Addressing Critical Gaps in the Treatment of Eating Disorders
Published online 2017 Jan 19. doi: 10.1002/eat.22670
Abstract
Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: 1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and 2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.
Eating disorders are associated with high medical and psychiatric comorbidity, poor quality of life, and high mortality.1–3 Mortality from anorexia nervosa (AN) is the highest of all mental disorders, and eating disorders rank as the 12th leading cause of disability in young women in high-income nations.4 The development and evaluation of evidence-based psychosocial interventions (EBPIs) for eating disorders and other psychiatric disorders are remarkable advances. EBPIs refer to interventions that have been evaluated in randomized controlled clinical trials, where treatments, client samples, and outcomes have been well specified, and where the effects have been replicated by an independent research team. A current priority is to disseminate—transmit information about a treatment (e.g., its nature, effectiveness, indications, characteristics)—from research to practice, and implement, or actually adopt and use, those treatments in routine clinical practice,5 thus addressing the “research-practice gap.” Extending interventions from research to practice is a critical step in the process of improving mental health care, but another crucial step is extending treatments in ways that will reach the large number of people in need of clinical care but who are not receiving services, which we will refer to here as addressing the “treatment gap.” Disseminating EBPIs to clinical practice alone will not necessarily address this latter need. This paper discusses these critical gaps in the treatment of eating disorders, that is, the research-practice gap and the treatment gap, and the approaches that are needed to address them effectively.
Critical Gaps in Treatment
Research-Practice Gap
The research-practice gap refers to the discrepancy between what is known about effective treatment and what is actually provided to patients who receive care.6 Among those who actually receive services for mental health problems, what do they receive? As part of the National Comorbidity Survey-Replication in the United States (US), over 9,000 individuals with psychiatric disorders answered questions about their treatment that included who the service provider was (e.g., psychiatrist, family physician, social worker, spiritual advisor, other) and the type of treatment they received (e.g., self-help group, medication, hospital admission).7 Minimally adequate treatment was defined as receiving an intervention (e.g., medication, psychotherapy) that followed evidence-based guidelines for the specific disorder and included multiple contacts (rather than only one visit). For individuals with a psychiatric disorder, 21.5% received treatment from a mental health specialist; 41.7% received treatment if this is expanded to include contact with any health-care person, in addition to those trained in mental health. For those who did not meet full criteria for disorder (subclinical disorder), 4.4% received treatment from a mental health specialist and 10.1% received treatment if this is expanded to include any contact. Overall, across the entire sample, only 32.7% were classified as receiving at least minimally adequate treatment based on evidence-based treatment guidelines. This issue has been studied internationally as well. The World Health Organization (WHO)8 provided extensive data on mental disorder treatment receipt from surveys of over 60,000 adults in 14 countries in the Americas, Europe, the Middle East, Africa, and Asia. The proportion of respondents who received treatment for emotional or substance-use disorders during the previous 12 months ranged from a low of 0.8% (Nigeria) to a high of 15.3% (US)—percentages refer to those who received treatment among those in need. “Receiving services” was based on asking respondents if they ever saw anyone from a long list of caregivers as an outpatient or inpatient for problems with emotions, nerves, mental health, or use of alcohol or drugs. Included were mental health professionals (e.g., psychiatrist, psychologist), general medical or other professionals (e.g., general practitioner, occupational therapist), religious counselors (e.g., minister, sheikh), and traditional healers (e.g., herbalist, spiritualist). The precise service provided by these individuals was not identified and the duration of the intervention was not specified, but receiving services required at least one contact. Thus when we say that 15% of individuals in the US with any type of mental health disorder received treatment, information is ambiguous and could be one contact with someone who has had no training in mental health.
There is worrisome evidence that access to EBPIs is actually diminishing. Based on service use data from two representative surveys of the US general population in 1998 (N = 22,953) and 2007 (N = 29,370), spending on psychotherapy declined by more than a third, from $12.74 billion in 1998 to $8.35 billion in 2007 (for ease of interpretation, these amounts are in current dollars, as of 2016); in contrast, the use of patients receiving psychotropic medication only increased from 44.1% to 57.4%.9 Importantly, it is not known the extent to which the treatments delivered were EBPIs but tempting to speculate that it might be a small proportion.10 Also there is the issue that the programs training the major providers of psychotherapy (i.e., psychiatrists, psychologists, social workers) are generally not providing competency-based instruction in EBPIs; although programs may provide exposure to EBPIs, few programs require the acquisition of competence through both a didactic and clinical supervision.11,12 Notably, the most recent American Psychological Association Standards of Accreditation, which go into effect in 2017, mandate some training in EBPIs (e.g., “must demonstrate a fundamental understanding of and competency in…evidence-based professional practice”),13 but it is unknown how this will be enforced, and further, how to do competency-based training has yet to be fully delineated. Also, this only affects accredited psychology training programs, and there are far more practitioners who are not psychologists as well as many who come from unaccredited programs for which these standards would not apply.
Likewise, when individuals with eating disorders receive care, more often than not, it is not an EBPI.14–16 The number of eating disorder specialist clinicians who report adhering to evidence-based protocols is between 6 and 35%, with far more clinicians reporting using an eclectic mix of techniques derived from EBPIs and some techniques that are not even supported at that level.17 Even when clinicians say that they are using an EBPI for eating disorders, such as cognitive-behavioral therapy (CBT) or family-based treatment (FBT), they often omit key elements of those approaches.18,19
There are a number of reasons to believe that translation from research to practice and dissemination of EBPIs in the field of eating disorders is warranted. First, it has been reliably demonstrated that there is specificity of effects for specialist psychological treatments for eating disorders. For example, 5 months of enhanced cognitive-behavioral therapy (CBT-E) has been shown to be markedly superior to 2 years of psychoanalytic psychotherapy for bulimia nervosa (BN),20 standing in stark contrast to the widespread claim that there are no differences in outcomes between psychological treatments and that they all work through common or non-specific processes.21 This study provides strong support for the specificity of a key EBPI for BN, and per Hollon and Wilson,22 provides one of the clearest examples of the superiority of one well-implemented psychological treatment over another. Many other randomized controlled trials demonstrate specificity of effects for other psychological treatments for eating disorders as well.23,24 Furthermore, pharmacological treatments for eating disorders have reliably shown small to moderate effects, whereas evidence-based psychological treatments have reliably demonstrated large effects and combining medication with psychotherapy interventions fails to significantly enhance outcomes.25–27
Second, data suggest that EBPIs are superior to TAU for eating disorders. For instance, CBT guided self-help (CBTgsh), delivered in 8 sessions in a health maintenance organization setting, resulted in greater abstinence from binge eating at 6- and 12-month follow-ups than TAU offered within the health plan among individuals with binge-type eating disorders.28 Furthermore, CBTgsh was also found to be more cost-effective, due to reduced use of TAU services in that group, resulting in lower net costs for the CBTgsh group despite the additional cost of CBTgsh itself.29 For adolescents with AN, FBT has been compared to standardized versions of the “usual” treatments offered in the community, including psychodynamic individual therapy, non-specific individual therapy, and systemic family therapy, and has consistently been demonstrated to be superior.24
Finally, there appears to be indication of an association between therapist competence and outcome, suggesting that implementing a treatment better has value and setting up the need for further training in EBPIs. Although these studies are not eating disorder-specific, they are suggestive. For example, among patients with depression receiving cognitive therapy, competence predicted session-to-session symptom change early in treatment and also predicted evaluator-rated end-of-treatment depressive symptom severity.30 Likewise, competence has been found to be significantly associated with outcome for patients with anxiety disorders receiving CBT,31,32 accounting for 48% of the variance in outcome in one study.32 Even amongst work that has not found a general competence-outcome association, relations between these constructs are suggested. For example, the relationship between competence and patient outcome with CBT was investigated among 43 therapists treating 1247 patients over the period of one year in England.33 Results found little support of a general association between CBT competence and patient outcome. However, significantly more patients of the most competent therapists demonstrated a reliable improvement in their symptoms of anxiety than would be expected by chance alone, and fewer experienced no reliable change. Likewise, significantly more patients treated by the least competent therapists experienced a reliable deterioration in their anxiety symptoms than would be expected.33 Taken together, these lines of study—the demonstrated specificity of effects for specialist psychological treatments for eating disorders, the superiority of EBPIs over TAU for eating disorders, and the competence-outcome association—indicate that translation from research to practice in the field of eating disorders is clearly warranted.
