Chances are you’ve heard of the internet. Unless you’re reading this after it’s been transcribed onto some parchment and brought to you by a psychologically-interested crow in which case you’ve got some further research to do.

In terms of eating disorders, most people may associate the internet with those ghastly pro-anorexia sites which for reasons beyond the scope of this article try to promote eating disorders to others. However, the internet can also have substantial benefits for people with eating disorders.

Unfortunately, many people with eating disorders are reluctant to access treatment and those that do show a preference for low-threshold interventions rather than the conventional health care provided for people with mental health issues. For this reason, an increasing number of internet-based interventions for the treatment of people with eating disorders have been developed. The aim of these is to make access to effective treatments easier for individuals who would be reluctant to do so otherwise.

Many internet-based programs have been developed with the aim of preventing eating disorders, but more recently there has also been an increase in interest in internet-based interventions targeting people who already suffer from a diagnosed eating disorder.

The aim of the study in question was to examine the value of internet-based interventions for the treatment of eating disorders via systematic review.

Method

The studies included in the systematic review were identified through searches of relevant electronic databases e.g. PsychINFO, PubMed and Web of Science. Additionally the reference lists of articles identified for inclusion were searched for potentially relevant studies.

Studies had to satisfy five eligibility criteria for selection and inclusion in the systematic review. Studies had to:

1. Be published in a peer-reviewed journal
2. Use a controlled design
3. Include the internet as at least one mode of delivery of treatment or self-help
4. Include participants aged at least 16 years with a diagnosed eating disorder
5. Use changed eating behaviour as a primary outcome measure

Studies were excluded from the systematic review if they addressed the prevention of eating disorders or weight-loss programmes.

Study method quality was assessed using a scale developed by Van den Berg and others whereby a total methodological quality score from 0-11 was awarded to each study included, with 11 being the highest rating of methodological quality.

Results

Included studies

• After following inclusion and exclusion criteria, a total of 8 studies were included for systematic review

Participant characteristics

• There were a total of 609 participants across all of the studies reviewed
• Three of the studies involved only female participants while the remaining five involved participants of both sexes
• Overall 97% of the participants were female and the average age of all participants was between 23.7 years and 44.6 years

Interventions

• Cognitive behavioural therapy (CBT) was the basis of all but one intervention
• Six of the studies offered an internet-based, guided self-help intervention and one used e-mail therapy that did not follow a structured treatment programme
• The extent of therapist support or guidance in the various internet-based interventions varied from no support to an average of two emails per week
• The shortest treatment programme studied was three days long and the two longest were six months

Effectiveness

• Six of the studies examined the effect of the intervention on bingeing and purging behaviours. Medium to large effect sizes of intervention were found for reducing bingeing and purging behaviours from before to after treatment across all six studies which examined them. However this effect size was only statistically significant in two of the studies
• Abstinence was defined (in some of the studies) as no longer fulfilling the criteria for a clinical eating disorder. All of the studies reviewed found a higher rate of abstinence in the internet-based intervention group compared with the control group. However this difference was only tested for statistical significance in four of the studies, all of which found the difference to be significant
• Of the six studies that included follow-up measures, five found that the positive results achieved following treatment were stable or even improved over the follow-up period
• Rates of patients dropping out from treatment early were between 9% and 47.2%, and rates of study dropouts (patients did not fill out the post-intervention assessment) ranged between 2.9% and 37.1%

Methodological quality

• Out of the eight studies reviewed, five were rated as having good method quality i.e. above 8/11 on the assessment scale used
• Two out of the eight studies were rated 7/11 on the methodological quality scale
• The remaining study failed to report the criteria to be eligible

Conclusion

The authors concluded that generally the results support the use of internet-based interventions as part of the treatment of eating disorders in adults. The systematic review particularly identified interventions that utilise the CBT principle of guided self-help as effective. The size of the effects and the stability of treatment outcomes of the internet-based interventions were comparable with those of interventions involving face-to-face interactions with patients.

However, they also state that further research is needed in this area due to the high degree of variability in the studies included in the systematic review. This was particularly problematic due to the relatively small number of studies included in the review. The authors identified that further research into different treatments, self-help programmes and predictors of treatment outcomes would be useful in making the promise of internet-based interventions more definitive in its effectiveness.

Summary

It is relatively easy to see how internet-based interventions may have several advantages. For example the lack of geographic boundaries which enables the treatment to be delivered easily over a wide area and to many people. Additionally, internet-based interventions can be cost-effective and provide greater control, flexibility and anonymity for patients. Internet-based interventions are particularly attractive for individuals who would not otherwise access treatment due to difficulty in doing so or fear of attracting stigma.

The internet-treatment needs to work for this to be true though and while this systematic review shows that internet-based interventions for people with eating disorders show some promise, it also highlights that much more research is needed to more conclusively demonstrate effectiveness and the stability of outcome in the long-term.

Links

Dölemeyer. R, Tietjen. A, Kersting. A, &. Wagner. B. Internet-based interventions for eating disorders in adults: a systematic review. BMC Psychiatry. 2013. 13: 207-223.

Fiarburn. C. G. &. Harrison. P. J. Eating Disorders. The Lancet. 2003. 361: 407-416. [Pubmed Abstract]

Van den Berg. M. H, Schoones. J. W, & Vliet Vlieland. T. P. Internet-based physical activity interventions: a systematic review of the literature. J Med Internet Research. 2007. 9(3): e26. [PubMed Abstract]