Open Access

The impact of indicated prevention and early intervention on co-morbid eating disorder and depressive symptoms: a systematic review

Journal of Eating Disorders20142:30

DOI: 10.1186/s40337-014-0030-2

Received: 22 September 2014

Accepted: 12 October 2014

Published: 13 November 2014

Abstract

Background

Depressive and eating disorder symptoms are highly comorbid. To date, however, little is known regarding the efficacy of existing programs in decreasing concurrent eating disorder and depressive symptoms.

Methods

We conducted a systematic review of selective and indicated controlled prevention and early intervention programs that assessed both eating disorder and depressive symptoms.

Results

We identified a total of 26 studies. The large majority of identified interventions (92%) were successful in decreasing eating disorder symptoms. However fewer than half (42%) were successful in decreasing both eating disorder and depressive symptoms. Intervention and participant characteristics did not predict success in decreasing depressive symptoms.

Conclusions

Indicated prevention and early intervention programs targeting eating disorder symptoms are limited in their success in decreasing concurrent depressive symptoms. Further efforts to develop more efficient interventions that are successful in decreasing both eating disorder and depressive symptoms are warranted.

Keywords

Eating disorders Depression Prevention Early intervention Systematic review

Review

Eating disorders and depressive disorders have revealed strong associations, and their relationships contribute to the complexity, burden, and treatment resistance of these disorders [1]. In view of these factors, understanding the effects of prevention and early intervention efforts on both eating disorder and depressive symptoms is an important concern, and would help inform intervention. However, to date, little attention has been paid to the success of interventions in decreasing both of these concerns. The aim of the present study was therefore to conduct a systematic review of indicated prevention and early intervention programs that assessed both eating disorder and depressive symptoms in order to clarify the efficacy of these programs in decreasing both types of symptomatology.

The lifetime comorbidity between eating disorders and major depressive disorders is high with estimates of 40% for Anorexia Nervosa and 50% for Bulimia Nervosa [2]. Importantly, in relation to eating disorders, comorbid depressive symptoms have been found to negatively affect the successfulness of early intervention efforts. Depressive symptoms have been found to predict attrition in self-help programs for binge eating disorder [3], and to predict drop-out from Internet interventions that have become more numerous in recent years [4]. Similarly, depressive symptoms have been found to predict poorer prognosis in self-help programs for eating disorders [3].

Several types of relationships have been hypothesized and described between eating disorder and depressive symptoms, namely that 1) eating disorder and depressive symptoms may develop simultaneously; 2) eating disorder symptoms may be a risk factor for depressive symptoms; 3) depressive symptoms may be a risk factor for eating disorder symptoms. While all of these models have received empirical support [5]-[7], compelling evidence from twin studies has revealed the importance of shared genetic factors in the development of comorbid eating disorder and depressive symptoms [8],[9]. In view of this, some authors have argued that the evidence to date provides greatest support for a comorbidity model in which eating disorders and depression stem from both common and specific etiological factors [10].

A number of theoretical models have proposed frameworks that account for these shared and specific risk factors including biological, cognitive, emotional-regulation, and feminist models. Biological models emphasize the importance of shared genetically transmitted biological factors, as described above, and in particular the importance of dysregulation of serotonergic pathways that have an impact on both mood and eating behaviors [11]. Cognitive models highlight the role of common cognitive distortions that play a role in the development of both depressive and eating disorder symptoms through a heightened focus on negative information [12]-[14]. Emotion-regulation models have revealed how maladaptive strategies for regulating emotions may contribute to both depressive and eating disorders symptoms [15]. Finally, feminist models of the comorbidity between depressive and eating disorder symptoms have highlighted the gendered aspects of these concerns and viewed both as products of the restricted roles accessible to women in Western society and the objectifying male gaze [16]-[18].

Despite the high rates of comorbidity and the number of theoretical frameworks accounting for this co-occurrence, to date little is known regarding the common course of eating disorder and depressive symptoms within interventions for high-risk individuals or early intervention programs. Previous work exploring the effect of prevention interventions for eating disorders on negative affect (which includes depressive symptoms but also more serious forms of negative affect) revealed that programs targeting individuals at high risk of eating disorders were more successful in decreasing negative affect [19]. Furthermore, programs including participants over the age of 15, in interactive formats, and including psychoeducational and cognitive dissonance content, produced the greatest decreases in negative affect [19]. While these findings are useful, they may not be transposable to depressive symptoms in interventions for symptomatic individuals as negative affect has not been found to affect prevention intervention attrition [20],[21]. Increasing our understanding of intervention effects on comorbid eating disorder and depressive symptoms is crucial as it has important clinical implications. In addition, this knowledge would convey important information regarding treatment efficiency and costs. Finally, strong theoretical bases exist for hypothesizing common underlying mechanisms accounting for eating disorder and depressive symptoms. However, a finding that interventions targeting these mechanisms (e.g., cognitive and emotional factors) were not successful in decreasing both types of symptomatology would point to a disconnect between theory and practice, and suggest a need for the theoretical accounts of the eating disorder/depression comorbidity to be revisited.

The aim of the present study was, therefore, to conduct a systematic review of interventions for high risk (indicated prevention) and symptomatic individuals (early intervention) that included both eating disorder and depression outcomes. Furthermore, consistent with previous findings [19], we expected that interventions that targeted individuals with higher initial levels of eating disorders and depressive symptoms would be most successful in decreasing both of these concerns. In addition, we hypothesized that interventions including a greater number of sessions, among younger participants (which might represent a shorter duration of symptoms), with content targeting negative thoughts and feelings would be most successful. Finally, as cognitive-behavioural therapy is widely recognized as one of the first line recommended treatments for depressive symptoms particularly among young people [22], we hypothesized that interventions implementing CBT strategies would be most successful in decreasing depressive symptoms.

Methods

This review was conducted in accordance to the PRISMA guidelines for systematic reviews [23]. The flow of information through different phases of the systematic review is shown in Figure1.
Figure 1

Systematic literature review flow diagram. Flow of information through the different phases of the systematic review.

