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      E-therapy in the treatment and prevention of eating disorders: A systematic review and meta-analysis

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          Abstract

          The widespread availability of the Internet and mobile-device applications (apps) is changing the treatment of mental health problems. The aim of the present study was to review the research on the effectiveness of e-therapy for eating disorders, using the methodology employed by the UK's National Institute for Health and Care Excellence (NICE). Electronic databases were searched for published randomised controlled trials of e-therapies, designed to prevent or treat any eating disorder in all age groups. Studies were meta-analysed where possible, and effect sizes with confidence intervals were calculated. The GRADE approach was used to determine the confidence in the effect estimates. Twenty trials met the inclusion criteria. For prevention, a CBT-based e-intervention was associated with small reductions in eating disorder psychopathology, weight concern and drive for thinness, with moderate confidence in the effect estimates. For treatment and relapse prevention, various e-therapies showed some beneficial effects, but for most outcomes, evidence came from single studies and confidence in the effect estimates was low. Overall, although some positive findings were identified, the value of e-therapy for eating disorders must be viewed as uncertain. Further research, with improved methods, is needed to establish the effectiveness of e-therapy for people with eating disorders.

          Highlights

          • Systematic review of e-therapy for eating disorders was conducted using NICE methods.

          • Twenty randomised controlled trials were included, of which 14 were meta-analysed.

          • Small effects were found for CBT-based preventive e-interventions.

          • For treatment and relapse prevention there were fewer effects and of lower quality.

          • The value of e-therapy for eating disorders is uncertain.

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          Most cited references34

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          Estimation of a common effect parameter from sparse follow-up data.

          Breslow (1981, Biometrika 68, 73-84) has shown that the Mantel-Haenszel odds ratio is a consistent estimator of a common odds ratio in sparse stratifications. For cohort studies, however, estimation of a common risk ratio or risk difference can be of greater interest. Under a binomial sparse-data model, the Mantel-Haenszel risk ratio and risk difference estimators are consistent in sparse stratifications, while the maximum likelihood and weighted least squares estimators are biased. Under Poisson sparse-data models, the Mantel-Haenszel and maximum likelihood rate ratio estimators have equal asymptotic variances under the null hypothesis and are consistent, while the weighted least squares estimators are again biased; similarly, of the common rate difference estimators the weighted least squares estimators are biased, while the estimator employing "Mantel-Haenszel" weights is consistent in sparse data. Variance estimators that are consistent in both sparse data and large strata can be derived for all the Mantel-Haenszel estimators.
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            Prevention of eating disorders in at-risk college-age women.

            Eating disorders, an important health problem among college-age women, may be preventable, given that modifiable risk factors for eating disorders have been identified and interventions have been evaluated to reduce these risk factors. To determine if an Internet-based psychosocial intervention can prevent the onset of eating disorders (EDs) in young women at risk for developing EDs. San Diego and the San Francisco Bay Area in California. College-age women with high weight and shape concerns were recruited via campus e-mails, posters, and mass media. Six hundred thirty-seven eligible participants were identified, of whom 157 were excluded, for a total sample of 480. Recruitment occurred between November 13, 2000, and October 10, 2003. Intervention A randomized controlled trial of an 8-week, Internet-based cognitive-behavioral intervention (Student Bodies) that included a moderated online discussion group. Participants were studied for up to 3 years. The main outcome measure was time to onset of a subclinical or clinical ED. Secondary measures included change in scores on the Weight Concerns Scale, Global Eating Disorder Examination Questionnaire, and Eating Disorder Inventory drive for thinness and bulimia subscales and depressed mood. Moderators of outcome were examined. There was a significant reduction in Weight Concerns Scale scores in the Student Bodies intervention group compared with the control group at postintervention (P or =25, calculated as weight in kilograms divided by height in meters squared) at baseline and (2) at 1 site, participants with baseline compensatory behaviors (eg, self-induced vomiting, laxative use, diuretic use, diet pill use, driven exercise). No intervention participant with an elevated baseline BMI developed an ED, while the rates of onset of ED in the comparable BMI control group (based on survival analysis) were 4.7% at 1 year and 11.9% at 2 years. In the subgroup with a BMI of 25 or higher, the cumulative survival incidence was significantly lower at 2 years for the intervention compared with the control group (95% confidence interval, 0% for intervention group; 2.7% to 21.1% for control group). For the San Francisco Bay Area site sample with baseline compensatory behaviors, 4% of participants in the intervention group developed EDs at 1 year and 14.4%, by 2 years. Rates for the comparable control group were 16% and 30.4%, respectively. Among college-age women with high weight and shape concerns, an 8-week, Internet-based cognitive-behavioral intervention can significantly reduce weight and shape concerns for up to 2 years and decrease risk for the onset of EDs, at least in some high-risk groups. To our knowledge, this is the first study to show that EDs can be prevented in high-risk groups.
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              Treating eating disorders over the internet: a systematic review and future research directions.

              To review the literature regarding internet-based treatment of eating disorders (ED). 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. 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. 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. Copyright © 2013 Wiley Periodicals, Inc., A Wiley Company.
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                Author and article information

                Contributors
                Journal
                Behav Res Ther
                Behav Res Ther
                Behaviour Research and Therapy
                Elsevier Science
                0005-7967
                1873-622X
                1 December 2014
                December 2014
                : 63
                : 122-131
                Affiliations
                [a ]National Collaborating Centre for Mental Health (NCCMH), 21 Prescot Street, London, E1 8BB, United Kingdom
                [b ]Centre for Research on Eating Disorders at Oxford (CREDO), University Department of Psychiatry, Warneford Hospital, Oxford, OX3 7JX, United Kingdom
                Author notes
                []Corresponding author. Tel.: +44 203 701 2634. c.e.loucas@ 123456gmail.com
                Article
                S0005-7967(14)00162-4
                10.1016/j.brat.2014.09.011
                4271736
                25461787
                ceca7e60-6a8f-467d-b68e-9d4f0581fc1f
                © 2014 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

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