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Table 1 Characteristics of studies included in the review

From: The use of technology in the treatment of youth with eating disorders: A scoping review

References

Study design

Study population

Race, ethnicity, and SES

Description of intervention

Mode of delivery

Level of support

Outcome measures

Results (effect size if available)

Empirical studies testing virtual care interventions in youth with eating disorders

        

Aardoom et al. [12, 22]

RCT

N = 273

Mean age = 24.4 (range not reported, over 16)

Sex = 99% females

Diagnosis = approximated DSM-5 diagnosis using EDE-Q self-report; 97.6% above clinical significance cut-off

Recruited = via Featback website of Dutch recovery e-community

The Netherlands

NR

Featback, a fully automated Internet-based monitoring and feedback intervention was offered alone and with additional high- and low-intensity online therapist support in comparison to a waiting list control

Online: depending on condition, all online including for therapist support

2 of the 4 conditions include email, chat, and Skype support from therapists

SEED

Featback was superior to waitlist control for bulimic psychopathology (d = 0.16) as well as for ED-related quality of life at 3 month follow up (d = 0.22)

No effect for anorexia nervosa psychopathology

Additional support significantly enhanced patient experience of treatment but did not impact effectiveness

Aardoom et al. [23]

RCT

N = 273

Mean age = 24.4 (range not reported, over 16)

Sex = 99% females

Diagnosis = approximated DSM-5 diagnosis using EDE-Q self-report; 97.6% above clinical significance cut-off

Recruited = via Featback website of Dutch recovery e-community

The Netherlands

NR

Featback, a fully automated Internet-based monitoring and feedback intervention was offered alone and with additional high- and low-intensity online therapist support in comparison to a waiting list control

Online: depending on condition, all online including for therapist support

2 of the 4 conditions include email, chat, and Skype support from therapists

SEED

Featback was superior to usual care for mild/moderate bulimic but not for mild/moderate symptoms of anorexia nervosa

Fully automated monitoring and feedback improved mild to moderate bulimic symptoms. Additional therapist support did not increase effectiveness for these patients

Anastasiadou et al. [24]

Multicentre RCT

N = 106

Mean age = 18.06 (SD 6.04)

Diagnosis = any ED, according to DSM-5 criteria

Recruited from public/private mental health services

Spain

NR

Standard CBT + TCApp, a mobile health intervention including monitoring and chat with therapists (12 weeks) compared to standard CBT alone

Hybrid: included both in-person CBT and the online mobile app in between appointments

Online chat support by therapist (therapist responded minimally once per week)

EDE-Q and SEED

There were significant but negligible reductions in EDE-Q (d = 0.11) and SEED scores (AN severity index: d = -0.09; BN severity index d = 0.09) for participants overall

No significant difference between the 2 groups on longitudinal EDE-Q total and subscales and in severity of SEED

Anderson et al. [25]

Case series

N = 10

Age 13–18 years (mean = 16.08, SD 1.99)

Sex = 8/10 were females

Diagnosis = AN or atypical AN, according to DSM-5 criteria

Recruited from medical ads

USA

Ethnicity: all Caucasian

SES, race: NR

Videoconference delivered Family-Based Treatment consisting of weekly family meetings with therapist (20 sessions over 6 months)

Online: intervention delivered completely via telehealth platform

No additional support outside of primary treatment

%mBMI, EDE

Weight increased from baseline to end of treatment (d = 0.53) and to 6 months follow-up

Changes in global EDE and subscales were significant at end of treatment (d = 1.06) and follow-up

Carrard et al. [26]

Uncontrolled trial

N = 127

Mean age = 24.7 (18–43 range, SD = 5.1)

Sex = female

Diagnosis = BN purging type or EDNOS bulimic type, according to DSM-IV criteria

Recruited from multiple European treatment centers and ads

Switzerland, Spain, Sweden, and Germany

NR

Internet self-help program based on classical CBT principles

Online: all modules and contact with coach via internet. 1 evaluation session done face to face

Weekly email contact with coach

EDI-2, SCL-90R

Severity of eating disorder symptoms and general psychopathology improved significantly. 45% of participants were considered clinically improved and 23% had no symptoms at end of self-treatment program

