Although impressive progress has been made toward developing empirically‐supported psychological treatments, the reality remains that a significant proportion of people with mental health problems do ...not receive these treatments. Finding ways to reduce this treatment gap is crucial. Since app‐supported smartphone interventions are touted as a possible solution, access to up‐to‐date guidance around the evidence base and clinical utility of these interventions is needed. We conducted a meta‐analysis of 66 randomized controlled trials of app‐supported smartphone interventions for mental health problems. Smartphone interventions significantly outperformed control conditions in improving depressive (g=0.28, n=54) and generalized anxiety (g=0.30, n=39) symptoms, stress levels (g=0.35, n=27), quality of life (g=0.35, n=43), general psychiatric distress (g=0.40, n=12), social anxiety symptoms (g=0.58, n=6), and positive affect (g=0.44, n=6), with most effects being robust even after adjusting for various possible biasing factors (type of control condition, risk of bias rating). Smartphone interventions conferred no significant benefit over control conditions on panic symptoms (g=–0.05, n=3), post‐traumatic stress symptoms (g=0.18, n=4), and negative affect (g=–0.08, n=5). Studies that delivered a cognitive behavior therapy (CBT)‐based app and offered professional guidance and reminders to engage produced larger effects on multiple outcomes. Smartphone interventions did not differ significantly from active interventions (face‐to‐face, computerized treatment), although the number of studies was low (n≤13). The efficacy of app‐supported smartphone interventions for common mental health problems was thus confirmed. Although mental health apps are not intended to replace professional clinical services, the present findings highlight the potential of apps to serve as a cost‐effective, easily accessible, and low intensity intervention for those who cannot receive standard psychological treatment.
Objective
Research investigating the effects of COVID‐19 on eating disorders is growing rapidly. A comprehensive evaluation of this literature is needed to identify key findings and evidence gaps to ...better inform policy decisions related to the management of eating disorders during and after this crisis. We conducted a systematic scoping review synthesizing and appraising this literature.
Method
Empirical research on COVID‐19 impacts on eating disorder severity, prevalence, and demand for treatment was searched. No sample restrictions were applied. Findings (n = 70 studies) were synthesized across six themes: (a) suspected eating disorder cases during COVID‐19; (b) perceived pandemic impacts on symptoms; (c) symptom severity pre versus during the pandemic; (d) pandemic‐related correlates of symptom severity; (e) impacts on carers/parents; and (f) treatment experiences during COVID‐19.
Results
Pandemic impacts on rates of probable eating disorders, symptom deterioration, and general mental health varied substantially. Symptom escalation and mental health worsening during―and due to―the pandemic were commonly reported, and those most susceptible included confirmed eating disorder cases, at‐risk populations (young women, athletes, parent/carers), and individuals highly anxious or fearful of COVID‐19. Evidence emerged for increased demand for specialist eating disorder services during the pandemic. The forced transition to online treatment was challenging for many, yet telehealth alternatives seemed feasible and effective.
Discussion
Evidence for COVID‐19 effects is mostly limited to participant self‐report or retrospective recall, cross‐sectional and descriptive studies, and samples of convenience. Several novel pathways for future research that aim to better understand, monitor, and support those negatively affected by the pandemic are formulated.
Resumen
Objetivo
La investigación que se hace sobre los efectos de COVID‐19 en los trastornos de la conducta alimentaria está creciendo rápidamente. Se necesita una evaluación exhaustiva de esta literatura para identificar los hallazgos clave y evidenciar las brechas para informar mejor las decisiones de políticas públicas relacionadas con el manejo de los trastornos de la conducta alimentaria durante y después de esta crisis. Se realizó una revisión sistemática del alcance que sintetizó y valoró esta literatura.
Método
Se buscó investigación empírica sobre los impactos de COVID‐19 en la gravedad, prevalencia y demanda de tratamiento de los trastornos de la conducta alimentaria. No se aplicaron restricciones a la muestra. Los hallazgos (n = 70 estudios) se sintetizaron en seis temas: (1) casos sospechosos de trastornos de la conducta alimentaria durante COVID‐19; (2) impacto percibido en los síntomas; (3) gravedad de los síntomas antes versus durante la pandemia; (4) correlatos relacionados con la pandemia de la gravedad de los síntomas; (5) impactos en los cuidadores/padres; (6) experiencias de tratamiento durante COVID‐19.
