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Previous studies have shown an unmet need in the treatment of eating disorders. In the last decade, interest in technology-based interventions (TBIs) (including computer- and Internet-based interventions [CBIs] or mobile interventions) for providing evidence-based therapies to individuals with different mental disorders has increased.
The aim of this review was to systematically evaluate the potential of TBIs in the field of eating disorders, namely for anorexia nervosa (AN) and bulimia nervosa (BN), for both prevention and treatment, and also for carers of eating disorder patients.
A systematic literature search was conducted using Medline and PsycINFO. Bibliographies of retrieved articles were also reviewed without date or study type restrictions.
Forty studies resulting in 45 publications reporting outcomes fulfilled the inclusion criteria: 22 randomized controlled trials, 2 controlled studies, and 16 uncontrolled studies. In total, 3646 patients were included. Overall, the studies provided evidence for the efficacy of guided CBIs, especially for BN patients and for compliant patients. Furthermore, videoconferencing also appeared to be a promising approach. Evaluation results of Internet-based prevention of eating disorders and Internet-based programs for carers of eating disorder patients were also encouraging. Finally, there was preliminary evidence for the efficacy of mobile interventions.
TBIs may be an additional way of delivering evidence-based treatments to eating disorder patients and their use is likely to increase in the near future. TBIs may also be considered for the prevention of eating disorders and to support carers of eating disorder patients. Areas of future research and important issues such as guidance, therapeutic alliance, and dissemination are discussed.
Up to 4% of women have an eating disorder. Among these, the prevalence is 0.3% for anorexia nervosa (AN), 1% for bulimia nervosa (BN) [
However, previous international studies on health service utilization showed an unmet need for the treatment of patients with eating disorders [
Technology-based interventions (TBIs), including computer- and Internet-based interventions (CBIs) or mobile interventions, have the potential to reach patients who otherwise may not access help, and to improve health care for those seeking treatment, by offering immediate access to evidence-based interventions. Communication in TBIs can take place synchronously (in real time, such as videoconference, chat rooms) or asynchronously (with lag between contacts, such as email, postings on a secure website, text messaging). Information exchange can occur in writing, just via audio communication, or via webcam. TBIs can be administered individually or in the form of group sessions.
There are various forms of CBIs that differ especially in their amount of therapist guidance:
Computer- and Internet-based unguided self-help (unguided CBI): this is the generic term for self-help interventions primarily delivered via computer technology. Available programs mainly are multimedia-based as well as CBT-based. Patients can either use them at home or in health care settings, and programs are designed to enable patients to work through them independent of a therapist.
Computer- and Internet-based guided self-help (guided CBI): support can range from screening for suitability, offering technical advice, monitoring progress and outcome, as well as giving emotional support [
Internet-based therapist-delivered treatments: these can be delivered using different methods, such as email, chat rooms, and videoconferencing, either solely Internet-delivered or in combination with face-to-face treatment. Patients have regular contact with a therapist.
In the last decade, a large body of empirical evidence on the acceptance and efficacy of CBIs for mental disorders has accrued. Several reviews and meta-analyses have shown that new CBI treatments hold great promise in the treatment of adults with depression [
Researchers in the field of eating disorders thus hypothesized that CBIs may also be a suitable approach for eating disorder patients because they mostly come from an age group that uses the computer and Internet frequently. This led them to examine the efficacy of CBIs for eating disorders. There are some reviews of CBIs in the field of eating disorders, but most of them do not meet the requirements of a systematic review [
Nevertheless, these reviews do not give a comprehensive overview of the current state of research in the field of TBIs in eating disorders due to their strict inclusion criteria. Our review addresses the fast changes in new technologies and the growing knowledge and increasing research on TBIs for eating disorders. The aims of this review are to provide a comprehensive and up-to-date picture on the developing field of TBIs for eating disorders, specifically for AN and BN, by including a wider range of study designs beyond just RCTs and to discuss the past findings with respect to both acceptance and efficacy of TBIs for AN and BN. We primarily focus on treatment studies, but also consider studies on prevention, motivation, and on programs for carers of eating disorder patients.
