constituted cost-utility acceptability curves with quality-of-life adjusted life years (QALYs) and societal costs over the entire study duration. RESULTS: No significant differences between the conditions were found regarding QALYs, health care costs and societal costs. Nonsignificant differences in QALYs were in favor of the Featback conditions and the lowest societal costs per participant were observed in the Featback only condition (€16,741) while the highest costs were seen in the care-as-usual condition (€28,479). The Featback only condition had the highest probability of being efficient compared to the alternatives for all acceptable willingness-to-pay values. DISCUSSION: Featback, an internet-based unguided self-help intervention, was likely to be efficient compared to Featback with guidance from an expert patient, guidance alone and a care-as-usual condition. Results suggest that scalable interventions such as Featback may reduce health care costs and help individuals with eating disorders that are currently not reached by other forms of treatment. PUBLIC SIGNIFICANCE STATEMENT: Internet-based interventions for eating disorders might reach individuals in society who currently do not receive appropriate treatment at low costs. Featback, an online automated self-help program for eating disorders, was found to improve quality of life slightly while reducing costs for society, compared to a do-nothing approach. Consequently, implementing internet-based interventions such as Featback likely benefits both individuals suffering from an eating disorder and society as a whole.

The ICECAP-A instrument for capabilities: assessment of construct validity and test-retest reliability in a general Dutch population.

PURPOSE: The ICEpop CAPability measure for Adults (ICECAP-A) assesses five capabilities that are important to one's well-being. The instrument might be an important addition to generic health questionnaires when evaluating quality of life extending beyond health. This study aimed to conduct a psychometric assessment of the Dutch translation of the ICECAP-A. METHODS: Construct validity of the instrument was assessed in two ways. First, by measuring correlations with the EQ-5D-5L questionnaire and a measure of self-efficacy and, second, by investigating the ability to distinguish between groups known to differ on the construct the ICECAP-A means to capture. Additionally, test-retest reliability was evaluated. RESULTS: In total, 1002 participants representative of the general Dutch population completed an online survey. For test-retest reliability, 252 participants completed the same questionnaire 2 weeks later. The ICECAP-A indicated moderate to strong correlations with the EQ-5D-5L and a strong correlation with self-efficacy. Furthermore, it was capable of differentiating known groups. Moreover, results indicated adequate test-retest reliability with an intraclass correlation coefficient of 0.79. CONCLUSION: In summary, results suggest adequate test-retest reliability and construct validity and indicate that the ICECAP-A might be of added value, especially when considering areas outside of the traditional health intervention model.

Eating disorder psychopathology dimensions based on individual co-occurrence patterns of symptoms over time: a dynamic time warp analysis in a large naturalistic patient cohort.

PURPOSE: Most of the network approaches in eating disorders found the highest degree of centrality for symptoms related to weight and shape concerns. However, longitudinal analyses are scarce and may increase our insight of the complex characteristics and dynamics over time. In the current study, an alternative non-linear method to perform longitudinal network analyses, the dynamic time warp approach, was used to examine whether robust dimensions of eating disorder psychopathology symptoms could be found based on the individual dynamic interplay of eating disorder symptoms co-occurrence patterns in time. METHODS: The study sample included a naturalistic cohort of patients (N = 255) with all eating disorder subtypes who were assessed with the eating disorder examination questionnaire (EDE-Q) at a minimum of four times during treatment. Dynamic time warp analyses yielded distance matrices within each individual patient, which were subsequently aggregated into symptom networks and dimensions at the group level. RESULTS: Aggregation of the individual distance matrices at the group level yielded four robust symptom dimensions: 1. restraint/rules, 2. secret eating/fasting, 3. worries/preoccupation, and 4. weight and shape concern. The items 'fear of weight gain' and 'guilt' were bridge symptoms between the dimensions 1, 3 and 4. CONCLUSION: Dynamic time warp could capture the within-person dynamics of eating disorder symptoms. Sumscores of the four dimensions could be used to follow patients over time. This approach could be applied in the future to visualize eating disorder symptom dynamics and signal the central symptoms within an individual and groups of patients. LEVEL OF EVIDENCE: Level III: evidence obtained from well-designed cohort or case-control analytic studies. .