Treatment Gap
The treatment gap refers to the difference in the proportion of people who have disorders or a particular disorder (prevalence) and the proportion of those individuals who actually receive care.34,35 In the US, millions of children, adolescents, and adults experience eating disorders and other significant mental health problems and receive no help whatsoever. Based on results of the National Comorbidity Survey-Replication, lifetime prevalence estimates of AN, BN, binge eating disorder (BED), subthreshold BED, and any binge eating in the US are 0.6%, 1.0%, 2.8%, 1.2%, and 4.5%.36 From a US population of approximately 300 million when this study was published,37 this translates to 30 million people being affected, and likely even more if we consider the US population growth since that time.38 In terms of mental disorders more generally, based on results of the National Comorbidity Survey and its Replication, 26% of the US population meet criteria for a psychiatric disorder within the past 12 months,39,40 and 46% of the US population have met criteria for a psychiatric disorder at some point in their lives.41 For ease of computation, consider that approximately 25% of the US population experience a psychiatric disorder during a given year and 50% in their lifetime. This translates to 75 million and 150 million people, respectively, using the US population of 300 million from the time period when these studies were published. Remarkably, these may even be conservative estimates, as some disorders (e.g., schizophrenia) as well as subclinical disorders often are omitted from prevalence surveys. Separate lines of research have addressed the extent to which individuals in need of services actually receive them. In the US, approximately 70% in need of services do not receive any services,42 with the problem of access to care being even worse for certain groups. For example, racial/ethnic minority groups (e.g., African American, Hispanic, Native American) have much less access to care for mental disorders than do European Americans.43 African Americans are less likely to have access to services than are European Americans (12.5 vs. 25.4%), and Hispanic Americans are less likely to have adequate care than are European Americans (10.7 vs. 22.7%).44 Internationally, as many as 97% or more of those with severe mental health disorders go untreated in some countries.45
The statistics regarding receipt of any treatment for eating disorders are equally dire—in the National Comorbidity Survey-Replication, only 16% of individuals with BN and 29% of individuals with BED had received treatment for emotional problems in the past 12 months.36 Similarly, less than 20% of college students with eating disorders report receiving treatment.46 There is a paradox such that few individuals with an eating disorder receive treatment specifically for the eating disorder, yet these individuals are actually more likely to receive treatment and incur higher health services use costs than individuals who do not have an eating disorder.47 Furthermore, individuals from racial/ethnic minority backgrounds with eating disorders are significantly less likely than their White counterparts to be diagnosed with an eating disorder, receive care or a referral for further evaluation, or to even be asked by a doctor about eating disorder symptoms.48–50 The lack of available services for most people and systematic disparities in accessibility of services underlie the importance of delivering services in ways that can reach many more people as well as target special groups.
Barriers to mental health care.
Many impediments or barriers stand in the way of people receiving mental health interventions51–53 and thus perpetuate the treatment gap. To begin, receiving services for psychological dysfunction encompasses multiple steps that include experiencing symptoms or some form of dysfunction, identifying those as symptoms or something in need of help, deciding whether action is needed to do something about the symptoms, identifying the options for intervention (e.g., a psychosocial “treatment” or something else), seeking and actually obtaining treatment if that is the option selected, beginning the treatment, and remaining in treatment as needed, and with recurrent disorders traversing the process or abbreviated variants again. These seem like a natural flow of steps, and once one started, the rest of the steps would unfold. Actually, multiple obstacles at each of steps can impede or prevent the individual from moving forward and receiving care.54 For example, many people (approximately one third of individuals in a survey of six countries) believe professional mental health care is worse than or equal to no help at all for mental disorders.55 Even when the process does unfold, remarkable delays occur. In fact, almost half of individuals with eating disorders will wait over a year after recognizing symptoms before seeking treatment.56 This delay is often longer for BED, perhaps due to a lack of awareness of this disorder, in comparison to AN and BN, which tend to be acted upon earlier. Furthermore, those surveyed report a lag time of fifteen months between identifying symptoms and starting treatment, oftentimes due to long wait times.56
Several other specific barriers impede seeking and obtaining mental health services generally and specific to eating disorders.51–53,57 Although their elaboration is beyond the goals of the present article, they are important to mention in the context of understanding and addressing the treatment gap. They include: cost of mental health services (including not only copayments or full payment for services but also indirect costs, such as time spent in session and payment to babysitter); policy and legal constraints (e.g., restrictions on which conditions are reimbursed); stigma; mental health literacy; cultural and ethnic influences; general issues in case identification (i.e., not identifying individuals at risk early in their course toward dysfunction); and especially relevant in relation to eating disorders, denial of the illness or low motivation to change.
These barriers may result from system factors, attitudinal factors, or both. For example cultural and ethnic influences may result from less access to services due to systemic issues, such as reduced number of providers in close proximity to ethnic minority clients, as well as from biases on the part of the provider who may believe eating disorders are uncommon in ethnic minority groups and thus fail to detect an eating disorder in a minority client. It should also be noted that a majority of individuals who receive treatment for an eating disorder are first seen by their primary care physician,58,59 and thus if primary care providers are not trained to identify eating disorders, many cases will be missed. Indeed, one study indicated that 92% of frontline medical providers (e.g., general practice physicians and nurse practitioners) believed they had missed an eating disorder diagnosis,60 highlighting the need for training in disorder identification as a means to increase access to care. Furthermore, many individuals who meet criteria for an eating disorder do not seek treatment given the ego-syntonic nature of their disorder or a general lack of motivation to change. It is possible that more attractive or convenient treatment delivery formats might spur some of these individuals to seek treatment when they otherwise might not have, but these issues (i.e., ego-syntonic nature, low motivation) will likely always contribute as barriers to treatment seeking in this population.
Dominant model of treatment delivery.
Another critical barrier in mental disorders in general and eating disorders specifically14 is the dominant model of treatment delivery, i.e., the most frequent way psychological interventions are provided to individuals who seek treatment. For purposes of this discussion, it is critical to distinguish a treatment technique from its delivery format. For example, in the context of physical health care, some vaccines (the intervention) can be provided by injection, nasal spray, orally, or needle-free patch. In the context of mental health care, so too can we distinguish the intervention (e.g., CBT) from the models of delivery (e.g., by a live therapist, smartphone “app,” or the Web).
