E-mental health
Comorbidity, relapse, chronicity, and mortality are common in eating disorders (EDs), which indicates the seriousness of these psychiatric disorders [
1,
2]. Unfortunately, many individuals with EDs do not receive appropriate healthcare [
3]. A study in the Netherlands showed that it often takes many years to recognize that one is suffering from an ED and more than 4 years to seek treatment [
4]. Explanations for not receiving fitting care seem to range from geographical and financial reasons to fear of loss of control, fear of stigmatization, and feelings of shame [
5‐
7]. A simulation study by Moessner and Bauer [
8] suggested that we can most effectively help people with an ED, not by improving existing treatments or aftercare, but by guiding them to care more quickly and focusing on prevention. Additionally, the earlier patients with an ED receive proper treatment, the higher the chances are for full recovery [
9]. Recently, e-mental health (i.e., offering care or treatment via technological means such as websites, teleconferences, and smartphone applications) has been proposed as a solution to bridge this treatment gap that exists for individuals with an ED. E-mental health has the potential to reduce barriers to seek help, since it can provide inexpensive, anonymous, and easily accessible interventions [
9]. Consequently, such low-threshold interventions could help to improve early detection and intervention of ED problems and to promptly guide individuals to more intensive care if needed.
Nevertheless, research regarding the effects of e-mental health on ED pathology and help-seeking behavior is still scarce. Results of a recent meta-analytic review [
10] demonstrated that Internet-based programs, of which most relied on cognitive behavioral principles, successfully decreased ED-related symptoms such as body dissatisfaction, symptoms of bulimia nervosa, shape and weight concerns, dietary restriction, and negative affect, and increased self-esteem and self-efficacy. Two examples of Internet prevention interventions that have been proven effective in randomized controlled trials (RCTs) are Student Bodies [
11] and the Body Project [
12]. Student Bodies is a cognitive-behavioral Internet-based program, including psychoeducation, self-monitoring journals, behavioral exercises, and weekly assignments, aimed at improving eating- and body-related issues in people at risk for developing an ED. The Body Project appeals to the same group, but it employs a dissonance-based approach, by letting users critique the thin body ideal in written, verbal, and behavioral exercises. The strength of such interventions is their ability to reach an underserved population. However, they should not be seen as a replacement for face-to-face treatment, but rather as an addition to the stepped-care treatment of EDs [
9]. Additionally, confidence in results from RCTs regarding e-mental health for EDs (covering a wide range of interventions but excluding studies in which the therapist was the primary means of delivering the intervention) is generally low (often because of the high risk of bias and inconsistency and the indirectness of and imprecision in outcomes), so more solid research regarding the form and content of such interventions is needed [
13].
Naturally, there are limitations to low-threshold Internet interventions aimed at prevention and early intervention of EDs in the extent to which they can respond to the personal situation of users, especially when compared with interventions in which intensive and direct contact with a professional is possible, such as blended care. Nevertheless, it is important for low-threshold Internet-based interventions not to employ a ”one-size-fits-all” approach. Indeed, not everyone profits from or prefers the same content of treatment, and the Internet is a highly suitable medium to convey interventions in a flexible and interactive way. The Internet-based program ”Featback” combines prevention and (early) intervention for individuals with ED symptoms. The program aims to make users aware of their eating-related and underlying problems. Users are encouraged to share their problems with their environment and, for more severe problems, to seek professional help. The program can be used anonymously, reducing the barrier to subscribe. It contains psychoeducation, a fully automated symptom monitoring and feedback system, and weekly chat or e-mail contact with a coach. A more detailed account of Featback is presented in the “Interventions” section of this article. Featback is based on ES[S]PRIT [
14], a program originally developed in Germany. Research on ES[S]PRIT suggested the intervention is both feasible [
14] and acceptable [
15] and improves self-efficacy in young individuals with ED-related problems [
16] and enhances help-seeking behaviors [
17,
18].
The current research group has performed a first RCT investigating the effectiveness and cost-effectiveness of Featback [
19]. Featback was offered with or without chat, Skype, or e-mail support from a therapist, which resulted in four conditions: (1) Featback only, (2) Featback with weekly support from a therapist, (3) Featback with support from a therapist three times a week, and (4) a waiting list control condition when Featback was complemented with therapist support once or three times a week. It was found that Featback (with or without support) was more effective in reducing symptoms of bulimia nervosa (
d = − 0.16) and symptoms of anxiety and depression (
d = − 0.31) than the waiting list control [
20]. Contrary to our expectations, no difference in effectiveness between the active interventions was found. Regarding the cost-effectiveness, it was found that Featback with or without therapist support represented good value for the money when compared to a waiting list [
21], indicating that Featback might be a good alternative to care as usual, especially for individuals who experience difficulties in seeking professional help. Although no added effect on ED psychopathology was found, Featback users were significantly more satisfied with the intervention when Featback was complemented with weekly or three-weekly therapist support. Finally, moderator analyses showed that Featback was most effective for individuals with mild to moderate bulimia nervosa symptoms [
22]. The present study aims to follow up and build on these findings by further investigating the (cost-)effectiveness of Featback and by investigating the added value of expert-patient support.
