Self-help and guided self-help for eating disorders
ABSTRACT Anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS) are common and disabling disorders. Many patients experience difficulties accessing specialist psychological treatments. Pure self-help (PSH: self-help material only) or guided self-help (GSH: self-help material with therapist guidance), may bridge this gap.
Main objective:Evaluate evidence from randomised controlled trials (RCTs) / controlled clinical trials (CCTs) for the efficacy of PSH/GSH with respect to eating disorder symptoms, compared with waiting list or placebo/attention control, other psychological or pharmacological treatments (or combinations/augmentations) in people with eating disorders. Secondary objective:Evaluate evidence for the efficacy of PSH/GSH regarding comorbid symptomatology and costs.
CCDANCTR-Studies and CCDANCTR-References were searched in November 2005, other electronic databases were searched, relevant journals and grey literature were checked, and personal approaches were made to authors.
Published/unpublished RCTs/CCTs evaluating PSH/GSH for any eating disorder.
Data was extracted using a customized spreadsheet. Relative Risks (RR) were calculated from dichotomous data and weighted/standardized mean differences (WMD/SMD) from continuous data, using a random effects model.
Twelve RCTs and three CCTs were identified, all focusing on BN, BED, EDNOS or combinations of these, in adults, using manual-based PSH/GSH across various settings. Primary comparisons:At end of treatment, PSH/GSH did not significantly differ from waiting list in abstinence from bingeing (RR 0.72, 95% CI 0.47 to 1.09), or purging (RR 0.86, 95% CI 0.68 to 1.08), although these treatments produced greater improvement on other eating disorder symptoms, psychiatric symptomatology and interpersonal functioning but not depression. Compared to other formal psychological therapies, PSH/GSH did not differ significantly at end of treatment or follow-up in improvement on bingeing and purging (RR 0.99, 95% CI 0.75 to 1.31), other eating disorder symptoms, level of interpersonal functioning or depression. There were no significant differences in treatment dropout. Secondary comparisons:One small study in BED found that cognitive-behavioural GSH compared to a non-specific control treatment produced significantly greater improvements in abstinence from bingeing and other eating disorder symptoms. Studies comparing PSH with GSH found no significant differences between treatment groups at end of treatment or follow-up. Comparison between different types of PSH/GSH found significant differences on eating disorder symptoms but not on bingeing/purging abstinence rates.
PSH/GSH may have some utility as a first step in treatment and may have potential as an alternative to formal therapist-delivered psychological therapy. Future research should focus on producing large well-conducted studies of self-help treatments in eating disorders including health economic evaluations, different types and modes of delivering self-help (e.g. computerised versus manual-based) and different populations and settings.
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ABSTRACT: Abstract Background A critical part of future service delivery will involve improving the degree to which people become engaged in ‘self-management’. Providing better support for self-management has the potential to make a significant contribution to NHS efficiency, as well as providing benefits in patient health and quality of care. Objective To determine which models of self-management support are associated with significant reductions in health services utilisation (including hospital use) without compromising outcomes, among patients with long-term conditions. Data sources Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health, EconLit (the American Economic Association’s electronic bibliography), EMBASE, Health Economics Evaluations Database, MEDLINE (the US National Library of Medicine’s database), MEDLINE In-Process & Other Non-Indexed Citations, NHS Economic Evaluation Database (NHS EED) and PsycINFO (the behavioural science and mental health database), as well as the reference lists of published reviews of self-management support. Methods We included patients with long-term conditions in all health-care settings and self-management support interventions with varying levels of additional professional support and input from multidisciplinary teams. Main outcome measures were quantitative measures of service utilisation (including hospital use) and quality of life (QoL). We presented the results for each condition group using a permutation plot, plotting the effect of interventions on utilisation and outcomes simultaneously and placing them in quadrants of the cost-effectiveness plane depending on the pattern of outcomes. We also conducted conventional meta-analyses of outcomes. Results We found 184 studies that met the inclusion criteria and provided data for analysis. The most common categories of long-term conditions included in the