We searched Medline and PsycINFO for eligible studies published in English, German, Spanish, Italian, French, or Portuguese up to August 2014. The following search terms were used: “(online* OR internet* OR e-mail* OR email* OR web* OR media* OR computer* OR remote* OR tele* OR virtual* OR “interactive voice response*” OR www OR cd* OR dvd* OR flopp* OR audio* OR video* OR palmtop* OR e-health* OR technolog* OR chat* OR software* OR text-messag* OR “text messag*” OR “internet telephony” OR mobile* OR sms*).” Search terms were combined with (anore* OR bulimi* OR “eating disorder*” OR “disordered eating” OR body*image*) in title. The bibliographies of the retrieved articles were also reviewed.
We included studies that met the following inclusion criteria: (1) technology-based psychological interventions, (2) samples including patients with AN and/or BN according to
We excluded psychoeducational or counseling interventions, online support groups, as well as computer-based assessment methods. Studies that evaluated virtual reality in the treatment of body image were excluded because a review covering this issue has already been published [
We separately evaluated CBIs and mobile interventions and divided studies on CBIs into the following main categories: treatment of AN and BN, relapse prevention, prevention and early intervention, and interventions for carers. Treatment studies for AN and BN were further classified into 3 sections depending on the amount of guidance patients received. Studies in which patients were offered no contact with a coach or a clinician were classified as “unguided CBIs.” Studies in which patients worked through programs delivered on a computer or via the Internet and were guided by email, phone, or face-to-face contact with a professional were classified as “guided CBIs.” Finally, interventions that were completely delivered by a therapist (email therapy, videoconferencing) were classified as “therapist-delivered treatments.”
For studies for which relevant data were available, effect sizes (standardized mean differences) were calculated using pooled standard deviations [
PRISMA flow chart of the literature search.
A total of 40 studies met the inclusion criteria with outcomes reported in 45 publications. There were 41 publications on the results of the efficacy of CBIs (n=21 CBIs for the treatment of eating disorder patients; n=12 programs for prevention and early intervention of eating disorders; n=3 relapse prevention interventions; n=5 interventions for carers of eating disorder patients). A total of 4 publications reported on the efficacy of mobile interventions. Overall, 5 studies focused on AN and 5 studies on adolescents. 22 of the included studies were RCTs, 2 were controlled studies, and the remaining 16 studies were uncontrolled. The studies included a total number of 3646 patients.
In the following, results in effect sizes are given for all categories. Effect sizes and confidence intervals for all individual studies are presented in
Studies evaluating efficacy of computer- and Internet-based treatment for eating disorders.a
Study | Diagnosis (N) | Intervention (study design) | Duration | |
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Bara-Carril et al [ |
BN (N=46); EDNOS (N=11) | “Overcoming Bulimia” (uncontrolled study) | 8 modules, 4-8 weeks |
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Schmidt et al [ |
BN (N=60); EDNOS (N=37) | “Overcoming Bulimia” (RCT) | 8 modules, 8-12 weeks |
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Johnston et al [ |
BN (N=94) | Therapeutic writing (RCT) | 20 min on 3 consecutive days |
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Huon [ |
BN (N=120) | Internet-guided self-help (RCT) | 7 modules, 7 months |
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Graham & Walton [ |
BN (N=13); BED (N=27) | “Overcoming Bulimia” (uncontrolled study) | 8 modules, 8 weeks |
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Murray et al [ |
BN (N=77); EDNOS (N=5) | “Overcoming Bulimia” (controlled study) | 8 modules, 8-12 weeks |
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Sánchez-Ortiz et al [ |
BN (N=39); EDNOS (N=37) | “Overcoming Bulimia” (RCT) | 8 modules, 8-12 weeks; continued access to the online sessions for 24 weeks |
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Ljotsson et al [ |
BN (N=33); BED (N=36) | “Overcoming Binge eating” (RCT) | 6 modules, 12 weeks |
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Carrard et al [ |
BN (N=41); EDNOS (N=4) | “SALUT” (uncontrolled study) | 7 modules, 4 months |
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Liwowsky et al [ |
BN (N=22) | “SALUT” (uncontrolled study) | 7 modules, 4 months |
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Nevonen et al [ |
BN (N=27); EDNOS (N=11) | “SALUT” (uncontrolled study) | 7 modules, 6 months |
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Fernández-Aranda et al [ |
BN (N=62) | “SALUT” (controlled study) | 7 modules, 4 months |
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Carrard et al [ |
BN (N=100); EDNOS (N=27) | “SALUT” (uncontrolled study) | 7 modules, 4 months |
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Wagner et al [ |
BN/EDNOS (N=155) | “SALUT” (RCT) | 7 modules, 4-7 months |
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Leung et al [ |