Imagine food, weight and shape: mental imagery in women with eating disorders compared with healthy controls.

BACKGROUND: Research into mental disorders has found mental imagery to be a maintaining factor for psychological distress. However, studies investigating mental imagery in eating disorders are scarce. AIM: The aim of the present study was to compare spontaneous mental imagery related to eating, weight and/or appearance and intrusive prospective imagery in women with an eating disorder with female healthy controls. METHODS: Spontaneous mental imagery and intrusive prospective imagery were assessed in adult women with an eating disorder (n = 29) and in female healthy controls (n = 32) using a semi-structured interview and the Impact of Future Events Scale, respectively. RESULTS: In comparison with healthy controls, the spontaneous mental images in individuals with an eating disorder involved more sensory modalities (U = 156.50, p < .001, r = -.51), were more vivid (t (52) = 2.04, p = .047, d = .55), negative (U = 103.00, p < .001, r = -.62), and anxiety provoking (U = 158.50, p < .001, r = -.49), and were experienced with a lower sense of control (U = 215.00, p = .009, r = -.36). The emotional impact of intrusive prospective imagery (U = 105.00, p < .001, r = -.66) was also higher in individuals with an eating disorder, as was the number of negative prospective images (U = 283.00, p = .016, r = -.31). CONCLUSIONS: Our findings are consistent with previous research on mental imagery in other psychiatric disorders, and provide possibilities for incorporating imagery-based techniques in treatment interventions.

Cognitive Remediation Therapy Does Not Enhance Treatment Effect in Obsessive-Compulsive Disorder and Anorexia Nervosa: A Randomized Controlled Trial.

BACKGROUND: Guideline-recommended therapies are moderately successful in the treatment of obsessive-compulsive disorder (OCD) and anorexia nervosa (AN), leaving room for improvement. Cognitive inflexibility, a common trait in both disorders, is likely to prevent patients from engaging in treatment and from fully benefiting from existing therapies. Cognitive remediation therapy (CRT) is a practical augmentation intervention aimed at ameliorating this impairing cognitive style prior to disorder-specific therapy. OBJECTIVE: To compare the effectiveness of CRT and a control treatment that was not aimed at enhancing flexibility, named specialized attention therapy (SAT), as add-ons to treatment as usual (TAU). METHODS: In a randomized controlled multicenter clinical trial, 71 adult patients with OCD and 61 with AN were randomized to ten twice-weekly sessions with either CRT or SAT, followed by TAU. Patients were evaluated at baseline, post-CRT/SAT, and after 6 and 12 months, with outcomes being quantified using the Yale-Brown Obsessive Compulsive Scale for OCD and the Eating Disorder Examination Questionnaire for AN. RESULTS: Across study groups, most importantly CRT+TAU was not superior to control treatment (SAT)+TAU in reducing OCD and AN pathology. Contrary to expectations, SAT+TAU may have been more effective than CRT+TAU in patients being treated for OCD. CONCLUSIONS: CRT did not enhance the effect of TAU for OCD and AN more than SAT. Unexpectedly, SAT, the control condition, may have had an augmentation effect on TAU in OCD patients. Although this latter finding may have been due to chance, the effect of SAT delivered as a pretreatment add-on intervention for adults with OCD and AN merits future efforts at replication.

Depressive symptoms rather than executive functioning predict group cognitive behavioural therapy outcome in binge eating disorder.

Executive functions play an important role in mediating self-control and self-regulation. It has been suggested that the inability to control eating in Binge Eating Disorder (BED) may indicate inefficiencies in executive functioning. This study investigated whether executive functioning predicted cognitive behavioural therapy outcome in BED while accounting for other possible predictors: depressive symptoms, interpersonal factors, eating disorder psychopathology, and self-esteem. Executive functioning and other predictors were assessed in 91 patients with BED by means of neuropsychological tests and questionnaires at baseline. Eating disorder (ED) symptoms were assessed during treatment at variable time points. Potential predictor variables were investigated using multivariate Cox regression models. Recovery was defined by means of two different indicators based on the Eating Disorder Examination-Questionnaire: (a) showing a 50% reduction in baseline symptom ED severity and/or reaching the clinical significance cut-off; and (b) achieving abstinence of objective binge eating. Severity of depressive symptoms was a significant predictor for outcome on both indicators. Patients with no or mild depressive symptoms recovered faster (i.e., 50% reduction in ED symptoms and abstinence of objective binge eating) than those with severe depressive symptoms, which is in line with previous studies. Executive functioning was not related to treatment outcome in this study.