studies were cardiovascular (29%), respiratory (24%) and mental health (16%). Of the interventions, 5% were categorised as ‘pure self-management’ (without additional professional support), 20% as ‘supported self-management’ (< 2 hours’ support), 47% as ‘intensive self-management’ (> 2 hours’ support) and 28% as ‘case management’ (> 2 hours’ support including input from a multidisciplinary team). We analysed data across categories of long-term conditions and also analysed comparing self-management support (pure, supported, intense) with case management. Only a minority of self-management support studies reported reductions in health-care utilisation in association with decrements in health. Self-management support was associated with small but significant improvements in QoL. Evidence for significant reductions in utilisation following self-management support interventions were strongest for interventions in respiratory and cardiovascular disorders. Caution should be exercised in the interpretation of the results, as we found evidence that studies at higher risk of bias were more likely to report benefits on some outcomes. Data on hospital use outcomes were also consistent with the possibility of small-study bias. Limitations Self-management support is a complex area in which to undertake literature searches. Our analyses were limited by poor reporting of outcomes in the included studies, especially concerning health-care utilisation and costs. Conclusions Very few self-management support interventions achieve reductions in utilisation while compromising patient outcomes. Evidence for significant reductions in utilisation were strongest for respiratory disorders and cardiac disorders. Research priorities relate to better reporting of the content of self-management support, exploration of the impact of multimorbidity and assessment of factors influencing the wider implementation of self-management support. Study registration This study is registered as PROSPERO CRD42012002694. Funding The National Institute for Health Research Health Services and Delivery Research programme.
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ABSTRACT: Objective Technology assisted guided self-help has been proven to be effective in the treatment of bulimia nervosa (BN). The aim of this study was to determine predictors of good long-term outcome as well as drop-out, in order to identify patients for whom these interventions are most suitable.Methods One hundred and fifty six patients with BN were assigned to either 7 months internet-based guided self-help (INT-GSH) or to conventional guided bibliotherapy (BIB-GSH), both guided by e-mail support. Evaluations were taken at baseline, after 4, 7, and 18 months. As potential predictors, psychiatric comorbidity, personality features, and eating disorder psychopathology were considered.ResultsHigher motivation, lower frequency of binge eating, and lower body dissatisfaction at baseline predicted good outcome after the end of treatment. Lower frequency of binge eating predicted good outcome at long-term follow-up. Factors prediciting drop-out were higher depression and lower self-directedness at baseline.Conclusion Technology assisted self-help can be recommended for patients with a high motivation to change, lower binge-eating frequency and lower depression scores. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.European Eating Disorders Review 11/2014; 23(2). DOI:10.1002/erv.2336 · 1.38 Impact Factor
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ABSTRACT: Recent advances in the availability of mobile applications and Internet-based programs for eating disorder treatment call for a discussion of the acceptability, efficacy, and implications of these tools, as well as the practicality of using them to augment treatment as usual. The authors review and critically evaluate several conceptual, ethical, and pragmatic issues associated with employing a mobile-guided self-help intervention for anorexia nervosa (AN). The authors then describe the development of a mobile guided self-help intervention currently under evaluation among inpatients and outpatients with AN. We delineate ways in which these tools can enhance the accuracy of assessment, increase access to psychotherapy (such as by facilitating motivation and confidence to change), and complement the efficacy of adjunct treatments for eating disorders. Moreover, the portability of mobile-guided self-help is particularly appealing given the range of precipitating and maintaining factors that individuals with eating disorders face in their natural environments. We describe preliminary feedback from pilot research investigating the acceptability and feasibility of a mobile-guided self-help intervention for inpatients and outpatients with AN. We conclude by offering practical suggestions for clinicians who seek to incorporate aspects of mobile-guided self-help in their daily practice for people with eating disorders.Professional Psychology Research and Practice 06/2014; 45(5). DOI:10.1037/a0036203 · 1.34 Impact Factor