Face-to-Face Therapy vs. Email Therapy for Binge Eating

Finding more flexible approaches to treating binge eating may lead to a more patient-centered and cost-effective way to get these individuals into treatment, according to a team of British scientists.

Guided self-help is recommended as a first step for persons with recurrent binge eating, but few studies have examined how best to deliver this treatment. An ongoing clinical trial using a randomized controlled design is now investigating the effectiveness of providing guided self-help either in person or via email (Trials 2014; 15:181). Dr. Paul E. Jenkins and three coworkers at the Cotswold House Eating Disorders Service, Warneford Hospital, Oxford, UK, are conducting the study with two active treatment groups and a waiting list control. Participants are randomly assigned to one of the three conditions: face-to-face guided self-help, email-guided self-help, or a waiting list control. Each treatment lasts 12 weeks, and follow-up is set for 6 months after treatment ends. The researchers are looking at effectiveness, attrition and dropping-out, and the relative cost-effectiveness of the two treatments.

To be eligible for the study, participants must demonstrate a pattern of regular binge eating in the context of an eating disorder and be 17.5 years of age or older. Those with recent rapid weight loss, a body mass index (BMI) lower than 18.5 kg/m2, a major medical condition that might interfere with treatment, excessive drug or alcohol use, and active and untreated psychosis or severe depression are excluded from the trial.

The two treatments

Participants in the face-to-face sessions use a self-help manual, Overcoming Binge Eating (Christopher G. Fairburn, Guilford Press, 2013), and attend 10 sessions of in-person therapy delivered during 20- to 25-minute sessions. The manual is based on cognitive behavior therapy-enhanced and addresses many core elements of an eating disorder, including self-monitoring, psychoeducation, and regular weighing.

In the email-supported treatment group, patient and therapist use the Internet for all contacts (except the initial appointment). Participants are advised to follow treatment closely (“steps”) and to contact the therapist at least once a week. Over 12 weeks the participants will receive feedback from the therapist up to twice a week.

Therapists are advised to follow similar guidelines as the therapists who are using face-to-face contact, such as discussing problems, identifying solutions, and monitoring the participant’s progress—but all via the Internet. The email program is sent through special secure software. If the therapist sees any significant increased risk (medical or suicidal, for example), he or she will immediately schedule a telephone call or a face-to-face meeting with the participant.

The researchers will use a number of self-report measures to evaluate the differences between the two approaches. The primary outcome will be the frequency of objective bulimic episodes, assessed by the Eating Disorder Examination Questionnaire (EDE-Q). Secondary outcome measures include an evaluation of overall eating psychopathology, and other disordered eating behaviors, including self-induced vomiting, psychological distress, changes in self-esteem, functional impairment and healthcare use. In addition to information from the EDE-Q, data will be collected from the Clinical Outcomes in Routine Evaluations-Outcome Measure, a 34-item measure of general psychological distress (BMC Psychiatry 2013; 13:99). Participants review the previous week and rate their symptoms on a 5-point frequency scale. The Rosenberg Self-Esteem Scale includes 10 items that measure global self-esteem and are graded on a 1-to-4-point scale. A third measure, the Clinical Impairment Assessment, is a 16-item self-report in which participants review the preceding 28 days and indicate to what degree symptoms of an eating disorder have affected different areas of their life (Behav Res Ther 2008;46:1105). The Helping Alliance questionnaire is a 19-item measure of therapeutic alliance (Sante Publique 2014; 26: 337[in French]. The authors also developed a questionnaire just for this trial that will assess healthcare use. They will use the results to estimate cost-effectiveness by monitoring how participants use resources for example, measuring the time therapists spend providing patient care.

The authors hope their results will highlight different ways of delivering first-step eating disorders care. However, they add the caveat that although Internet-delivered interventions hold promise and are highly accepted by patients, there are some drawbacks, including problems inherent with email communication in general. Thus, the participants using email may need guidance with commitment or motivation to continue, as opposed to treatment that requires regular in-person attendance. Thus, “e-therapy” may be appropriate for some patients and not for others.

The clinical trial is now recruiting participants in the United Kingdom, and is scheduled to continue until July 2017.