An overview and investigation of relapse predictors in anorexia nervosa: A systematic review and meta-analysis.

OBJECTIVE: An extensive number of predictors has been examined across the literature to improve knowledge of relapse in anorexia nervosa (AN). These studies provide various recovery and relapse definitions, follow-up durations and relapse rates. The current study summarizes these values and predictors of relapse in AN in a review and meta-analysis. METHOD: The study was executed according to PRISMA guidelines. Different databases were searched and studies in which participants did not receive an official clinical diagnosis were excluded. A quality analysis was performed using the National Institute of Health's Study Quality Assessment Tool. Random-effects meta-analyses were conducted to summarize data. RESULTS: Definitions of relapse and recovery were diverse. During an average follow-up period of 31 months an average relapse rate of 37% was found. Predictive variables from 28 studies were grouped in six categories: age and sex, symptoms and behaviors, AN subtype and duration, weight or weight change, comorbidity, and personality. The studies were characterized by non-significant and contradictory results. Meta-analyses were performed for the predictors age, AN duration, pre-treatment BMI, post-treatment BMI and depression. These yielded significant effects for post-treatment BMI and depression: higher pre-treatment depression (SMD = .40 CI [.21-.59] and lower post-treatment BMI (SMD = -.35 CI [-.63 to -.07]) increased relapse chances in AN. DISCUSSION: Our results emphasized a lack of sufficiently powered studies, consistent results, and robust findings. Solely post-treatment BMI and pre-treatment depression predicted relapse. Future research should use uniform definitions, larger samples and better designs, to improve our understanding of relapse in AN. PUBLIC SIGNIFICANCE: Knowledge about predictors is important to understand high relapse rates. Our study performed a review and meta-analysis of relapse predictors in AN. Related to the heterogeneity in studies examining predictors, an overview of relapse and recovery definitions, follow-up durations and relapse rates for AN was provided. Significant effects were found for post-treatment BMI and pre-treatment depression. More studies with uniform definitions are needed to improve clinical implications.

OBJETIVO: En la literatura se ha examinado un amplio número de predictores para mejorar el conocimiento de la recaída en la anorexia nerviosa (AN). Estos estudios proporcionan diversas definiciones de recuperación y recaída, duraciones del seguimiento y tasas de recaída. El presente estudio resume estos valores y predictores de recaída en AN en una revisión y metaanálisis. MÉTODO: El estudio se realizó siguiendo las directrices PRISMA. Se realizaron búsquedas en diferentes bases de datos y se excluyeron los estudios en los que los participantes no recibieron un diagnóstico clínico oficial. Se realizó un análisis de calidad mediante la herramienta de evaluación de la calidad de los estudios del Instituto Nacional de Salud. Se realizaron metaanálisis de efectos aleatorios para resumir los datos. RESULTADOS: Las definiciones de recaída y recuperación fueron diversas. Durante un período de seguimiento promedio de 31 meses se encontró una tasa media de recaída del 37%. Las variables predictivas de 28 estudios se agruparon en seis categorías: edad y sexo, síntomas y conductas, subtipo y duración de la AN, peso o cambio de peso, comorbilidad y personalidad. Los estudios se caracterizaron por resultados no significativos y contradictorios. Se realizaron metaanálisis para los predictores edad, duración de la AN, IMC pretratamiento, IMC postratamiento y depresión. Éstos arrojaron efectos significativos para el IMC postratamiento y la depresión: una mayor depresión pretratamiento (DME = −,40; IC: [21 a, 59] y un menor IMC postratamiento (DME = −,35; IC: [−,63 a −,07]) aumentaron las probabilidades de recaída en la AN. DISCUSIÓN: Nuestros resultados enfatizaron la falta de estudios con suficiente potencia, resultados consistentes y hallazgos robustos. Sólo el IMC postratamiento y la depresión pretratamiento predijeron la recaída. Las investigaciones futuras deberían utilizar definiciones uniformes, muestras más grandes y mejores diseños, para mejorar nuestra comprensión de la recaída en la AN.

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.

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.

Predictors of recovery in eating disorders: A focus on different definitions.

