Eating disorders, including anorexia nervosa, bulimia nervosa, and binge-eating, may impact as many as 20 million women and 10 million men at some point in their lives, according to the American Psychological Association (APA).1 Many of these individuals turn to mental health and wellness apps (mobile health apps, or mHealth apps), which often claim to help manage such disorders, but clinicians have raised concerns about their credibility.2 The extent to which mHealth apps protect patients’ privacy and data is also unclear.

With people relying more and more on virtual healthcare, it’s likely your patients with varying types of eating disorders have asked about these apps. Here’s what you need to know.

Current mHealth App Recommendations and Options for Eating Disorders

There are more than 10,000 mHealth apps on the market3 and a slow-growing body of clinical guidance on their use. For specific eating disorder apps:

  • The American Psychiatric Association has established a framework for clinicians to evaluate the potential of a mental-health app for their patients.3 Considerations should include the app’s: background, risk/privacy and safety; benefit/efficacy; engagement; and data sharing. Their online supplement includes a model screening list of questions to ask.
  • The National Association of Anorexia Nervosa and Associated Disorders recommends four specific eating disorder apps: Recovery Record, Rise Up + Recover, Jouvrie, and Mindshift.4
  • The nonprofit group One Mind PsyberGuide offers a curated list of apps that they deem credible (some have expert reviews).5

How do mHealth apps work for eating disorder management? In general, mobile health apps can easily replace pen-and-paper methods of implementing the CBT concept of self-monitoring, and that removes the possibility of a patient forgetting to bring their journal to a session. These apps allow users to engage in self-monitoring by logging meals, thoughts, feelings, and behaviors and gives them easy access to coping tactics. Additional features are included in some apps.

Recovery Record, for example, is HIPAA-compliant and can link with a person’s treatment team. Clinicians can connect to view patient data and customize treatment accordingly by adjusting goals, meal plans, and setting coping skills. Additionally, questionnaires and assessments can be sent and scored in the app. Patients can see when their clinicians have reviewed their logs, and a two-way messaging feature can be enabled if desired. The app also lets users anonymously send and receive affirmations and encouragement to others, and it offers rewards to help keep users motivated.

Rise Up + Recover also features tracking and coping skills, but rather than direct connectivity with clinicians, users can export PDF summaries of their data to share. The app also lets users share motivational quotes and affirmations and can search for local eating-disorder specialists.

The Data on mHealth Apps

Studies investigating app-related therapies often center on apps that have been developed by research teams and clinicians, although sometimes consumer-based apps are used. In 2019, one study found that although psychologists recognized the potential of a specific mHealth app for treatment of an eating disorder, they were reluctant to adopt its use, in part because of a reported lack of time and guidance from leaders.6

A gradual approach to embracing mHealth was cut short when COVID lockdowns gave the medical community at large no choice but to rapidly integrate telehealth and digital therapies, but research conducted before the pandemic indicated that digital interventions for eating disorders showed promise.

A couple of highlights:

  • Digital therapy delivering CBT-guided self-help along with a smartphone app (Noom Monitor) provided significant reduction in symptoms and higher rates of remission for people who were diagnosed with binge eating disorder or bulimia nervosa compared with standard care in a study published in February 2020.7 After receiving 12 weeks of telehealth training with a non-specialist health coach and continued use of the app, the intervention group had better outcomes on follow up at Weeks 4, 8, 12, 26, and 52 compared with the control group.
  • In a national study of college-aged women, published in August 2020, researchers found that women using a CBT-based app for eating disorder treatment fared significantly better when compared to a control group receiving in-person treatment.8 Most of the test group (83%) started the intervention while only 28% of the control group sought treatment
  • A commentary published in the same issue of JAMA Network Open by Shatkin noted the need for mental health services on college campuses and said that “simply getting patients into treatment is half the battle when it comes to mental illness.”9

The Uphill Push to Eating Disorder Treatment & Adherence

Why is it difficult to move patients with eating disorders into treatment? In a word, shame. According to Edward Abramson, PhD, a licensed clinical psychologist, professor emeritus of psychology at California State University, former director of the Eating Disorders Center at Chico Community Hospital in California, and author of “It’s NOT Just Baby Fat!,” noted that one of the issues that frequently comes up with bulimics, for example, is shame of their binge-purge behaviors.

“I don’t know how many women have told me things like ‘It’s disgusting, it’s gross, only an idiot would do this, why can’t I stop, etc,” he told Psycom Pro.