In relation to various forms of traditional, cognitive-behavioral, and other therapies, the dominant model of delivery has three interrelated characteristics: 1) treatment sessions are provided in person and one-to-one with a client (individual, couple, family); 2) treatment is administered by a highly trained (e.g., Master’s or doctoral level) mental health professional; and 3) sessions are held at a clinic, private office, or health-care facility. Currently in the US, the vast majority of psychosocial treatments are administered using the dominant model. This model applies to EBPIs as well as the much larger number of interventions yet to be evaluated empirically including TAU, or practices that are routinely used in a clinical service.
Limitations of the dominant model in reaching people.
The dominant model may limit the degree to which treatment can be extended to reach many individuals in need. Meeting with a mental health professional individually in treatment conveys the constraints of the model. To begin, there are many mental health professionals but not enough to meet the demands using the dominant model. The estimated number of mental health professionals in the US who provide services is approximately 700,000,61 which may be an underestimate given the range of providers not usually counted, including other professionals (e.g., pastoral counselors) and individuals with various titles (e.g., personal coaches, healers). Even so, it is difficult to envision that the number could help sufficiently if 25% of the US population in any given year meets criteria for a psychiatric disorder leaving aside those with subclinical disorders, or that there are enough professionals trained in eating disorders to serve up to 30 million people in the US who will have a clinically significant eating disorder at some point in their lives.62
An initial reaction might be to claim that it is not the model of delivery that is the problem but the fact that we just need more trained mental health professionals who can provide treatment. Having more mental health professionals might be valuable but cannot be expected by itself to be able to reach the vast numbers of people in need of care who are receiving none whatsoever, given the geographical distribution, interests, and composition of the professional workforce. First, in the US, mental health professionals are concentrated in highly populated, affluent urban areas and in cities with major universities.63 All of the states in the US include rural areas where the concentration of people to square miles of land is low.64 For these areas and small towns more generally, very few and more commonly no mental health professionals may be available, and it is even less likely that any providers with training in eating disorders will be available.
Second, the majority of mental health professionals do not provide care to populations and clinical problems for which there is an especially great demand (children and the elderly, individuals of minority groups, special populations in need such as victims of violence, single-mothers, individuals of lower income). For example, most psychiatric disorders have their onset in childhood and adolescence, including eating disorders,65–67 but most individuals in the mental health professions are trained in the treatment of adults. Children’s access to evidence-based mental health treatment is an urgent matter in its own right.68
Finally, disproportionately few mental health professionals reflect the cultural and ethnic characteristics of those in need of care. Indeed, eating disorders have been found to affect individuals across all racial and ethnic groups.49,69 Individuals do not necessarily have to be treated by persons of the same racial/ethnic and cultural group with which they identify. Yet entering into treatment, forming an alliance, being able to communicate in one’s primary language, and having a shared view of psychological problems can all depend on having a match between therapist and patient in relation to race/ethnicity and culture. A mismatch of race/ethnicity and culture between prospective client and therapist at minimum adds another obstacle for receiving services. A mismatch can have (but does not invariably have) a variety of deleterious influences including not remaining in treatment, less quality of the alliance, and less therapeutic change.70,71 In one review, when there was an ethnic adaptation to treatment, treatment was much more effective than when not in the native language of the client or not ethnically adapted in some way (e.g., 2 – 4x more as measured by effect size).72 In short, having poor ethnic and cultural representation among mental health professionals who can provide services maintains and fosters huge disparities among groups and obstacles for entering treatment.
For the above reasons, expanding the workforce to deliver treatment with the usual, in-person, one-to-one model of care, with a trained mental health professional is likely not enough to have major impact on reaching the vast number of people in need of services for mental disorders in general and eating disorders specifically. What is being offered to those who have access to the dominant model can certainly be improved in terms of its quality, but this will not be enough to reach the large number of individuals who are currently not receiving any treatment whatsoever. The increased person power may not provide treatments where they are needed, for the problems that are needed, and attract the cultural and ethnic mix of clientele that are essential. Professional organizations and funding agencies that provide support for trainees can incentivize professional development in areas of need (e.g., training in rural psychology, mental health services for special groups), but the problem is that increasing more of what we are doing now in relation to the dominant model of delivery will not suffice in closing the treatment gap.
Another feature of the dominant model raises similar concerns in reaching individuals in need. Requiring clients to go to a special setting (e.g., clinic, private office) is a constraint, too. Settings where services are provided are not readily available for most individuals, and “going” to a setting raises a host of other barriers that are both system issues (e.g., transportation) and attitudinal issues (e.g., stigma).
Addressing Critical Gaps in Treatment
In order to address these critical gaps in treatment, we must: 1) ensure that more people who are receiving treatment obtain high-quality, evidence-based care; and 2) reach the large number of individuals who are unserved by current treatments. For example, in eating disorders, about 20% or less of those afflicted report receiving treatment.46 Consider the analogy of an iceberg and that those 20% are above the surface of the water. We certainly want to improve the quality of services received by those 20%, but it also important to make some type of treatment available for the 80% below the surface of the water who are currently receiving nothing whatsoever (see Figure 1). See Table 1 for an overview of novel models used to address both of these issues.
Depiction of the iceberg analogy: Ensuring that more people among the small minority who are receiving treatment obtain high-quality, evidence-based care and reaching the large number of individuals who are unserved by current treatments
Table 1.
Novel Models Used for Addressing the Research-Practice and Treatment Gaps: Key Characteristics and Examples
| Model | Key Characteristic | Examples | Sample References |
|---|---|---|---|
| Addressing the Research-Practice Gap: Ensuring More People Who Receive Treatment Receive Evidence-Based Psychosocial Interventions | |||
| Train-the-Trainer | Expert training is provided to a single therapist, who then trains other therapists at his/her center and act as an internal coach and champion. | There is preliminary support of this method for cognitive-behavioral therapy guided self-help (CBTgsh) for eating disorders. | Zandberg & Wilson82 |
| Web-Centered Training | Using the Internet to train and supervise therapists, which is lower in cost and more scalable than traditional methods. | In the field of eating disorders, the testing of comprehensive online training programs in enhanced cognitive-behavioral therapy (CBT-E) and interpersonal psychotherapy (IPT) is underway. | Fairburn & Patel96 Wilfley, Wilson, & Agras84,85 |
| Best-Buy Interventions | Implementation of interventions selected based on their cost-effectiveness, affordability, feasibility for the setting, and other criteria. Conceived as an economic tool to help countries select among evidence-based strategies to achieve a given amount of change. | Best buys for depression include generic antidepressants, brief psychotherapy, and treating it within the primary care setting. IPT might be considered a best buy given its ability to not only address eating disorders but also a variety of other mental health concerns. Likewise, CBT-E has the ability to address eating disorders across the diagnostic spectrum. On the dimension of cost-effectiveness for eating disorders, family-based treatment (FBT) and CBTgsh should be considered best buys. | Chisholm et al.102 Cuijpers et al.91 Fairburn109 Madden et al.110 |
| Electronic Support Tools | Can help ensure important topics are covered and aid in decision-making. | Support tools can help clinicians deliver smoking cessation treatment. In addition, the app Recovery Record allows clients with eating disorders to share data on their behaviors, thoughts, and emotions with their therapist. | Jenssen et al.111 Tregarthen et al.112 |
| Higher-Level Support and Policy | Higher-level support and policy has a greater likelihood of success in actually changing therapist behavior relative to relying on individual therapists to voluntarily receive training and modify their behavior. | In England, Improving Access to Psychological Therapies (IAPT) is a systematic way of organizing the delivery of evidence-based psychological treatment, according to NICE guidelines, within England’s National Health Service. | Layard & Clark113 |
| Addressing the Treatment Gap: Reaching Individuals Who Are Unserved by Current Treatments | |||
| Task Shifting | Expanding the workforce by using lay individuals to administer interventions that otherwise might be delivered by health professionals. | This approach was used to treat anxiety and depression in India. In addition, it has been utilized to train graduate students to treat binge eating with CBTgsh. | Patel et al.123 Zandberg & Wilson82 |
| Disruptive Innovations | A change in a product or service that extends it to a market that is not otherwise being served. | CBT for bulimia nervosa delivered via telemedicine is just as effective as face-to-face treatment, but costs considerably less. Many other online interventions for eating disorders have been tested and show preliminary support. | Crow et al.142 Aardoom et al.155 |
Models to Address the Research-Practice Gap
The first set of approaches addresses the research-practice gap and involves ensuring that more people who are treated receive high-quality, EBPI care. The past decades have seen the development and evaluation of empirically-supported psychological therapies in rigorous, randomized controlled efficacy studies.73 There is substantial evidence that patients are not receiving these treatments in routine clinical care.10,74 Even when patients do receive these treatments, they are often not competently delivered.75 This failing has been highlighted by the past director of the National Institute of Mental Health (NIMH): “We have powerful, empirically-supported psychosocial interventions, but they are not widely available…A serious deficit exists in training for empirically supported psychosocial interventions. Translational research will need to focus not only on ‘bench to bedside’ but also on ‘bedside to practice.”76 We highlight a number of novel models that can be used for the dissemination of EBPIs.
