Dr. Peter Musiat is a postdoctoral researcher at King’s College London and Flinders University. In recent year he has focused on research into e-mental health and self-help in eating disorders. His current interests are in the prevention of common mental disorders in students and children, and in gaining insights from health data.
Existing e-therapies for eating disorders
A rationale for developing and evaluating e-therapies, i.e. technology-mediated therapy interventions for patients with eating disorders, is that they have shown to be more suitable for self-help intervention than other disorders (Musiat & Schmidt, 2010). A level of convenience, accessibility, familiarity and anonymity exists with the use of e-therapies. As adolescents and young adults are an at-risk group for eating disorders, engaging with e-therapies can utilise their high familiarity with technology and encourage safe help-seeking.
There have been numerous studies investigating web-based intervention for the prevention of eating disorders (Beintner, Jacobi, & Taylor, 2011), but far fewer controlled studies have been published with regard to e-therapies for eating disorders, i.e. technology-mediated therapies (Loucas et al., 2014; Wagner et al., 2015). Early interventions were delivered via CDROM (Schmidt et al., 2008) and later translated for web-based delivery (Sánchez-Ortiz et al., 2011). E-therapies for eating disorders are associated with small to medium improvements in eating disorder pathology and, in the case of intervention for bulimia nervosa, Sanchez-Ortiz et al. (2011) found that up to one in four patients report no bingeing and/or purging after e-therapy. Although these results highlight some difficulties of treating eating disorders through e-therapies, these interventions may provide valuable support to those who do not wish to engage in or have no access to face-to-face treatment.
Over the past years, it has been highlighted that mobile applications may hold potential for supporting the treatment of eating disorders (Ambwani, Cardi, & Treasure, 2014). Although there are currently several hundred free and paid mobile applications for mental health available in popular app stores, most of these are not targeted toward individuals suffering from eating disorders (Donker et al., 2013). In addition, a plethora of apps are available that promote weight loss, or help users to meticulously monitor physical activity and food intake, which can be harmful to those experiencing or at risk of developing an eating disorder. A recent comprehensive review of mobile apps for eating disorders identified 39 apps specifically targeting sufferers and five apps targeting clinicians working with eating disorders (Fairburn & Rothwell, 2015). Although many of these apps provided information, only two were found to provide good information and three were found to be positively misleading. Results were similar with regard to the quality of treatment or advice provided by these apps (Fairburn & Rothwell, 2015).
Another review investigated the extent to which mobile apps offering eating disorder interventions are based on evidence-based principles (Juarascio, Manasse, Goldstein, Forman, & Butryn, 2015). It was found that apps designed to provide interventions for eating disorders did not use evidence-based principles and failed to utilise the capabilities of today’s smartphones, such as providing monitoring tools, prompting, or personalised content. However, some preliminary evidence for the utility of mobile applications in eating disorders is emerging. Darcy, Adler, Miner, and Lock (2014) investigated the clinical utility of a food-monitoring app during outpatient treatment for eating disorders and found that although patients used the app to a different extent, on balance, it facilitated the recording of intake better than pen-and-paper methods. The results from these studies highlight that there is still a huge knowledge gap with regard to developing high-quality evidence-based interventions and their efficacy for prevention, treatment, or aftercare.
Challenges faced in designing a e-therapies for eating disorders
Many of the challenges associated with designing e-therapy interventions for eating disorders are not unique to eating disorders, but are inherent to designing e-therapies for other mental illnesses. Although individuals using these interventions often report high satisfaction, they represent a minority of those that choose to engage with such interventions in the first place (Waller & Gilbody, 2009). A particular study found that although computerised treatments and smartphone applications were reported as more convenient to access compared to face to face support, participants had lower expectations and were less likely to engage with e-therapies for mental health (Musiat, Goldstone, & Tarrier, 2014). This highlights a need to improve public perception of e-therapies, in order to increase uptake. Once using e-therapies, intervention adherence is often low (Christensen, Griffiths, & Farrer, 2009) and dropout is high (Melville, Casey, & Kavanagh, 2010). A high dropout rate is problematic in accurately recording the effect of e-therapies on eating disorder symptomatology. Some evidence suggests that patients with bulimia that have a higher motivation to change, higher harm-avoidance, higher drive for thinness, lower frequency of binge eating, lower body dissatisfaction, lower BMI, and higher self-esteem are more likely to complete and benefit from e-therapies for BN (Högdahl, Birgegård, & Björck, 2013). However, more research is required to investigate how e-therapies can be developed to engage patients, motivate them to change and persist with recovery (Aardoom, Dingemans, & Van Furth, 2016).
Given the rapid changes in technology, it is hard to predict the future for e-therapies in eating disorders. However, some trends have already emerged and are likely to continue. To harness the potential of existing web-based treatments for eating disorders, there is a need to make these more accessible to those living with an eating disorder. Countries, such as Sweden and the Netherlands have successfully embedded e-therapies for mental illnesses into stepped-care, as well as so-called blended-care approaches, in which e-therapies are integrated into ongoing outpatient treatment (Wilhelmsen et al., 2013). It is likely that more high-quality mobile apps for eating disorders will emerge and that there will be increasing evidence for the effectiveness of those. With regard to technology-mediated intervention for eating disorders in general, there is an emerging trend for intervention supporting particular aspects of recovery, e.g. to increase motivation to change (Hötzel et al., 2014) or to support patients through meal times (Cardi, Clarke, & Treasure, 2013).