Dr. Abramson added that even when in therapy, it can be difficult for a person to talk about their eating disorder with their therapist. “I worked with a bulimic individual who had been to other therapists but had never quite gotten around to talking about their bulimia. They would talk about relationship issues, difficulties in school, or whatever,” he shared. “Upon hearing this, a colleague suggested that, in some cases, it’s the third therapist who finally hears about the eating disorder.”

A study published in the International Journal of Eating Disorders this past summer compared a test group (n=53) that received face-to-face CBT plus a mobile intervention, called TCApp, with a control group (n=53) that received face-to-face CBT only.10 Treatment was effective for both groups, with no advantage for the experimental group as hypothesized. The researchers explained that using the app “may be associated with reduced stigma and/or shame associated with seeking in‐person treatment and sharing ED‐related behaviors with the referral professional.”

Because of the shame and stigma felt by people with eating disorders who are considering treatment, digital therapies can help due to their impersonal nature. “Anything that can make it easier for people in the early stages of their disorder to deal with it is an improvement,” says Dr. Abramson. “By being able to go online and discuss, or track, or work on eating without having to actually deal face-to-face with a human being is probably an advantage.”

But Dr. Abramson stresses the importance of in-person therapy, if a person is willing to participate. “There is something to be said for human contact, so if a therapist can get beyond the defensiveness and really establish rapport with an eating-disordered person that is definitely a strength, because frequently folks with eating disorders need support to challenge and to try new behaviors and to run the risk – or what they expect to be the risk – of giving up some of the problematic behavior.”

Even with mHealth app use, patient adherence can be a challenge. In his commentary on the college study noted above, Dr. Shatkin wrote that “Among the 83% within the intervention group who initiated the SB-ED program [the name of the digital intervention], they completed only 31% of the content offered on average, yet they still reaped substantial benefit from the intervention. We might wonder how much more improvement would be seen if more of the treatment protocol were completed.” The study’s authors noted that this level of participation reflects the use of mental health apps in the real world, and they recommend that future research could target ways to keep people engaged.

The authors of the TCApp study further reported that only 35.8% of the experimental group used the app during the length of the study. Dr. Abramson says that in his experience of using nutrition apps with patients that people often do not complete the recommended treatment, noting that after the novelty wears off people tend not to follow through.

Combo Therapy May Do the Trick

Getting patients to stick with mHealth guided treatments may be more successful when used in combination with traditional therapy. According to Dr. Abramson, “The main advantage is that [apps] can also be used in the context of therapy so that in between weekly appointments, the therapist might recommend a particular app to keep track of the behaviors or present support for improved behaviors.”

mHealth’s Niche Patients

Digital therapy apps may also be particularly useful for teens whose parents are unsupportive of in-person treatment and for patients living in “rural settings where there’s less access to therapy,” adds Dr. Abramson. Other HCPs, such as primary care physicians and dentists, could also take advantage of recommending digital therapies when discussing a suspected eating disorder with a patient.

Says Dr. Abramson, “Dentists, for instance, are frequently the first medical professionals to recognize bulimia because they see the dental erosion as a result of repeated vomiting, and they could recommend an app to their patients who might be reluctant to go see a therapist.”

What Mental Health Clinicians Can Do Now

Consider mHealth apps and other digital therapies as an entry point to face-to-face therapy or as a tool to use along with it.

Researchers continue to explore how apps can improve outcomes for people with eating disorders. Even if digital therapy is used as a stepping-stone toward further treatment, getting help for an eating disorder or another mental health disorder is always a step in the right direction.

 

A Word About Digital Gratitude

An app does not have to be focused on eating disorders in order to help patients who have one. GratePic, an app that is focused on gratitude, is one that Dr. Abramson says he’ll probably use with patients (Disclosure: He is currently consulting on its development). “Traditionally, keeping a gratitude journal has been demonstrated to improve mood in a variety of different disorders, and in general life, so I think it would be good for eating-disordered folks as well,” he says.

People can use GratePic to take photos of things they feel grateful to have in their lives, and at set times they review the photos and positive feelings should follow. The app’s social networking aspect lets users share content. A beta-version of GratePic is available now on the App Store, with more features on the way pending the results of an NIH sponsored study that is set to wrap up in February 2021.

The app, and the concept, can be helpful in treating a range of conditions, but for someone with an eating disorder, for example, Dr. Abramson says a patient could use the app when they feel a binge or urge to binge coming on. If a therapist could teach them how to “catch [the urge] early enough and then review some positive photos, maybe that could help.

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Last Updated: Nov 17, 2020