Due to the widespread accessibility of cell phones and electronic devices, the mental health field has embraced the likelihood that treatment options could, and very well should expand over the next decade. As a result of this movement, various e-therapies have been developed that can provide immediate and direct treatment intervention to users via smartphone apps and computer-based programs. These e-health initiatives have been growing in popularity despite their early stages and researchers have made great strides in studying their efficacy. As researchers and clinicians feel that e-health programs should be evaluated just as traditional face-to-face therapies are, a meta-analysis published in the journal of Behavior Research and Therapy was performed to review research findings utilizing traditional evaluation methodology employed by the UK’s National Institute for Health and Care Excellence (NICE).
To carry out the review, a number of electronic databases were reviewed via searches for randomized control trials of e-therapy programs. As per the researchers, “No restrictions were placed on the type of sample recruited. The samples included participants from the general population, high-risk groups, and full cases. E-therapies were defined as interventions that were primarily delivered via a computer, mobile phone or tablet, although there could be limited additional therapist contact. The means of delivery included the Internet, downloadable software, CD-ROMs and mobile-device apps.” Ultimately twenty trials were utilized in this meta-analysis.
Suggestive of the work that is currently being done in the world of eating disorder e-treatment, 17 of the 20 studies included evaluated CBT-based interventions. Thirteen of these studies focused on eating disorder prevention and six investigated treatment interventions focused on preventing relapse. To evaluate the quality of the evidence, the GRADE approach was used to evaluate bias and assess the confidence in the effect estimates (quality of evidence) for each outcome. This five-category approach evaluated risk of bias, inconsistency, indirectness, imprecision and publication bias.
ED Prevention Studies: Eight of the 20 randomized control trials surrounded the use of CBT-based interventions to reduce body dissatisfaction among students’ bodies. When outcomes were evaluated, results were mixed:
-Study “Student Bodies” demonstrated a small improvement in the drive for thinness and weight concern at the end of the intervention and at follow-up however the evaluation for weight concern proved to be imprecise. Small effect sizes were noted for shape concerns, dietary restriction and global ED pathology at follow-up. Large improvements were found in cessation rate of binge eating, and purging behaviors (41% of the participants in intervention vs. 17% in control group) which was supported by results at follow-up though results may have been estimated imprecisely.
-Another study demonstrated that when compared with face to face group therapy, CBT-based e-therapy was inconclusive.
-Two studies compared CBT-based e-therapy with a waitlist control condition in the treatment of adults with BED. CBT-based e-therapies were associated with large improvements in the cessation of binge eating at the end of the intervention.
Relapse Prevention Studies: One study identified had investigated an online CBT-based relapse prevention program compared to face-to-face treatment protocols for women with anorexia nervosa who had recently been discharged from an inpatient hospital unit.
-Results demonstrated small improvements in clinician-rated bulimia, global eating disorder pathology at the end of intervention although estimates were imprecise
-Small improvements were noted for the frequency of inappropriate weight control behavior and self-rated bulimia at follow up, although the self-rate scale was imprecise. As such, evidence was inconclusive though confidence in the effect estimates was low to moderate.
In sum, the use of single studies in this meta-analysis contributed to difficulty making specific evaluations and often provided effect estimates that were quite low. While no ‘firm conclusions’ were made from this literature review, positive findings, especially for “Student Bodies” programs did emerge. There is evidence to suggest that CBT-based interventions may be meaningful and impactful, especially to those seeking an alternative to face-to-face therapies. Researchers feel that an additional barrier to outcomes in the aforementioned studies was the use of CD-ROM based programming, as opposed to higher tech devices such as computer apps or cellphone apps. Considering the desire and demand for mobile-based programming, this avenue is one worth exploring further and as per the article “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.”
It is an exciting time for the eating disorder community, as new and unique approaches are being further investigated. It is the responsibility of the ED community at large to develop telehealth and e-health programs that are rooted in traditional, gold-standard interventions to open up this inclusive and accessible form of treatment to all.
Loucas CE, Fairburn CG, Whittington C, Pennant ME, Stockton S, Kendall T. E-therapy in the treatment and prevention of eating disorders: A systematic review and meta-analysis. Behaviour Research and Therapy. 2014;63:122-131. doi:10.1016/j.brat.2014.09.011.