ED (N=280) | “SMART EATING” (uncontrolled study) | 6 components, open-end |
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Pretorius et al [ |
BN (N=61); EDNOS (N=40) | “Overcoming Bulimia” (adapted for adolescents) (uncontrolled study) | 8 modules, 3 months |
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Wagner et al [ |
BN (N=126) | “SALUT” (RCT) | 7 modules, 4-7 months |
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Robinson & Serfaty [ |
BN (N=18); BED (N=4); EDNOS (N=1) | Email therapy (uncontrolled study) | 3 months |
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Robinson & Serfaty [ |
BN (N=51); EDNOS (N=20); BED (N=26) | Email therapy (RCT) | 3 months |
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Simpson et al [ |
BN (N=5); AN (N=1); EDNOS (N=6) | Videoconferencing (uncontrolled study) | 12-20 sessions CBT; 6-8 optional sessions of nutritional education |
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Mitchell et al [ |
BN (N=71); EDNOS (N=57) | Videoconferencing (RCT) | 20 sessions manual-based CBT, 4 months |
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Fichter et al [ |
AN (N=258) | “VIA” (RCT) | 9 modules, 9 months |
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Mezei et al [ |
BN/EDNOS/BED/ AN binge-purging subtype (N=39) | “EDINA” (uncontrolled study) | Online platform for peer support and professional consultation, 4 months |
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Gollings & Paxton [ |
Body dissatisfaction and disordered eating (N=40) | “Set Your Body Free” (pilot RCT) | Weekly 90-min group sessions, 8 weeks |
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Paxton et al [ |
Body dissatisfaction (N=116) | “Set Your Body Free” (RCT) | Weekly 90-min group sessions, 8 weeks |
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Stice et al [ |
Body dissatisfaction (N=107) | “eBody Project” (RCT) | 6 modules, 3 weeks |
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Serdar et al [ |
Weight and/or shape concerns (N=333) | Dissonance-based eating disorder prevention (RCT) | 3 sessions for 60 min |
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Zabinski et al [ |
Weight concerns (N=60) | Synchronous Internet relay chat (RCT) | Weekly (60 min) chat discussions, 8 weeks |
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Ohlmer et al [ |
Women at risk for AN (N=36) | “Student Bodies” for AN (uncontrolled study) | Weekly sessions for 45-90 min, 10 weeks |
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Heinicke et al [ |
Body image or eating problems (N=73) | “My Body, My Life” (RCT) | Weekly 90-min online sessions, 6 weeks |
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Ruwaard et al [ |
Bulimic symptoms (N=105) | Online cognitive behavioral treatment (RCT) | 20 weeks |
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Jacobi et al [ |
Subthreshold eating disorder (N=29); Eating disorder symptoms at lower level (N=97) | “Student Bodies+” (RCT) | 8 sessions, 8 weeks |
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Hötzel et al [ |
Eating disorder symptoms (N=212) | “ESS-KIMO“ (RCT) | Weekly online sessions for 45 min, 6 weeks |
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Leung et al [ |
Eating disorder (N=185) | “SMART EATING” (uncontrolled study) | 11 worksheets to enhance individuals’ motivation to change their eating behaviors |
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Binford Hopf et al [ |
Parents of AN patients (N=13) | Internet-based chat support groups (uncontrolled study) | 15 weekly online chat sessions for 90 min |
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Grover et al [ |
Carers of AN patients (N=27) | “Overcoming anorexia online” (uncontrolled study) | 9 workbooks (encouraged 1 per week, but no formal time limit) |
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Grover et al [ |
Carers of AN patients (N=64) | “Overcoming anorexia online” (RCT) | 8 modules, 4 months |
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Hoyle et al [ |
Carers of AN patients (N=37) | “Overcoming anorexia online” (RCT) | 7 modules + 2 additional modules for carers, 7 weeks |
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Bruning Brown et al [ |
Parents of sophomore students (N=69) | “Student Bodies” parent intervention (RCT) | Unstructured web-based intervention, 4 weeks |
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Shapiro et al [ |
BN (N=31) | Text messaging (uncontrolled study) | Daily, 24 weeks + 12 CBT face-to-face group sessions for 90 min |
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Robinson et al [ |
BN (N=21) | SMS-based intervention (uncontrolled study) | Weekly, 6 months |
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Bauer et al [ |
BN (N=97); EDNOS (N=68) | Aftercare SMS-based intervention (RCT) | Weekly symptom report via SMS text message, 16 weeks |
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Cardi et al [ |
AN (N=18); BN (N=13) | Mp4 player or iPod with 10 video clips (vodcasts) (uncontrolled study) | Between 3 to 20 min each, workbook and daily monitoring forms, 3 weeks |
a AN: anorexia nervosa, BN: bulimia nervosa, BED: binge eating disorder, CBT: cognitive behavioral therapy, ED: eating disorder, EDNOS: eating disorders not otherwise specified, RCT: randomized controlled trial, SMS: short message service.