Fichter et al. [27]

RCT

N = 258

Mean age 23.8 (> 16 years old, SD: 6.5)

Sex = female

Diagnosis = AN or subthreshold AN without the requirement of amenorrhea according to DSM-IV criteria

Recruited from 1 of 8 hospitals in Germany specialized for ED treatment

Germany

Ethnicity: NR

SES: middle/upper class

Internet-based relapse prevention for AN after inpatient treatment using CBT strategies (9 months) compared to no intervention

Online: all components were online (chapters, electronic messaging, online chat room, automatic electronic messages)

Electronic message board for peer support + monthly 1 h chat session with therapist + therapist available via email at any time within 24 h

BMI

Patients in relapse prevention gained significantly more weight (0.62 BMI points) than patients in TAU condition (0.03 BMI points) (small to medium effect sizes for BMI change in each group from T1 to T2)

EDI-2 total score showed greater decrease in TAU group over time from T1 to T2

Fichter et al. [28]

RCT

N = 210

Mean age 23.95, > 16 years old

Sex = female

Diagnosis = AN or subthreshold AN without the requirement of amenorrhea according to DSM-IV criteria

Germany

Ethnicity: NR

SES: middle/upper class

Internet-based relapse prevention for AN after inpatient treatment using CBT strategies (9 months) compared to no intervention

Online: all components were online (chapters, electronic messaging, online chat room, automatic electronic messages)

Electronic message board for peer support + monthly 1 h chat session with therapist + therapist available via email at any time within 24 h

BMI

There was an overall increase in BMI after the intervention, with a greater increase in the “full completers” group compared to the “partial completers” and the control group. There was also a significant interaction of group by time

Giel et al. [29]

Uncontrolled trial

N = 16

Mean age 21.7 (SD 4.3)

No details on gender

Diagnosis = full or atypical AN according to ICD-10

Recruited from clinic after inpatient care when transitioning to outpatient care

Germany

NR

Relapse prevention program based on Maudsley Model of Anorexia Nervosa Treatment delivered by videoconference (10 sessions over 4 months)

Hybrid: 2 sessions face to face, 8 other sessions via videoconferencing

No additional support outside of primary treatment

Feasibility/acceptability; BMI, EDE-Q

Large effect size for BMI increase after treatment (r = 0.50), small to medium effect sizes for reduction of ED symptoms and scores (r range = 0.06 to 0.57)

Kim et al. [30]

Uncontrolled trial

N = 22

Sex = not specified

Mean age = 25.27 (SD 8.53)

Diagnosis = AN confirmed using SCID-5 according to DSM-5 criteria

Recruited = from outpatient clinic of Seoul Paik Hospital

South Korea

NR

TAU in-person (either MANTRA, specialist supportive clinical management, or FBT) augmented by videos about ED recovery tips + daily text messages + 1 weekly face-to-face guidance meeting

Hybrid: vodcast + text-message support + face-to-face therapy

Daily text message from researcher + weekly face-to-face guidance with researcher

Feasibility/acceptability; EDE-Q

Significant reduction in global EDE-Q score (Δη2 = 0.59) and all subscales. No significant change in BMI

Lock et al. [31]

Multicenter RCT

N = 40

Sex = 34 female (85%)

Mean age = 14.88 (range 12–18 years, SD 1.81)

Diagnosis = DSM-5 criteria for AN

Recruited = through clinics, hospitals, and online advertisements

Canada, USA

Ethnicity:85% white, 5% Asian, 20% other

SES: majority high income

Comparison of online guided self-help family-based treatment for parents of children with AN and family-based treatment delivered via videoconferencing

Online: self-help modules were completely internet-based. Family-based treatment was delivered fully via videoconferencing

Manualized guidance provided by a “coach” therapist (avg 3.90 h over 4–6 months). For videoconferencing group: no additional support outside of online therapy sessions

%EBW, EDE

In the videoconference arm, participants gained an average of 8.63 percentage points of EBW (Cohen's d = 1.46) and in the guided self-help arm, participants gained an average of 9.97 percentage points (Cohen's d = 1.51)