Data sources

The databases PsychInfo, ScienceDirect and Scopus were searched for studies and dissertations published between January 1984 and September 2013. Two searches were conducted in each database, first a title search, second a keyword search. The searches included combinations of words describing eating concerns (eating AND disorder or disordered or disorders or pathology or disturbance or disturbed), body image concerns (body image or dissatisfaction or shape or appearance), depressive symptoms (depression or depressive or negative affect) and controlled interventions (prevention or intervention or evaluation or program or self-help AND control or controlled). In addition, studies included in previous reviews of the efficacy of interventions aiming to reduce eating concerns as well as the reference sections of relevant articles were scanned for additional potentially eligible studies.

Study selection

The resulting list of studies was inspected by one author to identify those meeting the following criteria:
  1. (1)

    Peer-reviewed published work.

     
  2. (2)

    Controlled intervention design, compared to an active or minimally active condition such as treatment as usual, or psychoeducation (randomised or not).

     
  3. (3)

    Indicated interventions defined as interventions aimed at individuals who were identified as having minimal detectable signs or symptoms of an eating but did not meet diagnostic criteria [24]. In our review we included interventions that included participants who had been screened for symptoms as well as interventions allowing participants to self-select as having high levels of concern. In addition, we included self-help and guided self-help interventions as representing the lowest intensity treatment in a stepped care model [25].

     
  4. (4)

    The concurrent assessment of both disordered eating and depressive symptoms at baseline and post-intervention, using psychometrically established measures for assessing both eating concerns and depressive symptoms.

     

Data extraction

Data from the reviewed studies were extracted by one author (RR). The data extraction sheet listed the following categories designed to describe and compare the studies mean age, gender, country, inclusion criteria for the study, type of intervention, mode of delivery, depression and eating disorder symptom measure, effects of intervention at post-test and follow-up, baseline depression level, number of intervention sessions, and presence of content targeting negative thoughts and emotions.

Data analyses

Depression scores were transformed into percentile ranks using norms from the general population [26],[27]. Chi-square tests were conducted to explore the effect of initial ED levels operationalized by recruitment criteria (self-selected versus screened), CBT strategies, content targeting negative thoughts and feelings, and face-to-face delivery on successfully decreasing depressive symptoms, and successfully decreasing both depressive and eating disorder symptoms. Independent t-tests were conducted to test the effect of mean age, number of sessions, and initial levels of depressive symptoms (percentile ranks) on successfully decreasing depressive symptoms, and successfully decreasing both depressive and eating disorder symptoms. All analyses were conducted using SPSS 22.

Results

Our review identified 26 studies corresponding to our inclusion criteria (Table1). Of the 26, 13 studies (50%) were conducted in the U.S, 7 in Europe (27%), 4 (15%) in Australia, and 2 in Canada (8%). The age of participants ranged from 14.4 to 46.5years old. Nineteen of the studies (73%) used the Beck Depression Inventory [28] as a measure of depressive symptoms, 3 (11%) used the Center for Epidemiology Depression Scale [29], 1 (4%) used the Montgomery-Asberg Depression Rating Scale, 1 (4%) used the Schedule for Affective Disorders and Schizophrenia for School-Age Children [30], 1 (4.33%) used the Kessler Distress Scale [31] and 1 (4%) used the Hospital Anxiety and Depression Scale [32].
Table 1

Characteristics of studies included in the systematic review

Study

N intervention; N control; Gender

Mean age

Country

Inclusion criteria

Intervention; number of sessions

Depression assessment instrument

p-post

p follow up

Eating disorder symptoms

p-post

p follow up

Alloway [33]

N intervention =8; N control = 6; F

32

Canada

Diabetes

Psycho-education; 6 sessions

Beck depression inventory

ns

ns

 

ns

ns

EDI ≥40

EDI

EAT ≥17

EDI

Banasiak [34]

N intervention =54; N control =55; F

45

Australia

meeting full or modified criteria for BN

Guided self-help vs TAU; 8 sessions

Beck depression inventory

*

N/A

EDE-Q

*

N/A

EDI

*

N/A

Bearman [35]

N intervention =38; N control =35; F

18.9

USA

Self-selected undergrads

CBT vs control; 4 sessions

Beck depression inventory

*

ns

BPS

*

*

DRES

*

*

EDE-Q

*

ns

Carrard [36]

N intervention =37; N control =37; F

36

Switzerland

1 OBE a week for the past 3months, meeting BED

Internet CBT vs control; 11 sessions

Beck depression inventory

ns

N/A

EDE-Q

*

N/A

EDI

*

N/A

TFEQ

*

N/A

Carrard [37]

N intervention =22; N control =20; F

42

Switzerland

BED patients 30 < BMI < 50

Internet CBT vs control; 11 sessions

Beck depression inventory

*

ns

EDE-Q

ns

ns

TFEQ

ns

ns

Carter [38]

N intervention =28/28; N control =29; F

27

USA

BN

CBT self-help vs nonspecific self-help vs control; 8 sessions

Beck depression inventory

ns

N/A

OBE

*

N/A

EDE-Q

ns

N/A

Fichter [39]

N intervention =68; N control =61; F

25

Germany

AN-B/P patients

Self-help vs waitlist; 6 sessions

Beck depression inventory

ns

N/A

EDI

ns

N/A

SIAB-EX

*

N/A

Grilo [40]

N intervention =38/37; N control =15; M & F

46.5

USA

BED

CBT vs behavioural weight-loss vs control; 12 sessions

Beck depression inventory

ns

N/A

EDE-Q

*

N/A

TFEQ

*

N/A

Grilo [41]

N intervention =24; N control =24; M & F

45.8

USA

Obese with BED

Self-help CBT vs TAU; 8 sessions

Beck depression inventory

ns

N/A

EDE-Q

*

N/A

Heinicke [42]

N intervention =36; N control =37; F

14.4

Australia

Self-selected for body image or eating concerns

CBT vs WT; 6 sessions

Beck depression inventory

*

*

BSQ

*

*

DEBQ

*

*

EWLB

*

*

EDI

*

*

SATAQ

*

*

Jacobi [43]

