**3.2 Methods of self-help trial**

Participants were identified by an author (DK) from sequential surveys of consecutive women attendees in two family doctor waiting rooms over a series of morning, afternoon, evening and weekend clinics. They first completed a survey including informed consent, EDE-Q (see above section 2.2) screening questions, and reported weight and height. Respondents who were symptomatic were asked to complete the remaining survey questionnaires and were subsequently posted or not posted the relevant intervention packages. Assessments were conducted at baseline and a 3-month postal follow-up.

Assessments were the same as in the first trial described in section 2.2 above with the vignette being of that of a women with binge eating disorder (BED) and BMI 26 (i.e. above the normal range but not overweight or obese) and addition of a self-esteem questionnaire (Robson 1998, 1989). The background to the development of the questionnaire is described in the 1988 paper where self-esteem was defined as: "The sense of contentment and selfacceptance that stems from a person's appraisal of his own worth, significance, attractiveness, competence, and ability to satisfy his aspirations" (Robson, 1988). The Robson questionnaire aims to quantify this sense of self-esteem or the individual elements of self-appraisal. Seven components of self-esteem are evaluated: subjective sense of significance; worthiness; appearance and social acceptability; competence; resilience and determination; control over personal destiny; and the value of existence. The items are scored on an 8-point Likert scale from "completely disagree" (zero score) to "completely agree" (score of seven). The total score is a summation of the scores on each item. The reliability and validity of the questionnaire has been assessed in one non-patient group and two patient groups (Robson, 1989). In the non-patient group the split-half reliability score was 0.96 and the Cronbach alpha coefficient was 0.89. The test-retest correlation was 0.88 (p<0.0001).

The text used in the BED-MHL vignette was: *Emily (E) is a 25 year-old student who has been "chubby" since she was 13. Over the years she has tried several diets, but she has never been able to stick with the recommendations for very long. E has just started a new job and is finding it hard to adjust. To make herself feel better, E "treats" herself with her favourite foods. When E gets home from work she often goes to the kitchen for a snack and then finds that she is unable to stop eating, for example, a sandwich, a chocolate bar, a slice of cheesecake, some ice cream and some fruit. Later in the evening she will eat dinner and sometimes she loses control with this as well and eats the leftovers, along with that another slice of cake, some cereal, and some more ice cream. These episodes of overeating occur, on average, two to three times per week. The next day she will try to eat less to "make up" for overeating. E feels ashamed of herself when she loses control of her eating like this and she despises the shape of her body, although she has never talked to anyone about it. She has often thought about more extreme methods of controlling her weight, such as fasting, vomiting after eating, or using laxatives, but she has never tried any of these things. She has been told by her doctor that she is just over the 'normal' weight for her height.*

Participants were included if they were over 18 years, had current extreme weight and/or shape concerns and current regular clinically significant ED behaviours (as in the first trial). Women who at baseline were receiving treatment for an ED and women who were at high risk if left untreated, specifically those who were pregnant, and of very low weight (BMI< 17.5) were excluded.

Participants were blind to their group and outcome assessments were blind to the group allocation. A second author (PH) was responsible for randomization (using a sequence generated using SPSS RV.BINOM (1,0.5) function), allocation concealment and posting out of the intervention packages. This trial was approved by the University of Western Sydney Human Research Ethics Committee.

The EWD-HL intervention was presented in booklet format which included (i) information on different types of eating disorders and associated mental health and weight problems, (ii) available evidence based treatments for EDs and what they involve, (iii) information on eating and lifestyle for maintaining a healthy weight, or for weight loss or gain in those who are overweight or underweight, designed specifically for those with eating disorders, (in accordance with National Health and Medical Research Council Australian guidelines for levels of exercise and nutrition (NHMRC, 2003) and a reference to a self-help book (Kausman, 1998: "If not dieting, then what?"), (iv) information regarding attitudes and beliefs likely to sustain symptoms and/or hinder treatment-seeking, (v) lists and contacts of local community and specialist treatment facilities and the (local) EDs support group or consumer organisation, (vi) the cognitive-behavioural self-help manual and book by Cooper (1995) "Bulimia nervosa and Binge Eating: A guide to recovery" that has specific guidance through the stages of therapy, checklists of progress, encouragement when treatment goals are obtained and advice on 'lapses' and when and where to go for more help if needed, and (vii) an ED screening questionnaire the "SCOFF" (Morgan et al., 1999) to assist participants selfidentify an ED. In addition participants received a full copy of the book by Cooper (1995).

