A Web-Based Program Fills in For Patients Waiting For Outpatient Treatment

A web-based self-help program has shown promise for helping those with binge eating disorder (BED), bulimia nervosa (BN), and other specified eating and feeding disorders (OSFED) who are waiting for outpatient treatment. The program, named “everybody Plus,” helped bridge treatment gaps when patients were re-evaluated 6 and 12 months after participating in a randomized controlled study in Germany and the United Kingdom (Br Psych Open. 2024. 10e53. doi: 10.1192/bjo).

Guided self-help interventions are usually recommended as first-line treatment for bulimic-spectrum eating disorders because of their proven efficacy and because they are efficient and cost-effective when therapists are not readily available (also see “BED: A New Home-based Treatment Method,” elsewhere in this issue).

Eating disorder services often have lengthy waiting lists for treatment for such patients, and those with bulimic-spectrum disorders may be given a lower priority compared with anorexia nervosa patients. The program for everybody Plus is roughly based on the Student Bodies™ program for women with subclinical eating disorders (Behav Res Ther. 2012; 50: 93).

Dr. Bianka Vollert, of the Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany, and colleagues in the UK recently reported the results of their web-based program. They hypothesized that women offered the everyBody Plus program before starting usual face-to-face therapy would achieve clinically relevant symptom improvement quicker than those who waited for treatment.

A third of the sample was recruited in Germany (n = 113) and two-thirds were recruited in the UK (n=224). In Germany, 22 patients were recruited through outpatient therapy centers, 56 through therapists in private practice, and 35 were self-referred. In the UK, patients were recruited through various National Health Service sites (n = 119), self-referral, or eating disorder charities (n = 96), and universities (n = 9).

A group of 343 women 18 years or older were included if they met DSM-5 diagnostic criteria for bulimia nervosa, BED or OSFED with binge eating if they were currently on a waiting list for psychological intervention or treatment. The women were randomized to an intervention program (n=170) or to a control group placed on a waiting list (n=167). The intervention group had 8 weekly sessions that included such topics as dealing with ‘forbidden foods,’ binge eating/purging, improving body image, dealing with emotions, perfectionism, and self-esteem.

Each session took about 60 minutes to complete, and the participants kept weekly symptom monitoring diaries, which addressed body weight, frequency of binge eating, and compensatory behaviors. Also included were self-reflection diaries, free-text responses within each session, group forums, and homework tasks. The participants received individualized feedback based on their diary entries and free-text responses. Those in the control group were prompted to complete the symptom diary and other measures. No therapist feedback was provided.

Encouraging results

The overall results were encouraging. Although the time to face-to-face therapy was comparable between the intervention and control groups, at 12-month follow-up almost three times as many patients in the intervention group had achieved abstinence of core eating disorder symptoms over a period of at least 4 weeks, compared with the control group (35.7% vs 13.5%). Symptoms in the intervention group were also more rapidly reduced compared with those in the control group.

The more significant improvements were not only eating-disorder-related symptoms (weight, shape, and eating concerns, restrictive and intuitive eating), but also general psychopathology, including anxiety, depression, and quality of life over a year. At 6- and 12-month follow-up, the probability of being abstinent from core symptoms was significantly larger for the intervention group compared with controls.

The intervention group also showed greater improvements in eating disorder attitudes and behaviors, general psychopathology, anxiety, depression and quality of life, compared with the control group at most assessment points. Working alliance ratings with the online therapist were high. Most patients (88.7%) reported having regular (at least once per week) binge-eating episodes (at least once a week). Fewer than half reported regular vomiting and fasting as compensatory behaviors, and between a fifth and a third used medication or excessive exercise as means of weight control. Half the patients fulfilled the criteria for BED, about a third fulfilled criteria for BN, and the rest fulfilled criteria for OSFED. There was no significant difference in the distribution of symptoms or diagnoses between the two study arms.

Among all those who still had symptoms at the end of the intervention period, fewer binge eating and fasting episodes were found in the intervention group versus control group. However, there was no difference in vomiting and laxative use. This preliminary finding may highlight a need for clinicians to specifically attend to compensatory behaviors in face-to-face sessions, since these may be the more persistent and require more intensive input. Providing conditional and tailored content for those patients who report vomiting and laxative use may be indicated; however, it is unclear whether expanding the content will result in a significant difference in the frequency of such actions.

But some limitations

The authors reported that certain differences between Germany and Great Britain affected their results. The German patients were recruited through private practices and university outpatient services, and thus recruiting levels were lower in Germany than in the UK. Also, the study was limited to female patients, and future studies should include males as well.