N intervention =51; N control =52; F

22.3

Germany

> 42 WCS

Internet CBT vs control; 8 sessions

Beck depression inventory

d = .14

d = .15

EDE-Q

d = .23-.35

d = .41-.62

EDI

d = .08-.32

d = .35-.54

Ljotsson [44]

N intervention =35; N control =36; M & F

34

Sweden

MADRS score <30 BED or BN full or sub-threshold

Self-help CBT vs control; 12 sessions

Montgome-ry asberg depression rating scale

*

*

EDE-Q

*

*

EDI

*

*

BSQ

*

*

McLean [45]

N intervention =32; N control =3629F

43.92

Australia

BSQ ≥90 or EDE-Q WSC ≥3.5

CBT vs control; 8 sessions

KDS

ns

*

BSQ

*

*

EDEQ

*

*

BIAQ

*

*

SATAQ

*

*

DEBQ

*

*

Mitchell [46]

N intervention =30/33; N control =30; F

 

USA

Self-selected

CD vs yoga vs control; 6 sessions

CES-D

ns

N/A

EDDS

* (CD)

N/A

BES

ns

N/A

EDI

* (CD)

N/A

IBSS

ns

N/A

TFEQ

ns

N/A

BSQ

ns

N/A

OBrien [47]

N intervention =13; N control =11; F

22.2

Canada

EDI > 10, skipping 2 meals a week

Control vs psycho-education; 8 sessions

Beck depression inventory

ns

ns

BULIT

*

*

BSQ

*

ns

EAT

*

*

FFS

*

ns

Paxton [48]

N intervention =42/37; N control =37; F

25

Australia

BSQ >100, or BSQ =90-99 AND BULIT-R >104

CBT vs internet CBT vs waitlist; 8 sessions

Beck depression inventory

*

N/A

BSQ

*

N/A

BULIT

*

N/A

DEBQ

*

N/A

BIAQ

*

N/A

SATAQ

*

N/A

Robinson [49]

N intervention =36/34; N control =27; M & F

28

UK

BN, BED or EDNOS

eCBT vs writing vs waitlist; 24 sessions

Beck depression inventory

ns

N/A

QEDD

*

N/A

BITE

ns

N/A

Snchez [50]

N intervention =38; N control =38; F

23.9

UK

BN or EDNOS

iCBT vs waitlist; 8 sessions

Hospital anxiety and depression scale

N/A

*

EDE-Q

N/A

*

Stice [51]

N intervention =203; N control =205; F

21.6

USA

Self-selected and phone screened

CD vs education brochure; 4 sessions

Beck depression inventory

*

*

EDDI

*

*

DRES

*

*

BPS

*

*

Stice [52]

N intervention =25; N control =70; F

21.3

USA

Self-selected into eating disorders seminar

Psycho-education vs control; 28 sessions

Beck depression inventory

ns

ns

IBSS

*

*

BPS

*

*

DRES

*

*

EDDS

*

*

Stice [53]

N intervention =139; N control =167; F

15.7

USA

Self-selected

CD vs control; 4 sessions

CES-D

ns

ns

IBSS

*

ns

BPS

*

*

DRES

*

*

EDDI

*

*

Stice [54]

N intervention =39/19; N control =29/20; F

21.6

USA

Self-selected

CD vs ECD vs psycho-education; 4 sessions

Beck depression inventory

*

N/A

IBSS

*

N/A

BPS

*

N/A

DRES

*

N/A

EDDI

 

N/A

Stice [55]

N intervention =198; N control =200; F

18.4

USA

Self-selected

HW vs psycho-education; 4 sessions

K-SADS

ns

ns

BDS

*

ns

DRES

*

*

EDDI

*

ns

Stice [56]

N intervention =55/44; N control =75; F

20.9

USA

Self-selected

CD vs Peer CD vs educational brochure; 4 sessions

Beck depression inventory

*

 

IBSS

*

*

BPS

*

*

DRES

*

*

EDDI

*

*

Striegel [57]

N intervention =59; N control =64; M & F

37.2

USA

binge eating on average at least twice a week but missed more than one criterion for BN or BED

Guided self-help vs TAU; 8 sessions

Beck depression inventory

*

*

EDE-Q

*

*

Taylor [58]

N intervention =206; N control =215; F

20.8

USA

WCS >50

ECBT vs waitlist; 8 sessions

CES-D

ns

ns (.07)

WCS

*

*

EDI

*

*

Note: BED = Binge Eating Disorder; BES = Binge Eating Scale [59]; BIAQ = Body Image Avoidance Questionnaire [60]; BITE = Bulimia Investigatory Test Edinburgh [61]; BN = Bulimia nervosa; BPS = Satisfaction and Dissatisfaction with Body Parts Scale [62]; BPSS = BSQ = Body Shape Questionnaire [63]; BULIT = Bulimia Test Revised [64]; Beck Depression Inventory [28]; CBT = Cognitive Behavioural Therapy; CES-D = The Center for Epidemiologic Studies Depression Scale [29]; DRES = Dutch Restrained Eating Scale [65]; EAT = Eating Attitudes Test [66]; EDDI = Eating Disorder Diagnostic Interview [53]; EDDS = Eating Disorder Diagnostic Scale [67]; EDE-Q = Eating Disorder Examination Questionnaire [68]; EDI = Eating Disorders Inventory [69]; EDNOS = Eating Disorder Not otherwise Specified; EWLB = Extreme Weight Loss Behaviors; IBSS = Ideal Body Stereotype Scale [70]; FFS = Forbidden Food Survey [71]; Hospital Anxiety and Depression Scale [32]; KDS = Kessler Distress Scale [31]; K-SADS Schedule for Affective Disorders and Schizophrenia for School-Age Children [30]; MADRS = Montgomery Asberg Depression Rating Scale [72]; OBE = Objective Binge Episodes; SATAQ = Sociocultural Attitudes Towards Appearance Questionnaire [73]; SIAB-EX = Structured Inventory for Anorexic and Bulimic Disorders [74]; TAU = treatment as usual; TFEQ = Three Factor Eating Questionnaire [75]; WCS = Weight and Shape Concerns Scale [76].