The control group received the self-help book "Overcoming Low Self-esteem" (Fennell, 1999). This utilises cognitive and behavioural techniques in a self-help guide format for readers. It is comparable in length and context to the Cooper manual for EDs. Low selfesteem is common in people with EDs and has been the target of primary prevention programs and general strategies to improve self-esteem have been included in other selfhelp manuals for BN (e.g. Schmidt & Treasure (1993)). In addition (and as described above) we have found community women and symptomatic women most frequently identify the main problem for a women with BED or similar ED as one of 'low self-esteem' (e.g. Mond & Hay, 2008). However, findings in RCTs targeting self-esteem in universal programs aimed to reduce ED risk factors have been inconsistent (Wade et al., 2003).

#### **3.3 Results of self-help trial**

76 New Insights into the Prevention and Treatment of Bulimia Nervosa

occurred despite the waiting room poster drawing their attention to the booklet. Thus our intent in the randomized controlled trial was to ensure dissemination of the EWD-HL

The aims of the present feasibility trial were to test the ease of screening women in general practice for untreated EDs and the acceptance of an unsolicited self-help and EWD-HL intervention. Secondary aims were to inspect symptomatic and MHL outcomes compared to

Participants were identified by an author (DK) from sequential surveys of consecutive women attendees in two family doctor waiting rooms over a series of morning, afternoon, evening and weekend clinics. They first completed a survey including informed consent, EDE-Q (see above section 2.2) screening questions, and reported weight and height. Respondents who were symptomatic were asked to complete the remaining survey questionnaires and were subsequently posted or not posted the relevant intervention

Assessments were the same as in the first trial described in section 2.2 above with the vignette being of that of a women with binge eating disorder (BED) and BMI 26 (i.e. above the normal range but not overweight or obese) and addition of a self-esteem questionnaire (Robson 1998, 1989). The background to the development of the questionnaire is described in the 1988 paper where self-esteem was defined as: "The sense of contentment and selfacceptance that stems from a person's appraisal of his own worth, significance, attractiveness, competence, and ability to satisfy his aspirations" (Robson, 1988). The Robson questionnaire aims to quantify this sense of self-esteem or the individual elements of self-appraisal. Seven components of self-esteem are evaluated: subjective sense of significance; worthiness; appearance and social acceptability; competence; resilience and determination; control over personal destiny; and the value of existence. The items are scored on an 8-point Likert scale from "completely disagree" (zero score) to "completely agree" (score of seven). The total score is a summation of the scores on each item. The reliability and validity of the questionnaire has been assessed in one non-patient group and two patient groups (Robson, 1989). In the non-patient group the split-half reliability score was 0.96 and the Cronbach alpha coefficient was 0.89. The test-retest correlation was 0.88

The text used in the BED-MHL vignette was: *Emily (E) is a 25 year-old student who has been "chubby" since she was 13. Over the years she has tried several diets, but she has never been able to stick with the recommendations for very long. E has just started a new job and is finding it hard to adjust. To make herself feel better, E "treats" herself with her favourite foods. When E gets home from work she often goes to the kitchen for a snack and then finds that she is unable to stop eating, for example, a sandwich, a chocolate bar, a slice of cheesecake, some ice cream and some fruit. Later in the evening she will eat dinner and sometimes she loses control with this as well and eats the leftovers, along with that another slice of cake, some cereal, and some more ice cream. These episodes of overeating occur, on average, two to three times per week. The next day she will try to eat less to "make up" for overeating. E feels ashamed of herself when she loses control of her eating like this and she despises the shape of her body, although she has never talked to anyone about it. She has often thought about more extreme methods of controlling her weight, such as fasting, vomiting after eating, or using laxatives, but she has never tried any of these things. She has been told by her doctor that* 

packages. Assessments were conducted at baseline and a 3-month postal follow-up.

intervention to all women who were symptomatic.

a non-specific self-help intervention.