A total of 3 studies with 248 participants including 94 controls examined unguided CBIs for eating disorders. Unguided CBIs showed no effects [
Five different treatment approaches of guided CBIs for adults were evaluated in 12 publications. A total of 1051 participants were included. Overall, 135 participants were controls without intervention or on the waiting list; 56 were active controls. From pre- to posttreatment, small to large effects were found for binging and vomiting (in 1 study there was no effect for vomiting) and medium to large effects for eating disorder psychopathology (total score of the Eating Disorder Inventory-2 [EDI-2] [
There was 1 study evaluating the potential of CBIs for adolescents and 1 additional study that provided data in the context of a subgroup analysis comparing adult and adolescent patients receiving guided CBI. A total of 130 adolescents were included. Adolescents were compared to 97 adults in 1 study. Small to large effects for binging and medium to large effects for vomiting at both postintervention and follow-up were found [
Four studies examined the efficacy of Internet-based therapist-delivered treatments: 2 investigated email therapy and 2 evaluated videoconferencing. In all, 260 patients participated of whom 27 were waiting list patients and 100 active controls. Internet-based therapist-delivered treatments resulted in medium (BITE severity and symptoms, binging) [
There were 2 studies investigating the efficacy of 2 different Internet-based relapse prevention programs: 1 uncontrolled study and 1 RCT. A total of 297 patients were included, of whom 130 were treatment as usual (TAU) patients. Overall, small short-term effects were found for the global of the Eating Disorder Examination Questionnaire (EDE-Q) [
Seven studies investigated the efficacy of CBIs in the prevention of eating disorders. A total of 775 participants were included: 224 were controls without intervention, 207 active controls (face-to-face), and 49 video or brochure controls. Primary outcomes studied were mainly body dissatisfaction and thin-ideal internalization. From pre- to postintervention, there were small to medium effects for the Ideal-Body Stereotype Scale-Revised (IBSS-R [
Heinicke et al [
We identified 2 studies investigating Internet-based treatments for subthreshold eating disorders. A total of 231 participants were randomized, of whom 35 were active controls and 97 were on a waiting list. From pre- to postintervention, a medium effect for binging [
Internet-based treatments that aimed at enhancing motivation to change in eating disorders were the subject of 2 studies. A total of 397 participants were included, of whom 109 were waiting list controls. There were small time effects for binging [
There were 5 intervention studies including 210 carers of people with eating disorders. A control intervention called Beating Eating Disorders (BEAT; patient and carer organization) was offered to 30 carers, whereas 47 received no intervention. From baseline to postintervention and to follow-up, no effect was found for the Level of Expressed Emotion Scale (LEE [
Four studies evaluated mobile interventions for eating disorders. Three studies (total N=230; n=83 control patients) employed short message service (SMS) text messaging and 1 study used vodcasts (N=31). For SMS text messaging interventions, the baseline versus follow-up effects were small [
Abstinence rates ranged between 12% [
In the following, results of further relevant aspects of TBIs are presented. Note that not all studies mentioned so far provided data regarding these points.