*p<.05 or lower, ns = non-significant, that is p > .05.

Effect of interventions on eating disorder and depressive symptoms

Of the 27 studies, 24 (92%) revealed a statistically significant decrease in eating disorder symptoms while 12 (46%) revealed a statistically significant decrease in depressive symptoms. Eleven studies (42%) significantly decreased both depressive and eating disorder symptoms.

None of our hypothesized moderators of program success on depressive symptoms were supported. Programs with content targeting negative emotions or negative cognitions were not more likely to decrease depressive symptoms. Similarly, programs implementing CBT techniques were not more likely to decrease depressive symptoms. Furthermore, initial levels of depressive or eating disorder symptoms, age, and number of sessions also revealed no association with intervention efficacy in decreasing depressive symptoms (Table2).
Table 2

Characteristics of studies according to their success in decreasing depressive symptoms

  

Decreases in depressive symptomsa

Decreases in both depressive and eating disorder symptomsb

 

Range

Significant decrease

No significant decrease

Significant decrease

No significant decrease

(12 studies)

(15 studies)

(11 studies)

(16 studies)

Participant age [mean years, (SD)]

14.4-46.5

27.2 (9.8)

28.7 (10.5)

25.4 (8.8)

33.3 (10.7)

Number of sessions[mean (SD)]

4-28

7.1 (2.7)

10.1 (7.1)

6.7 (2.4)

10.4 (7.1)

Initial depressive symptoms percentile rank [mean rank(SD)] c

55-99

88.1 (6.9)

85.4 (13.4)

87.1 (7.8)

86.3 (13.1)

Use of a screening cut-off score , N (%)

 

7 (58%)

10 (67%)

6 (55%)

11 (69%)

Face to face format, N (%)

 

8 (67%)

10 (67%)

9 (82%)

9 (56%)

CBT theoretical framework, N (%)

 

9 (75%)

8 (53%)

8 (73%)

9 (56%)

Content targeting negative emotions and cognitions, N (%)

 

9 (75%)

10 (37%)

9 (82%)

10 (62%)

aFor the 12 studies that found significant decreases in depressive symptoms, and the 15 that found no significant decrease, the mean age of participants, the mean depressive symptoms percentile rank at baseline, and the number of studies using a cut-off score, face-to face format, CBT framework, and content targeting emotions and cognitions are presented.

bThe same information as in column ais provided for the 11 studies that found significant decreases in both depressive and eating disorder symptoms, and the 16 that did not.

cHigher rank indicates that the participants in the study reported higher initial levels of depression.

Similarly, none of the hypothesized moderators were able to distinguish between programs that successfully decreased both depressive and eating disorder symptoms, and those that were successful in decreasing only one, or none (Table2). However, there was a trend for number of sessions, t(24) = 1.75, p = 0.092, with interventions with fewer sessions tending to be more likely to conjointly decrease eating disorder and depressive symptoms.

Discussion

The aim of the present study was to review the efficacy of indicated prevention and early interventions programs in decreasing concurrent depressive and eating disorder symptoms. Overall, the findings revealed that while the majority of interventions were successful in achieving decreases in eating disorder symptoms, fewer than half of the interventions identified were successful in decreasing both eating disorder and depressive symptoms. These results suggest that existing interventions may be limited in their overall impact and their long-term effects as remaining depressive symptoms could increase the likelihood of later recrudescence in eating disorder symptomatology [1]. Furthermore, these findings highlight the need for increased attention to comorbid depressive symptoms in intervention development and evaluation.

The findings from our review reveal that while 92% of the interventions resulted in significant decreases in eating disorder symptoms, only 42% were successfully in decreasing concurrent depressive and eating disorder symptoms. An important consideration lies in the fact that all of the interventions identified were primarily designed to target eating disorder symptoms, thus publication bias might have affected these ratios and made it more unlikely for our review to identify interventions successful only in decreasing depressive symptoms. Nevertheless, despite the seemingly widespread recognition of the important role of depressive symptoms in eating disorder pathology, illustrated by the frequent inclusion of depressive symptoms as a secondary outcome and the consideration of the effects of eating disorder interventions on depressive symptoms or negative affect in meta-analyses of eating disorder prevention interventions [19], our findings suggest that eating disorder interventions reveal a limited capacity to decrease depressive symptoms. Interestingly, while their importance as a secondary outcome is recognized, the failure to impact depressive symptoms seems to have received little attention. One potential explanation could be a lack of clarity in the conceptualization of depressive symptoms within intervention evaluation. Depressive symptomatology might be assessed as a control factor that could moderate intervention effects, and consequently the lack of intervention effects on this dimension would not be interpreted as a limitation of the intervention success. However, the studies included in the present review assessed for change in depressive symptoms, and frequently referred to it as a secondary outcome, suggesting that the intervention had been hypothesized to positively impact depressive symptoms.

The limited success of the interventions included in this review in decreasing depressive symptoms given their general success in decreasing eating disorder symptoms, suggests that, consistent with theories of comorbidity in a subset of individuals at least, depressive symptoms may not be secondary to eating disorder symptomatology [10]. Some authors have suggested that individuals suffering from eating disorder symptoms may experience depressive symptoms due to the burden of the illness [5]. However, the finding that the improvement of eating disorder symptomatology was not robustly associated with improvement in depressive symptoms, suggests this may not be the only mechanism accounting for the comorbidity and supports theories highlighting common etiological factors [10].

Overall, our proposed moderating factors were not predictive of success in decreasing depressive symptoms. One potential explanation for this failure is that we lacked statistical power due to using dichotomous variables as outcomes and for many moderators, or that the continuous variables assessed lacked variability. However, it might also be that variables other than those assessed in these studies, predict intervention effects on depressive symptoms. Our finding did reveal a trend-level finding regarding number of sessions, with shorter interventions revealing a higher likelihood of decreasing both eating disorder and depressive symptoms. This finding is consistent with those of meta-analytic reviews of interventions targeting depressive symptoms among children and adolescents [77]. These authors hypothesized that engagement may be higher with shorter programs, accounting for the stronger effects.