Aardoom, J. J., Dingemans, A. E., & Van Furth, E. F. (2016). E-Health Interventions for Eating Disorders: Emerging Findings, Issues, and Opportunities. Current Psychiatry Reports, 18(4), 1-8.
Ambwani, S., Cardi, V., & Treasure, J. (2014). Mobile self-help interventions for anorexia nervosa: Conceptual, ethical, and methodological considerations for clinicians and researchers. Professional Psychology: Research and Practice, 45(5), 316.
Beintner, I., Jacobi, C., & Taylor, C. B. (2011). Effects of an Internet-based Prevention Programme for Eating Disorders in the USA and Germany - A Meta-analytic Review. European Eating Disorders Review.
Cardi, V., Clarke, A., & Treasure, J. (2013). The Use of Guided Self‐help Incorporating a Mobile Component in People with Eating Disorders: A Pilot Study. European Eating Disorders Review, 21(4), 315-322.
Christensen, H., Griffiths, K. M., & Farrer, L. (2009). Adherence in internet interventions for anxiety and depression: systematic review. Journal of Medical Internet Research, 11(2), e13.
Darcy, A. M., Adler, S., Miner, A., & Lock, J. (2014). How smartphone applications may be implemented in the treatment of eating disorders: case reports and case series data. Advances in Eating Disorders: Theory, Research and Practice, 2(3), 217-232.
Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, M.-R., & Christensen, H. (2013). Smartphones for smarter delivery of mental health programs: a systematic review. Journal of Medical Internet Research, 15(11), e247.
Fairburn, C. G., & Rothwell, E. R. (2015). Apps and eating disorders: A systematic clinical appraisal. International Journal of Eating Disorders, 48(7), 1038-1046.
Högdahl, L., Birgegård, A., & Björck, C. (2013). How effective is bibliotherapy-based self-help cognitive behavioral therapy with Internet support in clinical settings? Results from a pilot study. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 18(1), 37-44.
Hötzel, K., von Brachel, R., Schmidt, U., Rieger, E., Kosfelder, J., Hechler, T., . . . Vocks, S. (2014). An internet-based program to enhance motivation to change in females with symptoms of an eating disorder: a randomized controlled trial. Psychological Medicine, 44(09), 1947-1963.
Juarascio, A. S., Manasse, S. M., Goldstein, S. P., Forman, E. M., & Butryn, M. L. (2015). Review of smartphone applications for the treatment of eating disorders. European Eating Disorders Review, 23(1), 1-11.
Loucas, C. E., Fairburn, C. G., Whittington, C., Pennant, M. E., Stockton, S., & Kendall, T. (2014). E-therapy in the treatment and prevention of eating disorders: A systematic review and meta-analysis. Behaviour Research and Therapy, 63, 122-131.
Melville, K. M., Casey, L. M., & Kavanagh, D. J. (2010). Dropout from Internet-based treatment for psychological disorders. British Journal of Clinical Psychology, 49(4), 455-471.
Musiat, P., Goldstone, P., & Tarrier, N. (2014). Understanding the acceptability of e-mental health - attitudes and expectations towards computerised self-help treatments for mental health problems. BMC Psychiatry, 14(1), 109.
Musiat, P., & Schmidt, U. (2010). Self-help and stepped care in eating disorders. In W. Stewart Agras (Ed.), The Oxford handbook of eaing disorders (pp. 386-401). New York: Oxford University Press.
Sánchez-Ortiz, V., Munro, C., Stahl, D., House, J., Startup, H., Treasure, J., . . . Schmidt, U. (2011). A randomized controlled trial of internet-based cognitive-behavioural therapy for bulimia nervosa or related disorders in a student population. Psychological Medicine, 41(02), 407-417.
Schmidt, U., Andiappan, M., Grover, M., Robinson, S., Perkins, S., Dugmore, O., . . . Williams, C. (2008). Randomised controlled trial of CD–ROM-based cognitive–behavioural self-care for bulimia nervosa. The British Journal of Psychiatry, 193(6), 493-500.
Wagner, G., Penelo, E., Nobis, G., Mayrhofer, A., Wanner, C., Schau, J., . . . Imgart, H. (2015). Predictors for Good Therapeutic Outcome and Drop‐out in Technology Assisted Guided Self‐Help in the Treatment of Bulimia Nervosa and Bulimia like Phenotype. European Eating Disorders Review, 23(2), 163-169.
Waller, R., & Gilbody, S. (2009). Barriers to the uptake of computerized cognitive behavioural therapy: a systematic review of the quantitative and qualitative evidence. Psychological Medicine, 39(05), 705-712.
Wilhelmsen, M., Lillevoll, K., Risør, M. B., Høifødt, R., Johansen, M.-L., Waterloo, K., . . . Kolstrup, N. (2013). Motivation to persist with internet-based cognitive behavioural treatment using blended care: a qualitative study. BMC Psychiatry, 13(1), 1.
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