Internet-based cognitive behaviour therapy for the prevention, treatment and relapse prevention of eating disorders: A systematic review and meta-analysis

Abstract

Eating disorders (EDs) are undertreated worldwide. In the UK the lag between recognition of symptoms and treatment ranges from about 15 months to in excess of 2 years. Internet-based cognitive behaviour therapy (ICBT) could be a viable alternative to face-to-face cognitive behaviour therapy (CBT) that avoids the negative impacts of delayed interventions. Based on evidence from randomised controlled trials (RCTs), this systematic review investigated the efficacy of minimally guided self-help ICBT, without face-to-face therapy, for the prevention, treatment and relapse prevention of all types of EDs in adults. The electronic databases MEDLINE, PsychINFO, CENTRAL, Scopus, and Web of Science were searched between 1991 and 2021. Inclusion criteria specified RCTs with ICBT versus inactive comparison groups. The Cochrane Risk of Bias Tool-2 was used for quality assessments. Qualitative synthesis and meta-analyses were conducted. Findings typically showed medium significant beneficial effect sizes for prevention studies ranging from (−0.31 [95% CI: −0.57, −0.06] to −0.47 [95% CI: −0.82, −0.11]) and generally large effect sizes for the treatment studies ranging from (−0.30 [95% CI: −0.57, −0.03] to −1.11 [95% CI: −1.47, −0.75]). Relapse prevention studies yielded mainly small non-significant beneficial effects with significant effect sizes of (−0.29 [95% CI: −0.56, −0.03] and −0.43 [95% CI: −0.70, −0.16]). Only the treatment studies reached clinical significance and cognitive symptoms improved more than behavioural symptoms. ICBT appears to be efficacious for the prevention, treatment and relapse prevention of eating disorders with treatment interventions being the most beneficial. However, the evidence base is very small, particularly for treatment and relapse prevention, indicating the need for more high-quality RCTs.

Keywords

anorexia nervosa / binge-eating disorder / bulimia nervosa / cognitive behaviour therapy / eating disorder

References

[1] Aardoom, J. J., Dingemans, A. E., Spinhoven, P., & Furth, E. F. (2013). Treating eating disorders over the internet: A systematic review and future research directions. International Journal of Eating Disorders, 46(6), 539–552.

[2] Ágh, T., Kovács, G., Supina, D., Pawaskar, M., Herman, B. K., Vokó, Z., & Sheehan, D. V. (2016). A systematic review of the health-related quality of life and economic burdens of anorexia nervosa, bulimia nervosa, and binge eating disorder. Eating and Weight Disorders, 21(3), 353–364.

[3] Ali, K., Farrer, L., Fassnacht, D. B., Gulliver, A., Bauer, S., & Griffiths, K. M. (2017). Perceived barriers and facilitators towards help-seeking for eating disorders: A systematic review. International Journal of Eating Disorders, 50(1), 9–21.

[4] American Psychiatric Association. (2000). Diagnostic and statictical manual of mental disorders (4th ed.). American Psychiatric Association.

[5] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.

[6] Andersson, G. (2009). Using the internet to provide cognitive behaviour therapy. Behaviour Research and Therapy, 47(3), 175–180.

[7] Bauer, S., & Moessner, M. (2013). Harnessing the power of technology for the treatment and prevention of eating disorders. International Journal of Eating Disorders, 46(5), 508–515.

[8] Bauer, S., Moessner, M., Wolf, M., Haug, S., & Kordy, H. (2009). ES[S] PRIT–An internet-based programme for the prevention and early intervention of eating disorders in college students. British Journal of Guidance & Counselling, 37(3), 327–336.

[9] Beat. (2015). The costs of eating disorders. Social, Health and Economic Impacts. Retrieved 24 July 2021 from

[10] Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric properties of the Beck depression inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8(1), 77–100.

[11] Beintner, I., Jacobi, C., & Schmidt, U. H. (2014). Participation and outcome in manualized self-help for bulimia nervosa and binge eating disorder—A systematic review and metaregression analysis. Clinical Psychology Review, 34(2), 158–176.