Train-the-Trainer.
Current approaches to training therapists to conduct new treatments typically consist of a one or two day workshop delivered by an expert and provision of a manual for the therapy in question.74 Reviews have concluded that while workshops increase therapists’ knowledge, their impact on skills may be short-lived without further consultation.77 Alternatively, there is a strong theoretical case for the “train-the-trainer” approach, which is based on the principles of social cognitive theory,78 and features active learning via modeling, feedback on performance, building self-efficacy, and supportive interactions among therapists developing skills in a given treatment. This train-the-trainer approach centers around development of an internal coach and champion, and has been recommended as the most effective means of changing actual therapist behaviors rather than just attitudes and self-reported proficiency.74 Train-the-trainer models have been used to train community mental health center staff in evidence-based treatments by providing expert training to a single member of the staff who then trains the rest of the staff and serves as an internal coach and champion79,80 and to bring evidence-based treatment for trauma-spectrum disorders to resource-poor countries.81 Relevant to the field of eating disorders, there is preliminary support for the usefulness and acceptability of the train-the-trainer method for CBTgsh for eating disorders,82 and in the field of eating disorder prevention, a pilot effectiveness trial showed support for a train-the-trainer model for implementation of the Body Project, an in-person, cognitive-dissonance-based prevention program.83 Furthermore, Wilfley, Wilson, and Agras84,85 are currently testing the effectiveness of a train-the-trainer approach to training college counselors in interpersonal psychotherapy (IPT) for the treatment of eating disorders. College student counseling centers are an optimal setting in which to study the implementation of evidence-based treatment for eating disorders. These disorders typically begin in adolescence and the young adult years,65–67 and they constitute one of the most common mental health problems seen by college counseling centers/health services.86 In this study, several reasons dictated the choice of IPT: 1) readily acceptable to therapists and clients87,88; 2) hypothesized to result in high rates of adoption because it is perceived as similar to the type of psychotherapy many therapists in student counseling centers provide; 3) IPT, with its focus on interpersonal issues, is particularly appropriate for a population of young adults, especially females89,90; 4) broadly applicable to a wide range of clients with an eating disorder90; and 5) IPT may have broader therapeutic effects than just those on eating disorders.91–93 Thus, in this study, careful attention was given to setting and treatment type so as to maximize implementation success and sustainability. Just as sustainability of individual treatment effects is an important outcome in efficacy trials (e.g., whether a given treatment is associated with not only short-term but also long-term impact on disorder remission), sustainability is a key outcome that needs to be considered in implementation studies as well.
Web-Centered Training.
Standard methods for training and supervision require substantial time and resources, and while the train-the-trainer approach decreases the time and resources required relative to standard training, additional scalable, low-cost methods for training and ongoing supervision are needed to increase the number of clinicians trained to deliver high-quality care for eating disorders and other problems. Web-centered training may be such a solution that has several key advantages94: 1) training can be offered to geographically dispersed trainees using minimal person-based resources; 2) the website can be accessed anytime and anywhere to effectively accommodate clinicians’ busy schedules; 3) it enables trainees to repeatedly review and reference material, which will reinforce learning; 4) the process of training to fidelity can be customized to the trainee through quizzes, feedback, and refresher courses, which may prevent clinician “drift” and enhance sustainability of skills in the treatment15,95; 5) the website can be updated regularly, facilitating incorporation of new information; and 6) data collection on website usage can provide valuable information on the most accessed program features, informing program refinement. A comprehensive platform for training in CBT-E has been developed, with testing underway.96 Likewise, a comprehensive online training program and telephone-based simulation assessment for training in IPT has been developed, with testing currently in progress.97 Important to keep in mind is that multi-component trainings have most consistently demonstrated positive training outcomes relative to other training methods—studies evaluating the utility of reading, self-directed trainings, and workshops have shown that these methods do not routinely produce positive outcomes and that workshop follow-ups (e.g., including observation, feedback, consultation, and/or coaching) are essential for sustaining outcomes.77 As such, in order to improve the likelihood of changing therapist behaviors, alternative training delivery models must include active learning and follow-up, including consultation or coaching.74,77 With the IPT training platform, telephone simulation is being used as a more scalable method for ensuring active learning, follow-up, and clinician competence; this approach is easily accessible, standardized across trainees, and provides the ability to practice “without risk” to patients.98,99 Promising research suggests that simulation could be used for evaluating clinician training outcomes and for enhancing learning, and in the field of medicine, simulations are rated positively by students and educators.100
Best-Buy Interventions.
Best buy refers to an intervention for which, “there is compelling evidence that is not only highly cost effective, but is also feasible, low-cost (affordable), and appropriate to implement within the constraints of a local health system”(p. 2).101 Best buy also considers features such as appropriateness for the setting (e.g., culture, resources), capacity of the health system to deliver a given intervention to the targeted population, technical complexity of the intervention (e.g., level of training that might be required), and acceptability based on cultural, religious, and social norms.
Identifying best buys was conceived as an economic tool to help countries evaluate how to achieve a given amount of change, given the number of eligible individuals in need of the intervention, the potential savings of those changes, and the cost differences of alternative strategies.102–104 For example, in one analysis, four criteria (health impact, cost-effectiveness, cost of implementation, and feasibility of scaling up) were used to identify best-buy interventions that would have significant public health impact on noncommunicable diseases including cardiovascular disease, cancers, diabetes, and chronic lung disease.101 Best buys for cardiovascular disease and diabetes were counseling, multi-drug therapy, and aspirin. These were selected in light of the reduction of disease burden and very low cost. The example is not necessarily one that applies to all locales. The best-buy interventions can differ for a given disorder and country in light of variation in the health-care resources, infrastructure, and distribution of the population (e.g., very sparsely populated areas). More explicit designations of best buys have been identified for select mental disorders. For example, for clinical depression, generically produced antidepressant medication, brief psychotherapy, and treating depression in primary care qualified as best buys.102 For psychoses, treating people with antipsychotic drugs and with psychosocial support are regarded as best buys.