Our study was limited by some aspects of the available data. We used participant recruitment criteria (self-selected versus screened) as a proxy for eating disorder severity in part due to the wide variability in eating disorder instruments used and the lack of available normative data for some of those instruments. Using a more sensitive measure of eating disorder severity might have produced different results. Furthermore, while some studies provided rates of diagnosable depression in their sample of baseline, rates of depression at post-test were not available, precluding examination of decreases in diagnosable depression.

Nevertheless, these findings reveal the gap in knowledge and practice regarding the treatment of concurrent eating disorder and depressive symptoms and suggest some directions for future work:
  1. (1)

    Increasing our understanding of the course of depressive symptoms in relation to eating disorder symptoms during interventions might help clarify the mechanism of change in depressive symptoms and identify individuals benefiting less from the intervention effects on depressive symptoms.

     
  2. (2)

    Exploring participants experience of the causes of depressive symptoms, in particular as related or unrelated to their eating disorder symptoms, would contribute to increasing our understanding of the partial success of eating disorder interventions in decreasing concurrent eating disorder and depressive symptoms.

     
  3. (3)

    The development and evaluation of depression-specific modules in eating disorder interventions would provide evidence of increased efficacy in decreasing depressive symptoms.

     
  4. (4)

    Including measures of eating disorder symptoms in interventions primarily targeting depressive symptoms could further inform interventions for these comorbid concerns, and contribute to greater treatment efficiency.

     

Conclusions

Eating disorder and depressive symptoms are frequently comorbid and, in recognition of this, eating disorder interventions have often assessed depressive symptoms. The effect indicated prevention and early intervention programs on depressive symptoms is somewhat limited, however, and the characteristics of successful interventions are unclear. Further efforts are required to develop interventions that are successful in decreasing both eating disorder and depressive symptoms in order to increase treatment efficiency and the maintenance of therapeutic effects.

Authors contributions

RR conducted the literature search, data extraction and analysis, and prepared the manuscript. SP reviewed data extraction and interpretation, and contributed to writing of manuscript. Both authors read and approved the final manuscript.

Authors information

Rachel F Rodgers this work was conducted as a Honorary Visiting Academic at La Trobe University.

Declarations

Acknowledgements

The publication costs of this paper were supported by beyondblue. The authors are responsible for all content.

Authors’ Affiliations

(1)
Department of Counseling and Applied Educational Psychology, Northeastern University
(2)
Laboratoire de Stress Traumatique, Universite Paul Sabatier
(3)
La Trobe University