OBJECTIVE: Only half of the patients with eating disorders (EDs) fully recover. To increase these rates, knowledge about predictors is essential. Previous studies found that purging behaviors, BMI, ED duration, and depression, predicted symptomatic ED recovery. The current study investigated these four predictors for symptomatic improvement and the subjective experience of recovery. METHOD: Participants who completed the baseline and second wave of the Netherlands Eating disorder Registry (NER) (N = 374), were categorized into: (1) Subjective recovery; (2) Clinical improvement; (3) Symptomatic recovery. Using regression analyses, it was investigated if the four baseline factors predicted recovery at wave two. Effects were compared among a binge-purging and restricting group. RESULTS: In total, 136 participants were subjectively recovered, 135 showed clinical improvement, and 70 were symptomatically recovered. Overlap occurred between definitions. Lower depression scores predicted subjective recovery (OR 0.77, p < .001) and clinical improvement (OR 0.80, p < .001), and shorter ED duration predicted all definitions (OR 0.99, p < .001; OR 0.99, p < .001; OR 0.99, p = .013). Similar effects were found in the binge-purging group. DISCUSSION: Our study emphasized that the same predictors, like depression, apply to symptomatic improvement and the personal experience of recovery. Depression appears an important factor during ED treatment. PUBLIC SIGNIFICANCE: Recovery rates for EDs are low. To understand this, knowledge about predictors of ED recovery is essential. This study examined the effects of four established predictors across symptomatic improvement and subjective recovery (a more personal experience of recovery). Lower depression scores predicted both, indicating that depression appears important for multiple definitions of recovery and therefore warrants attention during ED treatment.

Economic evaluation of web-based guided self-help cognitive behavioral therapy-enhanced for binge-eating disorder compared to a waiting list: A randomized controlled trial.

INTRODUCTION: The aim is to perform an economic evaluation alongside a randomized controlled trial comparing guided self-help cognitive behavioral therapy-enhanced (CBT-E) for binge-eating disorder (BED) to a waiting list control condition. METHODS: BED patients (N = 212) were randomly assigned to guided self-help CBT-E or the 3-month waiting list. Measurements took place at baseline and the end-of-treatment. The cost-effectiveness analysis was performed using the number of binge-eating episodes during the last 28 days as an outcome indicator according to the eating disorder examination. A cost-utility analysis was performed using the EuroQol-5D. RESULTS: The difference in societal costs over the 3 months of the intervention between both conditions was €679 (confidence interval [CI] 50-1330). The incremental costs associated with one incremental binge eating episode prevented in the guided self-help condition was approximately €18 (CI 1-41). From a societal perspective there was a 96% likelihood that guided self-help CBT-E led to a greater number of binge-eating episodes prevented, but at higher costs. Each additional quality-adjusted life year (QALY) gained was associated with incremental costs of €34,000 (CI 2494-154,530). With a 95% likelihood guided self-help CBT-E led to greater QALY gain at higher costs compared to waiting for treatment. Based on the National Institute for Health and Clinical Excellence willingness-to-pay threshold of €35,000 per QALY, guided self-help CBT-E can be considered cost-effective with a likelihood of 95% from a societal perspective. DISCUSSION: Guided self-help CBT-E is likely a cost-effective treatment for BED in the short-term (3-month course of treatment). Comparison to treatment-as-usual is recommended for future research, as it enables an economic evaluation with a longer time horizon. PUBLIC SIGNIFICANCE: Offering treatment remotely has several benefits for patients suffering from binge-eating disorders. Guided self-help CBT-E is an efficacious and likely cost-effective treatment, reducing binge eating and improving quality-of-life, albeit at higher societal costs.

Course and predictors of eating disorder symptoms, anxiety symptoms, and pandemic-related eating disorder concerns among adults with eating disorders during the first year of the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic and public health mitigation measures have negatively impacted individuals with eating disorders (ED). We evaluated changes in and predictors of ED symptoms, pandemic-related ED concerns, and anxiety symptoms across the first 12 months of the COVID-19 pandemic among individuals with self-reported EDs in the United States (US), Sweden (SE), and the Netherlands (NL). METHOD: Participants in the US (N = 510), SE (N = 982), and NL (N = 510) completed an online survey assessing ED symptoms (binge eating, restriction, compensatory behaviors, and anxiety about being unable to exercise), general anxiety symptoms, and pandemic-related ED concerns about accessing food, lack of structure and social support, being in a triggering environment, and food and treatment costs. In the US and NL, respondents completed surveys beginning April 2020 and continuing monthly for a year. In SE, respondents completed baseline surveys in May 2020, a six-month follow-up around December 2020, and a 12-month follow-up in May 2021. RESULTS: Three patterns emerged: (1) a curvilinear course with the highest level of symptoms at baseline, declining through November 2020, and increasing through the rest of the year; (2) a linear declining course over time; and (3) a stable course with no changes. Worries about COVID-19 infection, lockdown, concerns about lack of structure and social support, and concerns about accessing food consistent with one's recovery meal plan predicted increases in ED symptoms. DISCUSSION: ED symptoms tracked with pandemic-related concerns in people with EDs. Conceptualizing predictors of symptoms may inform therapy and public health resources that reduce the impact of pandemics on mental health. PUBLIC SIGNIFICANCE: Our findings suggest that the COVID-19 pandemic had negative impacts on people with eating disorders, including amplification of mental health symptoms and stressors around peak periods of infection and COVID-19 restrictions. These findings inform medical providers, policy-makers, and community-based supports about the information and resource needs of this group to ensure efficient dissemination in future public health emergencies and during the ongoing COVID-19 pandemic.