When selecting an evidence-based treatment to disseminate, for example, using the train-the-trainer approach, web-centered training, or more traditional approaches, selection criteria should include: efficacy (i.e., short and long-term effects); cost-effectiveness; clinical range (transdiagnostic); ease of training and learning; and mode of treatment delivery (e.g., with limited external input and by therapists with minimal training vs. lengthy treatments that require a high level of professional input and expertise).15 Such a treatment would be considered a best-buy intervention. In particular, transdiagnostic treatments help solve the “too many empirically supported treatments problem”105(p. 58) and have the advantage of having greater clinical range and thus more practicality, which may enhance adoption by therapists.106 In that sense, IPT might be considered a best-buy intervention given, as previously mentioned, the ability of this intervention to not only address eating disorders but also a variety of other problems, including depression, anxiety, and post-traumatic stress disorder.91–93 Although it is acknowledged that IPT may work more slowly than CBT for BN,107,108 when considering treatment options for a health care delivery system (that needs to treat psychiatric disorders beyond just eating disorders), IPT should be regarded as a best buy because it can be used for a large client base in contrast to other EBPIs that may work for only one type of problem. Likewise, CBT-E is a transdiagnostic treatment for eating disorders and has the ability to address eating disorders across the diagnostic spectrum.109 Cost-effectiveness is also a key consideration in defining a best buy. For this reason, FBT should be considered a best buy given the fact that it is cost saving in comparison to weight restoration via inpatient hospitalization.110 Likewise, CBTgsh is an effective treatment for binge-type eating disorders that has the advantage of being very easy to learn and deliver, even by relatively inexperienced practitioners, making it very cost-effective.
Electronic Support Tools.
Electronic support tools for clinicians have the potential to enhance quality of care as well. Checklists can help the clinician ensure that important topics and points are covered when caring for patients and can also aid in decision-making. For instance, a clinical decision support tool to help clinicians deliver smoking cessation treatment, which prompts clinicians to ask patients specific questions, has preliminary support for its feasibility and acceptability in clinical care.111 Furthermore, Recovery Record, a direct-to-consumer mobile app that has been downloaded more than 100,000 times over two years, can be used by individuals with eating disorders to self-monitor meals, emotions, behaviors, and thoughts and share this information with their therapist.112 Such an app may increase adherence to self-monitoring, given the greater convenience of the app vs. paper-and-pencil format, and thus may ultimately enhance the effectiveness of treatment.
Higher-Level Support and Policy.
For access to evidence-based care to dramatically increase, higher-level support is required. One excellent example of this approach comes from a development in England called Improving Access to Psychological Therapies (IAPT), a systematic way of organizing the delivery of evidence-based psychological treatment, according to the National Institute for Health and Care Excellence (NICE) guidelines, within England’s National Health Service. It aims to provide, in every part of the country, teams of well-trained therapists working under expert supervision. The progress of each patient is measured every session, which not only provides the patient and therapist valuable information on symptom improvement but also provides information to the funders of IAPT (National Health Service) on whether they are getting their money’s worth. IAPT is a system, and it involves a team of people with different skills who are able to handle the range of problems that patients may enter treatment with, including offering treatments with different levels of intensity based on severity of presenting problems. IAPT started in late 2008, and by 2013, it had trained more than 3,600 therapists in CBT and was treating over 400,000 people per year, nearly half of whom recovered by the end of treatment.113 The National Health Service, in partnership with the National Collaborating Centre for Mental Health in England, released a commissioning guide in 2015 that introduces access and wait time standards for eating disorders, detailing that those referred for treatment for an eating disorder should receive NICE-concordant treatment within four weeks for routine cases and within one week for urgent cases.114 At the same time, the government announced an additional £30 million funding a year (starting in 2015 and recurrent for five years) to support the development of such services, which will be delivered within the IAPT framework and will promote access to evidence-based, outcome-focused treatment.115
In the US, the Veterans Health Administration (VHA), which operates the largest integrated healthcare system in the nation, is actively implementing a national initiative to disseminate and implement EBPIs. As an integrated system, VHA establishes its own policies and services and funds the care delivered by the system. The initiative includes: policy (i.e., national requirements for EBPI availability in VHA); staff training and support (e.g., competency-based staff training programs, longer-term consultation support including “virtual office hours” and local peer consultation); local clinical infrastructures and buy-in (e.g., local EBPI coordinators, quantitative assessment of impact of EBPIs, including effectiveness, acceptability, and service/cost offset); clinical implementation strategies (e.g., patient informed choice, assessing and enhancing the therapeutic relationship, case conceptualization and goals-based approach); and accountability (e.g., EBPI training program evaluation, including therapist- and patient-level outcomes).116 IAPT and the VHA model are initiatives that involve centralized control of money from the top and their implementation is mandated. Such programs have a much greater likelihood of success in actually changing therapist behavior relative to relying on individual therapists to voluntarily receive training and modify their behavior. Indeed, policy shapes behavior. Furthermore, programs such as these ensure not only improved access to treatment but also improved access to treatment that we know actually works.
Models to Address the Treatment Gap
The second set of approaches addresses the treatment gap and reaching individuals who are unserved by current treatments. Typically, as we develop treatments, we begin with a focus on a clinical disorder, a model of how that disorder may come about, how treatment can address key components of the disorder, and what we might draw from the human and nonhuman animal research in the way of principles or techniques. We then begin tests of treatment. For example, if one considers CBT, IPT, or FBT for eating disorders, many of these steps have been critical for developing these interventions. The viability of this model needs no more proof than the successes of these and many other EBPIs for eating and other disorders. However, to address the “bottom of the iceberg” problem, we need to expand the focus in how we develop the interventions or at least considerations to which we attend from the outset. Consider the goal or target as reaching a large number of individuals who are unserved by current treatments. We begin with the question: What are key characteristics we would want of treatments and models of delivery to achieve that goal? Table 2 lists several characteristics that might guide our development of treatment and focus our attention on delivery. There is no need for a single model to meet all or even most of these characteristics or to address all of the barriers to treatment discussed previously; rather, multiple models are likely to be needed to reach people in different contexts.
Table 2.
Key Characteristics of Models of Treatment Delivery to Reach More People in Need of Services
| Characteristic | Explained |
|---|---|
| Reach | Capacity to reach individuals not usually served or well served by the traditional dominant service delivery model |
| Scalability | Capacity to be applied on a large scale or larger scale than traditional service delivery |
| Affordability | Relatively low cost compared to the usual model that relies on individual treatment by highly trained (Master’s, doctoral degree) professionals |
| Expansion of the nonprofessional work force | Increase the number of providers who can deliver interventions |
| Expansion of settings where interventions are provided | Bring interventions to locales and everyday settings where people in need are likely to participate or attend already |
| Feasibility and flexibility of intervention delivery | Ensure the interventions can be implemented and adapted to varied local conditions to reach diverse groups in need |
| Flexibility and choice of alternatives for clients within a particular type or class of effective interventions | Allow choice or alternative ways to meet the criteria for what would be an effective intervention. Exercise and meditation, for examples, two very broad classes of intervention that affect mental health and clinical dysfunction. Yet, multiple options of precisely what is done to achieve similar outcomes are available. |
Note. Adapted from Kazdin.203
Multiple models have emerged from global health care, business, economics, and the media—all well outside of traditional psychological and psychiatric care.117,118 We highlight a number of examples below to convey different ways in which treatments can reach large numbers of individuals and in which key characteristics noted in Table 2 and different barriers to care can be addressed.
