MONTREAL – Psychotherapy for eating disorders can be delivered effectively by e-mail and can reach a segment of the population that might otherwise decline treatment, Paul Robinson, M.D., said at an international conference sponsored by the Academy for Eating Disorders.
He recruited 97 participants with eating disorders from a university e-mail list for his study. The diagnoses of bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified (EDNOS) all fulfilled DSM-IV criteria and were made using online questionnaires and assessments.
Roughly 80% of the cohort had received no previous treatment for their eating disorder, said Dr. Robinson, a psychiatrist with the eating disorders service of Royal Free Hospital, London.
“They were a population of people who don't approach mental health care or any sort of health care, and they said they wouldn't have done so if it hadn't been for this program,” Dr. Robinson said in an interview.
Study participants were randomized to e-mail bulimia therapy (EBT), to self-directed writing (SDW), or to a treatment waiting list, which was the control, he said.
The EBT group (36) received 12 weeks of e-mail therapy from professionals who were experienced in the outpatient management of eating disorders. Participants were asked to write twice weekly in a food, behavior, and emotions diary, to which the therapists responded.
“We looked at the diary and annotated it with our own comments,” said Dr. Robinson. “For example, if a patient wrote that she had eaten nothing for breakfast or lunch and then binged in the evening, we might have responded by saying that eating nothing all day might be triggering the binge at night,” he said.
Participants in the SDW group (34) were asked to write about their eating disorder and e-mail their comments to Dr. Robinson twice a week, although he acknowledged the e-mails he sent did not offer specific counseling to this group.
“They knew I was reading [their comments], and they knew that if I thought they were in danger I would act, and I think that was important to them,” he said.
Participants in the control group (27) waited 12 weeks and were then randomized to either EBT or SDW.
At the 12-week assessment, the e-mail therapy and SDW groups were combined into one “E-Therapy” group and compared with the control group.
The results showed that, while none of the control participants lost their eating disorder diagnosis, 18.6% of the E-Therapy group did.
Assessments using the Bulimic Investigatory Test, Edinburgh (BITE), severity and symptom scores showed a mean reduction in BITE severity score of 1.2 in the E-Therapy group, compared with a reduction of 0.2 in the control group. Similarly, the mean reduction in the BITE symptom score was significantly greater in the E-Therapy group (2.1 versus 0.3).
When asked about their desired body mass index (BMI), participants who had completed the e-mail therapy indicated that they were more willing to accept the idea of a higher BMI than were those participants in the control group.
There was a significant correlation between the number of words a participant wrote and the degree of symptom improvements in the e-mail bulimia therapy group only, Dr. Robinson said.
“It is hard to explain the response in the self-directed writing group, although there is quite a lot in the literature about the therapeutic efficacy of writing, and how it can lower depression scores,” he noted.
Although the study found no difference in outcome between EBT and SDW, there was a trend in favor of EBT. “In a bigger study, I would expect and hope that therapy patients would do better,” he said.
E-mail therapy was well accepted by the participants, with 84% saying that they would be willing to engage in further therapy either online or face to face. There also was a feeling among therapists that this form of therapy took about half the time of traditional therapy, although it was not measured, Dr. Robinson said.