The EDE Global score decreased on average from 2.94 to 1.55 (Cohen's d = 1.04), with roughly equivalent reductions noted across both treatment arms (videoconference: 2.89 to 1.56; Cohen's d = 1.03; guided self-help: 2.99 to 1.54; Cohen's d = 1.01)

Marco et al. [32]

RCT

N = 34

Mean age = 21.82 (range of 15–40, SD 5.75)

Sex = females

Diagnosis = BN, EDNOS, or AN, according to DSM-IV-TR

Recruited from outpatient program for EDs

Spain

NR

CBT for EDs (15 sessions) augmented by CBT for body image in EDs using virtual reality (8 psychotherapy sessions with VR techniques)

Hybrid: all components were technically in person, although the VR is a technology that could be done online now

No additional support outside of primary treatment

Body image (BAT, BIATQ, BASS, SIBID, BITE, EAT)

All participants significantly improved body image (η2 = 0.35, corresponding to a large effect size). Effect maintained during 1-year follow-up

Those with VR showed more improvement than those without VR

Neumayr et al. [33]

Pilot RCT

N = 40

Sex = female

Mean intervention group = 20.75 (range 15–36 years, SD 6.4), mean control group = 18.00 (range 15–30 years, SD 3.73)

Diagnosis = primary AN diagnosis, according to ICD-10 criteria

Recruited from inpatient treatment centers for EDs

Germany

NR

Therapist-guided smartphone-based aftercare (Recovery Record) + TAU vs. TAU alone

Hybrid: therapist-guided use of smartphone app w/in-app therapist feedback + face-to-face therapy (TAU)

Once or twice weekly in-app feedback from therapist

EDE-Q

No significant difference in BMI or EDE-Q (intervention vs. control group) from baseline to postintervention and from baseline to follow-up

From baseline to postintervention: nonsignificant between-group differences of moderate effect size on EDE-Q global score (mean difference, intervention group = -0.06; control group = 0.41, d = 0.56)

Sanchez-Ortiz et al. [34]

RCT

N = 76

Sex = 75 females, 1 male

Mean age = 23.9 (SD 5.9)

Diagnosis = DSM-IV criteria for BN or EDNOS

Recruited = from higher education institutions through university email addresses, posters, and pamphlets

United Kingdom

Ethnicity: 60% British, 40% other

SES: NR

Internet-based CBT with email support vs. waiting-list control

Online: internet CBT + email support

Email support from therapists ever 1–2 weeks

EDE

Differences between the internet CBT and the waitlist/delayed treatment groups increased significantly from baseline to 3 months on two of the three primary outcome variables (i.e., the EDE Global score and binge eating)

EDE Global score improved in internet CBT group (d = 1.28) from baseline to end of treatment and to a lesser extent in the waitlist/delayed treatment group (d = 0.52)

Shingleton et al. [35]

Replicated single-case alternating treatment design

N = 12

Sex 10 females (83%)

Mean age = 21.5 (SD 2.35)

Diagnosis = DSM-5 diagnostic criteria for AN, subclinical AN, or BN with high dietary restraint/restriction

Recruited via community and clinician referrals

USA

NR

Face-to-face therapy (motivational interview + CBT) augmented by motivational text-messages + smartphone self-monitoring. Each participant underwent a semi-randomized sequence of text message and no text message phases. The phases were 1 week in duration and summed to 4 weeks of receiving text messages and 4 weeks of not receiving text messages

Hybrid: in-person therapy + text messages + smartphone app

Participants received individualized motivational text message at each mealtime

RMQ; EDE-Q

No significant main effects of the text messages on self-reported kilocalorie intake or dietary restraint (operationalized as percentage of EDE-Q questions answered “yes”) when covarying for baseline BMI

Significant main effect of the text messages to increase precontemplation scores (Wald chi-square = 17.64) and to increase dietary restraint action scores (Wald chi-square = 14.85)

Wagner et al. [36]

RCT

N = 126

Sex = female

Mean age for adolescents = 19.31 (range 16–21, SD 1.77) and for adults mean = 26 (range 22–34, SD 3.34)