Resultados
El impacto de la pandemia en las tasas de probables trastornos de la conducta alimentaria, deterioro de los síntomas y salud mental en general variaron sustancialmente. La escala de síntomas y el empeoramiento de la salud mental durante y debido a la pandemia fueron reportados comúnmente, y los más susceptibles incluyeron casos confirmados de trastornos de la conducta alimentaria, poblaciones en riesgo (mujeres jóvenes, atletas, padres / cuidadores) e individuos con altos niveles de ansiedad o con miedo de COVID‐19. Surgió alguna evidencia de una mayor demanda de servicios especializados en trastornos de la conducta alimentaria durante la pandemia. La transición forzada al tratamiento en línea fue un desafío para muchos, sin embargo, las alternativas de telesalud parecían factibles y efectivas. Conclusiones. La evidencia de los efectos de COVID‐19 se limita principalmente al autoinforme de los participantes o al recuerdo retrospectivo, los estudios transversales y descriptivos, y las muestras de conveniencia. Se formulan varias vías novedosas para futuras investigaciones que tienen como objetivo comprender, monitorear y apoyar mejor a aquellos que fueron afectados negativamente por la pandemia.
Objective
Intuitive eating is an adaptive style of eating that has generated significant research attention. Theoretically, intuitive eating is a core construct that features prominently in the ...Acceptance Model of Intuitive Eating, a framework that explains how positive environmental influences can foster intuitive eating practices via body appreciation. Empirically, intuitive eating has been connected to a broad range of adaptive mental health indices. At present, a quantitative synthesis of intuitive eating and its correlates has yet to be conducted. This was the objective of the current meta‐analysis.
Method
Ninety‐seven studies (89% cross‐sectional) were included. Random effects meta‐analyses were conducted on 23 psychological correlates, divided into three clusters: eating behavior and body image disturbances, positive body image and other adaptive factors, and general psychopathology. Meta‐analytic path analyses were also computed to test the validity of the Acceptance Model.
Results
Intuitive eating was inversely associated with multiple indices of eating pathology, body image disturbances, and psychopathology (rs = −.23 to −.58). Intuitive eating was positively associated with numerous positive psychological constructs, such as positive body image, self‐esteem, and wellbeing (rs = .20 to .58). Men reported higher levels of intuitive eating than women (d = 0.39), with differences being largest in Caucasian samples. Meta‐analytic path analyses strongly supported the hypothesized pathways specified in the Acceptance Model of Intuitive Eating.
Conclusions
There is a strong evidence base for intuitive eating's connection to numerous adaptive psychological constructs. Attention should now shift toward prospective and experimental designs so that the temporal nature of these relationships can be identified.
Resumen
Objetivo
La alimentación intuitiva es un estilo de alimentación adaptativo que ha generado una atención significativa en la investigación. Teóricamente, la alimentación intuitiva es una construcción central que ocupa un lugar destacado en el Modelo de Aceptación de la Alimentación Intuitiva, un marco que explica cómo las influencias ambientales positivas pueden fomentar las prácticas alimentarias intuitivas a través de la apreciación corporal. Empíricamente, la alimentación intuitiva se ha relacionado con una amplia gama de índices adaptativos de salud mental. En la actualidad, aún no se ha realizado una síntesis cuantitativa de la alimentación intuitiva y sus correlatos. Este fue el objetivo del metanálisis actual.
Método
Se incluyeron noventa y siete estudios (89% de corte transversal). Se llevaron a cabo metanálisis de efectos aleatorios en 23 correlatos psicológicos, divididos en tres grupos: comportamiento alimentario y alteraciones de la imagen corporal, imagen corporal positiva y otros factores adaptativos, y psicopatología general. También se calcularon los análisis de ruta metaanalítica para probar la validez del Modelo de Aceptación.
Resultados
La alimentación intuitiva se asoció inversamente con múltiples índices de patología alimentaria, alteraciones de la imagen corporal y psicopatología (rs = −.23 a −.58). La alimentación intuitiva se asoció positivamente con numerosos constructos psicológicos positivos, como la imagen corporal positiva, la autoestima y el bienestar (rs = .20 a .58). Los hombres informaron niveles más altos de alimentación intuitiva que las mujeres (d = 0,39), y las diferencias fueron mayores en las muestras caucásicas. Los análisis de rutas metaanalíticas respaldaron firmemente las rutas hipotéticas especificadas en el Modelo de Aceptación de la Alimentación Intuitiva.
Conclusiones
Existe una sólida base de evidencia para la conexión de la alimentación intuitiva con numerosos constructos psicológicos adaptativos. Ahora la atención debe desplazarse hacia diseños prospectivos y experimentales para poder identificar la naturaleza temporal de estas relaciones.
