A Guided Internet Self-Treatment Program for BN

Can self-help through an
electronic medium succeed?

New electronic media and the Internet are increasingly becoming sources for information and self-help of all types. The premise of a recent study in four European countries was that a cognitive behavior therapy-based self-help online program might be useful for patients with bulimia nervosa (BN).

Dr. I. Carrard, of University Hospitals of Geneva, Geneva, Switzerland, and colleagues at four treatment centers in Spain, Sweden, and Germany recruited participants for a study through newspaper articles and advertisements. In Sweden, women on the participating study center’s waiting list were asked to take part in the study, while in Spain participants were consecutive referrals for assessment and treatment at the study center. The study was conducted over 4 months, with a 2-month follow-up. Three patient evaluation sessions were carried out in a face-to-face setting before and after the self-treatment program and after the follow-up period.

The Internet self-treatment program included a mandatory weekly email contact with a “coach,” who was a psychologist or a psychiatrist, and this contact continued throughout the 4-month self-treatment program. Participants were asked to write an email to the coach at least once a week, even if everything was going fine. They could write more than one email a week but were told that their coach would only answer one per week. The coaches were responsible for monitoring progress, answering questions, and providing general support and guidance. The open study did not include a control group. Participants were considered dropouts when 4 weeks had passed without any connection or email contact. Their access to the program was cancelled and they did not take part in the next evaluation sessions.

The program was designed specifically for bulimia nervosa (BN) patients, nonpurging subtype, and included 7 sequential modules based upon on classical CBT principles, with online exercises and theoretical portions that explained the techniques (see table). A fictitious student named “Sarah” who had BN shared her thoughts and gave examples of how to proceed with the program. The diary feedback and other exercise results were accessible by the coach, who could then tailor advice or support accordingly. Finally, three questionnaires, the Eating Disorder Inventory-2, the Symptom Checklist-90-revised, and the QATA questionnaire, a food frequency questionnaire, were used to collect data on sociodemographic facts, patient history, including past and current symptoms, and binge frequency, for example, were used. One hundred and twenty-seven women were enrolled. Their mean age was 24.7 years (range: 18-43 years) and the mean BMI was 21.5 kg/m2. Seventy percent were single, 45.7% were employed, and 35.4% were students. BN, purging type, was diagnosed in 76.4%; 3 had non-purging type BN, and 27 were diagnosed with an eating disorder not otherwise specified.

The Self-Treatment Program Module 1. Preparation for change. Participants were invited to explore their motivation to change with exercises using a CBT model of BN maintenance. Module 2. Self observation. Participants design a food diary to complete online during the entire course of the program, recording meals and episodes of binge eating and self-induced purging. Graphs show their progress. Module 3. Working on behavioral change. Participants were invited to plan meal times, to eat regularly, and to identify behavioral strategies to prevent binges. Module 4. Changing thoughts. Participants were asked to pinpoint automatic thoughts and emotions and to challenge automatic negative thoughts, and then to apply the same techniques to body shape dissatisfaction. Module 5. Problem-solving techniques. Participants were given problem-solving strategies. Module 6: Preventing relapse by reviewing the acquired techniques; some tips are given in case of relapse.

Promising results, but 25% dropped out

Twenty-three percent of the participants were symptom-free at the end of the study. The most positive effects were reported among women with BN, and 45.7% of the participants were considered clinically improved. Thirty-two participants (25.2%) dropped out of the online program during the 4 months of self-treatment and did not attend the post-study evaluation. Those who dropped out of the study before the second assessment spent an average of 44.5 days in the program; half of the dropouts reached the third module. The reasons for dropping out were rarely known, and were not recorded in the database. The authors noted that this percentage is comparable to other studies using self-help treatments, and that high dropout rates are common even when treatment is given in person.

Convenient times a big consideration

During the study, a third of the connections to the Internet program took place on weekends, and the most preferred hours were 9 pm to 10 pm or 7 am to 8 am, times when it would not have been possible to consult a psychotherapist. The authors do point out that this was an uncontrolled study without a comparison group, and that longer follow-up might allow a better evaluation of patients’ progress. Despite these limitations, this study adds to the body of research suggesting that web-based programs can offer a sizable number of patients accessible and often effective treatment.