Diagnosis = DSM-IV criteria for BN purging type, EDNOS with binge-eating or purging behavior

Recruited via ads

Austria

NR

Internet-based guided self-help program based on CBT strategies (4–7 months) compared to bibliotherapy

Online: programme via internet platform + weekly email support

Weekly emails from therapists guiding program use

EDI-2

No difference in outcome between conditions. Both groups had significant improvement over time with intervention for monthly binge eating, vomiting, and fasting in both groups

Wagner et al. [36]

RCT

N = 126

Sex = females

Mean age = 24.55

Diagnosis = DSM-IV criteria for BN purging type, EDNOS with binge-eating or purging behavior

Recruited via ads

Austria

NR

Internet-based (email) guided self-help vs. guided bibliotherapy

Online: internet-based self-help + weekly email support

Weekly emails from therapist guiding program use

EDI-2

No differences in abstinence and remission rates between the two groups

For all EDI-2 scale scores, the scores decreased over time but there were no differences between the two interventions and no interaction

Wagner et al. [37]

RCT

N = 126

Sex = females

Mean age = 24.55

Diagnosis = DSM-IV criteria for BN purging type, EDNOS with binge-eating or purging behavior

Recruited = via ads

Austria

NR

Internet-based (email) guided self-help vs. guided bibliotherapy

Online: internet-based self-help + weekly email support

Weekly emails from therapist guiding program use

BDI; GenPsy SIAB-EX; TCI-R; EDI-2; BNSOCQ

At the end of treatment, higher motivation to change, higher harm-avoidance, lower baseline frequency of binge eating and lower body dissatisfaction EDI-2 scores predicted good outcomes

At follow-up, less baseline frequency of binge eating and higher EDI-drive-for-thinness scores were associated with good outcome at follow-up

Higher BDI total scores and lower self-directedness scores at baseline predicted drop-out from therapy

Wilksch et al. [38]

Pragmatic RCT

N = 316 (220 met criteria for ED at baseline);

Sex = female

Mean age = 20.80 (range = 18–25 years, SD 2.26)

Diagnosis = AN, BN, BED, or OSFED assessed using EDE-Q

Recruited via self-referral by advertisements

Australia and New Zealand

NR

Media Smart-Targeted (MS-T), an internet self-help program vs. receiving tips for positive body image

Online: internet-based self-help program without support

No support provided via app

EDE-Q

MS-T participants were 75% less likely than controls to meet ED criteria at 12-month follow-up

This was statistically significant amongst both nontreatment seekers and treatment seekers who were 71% and 86% less likely than controls to meet diagnosis at 12-month follow-up, respectively

Observational and mixed-methods studies

        

Barney et al. [18]

Observational

Set at Adolescent and Young Adult Medicine clinic

Age range = 12–26 years

Sex = mostly females

1715 unique patients during this time

Diagnosis = any adolescent/young adult health concern, including all EDs

Info also included providers, clinical support staff, clerical support staff and other health professionals

USA

NR

Within 1 week of pandemic, all providers used Zoom for telemedicine. By week 2, daily telemedicine sessions began for urgent care, mental health, ED, and addiction treatments

Online: telemedicine clinics, daily 2 h in-person sessions for special cases only

All providers (e.g., nurses, fellows, physicians) continued their assessments and sessions online

Measured

healthcare service usage and qualitative user/provider experience

throughout pandemic

Telemedicine visits increased from 0 to 97% in one month, number of visits comparable to year prior. Providers identified several barriers and solutions to providing different types of care: using earphones for privacy, full training on Zoom, patients submitting results to their patient portal, training families to collect weight at home, having weight taken by nurses, etc. These were identified to help with barriers such as patients not having appropriate devices, technology literacy gap with families, lack of connection etc

Carretier et al. [39]

Case study and description of implementation of telemedicine during COVID-19 pandemic

N = 1 (case study)

16-year-old female teenager with restrictive AN

Recruited from the Maison des Adolescents where being treated pre-COVID-19

France

NR

Virtual day hospital care, including individual group, and family therapy was provided by videoconference by a multidisciplinary adolescent medicine clinic

