**Targeted Prevention in Bulimic Eating Disorders: Randomized Controlled Trials of a Mental Health Literacy and Self-Help Intervention**

Phillipa Hay1,6,Jonathan Mond2, Petra Buttner3, Susan Paxton4, Bryan Rodgers5, Frances Quirk6 and Diane Kancijanic1 *1School of Medicine, University of Western Sydney, 2School of Health Sciences, University of Western Sydney, 3School of Public Health, Tropical Medicine, and Rehabilitation Sciences, James Cook University, Townsville, Australia University of Western Sydney, 4School of Psychological Sciences, La Trobe University, 5Australian Demographic and Social Research Insittute, The Australian National University, 6School of Medicine and Dentistry, James Cook University, 7 School of Medicine, University of Western Sydney, Australia* 

### **1. Introduction**

68 New Insights into the Prevention and Treatment of Bulimia Nervosa

Sundgot-Borgen, J. (1994). Risk and trigger factors for the development of eating disorders in female elite athletes. *Medicine Science for Sports and Exercise, 26*, 414-419. Sundgot-Borgen, J., & Torstveit, M. (2004). Prevalence of eating disorders in elite athletes is higher than in the general population. *Clinical Journal of Sports Medicine, 14*, 25-32. Thompson , J. K., & Heinberg , L. J. (1999). The media's influence on body image distrubance

Torres-McGehee , T. M., & Monsma, E. V. (n.d). Eating disorder risk and the role of context

Torres-McGehee, T. M., Monsma, E. V., Dompier, T. P., & Washburn, S. A. (n.d.). Eating

Torres-McGehee, T. M., Green, J. M., Leeper, J. D., Leaver-Dunn, D., Richardson, M., &

Tylka, T. L., & Subich, L. M. (2004). Examining a multidimensional model of eating disorder

Vincent, A., & McCabe, M. P. (2000). Gender differences among adolescents in family and

Weise-Bjornstal, D. M., Smith, A. M., Shaffer, S. M., & et al. (1998). An integrated model of

Wilfley, D. E., Schwartz, M. B., Spurrell, E. B., & Fairburn, C. G. (2000). Using the eating

Yang, J., Peek-Asa, C., Corlette, J. D., Cheng, G., Foster, D. T., & Albright, J. (2007).

disorder. *International Journal of Eating Disorders, 27*, 259-269.

competitive athletes. *Clinical Journal of Sports Medicine, 17*, 481-487.

York: Raven Press.

*Social Issues, 55*, 339-353.

*Training, 46*, 345-351.

328.

*Manuscript submitted for publication*.

*Journal of Youth and Adolescence, 29*, 206-221.

*Applied Sports Psychology, 10*, 46-69.

*publication*.

Matthysse, *The genetics of neurological and psychiatric disorders* (pp. 115-120). New

and eating disorders: We've reviled them, now can we rehabilitate them? *Journal of* 

specific body images among collegiate cheerleaders. *Manuscript submitted for* 

Disorder Risk and the Role of Clothing on Body Image in Collegiate Cheerleaders.

Bishop, P. A. (2009). Body Image, anthropometric measures, and eating-disorder prevalance in auxiliary unit members. *Journal of Athletic Training, 44*, 418-426. Torres-McGehee, T. M., Monsma, E. V., Gay, J. L., Minton, D. M., & Mady, A. N. (In Press).

Prevalence of eating disorder risk and body image distortion among National Collegiate Assocation Division I varsity equestrian athletes. *Journal of Athletic* 

symptomatology among college women. *Journal of Counseling Psychology, 51*(3), 314-

peer influences on body dissatisfaction, weight loss, and binge eating behaviors.

the response to sport injury: Psychological ad sociological dynamics. *Journal of* 

disorder examinatino to identify the specific psychopathology of binge eating

Prevalence of and risk factors associated with symptoms ofdepression in

Eating disorders (EDs) in the community are associated with high burden and poor quality of life (Mathers et al., 2000, Hay & Mond, 2005). It is also known that people with EDs have frequent chronic medical complications (Mehler, 2003), increased risk of obesity especially for the more common bulimic EDs such as binge eating disorder (Neumark-Sztainer et al., 2006; Hudson et al., 2007)) and high levels of co-morbidity with both depression and anxiety (Hudson et al., 2007). However, there is a wide gap between the presence of a disorder and its identification and treatment. It is well-documented that the overwhelming majority of people in the community with an ED do not seek help for their eating behaviours (Hart et al., in press; Welch & Fairburn 1994), and that even fewer access appropriate or evidencebased treatments (Cachelin & Striegel-Moore,2006; Mond et al., 2009). This is problematic as many randomised controlled trials support the efficacy of treatments, such as cognitivebehaviour therapy for bulimic EDs (Hay et al., 2004) and unmet treatment needs likely add to the general community burden from psychiatric disorders (Andrews et al., 2000). In addition, these disorders often become chronic with longitudinal studies indicating persistence of symptoms over many years (Fairburn et al., 2000, Evans et al., 2011).