Expert-patient support
An explanation of why additional support from a psychologist did not add to the effectiveness of Featback [
20] may be that although individuals suffering from ED symptoms appreciate the empathy and support of therapists, it may not be enough to reduce ED psychopathology. Support by expert patients (i.e., recovered individuals with a lived ED experience, also referred to as peers or mentors) may prove to be more effective for those reluctant to seek help and in the aftercare for individuals who have completed treatment and are at risk for relapse [
23]. Specifically, expert patients may be more effective in changing behavior and inspiring hope of recovery, because of a perceived similarity and credibility [
23]. The self-evident credibility of expert patients may make their interventions more valuable, since reliable [
24] and personalized [
25] messages are found to be more effective in changing behavior. Additionally, the shared experiences and accompanying (perceived) similarity enhances experienced social support and feelings of closeness [
26‐
30] and various bonding behaviors [
31,
32]. The idea that people who share a common background or problem have a unique resource to offer each other appears to be at the heart of peer support [
33]. Relatedly, expert patients are thought to be effective in enhancing self-efficacy in patients, since they can powerfully model health behaviors and enhance patients’ belief in their own capabilities [
23,
34,
35], which is one of the primary goals of Featback. Concordantly, in the current study it is hypothesized that the credibility and the shared background of an expert patient and participant are sufficient to establish feelings of closeness and make participants more receptive to interventions aimed at reducing ED symptomatology and enhancing experienced social support and self-efficacy.
The body of literature on the effectiveness of support by expert patients is growing. Many studies have investigated expert-patient support for patients with chronic somatic illnesses in comparison to treatment as usual and found positive, albeit small, effects on self-efficacy, self-management, illness-related quality of life, and worry about the illness [
33,
36‐
41]. Adding expert-patient support to usual care has also been found cost-effective for patients with various chronic somatic illnesses [
42]. However, results on the effectiveness of expert-patient support in mental illness are mixed. For example, in some studies expert-patient support was associated with reductions in depressive symptomatology in patients with major depression and was found to be as effective as professionally administered treatment and superior to a waiting list [
43,
44]. Furthermore, increases in self-efficacy were found in patients with severe mental illness who received expert-patient support in addition to treatment as usual in comparison to patients who received treatment as usual only [
45]. On the other hand, several studies found that adding expert-patient support to treatment as usual had no significant effect on psychopathology, quality of life, empowerment, or user satisfaction [
46]. In addition, the type and objectives of the expert patient interventions are highly heterogeneous [
47], and confidence in both positive and null findings is repeatedly low because of the high risk of bias [
46]. This complicates assessment of the value of expert-patient support for mental illness and warrants further research.
Regarding EDs, currently only a few studies have been completed [
48]. Perez, Kroon van Diest, and Cutts [
49] report that individuals recovering from an ED who are assigned to an expert patient indicate better relationships, a higher quality of life, and increased intervention usage than recovering individuals who are not assigned to an expert patient. Results of two pilot studies are in line with these findings [
50,
51]. However, there were no active control conditions in these studies. Additionally, Cardi et al. [
52] and Beveridge et al. [
53] are currently conducting trials on the topic of expert-patient support and EDs. In summary, expert patients may have positive effects on self-efficacy, belonging, and psychopathology [
48], but findings are currently too circumstantial to provide convincing proof for the effectiveness of expert-patient support for EDs or recommendations on its implementation, so further investigation is necessary.
Aims and research questions
The current study builds on the study by Aardoom et al. [
20] by investigating whether the results regarding the effectiveness of Featback will hold. More specifically, the first aim is to investigate the (cost-)effectiveness of the Internet-based intervention Featback in comparison to Featback with support from an expert patient, support from an expert patient without Featback, and a waiting list control condition (WLC). The primary outcome measures of the current study are ED-related attitudes. Secondary outcome measures include self-efficacy, social support, symptoms of depression and anxiety, motivation to change, user satisfaction, intervention usage, and help-seeking attitudes and behaviors. Finally, cost-effectiveness will be evaluated through the reported quality of life, outcomes for patients in terms of capabilities, and medical and societal costs. We have two hypotheses accompanying the first research aim.
(H1)
Our primary hypothesis is that Featback without expert-patient support, Featback with expert-patient support, and expert-patient support without Featback will be more effective in reducing ED psychopathology and more cost-effective compared to a waiting list.
(H2)
Secondly, we hypothesize that the combination of expert-patient support plus an online intervention will be more effective in reducing ED psychopathology and more cost-effective compared to expert-patient support or Featback only and that the improved effectiveness will be maintained up until a year later.
The second aim of this study is to investigate predictors and moderators of intervention response to explore what works for whom. Predictors and moderators that will be tested as predictors or moderators of treatment response and/or intervention usage are age, gender, and educational level, motivation to change, social support, severity of ED symptoms, severity of symptoms of depression and anxiety, self-efficacy, self-esteem, and closeness or perceived similarity of participants with expert patients. Additionally, self-efficacy is examined as a mediator. Besides the exploratory tests, there are two hypotheses concerning the second aim of this study.
(H3)
Since a perceived similarity of participants to expert patients might enhance the receptivity and self-efficacy of participants, it is hypothesized that participants who feel more similar to the expert patient they are assigned to have better outcomes in terms of ED symptomatology, self-efficacy, and experienced social support.
(H4)
It is hypothesized that, since the effectiveness of expert patients is theorized to come from effectively improving self-efficacy, changes in self-efficacy during the intervention period mediate subsequent long-term effects of the intervention on ED-related symptoms and experienced social support.
Thirdly, we aim to investigate practical experiences with Featback, such as intervention usage and user satisfaction.
(H5)
It is expected that Featback with weekly expert-patient support will enhance intervention usage as well as satisfaction with the intervention compared to Featback alone.