[12] Beintner, I., Jacobi, C., & Taylor, C. B. (2012). Effects of an internet-based prevention programme for eating disorders in the USA and Germany—A meta-analytic review. European Eating Disorders Review, 20(1), 1–8.

[13] Bengtsson, J., Nordin, S., & Carlbring, P. (2015). Therapists' experiences of conducting cognitive behavioural therapy online Vis-à-Vis face-to-face. Cognitive Behaviour Therapy, 44(6), 470–479.

[14] Carrard, I., Crépin, C., Rouget, P., Lam, T., Golay, A., & Van der Linden, M. (2011). Randomised controlled trial of a guided self-help treatment on the internet for binge eating disorder. Behaviour Research and Therapy, 49(8), 482–491.

[15] Cavanagh, K., Shapiro, D. A., Berg, S., Swain, S., Barkham, M., & Proudfoot, J. (2006). The effectiveness of computerized cognitive behavioural therapy in routine care. British Journal of Clinical Psychology, 45(4), 499–514.

[16] Cochrane Collaboration. (2014). Review manager. In (Version 5.3).

[17] Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Erlbaum.

[18] Cooper, P. J., Taylor, M. J., Cooper, Z., & Fairburn, C. G. (1987). The development and validation of the body shape questionnaire. International Journal of Eating Disorders, 6(4), 485–494.

[19] Derogatis, L. R. (1975). The SCL-90 manual. I. Scoring, administration, and procedures for the SCL-90. Clinical Psychometric Research.

[20] Dölemeyer, R., Tietjen, A., Kersting, A., & Wagner, B. (2013). Internet-based interventions for eating disorders in adults: A systematic review. BMC Psychiatry, 13(1), 207.

[21] Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disorders: Interview or self-report questionnaire? International Journal of Eating Disorders, 16(4), 363–370.

[22] Fairburn, C. G., & Patel, V. (2014). The global dissemination of psychological treatments: A road map for research and practice. The American Journal of Psychiatry, 171(5), 495–498.

[23] Fichter, M. M., Quadflieg, N., & Lindner, S. (2013). Internet-based relapse prevention for anorexia nervosa: Nine-month follow-up. Journal of Eating Disorders, 1(1), 23.

[24] Fichter, M. M., Quadflieg, N., Nisslmüller, K., Lindner, S., Osen, B., Huber, T., & Wünsch-Leiteritz, W. (2012). Does internet-based prevention reduce the risk of relapse for anorexia nervosa? Behaviour Research and Therapy, 50(3), 180–190.

[25] Fitzsimmons-Craft, E. E., Taylor, C. B., Graham, A. K., Sadeh-Sharvit, S., Balantekin, K. N., Eichen, D. M., Monterubio, G. E., Goel, N. J., Flatt, R. E., Karam, A. M., Firebaugh, M. L., Jacobi, C., Jo, B., Trockel, M. T., & Wilfley, D. E. (2020). Effectiveness of a digital cognitive behavior therapy-guided self-help intervention for eating disorders in college women: A cluster randomized clinical trial. JAMA Network Open, 3(8), e2015633.

[26] Garfield, S. L. (1994). Research on client variables in psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed.). Wiley.

[27] Garner, D. M. (1991). EDI-2, eating disorder inventory-2. Psychological Assessment Resources.

[28] Garner, D. M., & Olmsted, M. (1984). Eating disorder inventory manual. Psychological Assessment Resources.

[29] Haggerty, R. J., & Mrazek, P. J. (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. National Academy Press.

[30] Harrer, M., Adam, S. H., Messner, E. M., Baumeister, H., Cuijpers, P., Bruffaerts, R., Auerbach, R. P., Kessler, R. C., Jacobi, C., Taylor, C. B., & Ebert, D. D. (2020). Prevention of eating disorders at universities: A systematic review and meta-analysis. International Journal of Eating Disorders, 53(6), 813–833.

[31] Higgins, J. P. T., & Green, S. (2008). Cochrane handbook for systematic reviews of interventions. Wiley Blackwell.

[32] Hrobjartsson, A., Emanuelsson, F., Thomsen, A. S. S., Hilden, J., & Brorson, S. (2014). Bias due to lack of patient blinding in clinical trials. A systematic review of trials randomizing patients to blind and nonblind sub-studies. International Journal of Epidemiology, 43(4), 1272–1283.