**3.2 Methods of self-help trial** 

(p<0.0001).

*she is just over the 'normal' weight for her height.*

Three hundred and twenty six women were approached over 6-months in two general practices. One hundred and sixty-three women were screened of whom 44 (13.5%) women met criteria and 36 (80%) agreed to do the full assessments and to have a follow-up assessment. Most were in full or part-time employment (57%) or employed in home duties (20%). Sixty per cent were married or living as married, 15% were separated or divorced, 74% had children, 43% had at least completed high school and 47% had completed a tertiary level qualification or degree. Mean age was 40.1 years (SD 11.9) and mean BMI was 30 (SD 7.5). The majority 40 (90%) were binge eating (7 subjective bingeing only) and 9 (20%) were using laxatives, diuretics or self-induced vomiting.

Targeted Prevention in Bulimic Eating Disorders:

received the self-esteem book.

the self-help treatment section.

Randomized Controlled Trials of a Mental Health Literacy and Self-Help Intervention 79

medication (antidepressants), and primary care or other non-specialists were more often regarded as helpful than specialist care. BED was identified as the main problem by 17%, and increased at follow-up in those who had the EWD-HL intervention and ED self-help book, indicating some effect on recognition at least with this. Perceived helpfulness of evidence base treatments such as cognitive-behaviour therapy or anti-depressants did not seem to change and regard for specialists as the most helpful professionals did not increase. There was improvement overall but few differences in symptoms, mental health related quality of life or self-esteem between randomized groups at follow-up (as shown on Table 4). There were reduced numbers with objective but not subjective binge eating in those who

No-one listed a self-help manual as most helpful at baseline but one person who received the self-esteem self-help book did list a self-help manual as most helpful treatment at followup. At follow-up 8/12 reported reading the ED self-help book (and most read about 50% of it), all found it not difficult to understand, 6/12 thought it informative (notably the first psycho-educative section of the book) but only 1 described it as personally helpful. Seven of 11 reported reading the self-esteem self-help book (and most read around 40% of it), all found it not difficult to understand, 7/11 thought it informative and 4/11 described it as personally helpful with again most finding the psycho-education sections more helpful than

**Baseline 3-month follow-up** 

Mean (SD)

Although more than half of the respondents reported reading and understanding a significant proportion of the self help material, this appears to have had no impact on

Median (IQ range)

N 44 12 11

Objective binge eating 4 (0-8) 2 (0-4) 0 (0-5) Subjective binge eating 5 (0-10) 2 (0-4) 2 (0-10)

EDE-Q Global score 3.3 (0.9) 2.7 (1.2) 3.1 (1.0) EDE-Q Restraint 2.9 (1.4) 2.9 (1.6) 2.5 (1.3) EDE-Q Eating concern 2.0 (1.4) 1.4 (1.4) 2.5 (1.3) EDE-Q Weight concern 3.9 (0.9) 3.4 (1.6) 3.7 (0.9) EDE-Q Shape concern 4.4 (1.0) 4.1 (1.6) 4.1 (1.2)