Task Shifting.
Task shifting is a method to strengthen and expand the health-care work force by redistributing the tasks of delivering services to a broad range of individuals with less training and fewer qualifications than traditional workers.119 This redistribution allows an increase in the total number of health workers (e.g., nonprofessionals, lay individuals) to scale up the scope of providing services. The concept and practice of task shifting are not new and currently are in place in many developed countries (e.g., Australia, England, US) where nurses, nurse assistants, and pharmacologists provide services once reserved for doctors. Task shifting emerged from global health initiatives, particularly in developing countries (e.g., Ethiopia, Haiti, Malawi, and Namibia). These initiatives focused on treating and preventing infectious (e.g., malaria, HIV/AIDS, tuberculosis) and noncommunicable disease (e.g., cardiovascular disease, diabetes, cancer, respiratory disease) and improving living conditions and education.101,120–122 These initiatives provide an important context because they contended with key challenges of meeting health-care needs in many cultures, under a variety of conditions (e.g., enormous resource constraints, geographical obstacles), and where people in need of services were not receiving them. Empirical evaluations have shown task shifting to rapidly increase access to services, reach large numbers of individuals in need, yield good health outcomes, and have high levels of patient and counselor satisfaction.119
Task shifting was extended to mental health problems because of its ability to be scaled up to provide services to individuals who otherwise did not have access to care and its adaptability to diverse countries, cultures, and local conditions. An exemplary application of task shifting in mental health was a randomized controlled trial of treatment of anxiety and depression in India.123,124 Twenty-four public and private facilities (including more than 2,700 individuals with depression or anxiety) received a stepped-care intervention beginning with psychoeducation and then IPT, as needed and as administered by lay counselors. The lay counselors had no health background and underwent a structured two-month training course. Medication was available as was specialist attention (health professional) for suicidal patients. At 6 and 12 months after treatment, the intervention group had higher rates of recovery than did a treatment-as-usual control group administered by a primary health-care worker, as well as lower severity symptom scores, lower disability, fewer planned or attempted suicides, and fewer days of lost work. Overall, the study showed that lay counselors could be trained to administer interventions with fidelity and that their interventions reduced the rates of disorder in a large sample. This is an excellent example of extending EBPIs developed in controlled research settings to community applications but with a change in the model of delivery of those treatments. Other studies have demonstrated the impact of task shifting as a model of delivery for the treatment of depression and schizophrenia.125,126 These demonstrations not only establish the clinical utility of task shifting but also add to the evidence that lay counselors can deliver effective treatment and that outcome effects are not sacrificed in the process.
In the field of eating disorders, task shifting has been used to train relatively inexperienced practitioners lacking formal professional credentials (i.e., clinical psychology graduate students with limited or no previous experience treating eating disorders) to administer for recurrent binge eating.82 This study also used the train-the-trainer implementation strategy, as after receiving expert-led training in CBTgsh, a master’s-level graduate student in clinical psychology subsequently trained and supervised the less experienced graduate students to implement the treatment in an open clinical trial. Participants were 38 students with recurrent binge eating, with intent-to-treat analyses revealing that 42.1% were abstinent from binge eating at post-treatment and 47.4% at one-month follow-up—outcomes that compared favorably with randomized controlled efficacy trials of CBTgsh.28,127,128 Participants also reported significant reductions in eating disorder-specific psychopathology, general psychopathology, and high levels of treatment acceptability, with findings thus strongly suggesting that such task shifting can be done without compromising clinical outcomes. Likewise, non-specialist “facilitators” with no formal clinical qualifications achieved an outcome of 50% abstinence from binge eating using CBTgsh for individuals with BED,129 and a culturally adapted version of CBTgsh for Mexican Americans with binge eating, using master’s-level psychology students facilitators providing support sessions over the phone, achieved an outcome of 36% abstinence.130 The delivery of group CBT for adolescent girls with recurrent binge eating has also been task-shifted to master’s-level counselors and health care professionals through use of comprehensive facilitator materials with strong outcomes—100% of participants in the CBT group were abstinent at 6-month follow-up vs. 50% in the TAU group.131 However, a limitation to these studies is that the individuals to whom work was task shifted were psychology graduate students or master’s-level clinicians—individuals with a keen interest, or even training, in psychological treatment and a desire for a professional career in the field. Furthermore, there are not large numbers of such individuals available. As such, future research will need to consider other individuals (e.g., peers, lay people) to whom work could be task shifted to provide eating disorders treatment. One example of this comes from FBT, which shifts the task of re-feeding underweight adolescents with AN from professionals (e.g., highly skilled nursing staff on inpatient eating disorder units) to parents (i.e., lay people).132 Task shifting has been successfully used for eating disorder prevention as well. The training of peer leaders to implement the Body Project, a cognitive dissonance-based in-person eating disorder prevention program, was task shifted to undergraduate students using a hybrid task shifting/train-the-trainer model, with almost no evidence to suggest that the presence of a doctoral-level trainer yielded superior participant outcomes compared to training by undergraduate students alone.133
As any single model of delivering treatment, task shifting has its own unique challenges. Among them is the two-fold task of obtaining personnel. The first of these tasks is to recruit the individuals who will deliver treatment. This is easier in most circumstances that obtaining trained mental health professionals, but still can be an issue depending on the scope and scale of the treatment that is to be delivered and other potential constraints (e.g., applications in multiple rural settings). The second personnel challenge is obtaining sufficient trainers to develop the skills in those who provide direct treatment. In some of the physical health task-shifting work, administration of treatment (e.g., medication) was more straightforward than administration of psychotherapy would be. These challenges do not at all detract from the contributions of task shifting, and many of the concerns highlighted have been addressed empirically in early applications of task shifting.119
Disruptive Innovations.
Disruptive technology or disruptive innovations emerged from business rather than health care.134–136 The concept pertains to a change in a product or service that is not a linear, evolutionary, or incremental step. Rather the product or service often provides a disruptive, disjunctive, or qualitative leap and develops or extends a market that is not otherwise being served. Examples include innovations in manufacturing (e.g., interchangeable parts, assembly line in car production), business (e.g., cell phone, smartphone, tablet), consumer purchasing (e.g., via credit cards, smartphones, and PayPal), social networking (e.g., Facebook, Twitter, LinkedIn), and health care (e.g., home pregnancy tests, medical robotics, and urgent care, walk-in, and minute clinics).134 These innovations often provide simpler, less expensive, or more convenient solutions to problems and often can be scaled to reach people who would not otherwise have access.
