**4. Conclusions**

In this chapter we describe two attempts to identify and assist women with EDs in the community, one a sample of younger women from tertiary education institutions and one a sample of older women attending their family doctors. In the first trial we did not replicate the positive findings of an earlier study which found a brief BN-MHL intervention improved mental health related quality of life when compared to a control condition of information about ED services only. The MHL intervention had little impact on changing attitudes and beliefs about EDs, their identification or their treatment. However, the present studies were possibly underpowered to show differences. The second study was with an enhanced intervention that included provision of an evidence-based self-help book. There may have been a small impact on identification of the ED but overwhelmingly participants still had a comparatively low regard for specialist treatments and rated getting more information as the most helpful approach for a fictitious person with a bulimic ED.

Given that identifying the main problem for the woman with a bulimic ED in the vignette as low self-esteem it was of interest that the self-esteem self-help book appeared better received and more found it personally helpful than the ED self-help book. Anecdotal comments were that the title of the ED book was disconcerting and some women were puzzled as to why they had received it. Although not overt we suspected that it may have been perceived as stigmatising by some participants. Many community women perceive significant stigma and discrimination for those who have a known ED (Hepworth & Paxton, 2007) and particularly for those with binge eating and (over) weight (Darby et al., manuscript in preparation). We think it is likely that self-help books for binge eating and BN such as that used in the present study are thus best provided in the context of a consultation where their role and relevance can be explained.

An additional factor (the 'elephant in the room') is the ambivalence people have towards the ED behaviours. We have found that despite distress from ED symptoms, people with EDs have a favourable regard for ED weight losing strategies (Mond et al., 2010) and are much more likely to seek help to lose weight than to modify disordered eating (Hay et al., 1998; Mond et al., 2007; Evans et al., 2011). This apparent paradox is perhaps understandable in the context of widespread public and community concerns about obesity and negative community attitudes towards weight disorders with widespread cultural positive regard for being thin. If a woman's main concern is to receive help for a perceived or actual overweight problem, then she may be less likely to want to engage in treatments that are not known to reduce weight. In addition, we have found many women and up to a third of general practitioners and other key health professionals consider weight gain to be likely with treatment for bulimia nervosa (Hay et al., 2007b).

The question of how best to improve ED-MHL for people with disordered eating, and if an improvement subsequently leads to an increase in accessing evidence-based treatments from appropriately trained professionals thereby reducing community and individual burden from EDs is still unanswered. Large scale universal public health campaigns and /or programs that target health care professionals are alternatives to the targeted programs described here. One focussing on depression and its treatment has likely had an effect in 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 being' centres.