N 36 12 11 SF-12 mental health 42.2 (11.1) 44.0 (11.0) 42.6 (9.5) K-10 19.2 (7.4) 18.1 (7.4) 16.5 (4.2) BMI kg/m2 30 (7.5) 31.8 (8.9) 31.8 (9.0) Self-esteem 48.6 (7.7) 52.4 (4.7) 51.3 (7.9) Table 4. **Health outcomes following a EWD-HL/Self-Help (SH) intervention.** SF-12 measures mental health component score of health related quality of life, the K-10 measures

psychological distress, BMI=body mass index

**BED-MHL & ED SH Self-esteem SH** 

Twenty-three (52%) participants completed 3-month follow-up. There were no statistically significant differences in level of ED symptoms on the EDE-Q or other outcome variables between those who did and did not complete follow-up. Because of the small absolute numbers per group who completed follow-up descriptive data only are reported, no between group statistical tests were performed and sensitivity analyses were not performed. At baseline the MHL responses found most identified the problem as one of low self-esteem (see Table 3), vitamins and minerals were more favorably regarded than evidence based


Table 3. **Binge eating disorder mental health literacy (BED-MHL) outcomes following a EWD-HL/Self-Help (SH) intervention.** Specialist refers to psychiatrist or psychologist, nonspecialist refers to a counsellor or social worker. Because of low numbers % are not presented for follow-up data.

Twenty-three (52%) participants completed 3-month follow-up. There were no statistically significant differences in level of ED symptoms on the EDE-Q or other outcome variables between those who did and did not complete follow-up. Because of the small absolute numbers per group who completed follow-up descriptive data only are reported, no between group statistical tests were performed and sensitivity analyses were not performed. At baseline the MHL responses found most identified the problem as one of low self-esteem (see Table 3), vitamins and minerals were more favorably regarded than evidence based

**Baseline 3-month follow-up**

**N** 36 12 11

Bulimia nervosa 2 (5%) 0 0 Binge eating disorder 6 (17%) 4 1 Other ED 2 (5%) 0 0 Low self-esteem 18 (50%) 0 5 Other 7 ( 19%) 5 4 Not answered 1 (3%) 3 1

 Getting information 8 (22%) 4 5 Cognitive-behaviour 4 (11%) 2 1 Other psychotherapy 4 (11%) 0 0 Self-help manual 0 (0%) 0 1 Other 16 (44%) 5 3 Not answered 4 (11%) 1 1

Vitamins/minerals 21 (58%) 9 5 Anti-depressant 8 (22%) 2 2 Herbal 5 (14%) 0 4 Other 0 0 0 Not answered 2 (5%) 1 0

 Dietitian 8 (22%) 4 2 Specialist 5 (14%) 1 2 Non-specialist 5 (14%) 0 0 Family doctor 11 (31%) 3 3 Other 5 (14%) 4 4 Not answered 2 (5%) 0 0

Table 3. **Binge eating disorder mental health literacy (BED-MHL) outcomes following a EWD-HL/Self-Help (SH) intervention.** Specialist refers to psychiatrist or psychologist, non-

specialist refers to a counsellor or social worker. Because of low numbers % are not

**Main problem** 

**Most helpful therapy** 

**Most helpful medication** 

**Most helpful professional** 

presented for follow-up data.

EWD-HL & ED SH Self-esteem SH

medication (antidepressants), and primary care or other non-specialists were more often regarded as helpful than specialist care. BED was identified as the main problem by 17%, and increased at follow-up in those who had the EWD-HL intervention and ED self-help book, indicating some effect on recognition at least with this. Perceived helpfulness of evidence base treatments such as cognitive-behaviour therapy or anti-depressants did not seem to change and regard for specialists as the most helpful professionals did not increase. There was improvement overall but few differences in symptoms, mental health related quality of life or self-esteem between randomized groups at follow-up (as shown on Table 4). There were reduced numbers with objective but not subjective binge eating in those who received the self-esteem book.

No-one listed a self-help manual as most helpful at baseline but one person who received the self-esteem self-help book did list a self-help manual as most helpful treatment at followup. At follow-up 8/12 reported reading the ED self-help book (and most read about 50% of it), all found it not difficult to understand, 6/12 thought it informative (notably the first psycho-educative section of the book) but only 1 described it as personally helpful. Seven of 11 reported reading the self-esteem self-help book (and most read around 40% of it), all found it not difficult to understand, 7/11 thought it informative and 4/11 described it as personally helpful with again most finding the psycho-education sections more helpful than the self-help treatment section.