Abstract Background Although accumulated evidence suggests that fluctuations in depressed mood are common among individuals with depression, and may be associated with onset, duration, and severity ...of illness, a systematic appraisal of putative predictors of depressed mood is lacking. Methods A systematic search for relevant studies in the literature was conducted using PsycInfo and PubMed databases via EbscoHost in February 2016. The search was limited to articles using the experience sampling method, an approach suitable for capturing in situ fluctuations in mood states. Results Forty-two studies met inclusion criteria for the review, from which three key risk factors (poor sleep, stress, and significant life events) and two protective factors (physical activity and quality of social interactions) were identified. The majority of papers supported concurrent and lagged associations between these putative protective/risk factors and depressed mood. Limitations Despite support for each of the proposed protective/risk factors, few studies evaluated multiple factors in the same study. Moreover, the time course for the effects of these predictors on depressed mood remains largely unknown. Conclusions The present review identified several putative risk and protective factors for depressed mood. A review of the literature suggests that poor sleep, negative social interactions, and stressful negative events may temporally precede spikes in depressed mood. In contrast, exercise and positive social interactions have been shown to predict subsequent declines in depressed mood. However, the lack of multivariate models in which the unique contributions of various predictors could be evaluated means that the current state of knowledge prevents firm conclusions about which factors are most predictive of depressed mood. More complex modeling of these effects is necessary in order to provide insights useful for clinical treatment in daily life of the depressed mood component of depressive disorders.
The current COVID‐19 pandemic has created a global context likely to increase eating disorder (ED) risk and symptoms, decrease factors that protect against EDs, and exacerbate barriers to care. Three ...pathways exist by which this pandemic may exacerbate ED risk. One, the disruptions to daily routines and constraints to outdoor activities may increase weight and shape concerns, and negatively impact eating, exercise, and sleeping patterns, which may in turn increase ED risk and symptoms. Relatedly, the pandemic and accompanying social restrictions may deprive individuals of social support and adaptive coping strategies, thereby potentially elevating ED risk and symptoms by removing protective factors. Two, increased exposure to ED‐specific or anxiety‐provoking media, as well as increased reliance on video conferencing, may increase ED risk and symptoms. Three, fears of contagion may increase ED symptoms specifically related to health concerns, or by the pursuit of restrictive diets focused on increasing immunity. In addition, elevated rates of stress and negative affect due to the pandemic and social isolation may also contribute to increasing risk. Evaluating and assessing these factors are key to better understanding the impact of the pandemic on ED risk and recovery and to inform resource dissemination and targets.
Digital interventions show promise as an effective prevention or self-management option for eating disorders (EDs). However, it remains unclear how, for whom, and through what mechanisms they work in ...this population, as a synthesis of outcome predictors, moderators, and mediators is lacking. This systematic review synthesized empirical research investigating predictors, mediators, and moderators of response to digital interventions for EDs.
Six databases were searched (PROSPERO CRD42022295565) for studies that assessed predictors, moderators, or mediators of response (i.e., uptake, drop-out, engagement, and symptom level change) to a digital prevention or treatment program for EDs. Variables were grouped into several overarching categories (demographic, symptom severity, psychological, etc.) and were synthesized qualitatively across samples without a formally diagnosed ED (typically prevention-focused) and samples with a formally diagnosed ED (typically treatment-focused).
Eighty-six studies were included. For studies recruiting samples without a formal diagnosis (n = 70 studies), most predictors explored were statistically unrelated to outcome, although participant age, baseline symptom severity, confidence to change, motivation, and program engagement showed preliminary evidence of prognostic potential. No robust moderators or mediators were identified. Few studies recruiting samples with a formal diagnosis emerged (n = 16), of which no reliable predictors, moderators, or mediators were identified.
It remains unclear how, for whom, and under what circumstances digital programs targeting EDs work. We offer several recommendations for future research with the aim of advancing understanding of client characteristics and intervention elements that signal success from this intervention modality.
Digital interventions have shown potential as an effective, scalable, and accessible intervention option for EDs. However, responsiveness varies, so advancing understanding of predictors, mediators, and moderators of outcome to digital interventions for EDs is needed. Such knowledge is important for enabling safe and efficient treatment matching, and for informing future development of effective digital interventions.
Our ability to predict responsiveness to digital interventions for eating disorders has thus far been poor, potentially for three reasons: (1) there has been a narrow set of predictors explored; (2) ...prediction has mostly focused on symptom change, ignoring other aspects of the user journey (uptake, early engagement); and (3) there is an excessive focus on the unique effects of predictors rather than the combined contributions of a predictor set. We evaluated the univariate and multivariate effects of outcome predictors in the context of a randomized trial (n = 398) of digitally delivered interventions for recurrent binge eating.
