ICBT for Eating Disorders

Study

Population

Conditions

Duration

Effect size

Within groups

Between groups

Grover et al. (2011)

Carers of people with AN (n = 64)

Overcoming Anorexia Online with limited clinician supportive guidance (by e-mail or phone) or usual care

4 months

6-month follow-up

Not reported

Fichter et al. (2012)

Participants (n = 258 females) with AN

ICBT/relapse prevention (RP)

TAU

9 months

No follow-up

Not reported

Hoyle et al. (2013)

Carers of people with AN (n = 37)

Participants (n = 17) with AN

Overcoming Anorexia Online

Guidance (OAO-G) vs no guidance (OAO-NoG)

7 weeks

3-month follow-up

OAO-G: level of expressed emotion (pre to post d = 0.50, pre to follow-up d = 0.60), ED impact scale (pre to post d = 0.13, pre to follow-up d = 0.11), starvation (pre to post d = 0.37, pre to follow-up d = 0.57), bulimic behaviours (pre to post d = 0.07, pre to follow-up d = 0.39)

OAO-NoG: Level of Expressed Emotion (pre to post d = 0.07, pre to follow-up d = 0.11), ED impact scale (pre to post d = 0.34, pre to follow-up d = 0.49), starvation (pre to post d = 0.61, pre to follow-up d = 0.79), bulimic behaviours (pre to post d = 0.20, pre to follow-up d = 0.05)

Not reported

Shapiro et al. (2007)

Participants (n = 66) with BED

CBT (CD-ROM)

CBT (group)

WLC

10 weeks

18-week follow-up

Not reported

Ljotson et al. (2007)

Participants (n = 65 females, n = 4 males) with full or subthreshold BN or BED

Internet-based guided self-help (IB-GSH)

WLC

3 months

6-month follow-up

Not reported

EDE-Q global (post d = 1.15)

Objective binge eating episodes (post d = 0.68)

Jones et al. (2008)

Participants (n = 73 females, n = 32 males) with full or subthreshold BED

ICBT

WLC

16 weeks

9-month follow-up

Binge eating episodes (pre to post d = −0.93, pre to follow-up d = −0.80)

BMI, all binge eating episodes (follow-up d = 0.06)

Robinson and Serfarty (2008)

Participants (n = 93 females, n = 4 males) with BN, BED or EDNOS

E-mail behavioural therapy

Unguided self-directed writing

WLC

3 months

No follow-up

Not reported

ET vs USW: none

USW vs WLC none

Carrard et al. (2011a)

Participants (n = 74 females) with full or subthreshold BED

ICBT

WLC

6 months

6-month follow-up

EDE-Q global (pre to post d = −1.19), objective binge eating episodes (pre to post d = −0.95)

EDE-Q global (post d = 0.3), objective binge eating episodes (post d = 0.45)

Sánchez-Ortiz et al. (2011a, b)

Participants (n = 76 females) with BN or EDNOS

ICBT

WLC

3 months

3-month follow-up

EDE global (pre to post d = −1.29, pre to follow-up d = −1.75), objective binge eating episodes (pre to post d = −0.80, pre- to follow-up d = −1.07), self-induced vomiting (pre to post d = −0.49, pre to follow-up d = −0.76), purging episodes (pre to post d = −0.60, pre to follow-up d = −0.87)

EDE global (post d = 1.2, follow-up d = 0.99), objective binge eating episodes (post d = 0.40)

Jacobi et al. (2012)

Participants (n = 126 females) with subthreshold ED

ICBT

WLC

8 weeks

6-month follow-up

Not reported

EDE-Q global (follow-up d = 0.50), binge episodes (follow-up d = 0.43), purging episodes (follow-up d = 0.33)

Ruwaard et al. (2012)

Participants (n = 104 females, n = 1 male) with full or subthreshold ED

ICBT

Unguided self-help (USH, book-based)

WLC

20 weeks

1-year follow-up

EDE-Q global (pre to post d = −1.22, pre to follow-up d = −1.17), binge eating (pre to post d = −1.04, pre to follow-up d = −0.96), purging (pre to post d = −0.75, pre to follow-up d = −0.66)

ICBT vs WLC:

EDE-Q global (post d = 0.51), binge eating (post d = 0.44), purging (post d = 0.45)