Online: all sessions moved online. for critical cases, some in-person appts possible

No additional support outside of multidisciplinary videoconference therapy

Qualitative case description and discussion

The center was able to move online quickly and efficiently. Benefits of telemedicine are discussed: teleconsultations allow to identify potential risk factors (ex. see how Anna deteriorated during the confinement), telemedicine reduces isolation of patients and allows for clinical support at home, the technology involved is mastered by adolescents and they feel comfortable using it, telemedicine can facilitate the discussion of difficult questions and help work on relationships (ex. helped Anna's family create a dialogue on ED)

Criquillion et al. [40]

Proposal for a non-randomized clinical trial

Goal is N = 50 patients

Sex not specified

Age range = between 12 and 35 years old

Recruited from a clinic for EDs, patients (42 patients currently involved in the testing of the app)

France

n/a

A psychoeducational smartphone application including real-time follow-up for use in clinical settings is proposed

Hybrid: partially virtual; followed at the medical clinic regularly, the app on the side for continuity

No support via app, although the patients are followed for the rest of their treatment by doctors at the clinic

Evolution of baseline characteristics

n/a

Datta et al. [15]

Observational

Description of patients seen at the clinic: N = 1582

82% female, 17% male, 1% non-binary

Mean age = 16.5 (age range up to 25 years, SD 1.72)

Diagnosis = mostly AN but included all EDs, as diagnosed by physicians in the specialized ED clinic

Recruited from a comprehensive care unit for EDs

USA

NR

Several parts of treatment were delivered via videoconference: 1) psychotherapy and medication management 2) therapeutic groups based on CBT, cognitive remediation therapy (CRT), process group (PG) and parent/patient tele-groups 3) new admission evaluations

Online: mostly videoconferencing for therapy session and group work. When necessary, some in-person

All online aspects of treatments were provided by clinicians: psychologists, psychiatrist, and dietitians. No support outside of regular treatment

Qualitative descriptions of the changes made at the treatment center

All aspects of new admissions, psychotherapy, medication management, and therapeutic groups were moved online where they used videoconferencing. benefits/takeaways are these: 1) useful for parents to take part in initial evaluations remotely 2) remote work generates exposures for social anxiety triggers and complaints 3) videoconferencing useful for bed restriction patients 4) setting group rules is possible and helps when conducting remote group sessions

Davis et al. [16]

Observational

No sample population

Description of Singapore hospital multidisciplinary ED service for patients 9 to 16 (mean 13.9, SD 1.5)

Singapore

NR

For inpatient: individual meal supervision by nurses. For outpatient: telehealth instituted for physicians and psychologists to manage selected cases and for ongoing engagement with families by psychologists

Hybrid: mix of in person and telehealth

No additional support described outside of videoconference therapy

n/a

The paper describes several considerations for use of telemedicine: for patient/family: willing to use telemedicine, weight stable or good consistent progress, parent willing to weigh patient, no safety concerns, no concerns of medical stability. for health care provider: develop patient eligibility criteria for telemedicine, undergo training in telemedicine

Kasson et al. [41]

Mixed method

(a) N = 14

Sex = 100% female

Age range = 14- 17 years

Diagnosis = clinical or subclinical ED according to DSM-5 criteria, based on self-report questionnaire (excluding clinical AN)

Recruited via Instagram & Facebook

(b) N = 30

Sex = 13% gender minority, 74% female, 13% male

Age range = 14 – 17 years

Diagnosis = same as above

Recruited via Instagram, Facebook, Snapchat, YouTube, & TikTok

USA

(a) 92% White; 8% Other

Hispanic 14%; Non-Hispanic 86%

71% sexual minority

(b) 74% White; 26% Other

13% Hispanic; 87% Non-Hispanic

57% sexual minority; 63% LGBTQ + group

Mobile phone and desktop application, Space from Body and Eating Concerns Program, based on CBT for EDs

n/a

n/a

Stanford-Washington Eating Disorder Screen

Using social media for recruitment of teens with EDs is feasible and may help in capturing more diverse samples