Longer-term impact of COVID-19 among individuals with self-reported eating disorders in the United States, the Netherlands, and Sweden.

OBJECTIVE: We assessed eating disorder (ED) illness status, symptomatology, treatment access, anxiety, and depression in the first year of the COVID-19 pandemic among individuals with a pre-existing ED in the United States (US), the Netherlands (NL), and Sweden (SE). METHODS: Participants completed online surveys in April-July 2020, at the early stage of the pandemic, and one year later. At one-year follow-up, we added questions addressing retrospective changes in ED symptoms, treatment, and anxiety/depression since the start of the COVID-19 pandemic. We present descriptive statistics and assess change in ED symptomatology, treatment, and anxiety/depression among those with an active or lingering ED. RESULTS: Participants (US n = 132; NL n = 219; SE n = 702) were mostly young and female with a history of anorexia nervosa (>60% in all three countries). Across countries, respondents reported impact of COVID-19 on ED symptoms at both time points, with improvement in US and NL at one-year follow-up, and stable but less impact on ED symptoms in SE. Furthermore, at one-year follow-up, roughly half of those in treatment reported reduced treatment access and quality, and the majority of the sample reported increased anxiety and depressive mood since the start of the pandemic. DISCUSSION: Our findings suggest that the self-perceived impact of COVID-19 changed over time but remained concerning even one year after the start of the pandemic. Clinicians, community organizations, and policy makers are encouraged to address potentially changing treatment needs in the face of public health emergency events. PUBLIC SIGNIFICANCE: Our findings suggest that the impact of COVID-19 on individuals with eating disorders decreased over time but remained concerning even one year after the start of the pandemic and that the impact differed across countries. Clinicians, community organizations, and policy makers are encouraged to incorporate this knowledge to address potentially changing treatment needs in the face of public health emergency events.

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 examination questionnaire (EDE-Q): validity and norms for Saudi nationals.

PURPOSE: The aim of this study was to develop an Arabic version of the EDE-Q and to assess its psychometric properties and utility as a screener in the Saudi population. An additional aim was to establish EDE-Q norms for Saudis. METHOD: EDE-Q data were collected in a convenience sample of the Saudi community (N = 2690), of which a subset was also subjected to the EDE interview (N = 98). Various models for the factor structure were evaluated on their fit by CFA. With ROC analysis, the AUC was calculated to test how well the EDE-Q discriminated between Saudis at high and low risk for eating disorders. RESULTS: The original four factor model of the EDE-Q was not supported. Best fit was found for a three factor model, including the weight/shape concern scale, dietary restraint scale and eating concern scale. The ROC analysis showed that the EDE-Q could accurately discriminate between individuals at high and low risk for an eating disorder according to the EDE interview. Optimal cut off of 2.93 on the global score yielded a sensitivity of 82% and specificity of 80%. EDE-Q scores were fairly associated with BMI. DISCUSSION: Psychometric characteristics of the Saudi version of the EDE-Q were satisfactory and results support the discriminant and convergent validity. Severity level of eating disorder pathology can be determined by the EDE-Q global score. Global scores were high compared to what is found in Western community samples, leading to high prevalence estimates for Saudis at high risk for eating disorders. LEVEL OF EVIDENCE: Not applicable, empirical psychometric study.

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.

Early impact of COVID-19 on individuals with self-reported eating disorders: A survey of ~1,000 individuals in the United States and the Netherlands.