ICBT vs USH:

EDE-Q global (post d = 0.37), binge eating (post d = 0.72), purging (post d = 0.53)

USH vs WLC:

none

Wagner et al. (2013)

Participants (n = 155 females) with BN purging type or EDNOS with binge eating or purging

ICBT

Guided bibliotherapy (BIB-GSH)

4–7 months

7- and 18-month follow-up

Objective binge eating (pre to post d = −0.24, pre to follow-up 7 d = −0.32, follow-up 18 d = −0.49)

Purging episodes (pre to post d = −0.33, pre to follow-up 7 d = −0.36, follow-up 18 d = −0.53), laxative misuse (pre to follow-up 18 d = −0.18), excessive exercise (pre to follow-up 18 d = −0.38), fasting (pre to post d = −0.40, pre to follow-up 7 d = −0.41, follow-up 18 d = −0.61

None

Reviewed trials differ in the populations studied (adults, adolescents, BN or BED and full or partial syndromes); the care settings involved (primary, secondary or tertiary); the availability, intensity and duration of guidance provided; the type of guidance offered (face-to-face, phone or e-mail); and the expertise and training of self-help guides. Nonetheless, evidence suggests that Internet-based self-help CBT interventions are clearly superior to waiting list control in reducing ED psychopathology and frequency of binge eating and purging and in improving ED-related quality of life (Campbell et al. 2011). Self-help ICBT treatments were also found to be more effective for individuals with less co-morbid psychopathology, binge eating as opposed to restrictive problems and individuals with binge eating disorder as opposed to bulimia nervosa (Campbell et al. 2011). This is further supported by the fact that BED patients were found to complete self-help programmes more often than BN patients and to benefit more as a result (Winn et al. 2004). Furthermore, online interventions reduce the risk of therapeutic drift, given their reliance on written and online materials.

ICBT programmes for eating disorders differ in terms of the level of guidance offered to users. Some programmes include regular e-mail or phone guidance, whereas others are unguided forms of intervention whereby the users complete sessions themselves at their own pace. Research shows that Internet-based self-help programmes that are delivered with guidance are as effective as the ‘gold-standard’ therapist-aided individual CBT in reducing or stopping bulimic symptoms with gains maintained over follow-up (Winn et al. 2004). Specifically, abstinence from binging was observed in more patients receiving guided forms of ICBT compared to unguided programmes. Guided programmes are also associated with better ED outcomes in terms of reductions in weight and shape concern, restraint and frequency of binge episodes (Winn et al. 2004). Furthermore, it was found that inclusion of face-to-face assessment and support from therapists enhanced study compliance, with higher levels of adherence predicting better ED outcomes (Campbell et al. 2011). Across studies, the study dropout rate is 16 % for Internet interventions, which is lower than self-help delivery in other forms such as CD-ROM (30 %) or bibliotherapy (29 %) (Winn et al. 2004). Another systematic review of self-help ICBT interventions found that study dropout rates ranged from 5.3 to 76.8 % (Campbell et al. 2011).

Case Description

Case History

The Problem

Holly is a 21-year-old university student with a 9-month history of bulimia nervosa. She typically eats little during the day (no breakfast, a salad for lunch and for dinner) but binges and vomits most evenings and often all day at the weekend.

Background

Both Holly’s maternal grandparents were obese, and as long as Holly could remember, her mother had struggled with her weight and had been on diets. Holly was plump as a child, and when she reached puberty, her mother tried to impress on her that she had inherited the family’s tendency to obesity and therefore needed to watch what she ate. Her younger brother would at times call her ‘fat legs’. Throughout her teens Holly was very sensitive about her weight and appearance and disliked her legs and tummy.