Self-assessment of eating disorder recovery: Absence of eating disorder psychopathology is not essential.

OBJECTIVE: The definition of recovery in eating disorders (EDs) according to researchers is not necessarily similar to the patient definition. This study aimed to explore the concept of recovery as assessed by those affected by an ED themselves. METHOD: Participants from the Netherlands Eating disorder Registry (NER) who reported an (former) ED diagnosis (n = 814) assessed their own recovery level: current ED, partial or full recovery. Furthermore, research-based criteria (Bardone-Cone et al., Behaviour Research and Therapy, 2010, 48, 194-202) were applied to define recovery. Within the self-assessed full recovery group (n = 179), participants who also fulfilled the research-based criteria were compared to those who were only recovered based on self-assessment in the following domains: ED psychopathology, psychiatric comorbidity, quality of life, and social and societal participation. RESULTS: Ninety-six of the participants (54%) who considered themselves recovered did not fulfill the research-based definition. The two recovery groups did not significantly differ in psychiatric comorbidity, quality of life, and social and societal participation. DISCUSSION: Absence of ED characteristics was not essential for individuals to consider themselves recovered. Although the self-assessed recovery status may be subjective, it does advocate the use of additional health indicators besides ED psychopathology when defining recovery.

Development and Validation of a Decision Tool for Early Identification of Adult Patients with Severe and Complex Eating Disorder Psychopathology in Need of Highly Specialized Care.

Patients with complex and severe eating disorders often receive a number of ineffective or/and insufficient treatments. Direct referral of these patients to highly specialized tertiary treatment facilities in an earlier stage of the disorder is likely to be more (cost)-effective. The aim of the study was to develop a decision tool that aids clinicians in early identification of these patients. After identification of criteria that were indicative of severity and complexity of eating disorder psychopathology by means of a systematic review of literature and consultation of a focus group, a Delphi method was applied to obtain consensus from experts on the list of relevant criteria. Finally, the decision tool was validated in clinical practice, and cut-off criteria were established. The tool demonstrated good feasibility and validity to identify patients for highly specialized tertiary care. The final decision tool consisted of five criteria that can easily be implemented in clinical practice. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

E-Health Interventions for Eating Disorders: Emerging Findings, Issues, and Opportunities.

This study aimed to review the emerging findings regarding E-health interventions for eating disorders and to critically discuss emerging issues as well as challenges for future research. Internet-based cognitive behavioral therapy and guided self-help have demonstrated promising results in terms of reducing eating disorder psychopathology. Emerging findings also suggest that E-health interventions reach an underserved population and improve access to care. The use of smartphone applications is becoming increasingly popular and has much potential although their clinical utility and effectiveness is presently unknown and requires investigation. Important challenges include the diagnostic process in E-health interventions, the optimization of E-health within existing health care models, and the investigation and implementation of blended care. More high-quality research is needed to bring the field forward and to determine the place for E-health in our health care service delivery systems.

Predictors of psychological outcome in patients with eating disorders: A routine outcome monitoring study.