[33] Jacobi, C., Beintner, I., Fittig, E., Trockel, M., Braks, K., Schade-Brittinger, C., & Dempfle, A. (2017). Web-based aftercare for women with bulimia nervosa following inpatient treatment: Randomized controlled efficacy trial. Journal of Medical Internet Research, 19(9), e321.

[34] Jacobi, C., Morris, L., Beckers, C., Bronisch-Holtze, J., Winter, J., Winzelberg, A. J., & Taylor, C. B. (2007). Maintenance of internet-based prevention: A randomized controlled trial. International Journal of Eating Disorders, 40(2), 114–119.

[35] Jacobi, C., Völker, U., Trockel, M. T., & Taylor, C. B. (2012). Effects of an internet-based intervention for subthreshold eating disorders: A randomized controlled trial. Behaviour Research and Therapy, 50(2), 93–99.

[36] Jacobi, C., Vollert, B., Kristian, H., von Bloh, P., Eiterich, N., Gorlich, D., & Taylor, C. B. (2023). Indicated, internet-based prevention for women with anorexia nervosa symptoms: A randomised controlled efficacy trial. Journal of Medical Internet Research, 24(6), e35947.

[37] Kahan, B. C., Rehal, S., & Cro, S. (2015). Blinded outcome assessment was infrequently used and poorly reported in open trials. PLoS ONE, 10(6), e0131926.

[38] Killen, J. D., Taylor, C. B., Hayward, C., Wilson, D. M., Haydel, K. F., Hammer, L. D., Simmonds, B., Robinson, T. N., Litt, I., Varady, A., & Kraemer, H. (1994). Pursuit of thinness and onset of eating disorder symptoms in a community sample of adolescent girls: A three-year prospective analysis. International Journal of Eating Disorders, 16(3), 227–238.

[39] Le, L. K.-D., Barendregt, J. J., Hay, P., & Mihalopoulos, C. (2017). Prevention of eating disorders: A systematic review and meta-analysis. Clinical Psychology Review, 53, 46–58.

[40] Lehtimaki, S., Martic, J., Wahl, B., Foster, K. T., & Schwalbe, N. (2021). Evidence on digital mental health interventions for adolescents and young people: Systematic overview. JMIR Mental Health, 8(4), e25847.

[41] Linardon, J., Shatte, A., Messer, M., Firth, J., & Fuller-Tyszkiewicz, M. (2020). E-mental health interventions for the treatment and prevention of eating disorders: An updated systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 88(11), 994–1007.

[42] Linardon, J., Wade, T. D., de la Piedad Garcia, X., & Brennan, L. (2017). The efficacy of cognitive-behavioral therapy for eating disorders: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 85(11), 1080–1094.

[43] Ljotsson, B., Lundin, C., Mitsell, K., Carlbring, P., Ramklint, M., & Ghaderi, A. (2007). Remote treatment of bulimia nervosa and binge eating disorder: A randomized trial of internet-assisted cognitive behavioural therapy. Behaviour Research and Therapy, 45(4), 649–661.

[44] Loucas, C. E., Fairburn, C. G., Whittington, C., Pennant, M. E., Stockton, S., & Kendall, T. (2014). E-therapy in the treatment and prevention of eating disorders: A systematic review and meta-analysis. Behaviour Research and Therapy, 63, 122–131.

[45] Low, K. G., Charanasomboon, S., Lesser, J., Reinhalter, K., Martin, R., Jones, H., Winzelberg, A., Abascal, L., & Taylor, C. B. (2006). Effectiveness of a computer-based interactive eating disorders prevention program at long-term follow-up. Eating Disorders, 14(1), 17–30.

[46] Melville, K. M., Casey, L. M., & Kavanagh, D. J. (2010). Dropout from internet-based treatment for psychological disorders. British Journal of Clinical Psychology, 49(4), 455–471.

[47] Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. BMJ, 339(7716), 332–336.

[48] Mohr, D. C., Siddique, J., Ho, J., Duffecy, J., Jin, L., & Fokuo, J. K. (2010). Interest in behavioral and psychological treatments delivered face-to-face, by telephone, and by internet. Annals of Behavioral Medicine, 40(1), 89–98.