Telemedicine, which refers to the use of communication and information technology to extend the reach of medical practice, is an example of a disruptive innovation that has changed how and where some patients receive medical care.137 Telemedicine has been in use for over 40 years.138 At the same time, leaps in both hardware and software have extended the range of remote applications, as illustrated by the development of diverse specialty areas (e.g., telepsychiatry, telesurgery, teleopthamology. teleaudiology, teleneurology).139–141 Other disruptive innovations in health care have utilized nonmedical settings, such as drug stores and shopping malls, to provide a range of services to measure blood pressure or cholesterol, treat various illnesses (e.g., allergies, pinkeye, strep throat) and skin conditions (e.g., cold sores, minor burns, wart removal), and provide vaccines (e.g., flu shots). Patient referrals can be made if the tests reveal the need for further diagnostic work or intervention. The field of eating disorders has begun to make use of this advance. CBT for BN delivered via telemedicine was found to be similarly effective as face-to-face treatment and cost substantially less.142 A study is also in progress to test the feasibility of telemedicine delivery of FBT for adolescents with AN.143 However, a barrier to telemedicine is, at least in the US, the lack of a universal reimbursement policy among public and private sector payers regarding payment for these services.144
Disruptive innovations could also provide more accessible ways of delivering mental health interventions directly to patients.145 The availability and use of computers, the Internet, and mobile phones have expanded tremendously. In 2014, nearly 90% of U.S. adults accessed the Internet,146 and as of 2015, 68% of U.S. adults had a smartphone, up from 35% in 2011.147 Although mental health professionals may be in short supply in developing countries and in certain parts of developed countries, mobile phones are not. In 2015, 37% of adults living in developing nations owned a smartphone.148 As access has grown so has the functionality of technology and at the same time, technological advances have become less expensive, more compact, and more powerful.149
Online delivery of treatment is a disruptive intervention that extends the dominant model of therapy. These programs often include the same core CBT sessions as used with in-person treatment and are divided into sessions (with video clips describing key information and assigned homework) that patients can complete from home. Scores of online, evidence-based self-help psychosocial interventions for a range of psychological problems are now available.150,151 These interventions can leap over many of the usual barriers of receiving treatment and expand on the dominant model of in-person, individual psychotherapy at a clinic. The NIMH in the US is clearly committed to the issue of using technology to advance mental health treatment, as evidenced by the focus of its strategic plan on the development of innovative, technology-based service delivery models152 and the creation of the National Advisory Mental Health Council Workgroup on Opportunities and Challenges of Developing Information Technologies on Behavioral and Social Science Research to track and guide this rapidly-changing area.153
Technological-based psychosocial interventions vary in the extent to which they utilize facets of the dominant model. For example, some Web-based treatments are administered one-to-one by a mental health professional but do not require the client to go to a clinic. Others are based on self-help and may involve no therapist at all. All variations can contribute to extending treatment to those who otherwise would not receive services. Yet, we still need demonstrations that technology in fact can and does reach large numbers of individuals and in the process has impact.
In the field of eating disorders, the growing number of reviews on the use of technology, the Internet, and mobile applications (“apps”) for the treatment of eating disorders demonstrates the high level of interest in this area.154–163 Just considering randomized controlled trials that have utilized technology for CBT delivery for individuals with clinical eating disorders, great advances have been made—from the testing of unguided CD-ROM-based programs164,165 to email as a vehicle for therapist input166,167 to Internet-based CBT.155,156,168–173 This research is in its infancy, and additional studies with stronger methodology are needed, as the majority compared Internet-based CBT for eating disorders to a waitlist control. The studies needed now are randomized comparisons with CBTgsh or with full CBT, and there are several ongoing or recently completed efforts with stronger control conditions: 1) an Internet-based version of group CBT for BN (CBT4BN), in which the group intervention was conducted via a therapeutic chat group, vs. face-to-face group CBT,174 finding that CBT4BN appeared to be efficacious, although with a slower trajectory of recovery compared to face-to-face group treatment175; 2) an Internet-based guided self-help CBT program for individuals with BED vs. face-to-face individual CBT (ongoing)176; and 3) Student Bodies-Eating Disorders (SB-ED), a CBTgsh program, utilizing brief 10–15 minute daily sessions, that is offered both via an Internet-based platform and mobile app, vs. referral to usual care among college women with clinical or subclinical eating disorders, with the exception of AN (ongoing).177,178 Previous work has established the SB-ED’s initial efficacy for reducing eating disorder psychopathology, weight concerns, binge eating, and purging.179–181
An example of a very large-scale application of Internet-based treatment outside of the field of eating disorders consisted of a Web-based intervention for smoking cessation.182 The program was available in two languages (Spanish and English) and was visited by over 290,000 individuals from 168 countries. Data reported for over 7,000 participants revealed smoking quit rates ranging from 39 to 50% at different points of assessment up to an 18-month follow-up. This program advanced the notion of Massive Open Online Interventions (MOOI) to resemble the model (Massive Open Online Courses-MOOC) in education. MOOI would make available interventions that could reach individuals on a scale as the demonstration in the context of cigarette smoking.
Technology has many forms and formats, and it is useful to consider technology at an early stage, even though facets (e.g., telepsychiatry) are not new. The next evolution in treatment delivery is the mobile app. Research suggests that Americans now use smartphone apps more frequently than personal computers to access the Internet183 and that consumers spend over 85% of their time on smartphones using apps.184 Just as the Internet made interventions more accessible in comparison to CD-ROM-delivered programs, apps may make treatment even more accessible given their portability, high level of functionality and interactivity, and capacity for in-the-moment intervention in the real world.185,186 There are several potential roles for apps. They may be used solely to monitor change in symptoms or other important features of a particular syndrome. Feedback can then be provided to both patient and therapist. They may also be used to enhance behavior changes between therapy sessions or to provide coping skills for use in particular situations. Such usages may reduce therapist time and enhance outcomes. They may be used to deliver self-help or guided self-help as well. However, a recent review of smartphone applications for the treatment of eating disorders found that existing, publicly available apps contained minimal CBT techniques, failed to incorporate smartphone capabilities, and none had been well evaluated.186
There are a number of issues related to the strengths, limits, and potential of technology.187 First, and most relevant to the present article, few applications of technology demonstrate that interventions can be scaled to reach large numbers and produce significant (statistically, clinically) clinical outcomes. Evidence for these might well be on the horizon, but there has been cogent concern voiced that the contribution of the use of technology may be oversold at this time or at least until better scaling with outcome evidence are forthcoming.158,188
Second, technologies bring their own set of limitations related to adoption including: acceptability by practitioners and the public as “treatment”; access to the Internet; and maintaining participation in a program that may not be or seem individualized. Indeed, engagement and adherence have been issues in technology-based programs for eating disorders as well as technology-based mental health programs in general.189 Interestingly, the utility and adoption of technology (by clinical services, therapists, and clients) may well improve in the next decade as a function of cohort effects as well as the availability of more sophisticated programs. Younger age individuals are increasingly at home with technology and social media, and young children routinely chat with relatives via cell phones and Skype. Of note, about one in four users abandon apps after just one use, and almost two-thirds of users use any given app less than 11 times.190 Future program development can take full advantage of the capabilities of technology by using approaches such as machine learning to become acquainted with an individual’s behavior patterns and subsequently deliver customized interventions during times of need, offering a form of personalized medicine. Highly sophisticated features such as these, as well as professional quality design and enhanced user experience, will increase the likelihood that users will engage with programs. Furthermore, at least in the field of eating disorders, the majority of the Internet-based programs tested have used longer, less frequent sessions (e.g., weekly 45 minute sessions) that mimic in-person delivery, but it may be that it is most optimal for technology-delivered programs to be engaged with for shorter periods of time more frequently. The overall point is clear. Technology even if at some early stage is central to our everyday lives and awaits newborns as they enter the world. How technology is viewed and accessed may well change as most people are “connected” to the Web most of the time.