BACKGROUND: Identifying predictors of psychological outcome for patients with eating disorders may improve the effectiveness of treatment. Patients with different pre-treatment characteristics and symptoms may benefit from different therapies. This study aimed to identify potential predictors of treatment outcome in a large naturalistic cohort of patients with an eating disorder. METHOD: The study sample included patients (N = 1153) with all types of eating disorders who were receiving residential, day, or outpatient treatment. Remission was defined by means of four different indicators based on the Eating Disorder Examination-Questionnaire global score: 1. achieving reliable change; 2. showing a 50% reduction in baseline symptom severity; 3. reaching the clinical significance cut-off point; and 4. a combination of indicators 2 and 3. Potential predictor variables were investigated in univariate and multivariate Cox regression models. RESULTS: Different predictors were found for the four outcome criteria. Patients with high levels of interpersonal distrust at baseline were less likely to have achieved reliable change in eating disorder psychopathology. Higher self-esteem and less body dissatisfaction at baseline was independently associated with a symptom reduction of more than 50% and/or reaching the clinical significance cut-off point. Contrary to our expectations, no differences in outcome were found between the eating disorder subtypes. DISCUSSION: Clinically, it is important to reduce the risk of poor outcome and to achieve a rapid response in treatment using an intervention designed for this purpose, such as shared decision making or an intervention directed at self-esteem or body image, which may act as a catalyst for change. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:863-873).

Web-Based Fully Automated Self-Help With Different Levels of Therapist Support for Individuals With Eating Disorder Symptoms: A Randomized Controlled Trial.

BACKGROUND: Despite the disabling nature of eating disorders (EDs), many individuals with ED symptoms do not receive appropriate mental health care. Internet-based interventions have potential to reduce the unmet needs by providing easily accessible health care services. OBJECTIVE: This study aimed to investigate the effectiveness of an Internet-based intervention for individuals with ED symptoms, called "Featback." In addition, the added value of different intensities of therapist support was investigated. METHODS: Participants (N=354) were aged 16 years or older with self-reported ED symptoms, including symptoms of anorexia nervosa, bulimia nervosa, and binge eating disorder. Participants were recruited via the website of Featback and the website of a Dutch pro-recovery-focused e-community for young women with ED problems. Participants were randomized to: (1) Featback, consisting of psychoeducation and a fully automated self-monitoring and feedback system, (2) Featback supplemented with low-intensity (weekly) digital therapist support, (3) Featback supplemented with high-intensity (3 times a week) digital therapist support, and (4) a waiting list control condition. Internet-administered self-report questionnaires were completed at baseline, post-intervention (ie, 8 weeks after baseline), and at 3- and 6-month follow-up. The primary outcome measure was ED psychopathology. Secondary outcome measures were symptoms of depression and anxiety, perseverative thinking, and ED-related quality of life. Statistical analyses were conducted according to an intent-to-treat approach using linear mixed models. RESULTS: The 3 Featback conditions were superior to a waiting list in reducing bulimic psychopathology (d=-0.16, 95% confidence interval (CI)=-0.31 to -0.01), symptoms of depression and anxiety (d=-0.28, 95% CI=-0.45 to -0.11), and perseverative thinking (d=-0.28, 95% CI=-0.45 to -0.11). No added value of therapist support was found in terms of symptom reduction although participants who received therapist support were significantly more satisfied with the intervention than those who did not receive supplemental therapist support. No significant differences between the Featback conditions supplemented with low- and high-intensity therapist support were found regarding the effectiveness and satisfaction with the intervention. CONCLUSIONS: The fully automated Internet-based self-monitoring and feedback intervention Featback was effective in reducing ED and comorbid psychopathology. Supplemental therapist support enhanced satisfaction with the intervention but did not increase its effectiveness. Automated interventions such as Featback can provide widely disseminable and easily accessible care. Such interventions could be incorporated within a stepped-care approach in the treatment of EDs and help to bridge the gap between mental disorders and mental health care services. TRIAL REGISTRATION: Netherlands Trial Registry: NTR3646; http://www.trialregister.nl/trialreg/admin/ rctview.asp?TC=3646 (Archived by WebCite at http://www.webcitation.org/6fgHTGKHE).

The effectiveness of cognitive remediation therapy in patients with a severe or enduring eating disorder: a randomized controlled trial.