References

  1. Berkman ND, Lohr KN, Bulik CM: Outcomes of eating disorders: a systematic review of the literature. Int J Eat Disord. 2007, 40: 293-309. 10.1002/eat.20369.View ArticlePubMedGoogle Scholar
  2. Hudson JI, Hiripi E, Pope HG, Kessler RC: The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007, 61: 348-358. 10.1016/j.biopsych.2006.03.040.PubMed CentralView ArticlePubMedGoogle Scholar
  3. Masheb RM, Grilo CM: Examination of predictors and moderators for self-help treatments of binge-eating disorder. J Consult Clin Psychol. 2008, 76 (5): 900-904. 10.1037/a0012917.PubMed CentralView ArticlePubMedGoogle Scholar
  4. Von Brachel R, Hötzel K, Hirschfeld G, Rieger E, Schmidt U, Kosfelder J, Hechler T, Schulte D, Vocks S: Internet-based motivation program for women with eating disorders: eating disorder pathology and depressive mood predict dropout. J Med Internet Res. 2014, 16: e92-10.2196/jmir.3104.PubMed CentralView ArticlePubMedGoogle Scholar
  5. Stice E, Hayward C, Cameron RP, Killen JD, Taylor CB: Body-image and eating disturbances predict onset of depression among female adolescents: a longitudinal study. J Abnorm Psychol. 2000, 109: 438-444. 10.1037/0021-843X.109.3.438.View ArticlePubMedGoogle Scholar
  6. Stice E, Presnell K, Spangler D: Risk factors for binge eating onset in adolescent girls: a 2-year prospective investigation. Health Psychol. 2002, 21: 131-138. 10.1037/0278-6133.21.2.131.View ArticlePubMedGoogle Scholar
  7. Presnell K, Stice E, Seidel A, Madeley MC: Depression and eating pathology: prospective reciprocal relations in adolescents. Clin Psychol Psychother. 2009, 16: 357-365. 10.1002/cpp.630.PubMed CentralView ArticlePubMedGoogle Scholar
  8. Wade TD, Bulik CM, Neale M, Kendler KS: Anorexia nervosa and major depression: shared genetic and environmental risk factors. Am J Psychiatry. 2000, 157: 469-471. 10.1176/appi.ajp.157.3.469.View ArticlePubMedGoogle Scholar
  9. Mangweth B, Hudson J, Pope H, Hausmann A, De Col C, Laird N, Beibl W, Tsuang M: Family study of the aggregation of eating disorders and mood disorders. Psychol Med. 2003, 33: 1319-1323. 10.1017/S0033291703008250.View ArticlePubMedGoogle Scholar
  10. Bulik CM: Anxiety, Depression, and Eating Disorders. Eating Disorders and Obesity: A Comprehensive Handbook. Edited by: Fairburn CG, Brownell KD. 2002, 193-198. 2Google Scholar
  11. Kaye W: Neurobiology of anorexia and bulimia nervosa. Physiol Behav. 2008, 94: 121-135. 10.1016/j.physbeh.2007.11.037.PubMed CentralView ArticlePubMedGoogle Scholar
  12. Cooper MJ: Cognitive theory in anorexia nervosa and bulimia nervosa: progress, development and future directions. Clin Psychol Rev. 2005, 25: 511-531. 10.1016/j.cpr.2005.01.003.View ArticlePubMedGoogle Scholar
  13. Benas JS, Gibb BE: Weight-related teasing, dysfunctional cognitions, and symptoms of depression and eating disturbances. Cogn Ther Res. 2008, 32 (2): 143-160. 10.1007/s10608-006-9030-0.View ArticleGoogle Scholar
  14. Cooper MJ: Beliefs and their relationship to eating attitudes and depressive symptoms in men. Eat Behav. 2006, 7: 423-426. 10.1016/j.eatbeh.2005.11.003.View ArticlePubMedGoogle Scholar
  15. Aldao A, Nolen-Hoeksema S, Schweizer S: Emotion-regulation strategies across psychopathology: a meta-analytic review. Clin Psychol Rev. 2010, 30: 217-237. 10.1016/j.cpr.2009.11.004.View ArticlePubMedGoogle Scholar
  16. Fredrickson BL, Roberts T: Objectification theory. Psychol Women Q. 1997, 21: 173-206. 10.1111/j.1471-6402.1997.tb00108.x.View ArticleGoogle Scholar
  17. Tiggemann M, Kuring JK: The role of body objectification in disordered eating and depressed mood. Br J Clin Psychol. 2004, 43: 299-311. 10.1348/0144665031752925.View ArticlePubMedGoogle Scholar
  18. Gilbert S, Thompson JK: Feminist explanations of the development of eating disorders: common themes, research findings, and methodological issues. Clin Psychol Sci Pract. 1996, 3: 183-202. 10.1111/j.1468-2850.1996.tb00070.x.View ArticleGoogle Scholar
  19. Stice E, Shaw H, Marti CN: A meta-analytic review of eating disorder prevention programs: encouraging findings. Ann Rev Clin Psychol. 2007, 3: 207-231. 10.1146/annurev.clinpsy.3.022806.091447.View ArticleGoogle Scholar
  20. Stice E, Rohde P, Shaw H, Gau J: An effectiveness trial of a selected dissonance-based eating disorder prevention program for female high school students: long-term effects. J Consult Clin Psychol. 2011, 79: 500-508. 10.1037/a0024351.PubMed CentralView ArticlePubMedGoogle Scholar
  21. Stice E, Ragan J: A preliminary controlled evaluation of an eating disturbance psychoeducational intervention for college students. Int J Eat Disord. 2002, 31: 159-171. 10.1002/eat.10018.View ArticlePubMedGoogle Scholar
  22. Whitty P, Gilbody S: NICE, but will they help people with depression? The new national institute for clinical excellence depression guidelines. Br J Psychiatry. 2005, 186: 177-178. 10.1192/bjp.186.3.177.View ArticlePubMedGoogle Scholar
  23. Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009, 6: e1000097-10.1371/journal.pmed.1000097.PubMed CentralView ArticlePubMedGoogle Scholar
  24. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. 2009, The National Academic Press, Washington DCGoogle Scholar
  25. Wilson GT, Vitousek KM, Loeb KL: Stepped care treatment for eating disorders. J Consult Clin Psychol. 2000, 68: 564-572. 10.1037/0022-006X.68.4.564.View ArticlePubMedGoogle Scholar
  26. Crawford J, Cayley C, Lovibond PF, Wilson PH, Hartley C: Percentile norms and accompanying interval estimates from an Australian general adult population sample for self-report mood scales (BAI, BDI, CRSD, CES-D, DASS, DASS-21, STAI-X, STAI-Y, SRDS, and SRAS). Aust Psychol. 2011, 46: 3-14. 10.1111/j.1742-9544.2010.00003.x.View ArticleGoogle Scholar
  27. Slade T, Grove R, Burgess P: Kessler psychological distress scale: normative data from the 2007 Australian national survey of mental health and wellbeing. Aust N Z J Psychiatry. 2011, 45: 308-316. 10.3109/00048674.2010.543653.View ArticlePubMedGoogle Scholar