Table 4. **Health outcomes following a EWD-HL/Self-Help (SH) intervention.** SF-12 measures mental health component score of health related quality of life, the K-10 measures psychological distress, BMI=body mass index

Although more than half of the respondents reported reading and understanding a significant proportion of the self help material, this appears to have had no impact on

Targeted Prevention in Bulimic Eating Disorders:

being' centres.

**6. References** 

162.

Press.

Vol 57, pp. 659–665.

**5. Acknowledgement** 

for assistance with data management.

Randomized Controlled Trials of a Mental Health Literacy and Self-Help Intervention 81

improving community attitudes in Australia (Jorm et al., 2006). However their impact for reducing impact from depression for individuals is hard to evaluate. New approaches in developing strategies to help people with EDs understand their problems and how to effectively seek treatment may need to more directly target weight concern and deliver community interventions in mental health stigma-free contexts such as 'lifestyle' or 'well

The first trial was funded by a grant from the Australian Rotary Health Research Fund. The second trial was funded by an internal UWS research grant to PH. We thank Amber Sajjad

Andrews., G., Slade, T. (2001) Interpreting scores on the Kessler Psychological Distress Scale (K10). *Aaustralian and NewZealand Journal of Public Health* Vol 25, pp. 494-497. Andrews, G., Sanderson, K., Slade, T. & Issakidis,C. (2000). Why does the burden of disease

treatment. *Bulletin of the World Health Organization*, Vol 78, pp. 446-454. Becker, A. E., Franko, D. L., Nussbaum, K., & Herzog, D. B. (2004). Secondary Prevention for

Cachelin, F. M., & Striegel-Moore, R. H. (2006). Help seeking and barriers to treatment in a

Darby, A., Hay, P., Mond, J., Quirk, F., Buettner, P., & Kennedy, L. (2009). The rising

Darby, A., Hay, P., Mond, J., Quirk, F. (in preparation). Societal reaction toward eating disorder sufferers: A paradox of positive regard and discrimination. Evans, E. J., Hay, P. J., Mond, J. M, Paxton, S. J., Quirk, F., Rodgers, B., Jhajj, A. K.,

*Eating Disorders: The Journal of Treatment and Prevention,* Vol 19, pp 270-285.

Fairburn, C.G., & Beglin, S.J. (1994). Assessment of eating disorders: Interview or self-report questionnaire? *International Journal of Eating Disorders*, Vol 16, pp. 363-370. Fairburn, C., Cooper, Z., Doll, H., Norman, P.,& O'Connor, M. (2000) The natural course of

*International Journal of Eating Disorders,* Vol 42*,* pp. 104-108.

Fairburn, C. G. (1995). *Overcoming binge eating*. New York: Guilford.

Fennall, M. (1999) *Overcoming low self-esteem.*. London: Constable Robinson.

persist? Relating the burden of anxiety and depression to effectiveness of

Eating Disorders: The Impact of Education, Screening, and Referral in a College-Based Screening Program. *International Journal of Eating Disorders,* Vol 36*,* pp. 157–

community sample of Mexican American and European American women with eating disorders. *International Journal of Eating Disorders,* Vol 39,pp. 1544-1561. Cooper P. (1995) *Bulimia Nervosa and Binge Eating. A guide to recovery*. London: Robinson

prevalence of co-morbid obesity and eating disorder behaviours from 1995 to 2005

Sawoniewska, M. A. (in press 2011). Barriers to help-seeking in young women with eating disorders: A qualitative exploration in a longitudinal community survey.

bulimia nervosa and binge eating disorder in young women. *Arch Gen Psychiatry*

curbing attempts to lose weight. At assessment, 29 (85%) women reported trying to lose weight in the previous six months whilst in the three month period between assessment and follow up 21 (91%) reported they had been trying to lose weight.