Thirty baseline variables were selected as predictors, ranging from specific symptoms, to key protective factors, to technological acceptance, and to online treatment attitudes. Outcomes included uptake, early engagement, and remission. Univariate (d) and multivariate (D) standardized mean differences were calculated to estimate the individual and combined effects of predictors, respectively.
At the univariate level, few predictors produced an effect size larger than what is considered small (d > .20) across outcomes. However, our multivariate approach enhanced prediction (Ds = .65 to 1.12), producing accuracy rates greater than chance (63%-71% accuracy). Less than half of the chosen variables proved to be useful in contributing to predictions in multivariate models.
Findings suggest that accuracy in outcome prediction from digitally delivered interventions may be better driven by the aggregation of many small effects rather than one or several largely influential predictors. Replication with different data streams (sensor, neuroimaging) would be useful.
Our ability to predict who will and will not benefit from digital interventions for eating disorders has been poor. We highlight the viability of a multivariate approach to outcome prediction, whereby prediction may be better driven by the aggregation of many small effects rather than one or a few influential predictors.
Objective
Prior reviews have shown that interventions targeting internalization of appearance standards are generally efficacious, though there is considerable heterogeneity in estimates across ...studies. This updated review of the literature evaluates whether efficacy estimates from RCTs systematically vary as a function of three related outcome measures (internalization, awareness, and perceived pressure regarding appearance standards).
Methods
Seven electronic databases were systematically searched from inception to February 8, 2023. The Cochrane Risk of Bias tool assessed each study's risk of bias. Studies included were randomized‐controlled trials evaluating body image/eating disorder prevention or intervention programs targeting internalization as a focal point of treatment. Effect sizes were meta‐analyzed and meta‐regression analyses were conducted investigating the impact of outcome measure choice on study effect size at post‐intervention and follow‐up.
Results
Thirty‐seven studies (N = 4809 participants) were included. The meta‐analytic findings as expected found interventions efficacious at reducing internalization post‐intervention (d = −0.47, 95% CI −0.60 to −0.34, k = 44), and at follow‐up (d = −0.28, 95% CI −0.39 to −0.17, k = 43), but also highly heterogenous (I2 = 52–67%). Operationalization of internalization moderated results at follow‐up but not post‐intervention timepoints, with awareness measures (compared with internalization measures) producing weaker effect sizes. Exploratory analyses found bigger effects when internalization was compared with all other measurement categories combined, suggesting possible issues with statistical power in main analyses.
Discussion
Mixed present findings suggest need for further evaluation of measurement effects on efficacy, and possible caution in choice of outcome measure for internalization‐based interventions.
Public significance statement
This review provides some preliminary evidence that choice of survey measures used in randomized controlled trials can impact our judgments about whether a trial reduces the extent to which participants endorse unrealistic appearance standards. Accuracy in measurement of this efficacy of trials is crucial, given the role that internalized appearance standards play in onset and maintenance of eating disorders.
o
Objetivo
Las revisiones anteriores han demostrado que las intervenciones dirigidas a la internalización de los estándares de apariencia son generalmente eficaces, aunque existe una heterogeneidad considerable en las estimaciones entre los estudios. Esta revisión actualizada de la bibliografía evalúa si las estimaciones de eficacia de los ECA varían sistemáticamente en función de tres medidas de resultado relacionadas (internalización, conciencia y presión percibida con respecto a los estándares de apariencia).
Método
Se realizaron búsquedas sistemáticas en siete bases de datos electrónicas desde su inicio hasta el 8 de febrero de 2023. La herramienta Cochrane Risk of Bias evaluó el riesgo de sesgo de cada estudio. Los estudios incluidos fueron ensayos controlados aleatorios (ECA) que evaluaron la prevención de la imagen corporal/trastornos alimentarios o programas de intervención dirigidos a la internalización como punto focal del tratamiento. Se metanalizaron los tamaños del efecto y se realizaron análisis de metarregresión que investigaron la repercusión de la elección de la medida de resultado sobre el tamaño del efecto del estudio después de la intervención y el seguimiento.
Resultados
Se incluyeron treinta y siete estudios (N = 4 809 participantes). Los hallazgos metaanalíticos como era de esperarse encontraron intervenciones eficaces para reducir la internalización después de la intervención (d = ‐0,47, IC del 95% ‐0,60 a ‐0,34, k = 44) y en el seguimiento (d = ‐0,28, IC del 95% ‐0,39 a ‐0,17, k = 43), pero también altamente heterogéneas (I2 = 52‐67%). La operacionalización de la internalización moderó los resultados en los puntos temporales de seguimiento pero no en posteriores a la intervención, y las medidas de sensibilización (en comparación con las medidas de internalización) produjeron tamaños del efecto más débiles. Los análisis exploratorios encontraron mayores efectos cuando la internalización se comparó con todas las demás categorías de medición combinadas, lo que sugiere posibles problemas con el poder estadístico en los análisis principales.