When Holly started university studies, she made new friends who accepted her for who she was and for a period her weight and appearance seemed to matter less. She also had a nice boyfriend a couple of years older than her who she got on very well with. However, when he finished university studies (2 years ahead of her), he decided to take up the offer of a job in New Zealand and said to her that because of the distance involved they should now finish their relationship. Holly felt very hurt and rejected and began to dwell on what was wrong with her and that perhaps he had ‘ditched’ her because she was ‘too fat’. She went on a strict diet and enrolled in daily exercise classes. Six 6 months later she had lost so much weight that her periods became irregular and her best friend said she looked scrawny. Holly was now living on salad and water and not much else. Having always been a good student, she found it much harder to concentrate, plagued as she was by thoughts about food and weight. She disliked her legs and tummy more than ever. She did much less well in her second year exams than expected and was very disappointed. One night Holly got very drunk and then went on a big food binge. ‘I no longer had the will power to control myself constantly’, Holly said. After this, regular binges set in and soon after she began to make herself sick after each binge to compensate. Binges became more frequent and more prolongued. Her weight rapidly increased, beyond her previous highest weight. Holly felt desperately out of control and consulted her general practitioner.

Assessment and Treatment

Holly was referred to a specialist eating disorder unit where she was seen for an initial assessment and given the diagnosis of bulimia nervosa. She was found to be anaemic and to have somewhat lowered potassium levels, as a result of her alternating food restriction, binging and purging. The eating disorders specialist explained to her that CBT was the treatment of choice for bulimia and that she had the option of either attending a CBT group or to work through the programme Overcoming Bulimia Online supported by e-mail by one of the unit’s therapists. As the date and time of the CBT group clashed with Holly’s university commitments, she decided to give the online treatment a go. She liked the idea of being able to start therapy immediately rather than having to wait for treatment. She also liked the idea that she could do things to help herself to overcome her problem. She was given log-in details and straightforward instructions on how best to use the online programme. For example, she learnt that it would be best if she set aside a particular time each week to work through an online module and to ‘talk’ to her e-mail therapist. Within a couple of days after her assessment, she was contacted by her e-mail support therapist who sent her a friendly welcome e-mail and who informed Holly that he would check in with her once or twice a week to enquire about her progress, answer any questions and support her use of the programme. Holly immediately started working through the first online module which gave her basic information about her bulimia. Although she had felt that she knew a lot about bulimia, she discovered a number of additional thought-provoking facts about it, e.g. the many negative effects this could have on her body and how dieting and purging maintains binge eating. She liked the clear and simple format of the programme and enjoyed the many interactive exercises. She found the case formulation (the vicious cycle of bulimia) particularly instructive. She realised that her bulimia was triggered by both her extreme undereating/dieting during the day and by stress/boredom, e.g. at weekends when she had little structure in her day and therefore felt even more tempted to binge than usual. After she had completed her own personalised case formulation online, she began to make changes to her daily diet, supported and encouraged in this endeavour by her e-mail therapist. Holly worked through all eight sessions of the programme. She learnt to self-monitor her food intake and reflect on her progress. She gradually returned to three balanced meals and also added regular snacks to her diet, to avoid letting herself get so hungry that a binge became likely. To her surprise, although she had predicted that her weight would skyrocket if she did allow herself to eat more regularly, her weight stabilised and over time even dropped a little. Her food cravings and binges waned. Working through the later modules, Holly learnt to problem solve and to think about how to cope with times when she felt particularly vulnerable and prone to binging. This involved finding more structure at weekends and during holidays and also identifying events that made her feel stressed, anxious or low and therefore tempted to soothe herself with a binge. Holly also learnt from the programme to identify unhelpful (e.g. catastrophic or distorted) cognitions that ‘tripped her up’ and to reframe these in an alternative less negative way. By the end of the 8-week programme, Holly’s bulimic episodes had significantly reduced to one or two binges a week only. She felt a lot more in control of her life and able to contemplate a future where she would be free of all bulimic episodes. She stayed in e-mail contact with her therapist for another couple of months using the skills she had learnt in the programme and reflecting on situations that she had handled particularly well or that had been particularly difficult. Although her therapist only checked in with her a couple of times a week, Holly felt very supported and encouraged by his e-mails and by the end of the follow-up period was symptom-free.

Cost-Effectiveness

Access to evidence-based psychological interventions is key to achieving better outcomes in mental health treatment (Poulsen et al. 2013). However, the cost of delivering individual therapy is high for both patients and healthcare services. There is a need therefore to develop cost-effective alternatives to face-to-face psychological therapy (Stuhldreher et al. 2012). Given the technological advances seen in recent years, the translation of psychological interventions such as CBT into online self-help programmes represents a relatively cheap and easily disseminable solution.