It has been argued that factors contributing to the low rates of help-seeking amongst people with EDs include poor knowledge about treatments amongst sufferers (Cachelin & Striegel-Moore, 2006; Hepworth & Paxton, 2007; Mond & Hay, 2008), feelings of shame (Cachelin & Striegel-Moore, 2006; Hepworth & Paxton, 2007), perceived stigmatisation of EDs (Stewart et al., 2006), ambivalence towards change (Hepworth & Paxton, 2007), cost (Cachelin &

Targeted Prevention in Bulimic Eating Disorders:

information about local mental health services only.

*isolated from her friends.* 

control participants were provided with the intervention at one year.

Randomized Controlled Trials of a Mental Health Literacy and Self-Help Intervention 71

vomiting and/or laxative/diuretic use and/or fasting or severe food restriction and/or 'driven' exercise and/or who self-identified on the BN-MHL survey as currently having a problem like that of 'Naomi' (see below – only one was included on this criteria alone). The majority of students (179, 84%) were Australian born and 150 (72%) were never married. At the start of the first year (baseline) the participants who agreed to follow-up were randomised to receive either a bulimia nervosa mental health literacy (BN-MHL) intervention (n=97) or information about their symptom scores and local mental health services only, with the comparison group (as required by ethical consideration) receiving the intervention at the end of the first year. The intervention comprised a single posted package of information about treatment of BN and related disorders, purchasing information on the book "Binge eating and Bulimia nervosa: A guide to recovery" (Cooper, 1995). The recommended book included a detailed psycho-educational section and a selfdirected cognitive-behaviour therapy. The package also provided recommended websites for further information on treatments, lists and contact details of local eating disorder specialist treatment facilities, and contact details for the (local) eating disorders support group and consumer organisation. At baseline the control group (n=120) received

Randomisation was by means of SPSS RV.BINOM (1,0.5) function and allocation was concealed from the research officer who communicated with the participants. In the covering letter informed consent was obtained, along with permission for follow-up in order to "find out how health issues and general health and well-being impacts on people's quality of life over time". Participants were not told they were part of a randomised controlled trial. Three respective institutional ethics committees approved the research (namely James Cook, La Trobe and Western Sydney universities), with the proviso that

ED symptoms were assessed with the Eating Disorder Examination Questionnaire (EDE-Q). The EDE-Q has been validated in community and clinic samples of people with EDs (Fairburn & Beglin, 1994; Mond et al., 2004). It yields a global score of ED attitudes and restraint, and four sub-scales (i.e. shape, weight and eating concern and dietary restraint) and also frequency of ED behaviours such as binge-eating over the preceding four weeks. BN-MHL was assessed with a questionnaire designed for this research (Mond et al., 2010). A vignette describing a (fictional) 19-year-old female suffering from BN called Naomi (N) was presented. Care was taken to ensure that the core features of the disorder were present while avoiding the use of medical terminology. The text of the vignette was: *N is a 19-yearold second year arts student. Although mildly overweight as an adolescent, N's current weight is within the normal range for her age and height. However, she thinks she is overweight. Upon starting university, N joined a fitness program at the gym and also started running regularly. Through this effort she gradually began to lose weight. N then started to "diet," avoiding all fatty foods, not eating between meals, and trying to eat set portions of "healthy foods," mainly fruit and vegetables and bread or rice, each day. N also continued with the exercise program, losing several more kilograms. However, she has found it difficult to maintain the weight loss and for the past 18 months her weight has been continually fluctuating, sometimes by as much as 5 kilograms within a few weeks. N has also found it difficult to control her eating. While able to restrict her dietary intake during the day, at night she is often unable to stop eating, bingeing on, for example, a block of chocolate and several pieces of fruit. To counteract the effects of this bingeing, N takes water tablets. On other occasions, she vomits after overeating. Because of her strict routines of eating and exercising, N has become* 

Striegel-Moore, 2006; Hepworth & Paxton, 2007), and a belief that one could or should handle the problem alone (Becker et al., 2004; Cachelin & Striegel-Moore, 2006).

Many of these reasons for the under-utilisation of health care in eating disorders are features of 'mental health literacy', a term introduced and defined by Jorm as "knowledge and beliefs about mental disorders that may aid in their recognition, management and treatment" (Jorm et al, 1997). Jorm and colleagues, and others, have argued that poor mental health literacy is a major factor in the individual, social and economic burden of mental health problems (Andrews et al., 2000; Jorm et al., 2000). There have been attempts to evaluate the efficacy of mental health literacy interventions in improving outcomes for patients with problems such as depression. In one study Jorm and colleagues (2003) reported a large community-based RCT (n=1094) for an evidenced based guide to treatments versus a general brochure for people with depressive symptoms. They found more positive outcomes in the former group but the effects were not large.

In the area of eating disorders we have conducted a small randomized controlled study of a brief postal mental health literacy intervention in community women with bulimic eating disorders. At the end of a year symptomatic improvement, less pessimism about how difficult eating disorders are to treat, improved recognition and knowledge, as well as increased help-seeking were observed in both groups (Hay et al., 2007a). Those randomized to receive the mental health literacy intervention also had improved mental health related quality of life. The study supported further investigations of the role of targeted health literacy interventions in eating disorders described in this chapter.