Twenty studies provided information about non-take-up rates. These ranged from 2.9% [
Murray et al [
Twenty-six studies provided data about compliance rates (we defined compliance as the full completion of the intervention regardless of whether participants completed posttreatment and/or follow-up assessment, and we only extracted data from studies that explicitly reported information on this). Between 18.4% [
Pretorius et al [
Most of the studies found no differences between completers and noncompleters in sociodemographic or clinical variables or in baseline scores [
Satisfaction was either measured by a satisfaction scale or assessed by qualitative comments. The majority of participants were satisfied with the programs and rated modules as pleasant, easy, and useful [
Follow-up dropout rates in the studies included in this review ranged from 4.7% [
Several studies reported predictors of outcome of TBIs in eating disorders. A better state of general psychological health was found to predict a better outcome [
Six eating disorder studies presented information about therapists’ time and efforts in guided CBIs. It ranged between 45 minutes and 135 minutes per patient [
Only 1 study on videoconferencing for eating disorder patients investigated therapeutic alliance. Therapists experienced differences between the delivery methods in terms of adherence to therapeutic tasks, adherence to therapeutic goals, and therapeutic bond, whereas patients did not [
Only 1 study compared cost-effectiveness of face-to-face CBT and CBT delivered via telemedicine [
Three studies provided information about adverse events occurring in the reviewed TBI studies. Sánchez-Ortiz et al [
Interest in research on TBIs for AN and BN has increased during the last decade. Forty studies whose outcome results were published in 45 papers fulfilled the inclusion criteria of this systematic review. Most studies dealt with guided CBIs (“Overcoming Bulimia,” “SALUT”) or programs for the prevention and early intervention of eating disorders. One has to consider that many of these treatments are derived from (guided) self-help interventions based on other media (eg, self-help manuals such as “Overcoming Bulimia”) that have been evaluated by a considerable number of researchers in the past and whose results have been summarized in a current meta-analysis [
With regard to BN, guided CBIs led to improvements in the core symptoms of binging and purging and global eating disorder psychopathology. Patients receiving guided CBIs improved more than controls. Guided CBI was shown to be as effective as guided bibliotherapy. Initial findings suggest that treatment results can also be maintained at follow-up. Furthermore, videoconferencing showed promise in treating patients with BN. Unfortunately, this approach has only been evaluated in 1 RCT so far.
With regard to AN, CBIs might be used for relapse prevention. However, only 1 study has empirically evaluated this kind of intervention in AN patients so far. Several case reports by Yager [
With regard to adolescents with eating disorders, research findings suggest that CBIs may be a treatment option for bulimic patients. However, results should be confirmed in RCTs and replicated by other research groups before widely recommending it.
Furthermore, CBIs may also be considered in the prevention and early intervention of eating disorders as well as for supporting carers of eating disorder patients. Finally, preliminary evidence suggests that mobile interventions are useful for patients with eating disorders in relapse prevention or as an adjunct to therapy (eg, symptom monitoring).
Efficacy results of TBIs are in-line with studies evaluating CBIs in other mental health disorders. For example, medium effects at posttreatment were also shown in a meta-analysis of CBIs for depressive disorders [
Although efficacy results in the reviewed studies are promising, high rates of non-take-up, noncompliance, and dropout in the reviewed studies severely hamper the validity of study results. Therefore, findings must be interpreted with some caution. The result that only slightly more than half of the participants (57%) completed the offered TBI parallels the report by Waller and Gilbody [
Guidance may be essential for both compliance and outcome of CBIs [
Studies of CBIs for various mental health disorders showed that guidance augments efficacy [
Overall, details about guidance are unsatisfactorily reported in most studies on CBIs for eating disorders. Information about the type and qualifications of coaches, about the type of support, as well as the timing, frequency, and overall amount of contact is often missing. However, all this important information is required to be able to compare the different programs and their efficacy and to get a clearer picture of how much and what kind of contact is needed to optimize the interventions.
The issue of human contact in guided CBIs also raises concerns about whether online therapy can establish any meaningful therapeutic alliance [
A systematic review investigating therapeutic relationships in e-therapy for mental health suggests that a therapeutic alliance equivalent to that in face-to-face therapy can be established in Internet-based therapy [
One strength of the present review is that we considered the whole spectrum of care from prevention, early intervention, treatment, relapse prevention of eating disorders, to interventions for carers of eating disorders. Furthermore, by including a wide range of study designs beyond just RCTs, a broad range of new types of TBIs were included. This made it possible to give a comprehensive up-to-date picture of the dynamic field of TBIs in eating disorders. Moreover, a wide range of aspects relevant to TBIs, such as acceptance, efficacy, predictors of outcome, need of guidance, and therapeutic alliance, were reviewed. This review is limited by the fact that a meta-analysis could not be performed due to the enormous heterogeneity of studies. Furthermore, diagnoses in studies were made in sometimes more but also less rigorous ways (informal clinical interview, semistructured clinical interview, questionnaire using
There are also several methodological limitations in the studies discussed in this review. We mainly followed the coding for weaknesses as suggested by Newman et al [
Consequentially, a number of challenges for future research arise that are detailed subsequently.