[49] Newton, M. S., & Ciliska, D. (2006). Internet-based innovations for the prevention of eating disorders: A systematic review. Eating Disorders, 14(5), 365–384.

[50] Norman, G. R., Sloan, J. A., & Wyrwich, K. W. (2003). Interpretation of changes in health-related quality of life: The remarkable universality of half a standard deviation. Medical Care, 41(5), 582–592.

[51] Orme, J. G., Reis, J., & Herz, E. J. (1986). Factorial and discriminant validity of the Center For Epidemiological Studies Depression (CES-D) scale. Journal of Clinical Psychology, 42(1), 28–33.

[52] Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hrobjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71.

[53] Peynenburg, V. A., Mehta, S., & Hadjistavropoulos, H. D. (2020). Postsecondary student perceptions and preferences for the treatment of depression and anxiety: Comparison of internet-delivered cognitive behaviour therapy to face-to-face cognitive behaviour therapy and medication. Canadian Journal of Behavioural Science, 52(3), 220–230.

[54] Probst, M., Vandereycken, W., Coppenolle, H. V., & Vanderlinden, J. (1995). The body attitude test for patients with an eating disorder: Psychometric characteristics of a new questionnaire. Eating Disorders, 3(2), 133–144.

[55] Proudfoot, J., Klein, B., Barak, A., Carlbring, P., Cuijpers, P., Lange, A., Ritterband, L., & Andersson, G. (2011). Establishing guidelines for executing and reporting internet intervention research. Cognitive Behaviour Therapy, 40(2), 82–97.

[56] Rodgers, R. F., Lombardo, C., Cerolini, S., Franko, D. L., Omori, M., Fuller-Tyszkiewicz, M., Linardon, J., Courtet, P., & Guillaume, S. (2020). The impact of the COVID-19 pandemic on eating disorder risk and symptoms. International Journal of Eating Disorders, 53(7), 1166–1170.

[57] Ruwaard, J., Lange, A., Broeksteeg, J., Renteria Agirre, A., Schrieken, B., Dolan, C. V., & Emmelkamp, P. (2013). Online cognitive-behavioral treatment of bulimic symptoms: A randomized controlled trial. Clinical Psychology and Psychotherapy, 20(4), 308–318.

[58] Saekow, J., Jones, M., Gibbs, E., Jacobi, C., Fitzsimmons-Craft, E. E., Wilfley, D., & Barr Taylor, C. (2015). StudentBodies-eating disorders: A randomized controlled trial of a coached online intervention for subclinical eating disorders. Internet Interventions, 2(4), 419–428.

[59] Sánchez-Ortiz, V. C., Munro, C., Stahl, D., House, J., Startup, H., Treasure, J., Williams, C., & Schmidt, U. (2011). A randomized controlled trial of internet-based cognitive-behavioural therapy for bulimia nervosa or related disorders in a student population. Psychological Medicine, 41(2), 407–417.

[60] Schlegl, S., Bürger, C., Schmidt, L., Herbst, N., & Voderholzer, U. (2015). The potential of technology-based psychological interventions for anorexia and bulimia nervosa: A systematic review and recommendations for future research. Journal of Medical Internet Research, 17(3), e85.

[61] Schulz, K. F., Altman, D. G., & Moher, D. (2010). CONSORT 2010 statement: Updated guidelines for reporting parallel group randomised trials. BMJ, 340(7748), 698–702.

[62] Schulz, K. F., & Grimes, D. A. (2002). Blinding in randomised trials: Hiding who got what. Lancet, 359(9307), 696–700.

[63] Sterne, J. A. C., Savović, J., Page, M. J., Elbers, R. G., Blencowe, N. S., Boutron, I., Cates, C. J., Cheng, H.-Y., Corbett, M. S., Eldridge, S. M., Hernán, M. A., Hopewell, S., Hróbjartsson, A., Junqueira, D. R., Jüni, P., Kirkham, J. J., Lasserson, T., Li, T., McAleenan, A., … Higgins, J. P. T. (2019). RoB 2: A revised tool for assessing risk of bias in randomised trials. British Medical Journal, 366, l4898.