Discusión
Los hallazgos actuales mixtos sugieren la necesidad de una evaluación adicional de los efectos de la medición sobre la eficacia, y la posible precaución en la elección de la medida de resultado para las intervenciones basadas en la internalización.
Schleider et al. propose that single session interventions (SSIs) could be a promising path toward catalyzing innovation in the development of accessible interventions for eating disorders (EDs). In ...this commentary, we contend that the arguments made by Schleider et al. raise many unresolved questions that continue to arise in the broader field. Drawing from our experiences with—and lessons learned from—developing, evaluating, and disseminating digital health interventions, we discuss four key empirical questions that should be addressed in order to realize the full potential of SSIs and other innovations in intervention delivery. These include: (i) for whom do we deliver an SSI; (ii) what are the optimal treatment mechanisms to target; (iii) what constitutes a “good” outcome; and (iv) where and how might we embed innovations like these. The SSI approach is a fruitful area of research enquiry, and we hope that this commentary generates further discussion and high‐quality, collaborative work related to improving treatment accessibility and clinical outcomes among people with EDs.
Objective
The present meta‐analysis summarizes existing evidence on the relationship between the internalization of body shape ideals (IBSI) and body dissatisfaction.
Method
Pooled effect sizes (r) ...were computed using a random‐effects model. The robustness of the results was examined using influence analyses. Potential predictors of effect heterogeneity were examined using subgroup analysis and univariable/multivariable meta‐regressions. Publication bias was examined using the three‐parameter selection model (3PSM).
Results
A total of 141 effect‐sizes from 78 studies (N = 39,491) were retrieved. Results revealed medium (r = .25; muscular/athletic‐ideal internalization) to very large (r = .43, general attractiveness‐ideal internalization; and r = .45, thin‐ideal internalization) relationships, all these being largely similar in male and female individuals.
Discussion
IBSI and body dissatisfaction were strongly linked: (a) in younger individuals (general attractiveness‐ideal internalization); (b) when IBSI was operationalized in terms of endorsement rather than mere awareness of appearance ideals; (c) in studies of lower methodological quality (muscular/athletic‐ideal internalization); and (d) when IBSI was assessed using instruments involving social comparisons. Given the largely cross‐sectional nature of data included in this meta‐analysis, further testing in prospective and experimental studies is needed to confirm hypotheses about causality of observed associations. Such findings would have impact for prevention and intervention studies.
Resumen
Objetivo
El presente metanálisis resume la evidencia existente sobre la relación entre la internalización de los ideales de la figura corporal (IBSI) y la insatisfacción corporal.
Método
Los tamaños de los efectos agrupados (r) se calcularon utilizando un modelo de efectos aleatorios. La robustez de los resultados se examinó mediante análisis de influencia. Los predictores potenciales de heterogeneidad del efecto se examinaron mediante análisis de subgrupos y metarregresión univariable/multivariable. El sesgo de publicación se examinó mediante la inspección visual de la simetría de la gráfica de embudo y la prueba de Egger.
Resultados
Se recuperó un total de 141 tamaños de efectos de 78 estudios (N = 39 491). Los resultados revelaron relaciones medias (r = .25; internalización muscular/atlética‐ideal) a relaciones muy grandes (r = .43, internalización ideal de atractivo general; y r = .45, internalización delgada‐ideal), siendo todas ellas en gran parte similares en individuos masculinos y femeninos.
Discusión
La Internalización de los Ideales de la Figura Ideal (IBSI) y la insatisfacción corporal fueron ligados fuertemente: (i) en individuos más jovenes (internalización atractivo‐ideal general); (ii) cuando IBSI se puso en marcha en términos de aprobación en lugar de la mera conciencia de los ideales de apariencia; (iii) en estudios de menor calidad metodológica (internalización muscular/atlética‐ideal); y (iv) cuando IBSI fue evaluado utilizando instrumentos que implican comparaciones sociales. Dada la gran naturaleza transversal de los datos incluidos en este metanálisis, se necesitan pruebas adicionales en estudios prospectivos y experimentales para confirmar hipótesis sobre la causalidad de las asociaciones observadas. Tales hallazgos tendrían impacto para los estudios de prevención e intervención.
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