There is need for more high-quality RCTs that adhere to the Consolidated Standards of Reporting Trials (CONSORT) statement [
Many questions regarding the optimal delivery method of TBIs, as well as the optimal dose in terms of frequency, intensity, and duration of interventions, still await qualified answers. Research shows that adding more therapy components does not lead to better results [
Usually TBIs are complex interventions (ie, they consist of a number of interacting components) [
Integrating more motivational components into programs and tailoring the treatment to the AN and BN patients’ needs in terms of severity of illness and comorbidity will be imperative to further improve interventions. Research on depression has shown that more severely affected patients respond better to tailored, rather than to nontailored treatment [
More research on how to enhance the uptake and utilization of TBIs and how to promote its broader dissemination and implementation in routine care is necessary. TBIs should be integrated into existing health care systems and efforts should be made to enhance their acceptability and adoption by patients as well as by health care delivery teams [
TBIs also have some disadvantages. Some patients may not be able to access technological interventions [
Last but not least, research needs to determine the limits of TBIs [
Unfortunately, the evidence for TBIs in the treatment of AN and BN remains insufficient because many approaches were investigated only once, by 1 research group, or only in uncontrolled studies. Nevertheless, the initial results are encouraging. At this stage, unguided CBIs cannot be recommended for the treatment of AN and BN, whereas guided CBIs may be a promising treatment approach, especially for BN. Videoconferencing may also be an approach worth pursuing further in research as well as in practice. Furthermore, Internet-based relapse prevention for AN inpatients may be an effective way to stabilize treatment success and to bridge the gap between inpatient and outpatient therapy. Guided CBIs seem to be a promising approach even in the treatment of adolescents with BN. Efficacy of email therapy still remains to be seen. CBIs might also be considered for the prevention of eating disorders as well as to support carers of eating disorder patients. Furthermore, evaluation of mobile interventions should be further pursued.
Until now, many TBIs have only been used within the context of research studies and have not become part of routine health care. Before a widespread implementation of TBIs, it is imperative to ascertain that they are also feasible under naturalistic conditions and across settings.
In conclusion, one should stay open-minded about the integration of novel technologies that may enhance psychological prevention and treatment of AN and BN and their carers. TBIs can especially serve as a first step in a stepped-care model. However, patient compliance, which is essential for TBIs to work, is still a major challenge. Future research is needed before widely recommending TBIs for AN and BN.
Studies evaluating efficacy of technology-based psychological treatments for anorexia and bulimia nervosa.
Within- and between-group effect sizes and confidence intervals for included studies (posttreatment and follow-up).
Definition of abstinence in studies included in the review as well as abstinence rates and results of significance test wherever data was available.
anorexia nervosa
Beating Eating Disorders
binge eating disorder
Bulimic Investigatory Test-Edinburgh
body mass index
bulimia nervosa
Body Shape Questionnaire
computer- and Internet-based intervention
cognitive behavioral therapy
Consolidated Standards of Reporting Trials
Diagnostic and Statistical Manual of Mental Disorders
Eating Attitudes Test
eating disorder
Eating Disorder Examination
Eating Disorder Examination Questionnaire
Eating Disorder Inventory-2/Eating Disorder Inventory-3
eating disorder not otherwise specified
Eating Disorder Symptom Impact Scale
Hospital Anxiety and Depression Scale
Ideal-Body Stereotype Scale-Revised
interpersonal psychotherapy
Level of Expressed Emotion Scale
Overcoming Anorexia Online
Parental Attitudes and Criticism Scale
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
randomized controlled trial
Structured Interview for Anorexic and Bulimic Syndromes
short message service
treatment as usual
technology-based interventions
Temperament and Character Inventory-Revised
None declared.