Finally and related, thinking about the use of technology would profit from a revolution. To stretch our thinking of what technology can do, let us go beyond improved ways of reaching people to entirely new interventions.191 A useful distinction has been noted in a discussion of the physical Internet, which is an active area of work in industry, engineering, and manufacturing, and refers to a way of transforming how physical objects (e.g., manufactured goods) are transported, stored, supplied, and used to achieve greater efficiency as well as sustainability.192 As one researcher noted in that context, “It’s [the physical internet] not about a better way of doing what you now do. It’s about doing things you’ve never thought of doing before” (p. 1106).193 The comment is instructive by keeping both facets in mind. We want to do things better (e.g., deliver EBPIs better, more broadly, with greater reach, and so on). In addition, we also want to rethink all facets of treatment and what technology offers that may lead us to solutions that are not just novel ways of delivering what is already available.
The distinction is not dichotomous but sensitizes us to options to consider and foster truly novel ways of helping people that do not follow from standard treatments (i.e., what we do now). For example, for both treatment and prevention, large-scale and fully automated and individualized interventions can be designed to promote exercise.194 Also, for individuals with stress, psychosocial symptoms, and impairment, support programs could be made routinely available and alleviate both mental and physical health problems.195 Or let us be much more ambitious. A huge problem in physical and mental health care is treatment adherence. For example, getting individuals to follow through on treatment (e.g., activities, taking medication, monitoring biological states, getting follow-up checkups, filling and refilling medication prescriptions) is an issue with direct impact on disability and mortality (e.g., cardiovascular disease, cancer, diabetes, HIV/AIDs). As another example, “matching markets” are used extensively to match consumers with products and messages that are especially relevant to them (e.g., traveling, lodging, purchasing special products, and taxi services).196 Perhaps this could be extended to mental health in some way so that people could be better targeted for the information, options, and services that might be of use to them. A recent systematic review indicated that social media can be successfully leveraged to provide health information, engage the adolescent and young adult community, and recruit research participants for health-related studies.197 However, privacy is a valid concern and ethical implications of and best practices for targeted marketing should be carefully considered. Future work will need determine how best to utilize matching markets so as to minimize the likelihood that individuals will feel stigmatized or distressed if targeted with mental health care information or services. For instance, it is possible that information about sensitive health topics disseminated by (online) peers might be more acceptable that messages coming from health professionals.
If technology as a means of providing mental health services takes the route of other disruptive innovations, the landscape of treatment may change considerably. When disruptive innovations first emerge (e.g., personal computer, cell phone), they do not compete head-to-head with the traditional product (e.g., mainframe computer, centralized computers in industry and on campuses, landline phones, pay phones). Over time the innovation may begin to compete and take over as the product develops and the use expands. The expansions include greater convenience, ease of use, and portability in relation to original products. Perhaps innovative treatment delivery models that are disruptive, including those involving technology, will have a similar course.
Summary and Conclusions
EBPIs represent an enormous research advance. We are now at the first point in history where behavioral and social sciences have established a large set of treatments with rigorous scientific evidence on their behalf. Many evidence-based treatments for eating disorders have also been established, including CBT, IPT, and FBT. This accomplishment has to be recognized as an evolutionary leap that allows us to consider what is needed for the next set of breakthroughs. The vast majority of EBPIs rely on a model of providing services that is one-to-one, in-person treatment delivered by a mental health professional and usually in a special setting. This model has proven itself as a platform for effective treatments. What is clear now is that we must not only ensure that more people who are receiving treatment for eating disorders and other mental disorders receive EBPIs but that we must also reach the large number of individuals who are unserved by current treatments.
In order to address the research-practice gap and ensure that more people among the small minority who are receiving treatment obtain high-quality, evidence-based care, the use of novel approaches will be required including: 1) train-the-trainer, which involves providing expert training to a single therapist who then trains other therapists at his/her center and acts as an internal coach and champion for the EBPI; 2) web-centered training, or using the Internet and technology to train and supervise therapists; 3) implementation of best-buy interventions, which are selected based on their cost-effectiveness, affordability, feasibility, and appropriateness for the setting; 4) electronic support tools that help clinicians ensure key treatment components are covered and aid in decision making; and 5) higher-level support and policy for the use of EBPIs, which has a greater likelihood of success in actually changing therapist behavior relative to relying on individual therapists to voluntarily change their behavior. To address the treatment gap and reach the large number of individuals who are unserved by current treatments, the approaches needed include: 1) task shifting, or expanding the workforce by using lay individuals to administer interventions; and 2) disruptive innovations, including the use of telemedicine, the Internet, and mobile apps for intervention delivery.
Eating disorders are still not considered serious mental illnesses in some states and countries,3 further limiting access to treatment. Exclusion from the serious mental illness category is significant, as this information can be used by insurers to determine which mental disorders are covered vs. excluded by their policies, and unfortunately, there is no accepted definition of this category or federal legislation defining this term.198 Thus, we may need to shift our focus to policy translation in order to accelerate progress to maximize the impact on population health.199 Indeed, there has been a call for strategic science—research designed to address gaps in knowledge important to policy decisions, derived from the reciprocal flow of information between researchers and policy makers.200
Notably, there may be therapist resistance toward strategies for addressing these critical gaps in treatment. Regarding tackling the research-practice gap, some clinicians hold negative attitudes toward treatment manuals and may overvalue certain treatment features despite a lack of evidence for them, including pre-therapy motivational work and the development of a strong working alliance as a facilitator of change.201 Likewise, clinicians may undervalue key elements of eating disorder treatment, such as the need to weigh patients, and may not use EBPIs on the grounds of spurious “justifications” (e.g., chronicity, comorbidity) that are not supported by the literature.201 In terms of strategies for addressing the treatment gap, therapists may worry that strategies such as task shifting and using online interventions will “put them out of business.” Indeed, a review paper found conflicting evidence regarding psychologists’ acceptance of online approaches.202 What will likely be most effective in terms of increasing use of the approaches reviewed here for tackling the research-practice and treatment gaps, as well as changing attitudes about them in the long-run, is higher-level support and policy. For instance, countries, states, or health care systems mandating the availability of EBPIs (as is being done with IAPT and the VHA model), requiring insurance reimbursement for telemedicine, providing more psychoeducation about what approaches like task shifting and mobile apps will mean (and not mean) for therapist practices, and incentivizing for the use of disruptive innovations. This kind of higher-level support has a greater likelihood of enacting widespread change versus reliance on individual behavior change, highlighting the need for strategic science. Thus, strategic science is greatly needed to dramatically increase the proportion of individuals who receive EBPIs when they receive care and to ensure coverage for novel methods and non-traditional providers of treatment for eating disorders.
There is an enormous need worldwide for interventions that reduce the personal and social burdens of eating disorders and other forms of mental illness. Research in eating disorders began and continues with the study of EBPIs in highly controlled settings. With that success, increased attention has been accorded to not only extending these to clinical practice for eating disorders through diverse dissemination efforts but also on delivering treatments in ways that reach the vast majority of individuals in need of services for eating disorders who are not otherwise served. By focusing on strategic science and conducting research to generate the data policy makers need in order to formulate relevant laws and regulations, progress in addressing critical gaps in treatment will be accelerated.