  28. Beck AT, Ward C, Mendelson M: Beck depression inventory (BDI). Arch Gen Psychiatry. 1961, 4: 561-571. 10.1001/archpsyc.1961.01710120031004.View ArticlePubMedGoogle Scholar
  29. Radloff LS: The CES-D scale a self-report depression scale for research in the general population. Appl Psychol Meas. 1977, 1: 385-401. 10.1177/014662167700100306.View ArticleGoogle Scholar
  30. Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, Williamson D, Ryan N: Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry. 1997, 36: 980-988. 10.1097/00004583-199707000-00021.View ArticlePubMedGoogle Scholar
  31. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand S-LT, Walters EE, Zaslavsky AM: Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002, 32: 959-976. 10.1017/S0033291702006074.View ArticlePubMedGoogle Scholar
  32. Zigmond AS, Snaith RP: The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983, 67: 361-370. 10.1111/j.1600-0447.1983.tb09716.x.View ArticlePubMedGoogle Scholar
  33. Alloway SC, Toth EL, McCargar LJ: Effectiveness of a group psychoeducation program for the treatment of subclinical disordered eating in women with type 1 diabetes. Can J Diet Pract Res. 2000, 62: 188-192.Google Scholar
  34. Banasiak SJ, Paxton SJ, Hay P: Guided self-help for bulimia nervosa in primary care: a randomized controlled trial. Psychol Med. 2005, 35: 1283-1294. 10.1017/S0033291705004769.View ArticlePubMedGoogle Scholar
  35. Bearman SK, Stice E, Chase A: Evaluation of an intervention targeting both depressive and bulimic pathology: a randomized prevention trial. Behav Ther. 2003, 34: 277-293. 10.1016/S0005-7894(03)80001-1.PubMed CentralView ArticlePubMedGoogle Scholar
  36. Carrard I, Crpin C, Rouget P, Lam T, Golay A, Van der Linden M: Randomised controlled trial of a guided self-help treatment on the internet for binge eating disorder. Behav Res Ther. 2011, 49: 482-491. 10.1016/j.brat.2011.05.004.View ArticlePubMedGoogle Scholar
  37. Carrard I, Crpin C, Rouget P, Lam T, van der Linden M, Alain Golay A: Acceptance and efficacy of a guided Internet self-help treatment program for obese patients with binge eating disorder. Clin Pract Epidemiol Ment Health. 2011, 7: 8-18. 10.2174/1745017901107010008.View ArticlePubMedGoogle Scholar
  38. Carter JC, Olmsted MP, Kaplan AS, McCabe RE, Mills JS, Aim A: Self-help for bulimia nervosa: a randomized controlled trial. Am J Psychiatry. 2003, 160: 973-978. 10.1176/appi.ajp.160.5.973.View ArticlePubMedGoogle Scholar
  39. Fichter M, Cebulla M, Quadflieg N, Naab S: Guided self-help for binge eating/purging anorexia nervosa before inpatient treatment. Psychother Res. 2008, 18: 594-603. 10.1080/10503300802123252.View ArticlePubMedGoogle Scholar
  40. Grilo CM, Masheb RM: A randomized controlled comparison of guided self-help cognitive behavioral therapy and behavioral weight loss for binge eating disorder. Behav Res Ther. 2005, 43: 1509-1525. 10.1016/j.brat.2004.11.010.View ArticlePubMedGoogle Scholar
  41. Grilo CM, White MA, Gueorguieva R, Barnes RD, Masheb RM: Self-help for binge eating disorder in primary care: a randomized controlled trial with ethnically and racially diverse obese patients. Behav Res Ther. 2013, 51: 855-861. 10.1016/j.brat.2013.10.002.View ArticlePubMedGoogle Scholar
  42. Heinicke BE, Paxton SJ, McLean SA, Wertheim EH: Internet-delivered targeted group intervention for body dissatisfaction and disordered eating in adolescent girls: a randomized controlled trial. J Abnorm Child Psychol. 2007, 35: 379-391. 10.1007/s10802-006-9097-9.View ArticlePubMedGoogle Scholar
  43. Jacobi C, Vlker U, Trockel MT, Taylor CB: Effects of an internet-based intervention for subthreshold eating disorders: a randomized controlled trial. Behav Res Ther. 2012, 50: 93-99. 10.1016/j.brat.2011.09.013.View ArticlePubMedGoogle Scholar
  44. Ljotsson B, Lundin C, Mitsell K, Carlbring P, Ramklint M, Ghaderi A: Remote treatment of bulimia nervosa and binge eating disorder: a randomized trial of Internet-assisted cognitive behavioural therapy. Behav Res Ther. 2007, 45: 649-661. 10.1016/j.brat.2006.06.010.View ArticlePubMedGoogle Scholar
  45. McLean SA, Paxton SJ, Wertheim EH: A body image and disordered eating intervention for women in midlife: a randomized controlled trial. J Consult Clin Psychol. 2011, 79: 751-758. 10.1037/a0026094.View ArticlePubMedGoogle Scholar
  46. Mitchell KS, Mazzeo SE, Rausch SM, Cooke KL: Innovative interventions for disordered eating: evaluating dissonance-based and yoga interventions. Int J Eat Disord. 2007, 40: 120-128. 10.1002/eat.20282.View ArticlePubMedGoogle Scholar
  47. OBrien KM, LeBow MD: Reducing maladaptive weight management practices: developing a psychoeducational intervention program. Eat Behav. 2007, 8: 195-210. 10.1016/j.eatbeh.2006.06.001.View ArticleGoogle Scholar
  48. Paxton SJ, McLean SA, Gollings EK, Faulkner C, Wertheim EH: Comparison of face-to-face and internet interventions for body image and eating problems in adult women: an RCT. Int J Eat Disord. 2007, 40: 692-704. 10.1002/eat.20446.View ArticlePubMedGoogle Scholar
  49. Robinson P, Serfaty M: Getting better byte by byte: a pilot randomised controlled trial of email therapy for bulimia nervosa and binge eating disorder. Eur Eat Disord Rev. 2008, 16: 84-93. 10.1002/erv.818.View ArticlePubMedGoogle Scholar
  50. Snchez-Ortiz V, Munro C, Stahl D, House J, Startup H, Treasure J, Williams C, Schmidt U: A randomized controlled trial of internet-based cognitive-behavioural therapy for bulimia nervosa or related disorders in a student population. Psychol Med. 2011, 41: 407-417. 10.1017/S0033291710000711.View ArticleGoogle Scholar
  51. Stice E, Butryn ML, Rohde P, Shaw H, Marti CN: An effectiveness trial of a new enhanced dissonance eating disorder prevention program among female college students. Behav Res Ther. 2013, 51: 862-871. 10.1016/j.brat.2013.10.003.PubMed CentralView ArticlePubMedGoogle Scholar