BACKGROUND: Individuals with eating disorders show deficits in neuropsychological functioning which might preexist and underlie the etiology of the eating disorders and influence relapse. Deficits in cognitive flexibility, i.e., set-shifting and central coherence, might perpetuate the symptoms. Cognitive remediation therapy (CRT) was developed to improve cognitive flexibility, thereby increasing the likelihood of improved outcome. The focus of CRT is on how patients think, rather than on what patients think. The present study investigated the effectiveness of CRT for patients with a severe or enduring eating disorder by means of a randomized controlled trial comparing intensive treatment as usual (TAU) to CRT plus TAU. METHODS: Eighty-two patients were randomly assigned to CRT plus TAU (n = 41) or TAU alone (n = 41). Outcome measures were set-shifting, central coherence, eating disorder and general psychopathology, motivation, quality of life and self-esteem. Assessments were performed at baseline (n = 82) and after 6 weeks (T1; n = 75) and 6 months (T2; n = 67). Data were analyzed by means of linear mixed model analyses. RESULTS: Patients who received CRT in addition to TAU improved significantly more with regard to eating disorder-related quality of life at the end of treatment (T1) and eating disorder psychopathology at follow-up (T2), compared to those who received TAU only. Moreover, moderator analyses revealed that patients with poor baseline set-shifting abilities benefited more from CRT than patients with no deficits in set-shifting abilities at baseline; the quality of life of the former group was higher than that of the latter at follow-up. CONCLUSIONS: CRT seems to be promising in enhancing the effectiveness of concurrent treatment.

Treating eating disorders over the internet: a systematic review and future research directions.

OBJECTIVE: To review the literature regarding internet-based treatment of eating disorders (ED). METHOD: Relevant studies were identified by searching electronic databases (including Medline, Embase, PsycInfo, and Web of Science). Eligible studies evaluated an internet-based treatment for ED, or an ED treatment that included at least one internet-based component. RESULTS: Twenty-one studies were included. Methodological quality varied. Internet-based treatments were superior to waiting lists in reducing ED psychopathology, frequency of binge eating and purging, and in improving (ED-related) quality of life. Internet-based treatment was more effective for individuals with less comorbid psychopathology, binge eating as opposed to restrictive problems, and individuals with binge eating disorder as opposed to bulimia nervosa. Higher levels of compliance were related to more improvements in ED symptoms. Study dropout ranged from 5.3 to 76.8%. Inclusion of face-to-face assessments and therapist support seemed to enhance study compliance. Overall, the internet can be considered an acceptable vehicle for delivering ED treatment. DISCUSSION: Future research should determine the utility of internet-based treatment by comparing them to face-to-face treatment. Research should furthermore focus on unraveling predictors and mediators of treatment outcome, compliance, and dropout, respectively. Studies with good methodological quality are needed with reports according to CONSORT guidelines.

Motives for using social networking sites: a uses & gratifications perspective amongst people with eating disorder symptoms.

Studies investigating motives for social networking sites (SNS) use amongst people with eating disorder (ED) symptoms are scarce. The uses and gratifications theory states that people actively select media content to gratify their individual needs and this may help to explain why individuals with eating disorder symptoms choose to expose themselves to specific media content and how they choose to respond. Some evidence exists that readiness to change may be a factor related to SNS use patterns in this population. The aim of the present study was to investigate the potential relationship between readiness to change ED cognitions/behaviors and SNS use motives in individuals with current or past ED symptoms, employing a uses and gratifications theory perspective. Participants were recruited from ED recovery websites; 103 individuals (16-55 years old) provided complete data. As hypothesized, ED symptom severity was inversely associated with readiness to change and time spent on (specific) SNS was not associated with ED symptom severity. The results of hierarchical regression analyses further suggested that if individuals felt less capable of overcoming their dysfunctional cognitions/behaviors about their body/eating (i.e., were less ready to change), they were more likely to be motivated to use SNSs for the purpose of impressing others and reputation management. The clinical implication is that high amounts of SNS use may not necessarily be harmful for people with EDs or recovering from EDs, whereas using SNSs for the purposes of impression management could potentially be related to being less ready to recover.

People who feel they are capable of overcoming their dysfunctional cognitions and/or behaviours about their body and/or eating, are less likely to use social networking sites for impression management purposes. Motives for social media use like popularity, self-presentation, and social expectations may potentially hinder recovery form an eating disorder. Clinicians should discuss motives of SNS use with their clients, rather than total amount of screen time, to help prevent any negative media effects.