[64] Taylor, C. B., Bryson, S., Luce, K. H., Cunning, D., Doyle, A. C., Abascal, L. B., Rockwell, R., Dev, P., Winzelberg, A. J., & Wilfley, D. E. (2006). Prevention of eating disorders in at-risk college-age women. Archives of General Psychiatry, 63(8), 881–888.

[65] Taylor, C. B., Fitzsimmons-Craft, E. E., & Graham, A. K. (2020). Digital technology can revolutionize mental health services delivery: The COVID-19 crisis as a catalyst for change. International Journal of Eating Disorders, 53(7), 1155–1157.

[66] Taylor, C. B., Graham, A. K., Flatt, R. E., Waldherr, K., & Fitzsimmons-Craft, E. E. (2021). Current state of scientific evidence on internet-based interventions for the treatment of depression, anxiety, eating disorders and substance abuse: An overview of systematic reviews and meta-analyses. European Journal of Public Health, 31(31 Suppl 1), i3–i10.

[67] Taylor, C. B., Kass, A. E., Trockel, M., Cunning, D., Weisman, H., Bailey, J., Sinton, M., Aspen, V., Schecthman, K., Jacobi, C., & Wilfley, D. E. (2016). Reducing eating disorder onset in a very high risk sample with significant comorbid depression: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 84(5), 402–414.

[68] Thormahlen, B., Weinryb, R. M., Noren, K., Vinnars, B., & Bagedahl-Strindlund, M. (2003). Patient factors predicting dropout from supportive-expressive psychotherapy for patients with personality disorders. Psychotherapy Research, 13(4), 493–509.

[69] Treasure, J., Schmidt, U., & Furth, E. V. (2003). Handbook of eating disorders (2nd ed.). John Wiley and Sons.

[70] Völker, U., Jacobi, C., Trockel, M. T., & Taylor, C. B. (2014). Moderators and mediators of outcome in internet-based indicated prevention for eating disorders. Behaviour Research and Therapy, 63, 114–121.

[71] Wagner, B., Nagl, M., Dölemeyer, R., Klinitzke, G., Steinig, J., Hilbert, A., & Kersting, A. (2016). Randomized controlled trial of an internet-based cognitive-behavioral treatment program for binge-eating disorder. Behavior Therapy, 47(4), 500–514.

[72] Waller, R., & Gilbody, S. (2008). Barriers to the uptake of computerized cognitive behavioural therapy: A systematic review of the quantitative and qualitative evidence. Psychological Medicine, 39(5), 705–712.

[73] Watson, H. J., Joyce, T., French, E., Willan, V., Kane, R. T., Tanner-Smith, E. E., McCormack, J., Dawkins, H., Hoiles, K. J., & Egan, S. J. (2016). Prevention of eating disorders: A systematic review of randomized, controlled trials. International Journal of Eating Disorders, 49(9), 833–862.

[74] Watson, H. J., McLagan, N., Zerwas, S. C., Crosby, R. D., Levine, M. D., Runfola, C. D., Peat, C. M., Moessner, M., Zimmer, B., Hofmeier, S. M., Hamer, R. M., Marcus, M. D., Bulik, C. M., & Crow, S. J. (2018). Cost-effectiveness of internet-based cognitive-behavioral treatment for bulimia nervosa: Results of a randomized controlled trial. Journal of Clinical Psychiatry, 79, 16m11314.

[75] Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology, Research and Practice, 24(2), 190–195.

[76] Winzelberg, A. J., Eppstein, D., Eldredge, K. L., Wilfley, D., Dasmahapatra, R., Taylor, C. B., & Dev, P. (2000). Effectiveness of an internet-based program for reducing risk factors for eating disorders. Journal of Consulting and Clinical Psychology, 68(2), 346–350.

[77] Zabinski, M. F., Pung, M. A., Wilfley, D. E., Eppstein, D. L., Winzelberg, A. J., Celio, A., & Taylor, C. B. (2001). Reducing risk factors for eating disorders: Targeting at-risk women with a computerized psychoeducational program. International Journal of Eating Disorders, 29(4), 401–408.

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