  52. Stice E, Orjada K, Tristan J: Trial of a psychoeducational eating disturbance intervention for college women: a replication and extension. Int J Eat Disord. 2006, 39: 233-239. 10.1002/eat.20252.View ArticlePubMedGoogle Scholar
  53. Stice E, Rohde P, Gau J, Shaw H: An effectiveness trial of a dissonance-based eating disorder prevention program for high-risk adolescents girls. J Consult Clin Psychol. 2009, 77: 825-834. 10.1037/a0016132.PubMed CentralView ArticlePubMedGoogle Scholar
  54. Stice E, Rohde P, Durant S, Shaw H: A preliminary trial of a prototype internet dissonance-based eating disorder prevention program for young women with body image concerns. J Consult Clin Psychol. 2012, 80: 907-916. 10.1037/a0028016.PubMed CentralView ArticlePubMedGoogle Scholar
  55. Stice E, Rohde P, Shaw H, Marti CN: Efficacy trial of a selective prevention program targeting both eating disorder symptoms and unhealthy weight gain among female college students. J Consult Clin Psychol. 2012, 80: 164-170. 10.1037/a0026484.PubMed CentralView ArticlePubMedGoogle Scholar
  56. Stice E, Rohde P, Durant S, Shaw H, Wade E: Effectiveness of peer-led dissonance-based eating disorder prevention groups: results from two randomized pilot trials. Behav Res Ther. 2013, 51: 197-206. 10.1016/j.brat.2013.01.004.PubMed CentralView ArticlePubMedGoogle Scholar
  57. Striegel-Moore RH, Wilson GT, DeBar L, Perrin N, Lynch F, Rosselli F, Kraemer HC: Cognitive behavioral guided self-help for the treatment of recurrent binge eating. J Consult Clin Psychol. 2010, 78: 312-321. 10.1037/a0018915.PubMed CentralView ArticlePubMedGoogle Scholar
  58. Taylor CB, Bryson S, Luce KH, Cunning D, Doyle AC, Abascal LB, Rockwell R, Dev P, Winzelberg AJ, Wilfley DE: Prevention of eating disorders in at-risk college-age women. Arch Gen Psychiatry. 2006, 63: 881-888. 10.1001/archpsyc.63.8.881.View ArticlePubMedGoogle Scholar
  59. Gormally J, Black S, Daston S, Rardin D: The assessment of binge eating severity among obese persons. Addict Behav. 1982, 7: 47-55. 10.1016/0306-4603(82)90024-7.View ArticlePubMedGoogle Scholar
  60. Rosen JC, Srebnik D, Saltzberg E, Wendt S: Development of a body image avoidance questionnaire. Psychol Assess J Consult Clin Psychol. 1991, 3: 32-37.Google Scholar
  61. Henderson M, Freeman CP: A self-rating scale for bulimia. The`BITE. Br J Psychiatry. 1987, 150: 18-24. 10.1192/bjp.150.1.18.View ArticlePubMedGoogle Scholar
  62. Berscheid E, Walster E, Bohrnstedt G: The happy American body: a survey report. Psychol Today. 1973, 7: 119-131.Google Scholar
  63. Cooper PJ, Taylor MJ, Cooper Z, Fairbum CG: The development and validation of the body shape questionnaire. Int J Eat Disord. 1987, 6: 485-494. 10.1002/1098-108X(198707)6:4<485::AID-EAT2260060405>3.0.CO;2-O.View ArticleGoogle Scholar
  64. Thelen MH, Farmer J, Wonderlich S, Smith M: A revision of the bulimia test: the BULITR. Psychol Assess J Consult Clin Psychol. 1991, 3: 119-124.Google Scholar
  65. Van Strien T, Frijters JE, Van Staveren WA, Defares PB, Deurenberg P: The predictive validity of the Dutch restrained eating scale. Int J Eat Disord. 1986, 5: 747-755. 10.1002/1098-108X(198605)5:4<747::AID-EAT2260050413>3.0.CO;2-6.View ArticleGoogle Scholar
  66. Garner DM, Garfinkel PE: The eating attitudes test: an index of the symptoms of anorexia nervosa. Psychol Med. 1979, 9: 273-279. 10.1017/S0033291700030762.View ArticlePubMedGoogle Scholar
  67. Stice E, Telch CF, Rizvi SL: Development and validation of the eating disorder diagnostic scale: a brief self-report measure of anorexia, bulimia, and binge-eating disorder. Psychol Assess. 2000, 12: 123-131. 10.1037/1040-3590.12.2.123.View ArticlePubMedGoogle Scholar
  68. Fairburn CG, Beglin SJ: Assessment of eating disorders: interview or self-report questionnaire?. Int J Eat Disord. 1994, 16: 363-370.PubMedGoogle Scholar
  69. Garner DM, Olmstead MP, Polivy J: Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int J Eat Disord. 1983, 2: 15-34. 10.1002/1098-108X(198321)2:2<15::AID-EAT2260020203>3.0.CO;2-6.View ArticleGoogle Scholar
  70. Stice E, Schupak-Neuberg E, Shaw HE, Stein RI: Relation of media exposure to eating disorder symptomatology: an examination of mediating mechanisms. J Abnorm Psychol. 1994, 103: 836-840. 10.1037/0021-843X.103.4.836.View ArticlePubMedGoogle Scholar
  71. Ruggiero L, Williamson D, Davis C, Schlundt DG, Carey MP: Forbidden food survey: measure of bulimics anticipated emotional reactions to specific foods. Addict Behav. 1988, 13: 267-274. 10.1016/0306-4603(88)90053-6.View ArticlePubMedGoogle Scholar
  72. Svanborg P, sberg M: A new self-rating scale for depression and anxiety states based on the comprehensive psychopathological rating scale. Acta Psychiatr Scand. 1994, 89: 21-28. 10.1111/j.1600-0447.1994.tb01480.x.View ArticlePubMedGoogle Scholar
  73. Thompson JK, van den Berg P, Roehrig M, Guarda AS, Heinberg LJ: The sociocultural attitudes towards appearance scale-3 (SATAQ-3): development and validation. Int J Eat Disord. 2004, 35: 293-304. 10.1002/eat.10257.View ArticlePubMedGoogle Scholar
  74. Fichter MM, Herpertz S, Quadflieg N, Herpertz-Dahlmann B: Structured interview for anorexic and bulimic disorders for DSM-IV and ICD-10: updated (third) revision. Int J Eat Disord. 1998, 24: 227-249. 10.1002/(SICI)1098-108X(199811)24:3<227::AID-EAT1>3.0.CO;2-O.View ArticlePubMedGoogle Scholar
  75. Stunkard AJ, Messick S: The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. J Psychosom Res. 1985, 29: 71-83. 10.1016/0022-3999(85)90010-8.View ArticlePubMedGoogle Scholar
  76. Jacobi C, Abascal L, Taylor CB: Screening for eating disorders and high-risk behavior: caution. Int J Eat Disord. 2004, 36: 280-295. 10.1002/eat.20048.View ArticlePubMedGoogle Scholar
  77. Stice E, Shaw H, Bohon C, Marti CN, Rohde P: A meta-analytic review of depression prevention programs for children and adolescents: factors that predict magnitude of intervention effects. J Consult Clin Psychol. 2009, 77: 486-503. 10.1037/a0015168.PubMed CentralView ArticlePubMedGoogle Scholar

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