ICBT programmes are brief and focal interventions and are therefore cost-effective in terms of a scalable implementation of evidence-based therapy (Perkins et al. 2004). Studies of the cost-effectiveness of guided self-help (CBTgsh) for EDs have shown encouraging results. For example, one study showed that a stepped care approach using CBTgsh for BN as the first step, followed by fluoxetine and therapist-delivered CBT if needed, resulted in substantially lower cost per effectively treated patient than immediate therapist-delivered CBT augmented with medication if needed (Crow et al. 2013). In addition, mean cost of CBTgsh treatment including supervision was significantly lower than for family therapy in adolescents with BN (Darby et al. 2009). It was also estimated that CBTgsh in addition to TAU resulted in significantly more binge-free days and a lower societal cost in terms of reduced TAU service use at 12-month follow-up in participants with symptoms of binge eating (Crow et al. 2013).

Evidence investigating the cost-effectiveness of online CBT programmes for EDs is currently lacking. On the face of it, ICBT programmes may be considered as less costly alternatives relative to face-to-face therapy. Even with guidance, these programmes require fewer guidance/support sessions than individual CBT therapy and e-mail guidance takes less therapist time per contact, suggesting that the direct costs of these interventions are low. Moreover, online interventions may also be less costly for patients in terms of travel cost and time spent traveling. However, the cost of developing and maintaining online intervention programmes also needs to be considered and is not insignificant. Large-scale randomised controlled trials with integrated health economic analyses are needed to compare the cost-effectiveness of ICBT programmes in comparison to face-to-face CBT and other forms of self-help interventions.

Clinical Implementation and Dissemination

A recent systematic review on self-help interventions in bulimic ED in general suggests that patients with BED, who are older, have a higher BMI and show less dietary restraint, are less likely to drop out of self-help interventions and might benefit substantially more from these than BN patients (Winn et al. 2004). In treating eating disorders, the first step is usually to re-establish a regular pattern of eating. This may present difficulties for patients receiving treatment due to different motivations, fears and concerns regarding changing eating behaviours and the impact this might have on their body weight. For example, BED patients typically hope to lose weight during treatment, despite the fact that weight loss is not the primary focus of CBT interventions for BED. Typically, they show unstructured eating behaviour outside binge eating episodes which requires the application of structure and the normalisation of meals without increasing calories consumed outside of binge episodes (Winn et al. 2004). Conversely, BN is characterised by an intense fear of gaining weight (Striegel-Moore et al. 2005) which may be worsened by changing patterns of dieting, binging and compensatory behaviours. Restriction is common outside of binge episodes and eating is associated with feelings of guilt (Striegel-Moore et al. 2005). BN patients need to increase the amount of calories consumed outside of binge episodes in order to normalise their eating behaviour, and motivation to do this is often low (Economics, Deloitte Access 2012). Self-help interventions should therefore aim to address these fears in the initial stages of treatment, in order to maximise compliance and improve outcome.

Provision of therapist guidance alongside self-help is associated with higher intervention completion rates, higher abstinence from binge eating and greater reduction of dietary restraint in BN patients (Winn et al. 2004). BN patients may therefore need more support and encouragement whilst undertaking self-help programmes (Winn et al. 2004). Guidance from mental health specialists (as opposed to other healthcare workers) is associated with better treatment completion rates and larger effects on key outcomes (Winn et al. 2004); therefore services may need to consider the implications of this in terms of cost and resources. Guides should also be trained sufficiently in how to guide patients through self-help treatment, as well as frequent monitoring of intervention deliverance in order to maximise treatment success (Winn et al. 2004).

Discussion and Future Challenges (Limitations Included)

Summary

Research suggests that online self-help CBT interventions are an effective way of increasing accessibility to evidence-based treatments for BN and BED (Perkins et al. 2004). Studies have shown that online CBT programmes are more effective at reducing ED psychopathology and frequency of bulimic symptoms compared to other forms of self-help (Campbell et al. 2011; Perkins et al. 2004; Winn et al. 2004). Guidance from specialist clinicians is also associated with improved adherence and outcomes in BN patients. Lower dropout rates were observed in BED patients who were older and showed less dietary restraint and higher BMI at baseline (Winn et al. 2004). ICBT programmes can contribute to improving access to effective treatment for patients with BN and BED, especially if features of their delivery are carefully considered (Winn et al. 2004).

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