**3. Self-help as a targeted intervention for bulimic EDs in primary care**

#### **3.1 Introduction to feasibility trial of self-help**

Self-help therapies have been introduced to help fill the gap between the high prevalence of bulimic-type EDs in the general population, and the lack of specialised professionals. Selfhelp can be appropriate for partial or less severe conditions, with guidance from trained non-specialised professionals in primary care services (GSH), or utilised in specialised services as a first step of a more comprehensive treatment, i.e. in a "stepped-care" approach.

**BN-MHL I-only BN-MHL I-only** 

Global EDE-Q 3.3 (1.1) 2.9 (1.2) 2.6 (1.3) 2.7 (1.3) 2.4 (1.2) EDE-Q Eating concern 2.4 (1.4) 1.9 (1.4) 1.7 (1.4) 1.9 (1.5) 1.6 (1.3) EDE-Q Shape concern 4.2 (1.2) 3.6 (1.4) 3.4 (1.6) 3.0 (1.5) 3.4 (1.5) EDE-Q Weight concern 3.9 (1.2) 3.4 (1.3) 3.1 (1.5) 3.1 (1.4) 2.9 (1.5) EDE-Q Restraint 3.0 (1.5) 2.6 (1.5) 2.2 (1.5) 2.4 (1.4) 2.0 (1.4) SF-12 MH 39 (12) 41 (11) 42 (11) 43 (12) 46 (12) K-10 23 (8) 22 (8) 21 (9) 22 (8) 21 (8) BMI kg/m2 26 (6) 25 (6) 26 (6) 26 (6) 26 (5)

Objective binge eating 1 (0-8) 0 (0-5) 0 (0-5) 0 (0-4) 0 (0-3) Subjective binge eating 4 (0-10) 2 (0-6) 0 (0-2)\* 0 (0-4) 0 (0-4) Table 2. **Health outcomes following a mental health literacy intervention in women with disordered eating.** SF-12 MH (mental health component score) measures mental health related quality of life, the K-10 measures psychological distress, BMI=body mass index,

In the trial of BN-MHL intervention we found the participants' BN-MHL at baseline to be similar to that in our previous surveys (Mond et al., 2010). Participants were most likely to identify the problem for the women with BN as one of low self-esteem and had modest or low regard for evidence based or specialist therapies compared to non-specialists. As we found previously (Hay et al., 2007a) a BN-MHL intervention had no significant impact on changing attitudes or improving symptoms and in this study it also had no significant

The findings indicated that merely providing people with information about treatments for bulimic EDs and also advising them to seek help did not result in notable changes in behaviour or beliefs. Our question then was - what interventions might help people with EDs improve recognition and understanding of treatments for their problem and thereby prompt effective help-seeking? We thus planned a second feasibility trial to investigate the impact of enhancing the MHL intervention by adding an evidence-based self-help treatment

Self-help therapies have been introduced to help fill the gap between the high prevalence of bulimic-type EDs in the general population, and the lack of specialised professionals. Selfhelp can be appropriate for partial or less severe conditions, with guidance from trained non-specialised professionals in primary care services (GSH), or utilised in specialised services as a first step of a more comprehensive treatment, i.e. in a "stepped-care" approach.

**3. Self-help as a targeted intervention for bulimic EDs in primary care** 

**N** 217 65 78 62 72

Mean (SD)

Median (IQ range)

**2.4 Summary and introduction to trial of self-help approaches** 

mean and SD, all p not significant excepting \*p=0.01

impact on improving mental health related quality of life.

manual to the MHL intervention.

**3.1 Introduction to feasibility trial of self-help** 

**Baseline 6-months 12-months** 

Manuals studied have included: "*Overcoming Binge Eating*" (Fairburn, 1995) or translations/adaptations of it; the manual: "*Bulimia Nervosa: a guide to recovery*" (Cooper, 1995) since updated; and the manual: "*Getting Better Bit(e) by Bit(e)*" (Schmidt & Treasure 1993).

Hay et al. (2004) and Stefano et al. (2006) examined abstinence rates from ED behaviours such as binge eating in meta-analyses of trials pure self-help (PSH) vs waitlist in bulimic disorders such as BN or binge eating disorder. Rates ranged from 30% to 36% for PSH - and were better for GSH which ranged from 33% to 43%, the latter of which can be comparable to full CBT in its outcomes. In all meta-analyses PSH was however favoured over waitlist where abstinence rates were, for example, between 5% and 11%. Despite promising if modest findings, there have been a number of problems with these studies including variable levels of therapist training and variation in evaluation tools and outcome measurements. Whilst it has been argued that self-help can be a first step in management for selected people seeking help for EDs its role in assisting people with EDs not accessing services or treatments is thus less clear.

In addition, as weight concern and seeking help to lose weight is a common feature of women who do not seek help for their ED (Hay et al., 1998; Mond et al., 2007) we thought it important to add nutrition and lifestyle intervention strategies to self-help to assist women who are overweight or obese to reduce further weight gain and/or maintain weight in the healthy range. This included specific advice on healthy exercise. We also chose a vignette of someone with binge eating disorder as that is a common bulimic eating disorder and is more frequently associated with weight disorder (Hudson et al., 2007, Darby et al., 2009). We thus developed the intervention to be for both eating and weight disorder health literacy (EWD-HL).

We based this second trial in general practice as unrecognised bulimic eating disorders are common in women attending their family doctors (King, 1989; Whitehouse et al. 1992; Hay et al., 1998; Mond et al., 2009). The family doctor is also the point of access for psychological treatments for people in Australia. To inform the present study we conducted an investigation into the dissemination of an EWD-HL intervention into primary care at two general practices in late 2005 (Hay et al., 2006). One hundred and fifty-five women (aged 18- 45 years) attending the two practices (over 3 months) in North Queensland (Australia) were screened through the distribution of an ED symptom and an ED-MHL survey by reception staff. Fourteen (9%) had a bulimic ED, and a further 12 (7.7%) had clinically significant symptoms. Attractive booklets containing information about ED and their treatments, a brief assessment screening questionnaire for Eating Disorders (the SCOFF (Morgan et al., 1999)) and information on local services and consumer groups were left in the waiting rooms, and a poster containing the SCOFF questions was displayed inviting patients to take a copy of the 'guide' booklet.

This survey confirmed a high level of untreated bulimic EDs in primary care settings as of the 23% women who self-identified an ED problem only one had sought professional help, in this instance from a counselor. In addition, patients reported they were prompted to discuss their ED symptoms with their GP as a result of reading the booklet. However, screening utilising reception staff was problematic and very inefficient compared to our previous method of embedding a research assistant (RA) in the practices (e.g. Hay et al., 1998). We also found the booklets needed to be provided to participants directly as, while many participants (54%) were interested in receiving a copy of the booklet when their attention was drawn to it, very few (14%) had picked it up in the waiting rooms. This

Targeted Prevention in Bulimic Eating Disorders:

Human Research Ethics Committee.

**3.3 Results of self-help trial** 

17.5) were excluded.

Randomized Controlled Trials of a Mental Health Literacy and Self-Help Intervention 77

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<

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

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).

using laxatives, diuretics or self-induced vomiting.

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

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 intervention to all women who were symptomatic.

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 a non-specific self-help intervention.
