آزمایش کنترل شده تصادفی درمان هدایت شده خودیاری در اینترنت برای اختلال پرخوری افراطی

Binge eating disorder (BED) is a common and under-treated condition with major health implications. Cognitive behavioural therapy (CBT) self-help manuals have proved to be efficient in BED treatment. Increasing evidence also support the use of new technology to improve treatment access and dissemination. This is the first randomised controlled study to evaluate the efficacy of an Internet guided self-help treatment programme, based on CBT, for adults with threshold and subthreshold BED. Seventy-four women were randomised into two groups. The first group received the six-month online programme with a six-month follow-up. The second group was placed in a six-month waiting list before participating in the six-month intervention. Guidance consisted of a regular e-mail contact with a coach during the whole intervention. Binge eating behaviour, drive for thinness, body dissatisfaction and interoceptive awareness significantly improved after the Internet self-help treatment intervention. The number of objective binge episodes, overall eating disorder symptoms score and perceived hunger also decreased. Improvements were maintained at six-month follow-up. Dropouts exhibited more shape concern and a higher drive for thinness. Overall, a transfer of CBT-based self-help techniques to the Internet was well accepted by patients, and showed positive results for eating disorders psychopathology.

Binge eating disorder (BED) is characterised by recurrent episodes of binge eating with a sense of loss of control and a marked distress, without the inappropriate compensatory behaviour observed in bulimia nervosa. BED appears to be a stable condition, more common than bulimia nervosa or anorexia nervosa (Hudson, Hiripi, Pope, & Kessler, 2007), with a raising prevalence. For instance, community surveys conducted in South Australia inferred an over twofold increase in the prevalence of binge eating between 1995 and 2005 (Hay, Mond, Buttner, & Darby, 2008). BED represents a serious public health problem (Hudson et al., 2007). It is often associated with obesity, psychological impairment and a lower quality of life (Grucza, Przybeck, & Cloninger, 2007). A recent study found that 70% of individuals with BED in a community sample were also obese, with 20% of people reporting a body mass index (BMI; weight in kg/height in m2) over 40 (Grucza et al., 2007). BED frequently occurs with mood and anxiety disorders, substance use disorders and a life history of suicide attempts. Studies showed that up to 74% of BED individuals reported additional lifetime psychiatric disorders (Grilo et al., 2009, Grucza et al., 2007, Javaras et al., 2008 and Wilfley et al., 2003). BED and associated psychopathology can be effectively treated by cognitive behavioural therapy (CBT; Wilfley et al., 2002 and Wilson et al., 2010). CBT for BED was also evaluated in self-help format, with results comparable to individual CBT or group therapy (Carter and Fairburn, 1998 and Grilo and Masheb, 2005). In a recent meta-analysis, CBT delivered in structured self-help was observed to have larger effects on the reduction of binge eating frequency and associated symptoms, such as eating, weight and shape concerns compared to available psychological, pharmacological and weight-loss treatments for BED (Vocks et al., 2010). But it has also been repeatedly demonstrated that CBT had no effect on weight reduction even if most of the studies participants were obese (Vocks et al., 2010). Acceptance and efficacy of CBT-based guided self-help were also demonstrated in a primary care context, using a broader definition of eating disorders (Striegel-Moore et al., 2010). This study provided new findings in favour of the use of guided self-help as first line treatment, with a more adequate replication of the conditions found in clinical practice. BED sufferers experience a limited access to treatment. The problem is under-treated and often not diagnosed. This might be due to a lack of information, and shame or denial on the part of the patients. Less than half of BED patients seek treatment for their eating disorder and BED is rarely screened by physicians (Crow, Peterson, Levine, Thuras, & Mitchell, 2004). Developing innovative treatment strategies, particularly using the latest information technology, could help promote treatment seeking and improve access to treatment (Bulik, Brownley, & Shapiro, 2007). The benefits of delivering CBT-based intervention on CD-ROM or through the Internet have been demonstrated in several studies for bulimia nervosa. Clinical evaluations of an online-guided self-help programme for bulimia nervosa, conducted in four countries as part of the European research project SALUT, showed reduction of eating disorder symptoms and psychopathology from all four countries (Carrard et al., 2010, Carrard et al., 2006, Fernandez-Aranda et al., 2009, Liwowsky et al., 2006 and Nevonen et al., 2006). A randomised controlled study of a three-month CD-ROM for bulimia nervosa suggested that providing guidance might increase adherence and benefits of computerised interventions (Schmidt et al., 2008). A subsequent randomised controlled trial within a student population of an Internet version of this CD-ROM, delivered with e-mail support, produced significant improvements on eating disorders psychopathology, affective symptoms and quality of life compared to a three-month waiting list (Sanchez-Ortiz et al., 2010). Until recently, little has been done on technology-enhanced delivery of CBT-based interventions for BED. To our knowledge, only one study evaluated the use of a CD-ROM programme for BED and overweight patients. A randomised controlled trial comparing the efficacy of a ten-week CD-ROM intervention, a CBT group and a waiting list had comparable reduction in binge days between CBT group and CD-ROM, both interventions showing better results than a waiting list (Shapiro et al., 2007). However, conclusions of this study were limited by a high rate of dropout. Online programmes have mainly targeted weight loss or weight maintenance in overweight or obese patients (Tate et al., 2006 and Tate et al., 2001) but BED, which is an eating disorder frequently found in people looking for weight loss (Spitzer et al., 1993), was not a direct focus. Only a single recent randomised controlled study evaluated an Internet intervention addressing binge eating and overweight in adolescents (Jones et al., 2008). This 16-week Internet programme, combining cognitive-behavioural principles for BED and weight loss intervention, had a significant effect on binge eating and weight maintenance simultaneously. This paper reports the results of a randomised controlled study to evaluate the efficacy of an Internet guided self-help treatment programme for BED in a community sample. The programme is based on CBT, and targets behavioural and psychological aspects of BED such as loss of control on eating and shape and weight concerns. Obesity, weight loss and weight management were not addressed directly in the programme. We hypothesised that key outcome variables related to binge eating and eating disorder psychopathology of the Internet intervention group would improve compared to a control group, and that the Internet self-help treatment programme would have positive effects on depression, psychological health, self-esteem and quality of life. We also hypothesised that these improvements would be sustained at follow-up.

To conclude, this study demonstrated that an Internet CBT-based self-help treatment programme for BED could be implemented on the Internet and still preserves its efficacy. The Internet programme was well accepted by BED sufferers seeking for a treatment. It had a positive impact on key factors of the illness. For many participants, it was their first eating disorder treatment. Without the visibility provided by the Internet, they would not have known where to ask for help. After the online intervention, some participants who still needed help were more willing to consult a clinician. For these reasons, an Internet self-help treatment programme can be recommended as a first step treatment for BED. Even if patients and frequently therapists can be prejudiced against the use of new technologies for self-help treatment, this is new without being new (Caspar, 2004). The CBT techniques used widely proved their efficacy before their implementation on the web. Self-help manuals have now been evaluated for many years due to the increasing need of new means to disseminate adequate treatment for eating disorders. After demonstration of acceptance and efficacy, further studies will have to evaluate cost-effectiveness of treatment techniques based on new technologies in comparison to other types of treatment delivery