OBJECTIVE: We evaluated the early impact of COVID-19 on people with self-reported eating disorders. METHOD: Participants in the United States (US, N = 511) and the Netherlands (NL, N = 510), recruited through ongoing studies and social media, completed an online survey that included both quantitative measures and free-text responses assessing the impact of COVID-19 on situational circumstances, eating disorder symptoms, eating disorder treatment, and general well-being. RESULTS: Results revealed strong and wide-ranging effects on eating disorder concerns and illness behaviors that were consistent with eating disorder type. Participants with anorexia nervosa (US 62% of sample; NL 69%) reported increased restriction and fears about being able to find foods consistent with their meal plan. Individuals with bulimia nervosa and binge-eating disorder (US 30% of sample; NL 15%) reported increases in their binge-eating episodes and urges to binge. Respondents noted marked increases in anxiety since 2019 and reported greater concerns about the impact of COVID-19 on their mental health than physical health. Although many participants acknowledged and appreciated the transition to telehealth, limitations of this treatment modality for this population were raised. Individuals with past histories of eating disorders noted concerns about relapse related to COVID-19 circumstances. Encouragingly, respondents also noted positive effects including greater connection with family, more time for self-care, and motivation to recover. DISCUSSIONS: COVID-19 is associated with increased anxiety and poses specific disorder-related challenges for individuals with eating disorders that require attention by healthcare professionals and carers.

A framework to conceptualize personal recovery from eating disorders: A systematic review and qualitative meta-synthesis of perspectives from individuals with lived experience.

BACKGROUND: An extensive literature exists describing treatment interventions and recovery from eating disorders (EDs); however, this body of knowledge is largely symptom-based and from a clinical perspective and thus limited in capturing perspectives and values of individuals with lived experience of an ED. In this study, we performed a systematic review to coproduce a conceptual framework for personal recovery from an ED based on primary qualitative data available in published literature. METHODS: A systematic review and qualitative meta-synthesis approach was used. Twenty studies focusing on ED recovery from the perspective of individuals with lived experience were included. The studies were searched for themes describing the components of personal recovery. All themes were analyzed and compared to the established connectedness; hope and optimism about the future; identity; meaning in life; and empowerment (CHIME) and Substance Abuse and Mental Health Services Administration (SAMHSA) frameworks of recovery, which are applicable to all mental disorders. Themes were labeled and organized into a framework outlining key components of the ED personal recovery process. RESULTS: Supportive relationships, hope, identity, meaning and purpose, empowerment, and self-compassion emerged as the central components of the recovery process. Symptom recovery and its relationship to the personal recovery process are also significant. DISCUSSION: Individuals with lived experience of EDs noted six essential elements in the personal ED recovery process. This framework is aligned with several of the key components of the CHIME and SAMHSA frameworks of recovery, incorporating person-centered elements of the recovery process. Future research should validate these constructs and develop instruments (or tools) that integrate the lived experiences into a measurement of recovery from an ED.

ANTECEDENTES: Existe una extensa literatura que describe las intervenciones de tratamiento y la recuperación de los trastornos de la conducta alimentaria (TCA); sin embargo, este conjunto de conocimientos se basa en gran medida en los síntomas y además desde una perspectiva clínica y, por lo tanto, es limitado para capturar las perspectivas y los valores de las personas con experiencia vivida de un TCA. En este estudio, realizamos una revisión sistemática para coproducir un marco conceptual para la recuperación personal de un TCA basado en datos cualitativos primarios disponibles en la literatura publicada. MÉTODOS: Se utilizó una revisión sistemática y un enfoque de meta-síntesis cualitativa. Se incluyeron veinte estudios centrados en la recuperación del TCA desde la perspectiva de individuos con experiencia vivida. Se buscaron en los estudios temas que describieran los componentes de la recuperación personal. Todos los temas fueron analizados y comparados con los marcos de recuperación establecidos de CHIME y SAMHSA, que son aplicables a todos los trastornos mentales. Los temas fueron etiquetados y organizados en un marco que describe los componentes clave del proceso de recuperación personal del TCA. RESULTADOS: las relaciones de apoyo, la esperanza, la identidad, el significado y el propósito, el empoderamiento y la autocompasión surgieron como los componentes centrales del proceso de recuperación. La recuperación de los síntomas y su relación con el proceso de recuperación personal también es significativa. CONCLUSIONES: Las personas con experiencia vivida de un TCA destacaron por seis elementos esenciales en el proceso personal de recuperación del TCA. Este marco está alineado con varios de los componentes clave de los marcos de recuperación de CHIME y SAMHSA, incorporando elementos centrados en la persona del proceso de recuperación. La investigación futura debería validar estos constructos y desarrollar instrumentos (o herramientas) que integren las experiencias vividas en una medición de recuperación de un TCA.

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.