The youth who participated in the survey were highly interested in a mobile app to help with ED recovery

Rajankar et al. [42]

Intervention description

India

n/a

Proposal for a new smartphone application combining awareness of etiology/informational section, health tracker, calorie tracker, virtual intervention (CBT, DBT, Self-help, support groups), and alert function notifying nearby NGOs/helplines

Smartphone app

n/a

n/a

n/a

Shaw [43]

Observational

N = 3

Sex = female

Age range = 12–17 years old

Diagnosis = AN, as diagnosed by treating physicians in a specialized ED clinic

Recruited from an eating disorder treatment service

United Kingdom

NR

7-week video-conference art therapy sessions held on Microsoft Teams platform

Online: videoconference

No additional support outside of videoconference therapy

Qualitative description of experience

Challenges when working with this client group online include increased body image concerns changed experience of gaze

Stewart et al. [44]

Mixed methods

N = 53

Age range =  < 18 years old

Diagnosis = AN, AAN, BN, ARFID, or other specified feeding and eating disorder, as diagnosed by treating physicians in the specialized ED clinic

Recruitment = all clinicians, young people, and parents working or receiving treatment at an outpatient community ED program for youth during data collection were eligible

United Kingdom

NR

Experience in response to COVID-19 pandemic changes: all but essential face-to-face contact was ceased, all outpatient treatment was delivered by video/phone calls

Online only (besides essential services)

No additional support outside primary treatment from family therapists, psychiatrists, nurse therapists, clinical psychologists

Questions about clinician, young people, and parent experience of providing/receiving online treatment

Young people (YP) and parents had overall positive experience with online therapy, low level of impact of technology on treatment experience; Qualitative Themes: Gratitude/something lost/something gained; home as a therapeutic space; changes in therapeutic relationship; implications for the future; trade-off between increasing and limiting access by moving online

Raykos et al. [45]

Uncontrolled trial

N = 25

Sex = 93% female

Mean age = 24.4 (SD 7.6)

Diagnosis = any ED, according to DSM-5 criteria, using EDE & SCID-5

Recruited from patients being followed in an outpatient ED clinic

Australia

70% Anglo/European-Australian

Rapid transition from face to face to telehealth care in an outpatient clinic for EDs, in the context of COVID-19. FBT or CBT was delivered via telehealth, based on age and diagnosis

Online: telehealth

No additional support provided outside regular treatment

EDE-Q, ED-15, CIA, BMI,

Throughout the study period, patients experienced a large decrease in ED symptoms, comparable to historic benchmarks at the clinic (from pre- to during COVID-19, EDE-Q d = 1.62)

Patients rated the quality of treatment and therapeutic alliance highly

Tregarthen et al. [46]

Observational

N = 108,996

Sex = 57,940 provided gender (87.2% female)

Mean age = 22 (reported by 48,830, range = 13–77 years)

Diagnosis = symptom severity assessed by EDE-Q, 87.2% were ≥ 1 SDs above community norms

Recruitment = app was made available for download in app stores

NR

CBT-based self-monitoring smartphone application

Online: smartphone app

No support provided via app

Acceptability; EDE-Q, BMI at baseline

Acceptability: 2,503 anonymous ratings: 84% were 5/5, 13.3% were 4/5, 1.7% were 3/5, and 1% were 2/5

BMI (calculated for 13,784 users): 10.6% met the BMI suggested weight criterion (< 17.5) for a diagnosis of anorexia nervosa

Any occurrence of objective binge episodes 78.8%, subjective binge episodes 76.79%. self-induced vomiting 41.9%, fasting 63.3%, excessive exercise 59.7%, laxative misuse 20.6%

Yaffa et al. [47]

Case series

N = 4

Sex = female

Age range = 13–17 years

Diagnosis = any ED

Recruitment = patients were receiving services at a specialized pediatric ED treatment center in a children’s hospital

Israel

NR

Management of pts in the context of COVID-19 pandemic and lockdown

Online: treatment via videoconferencing; in-person visits occurred only in specific conditions

No additional support outside videoconference treatment provided by psychiatrist, clinical nutritionists, psychotherapists

-

The condition of the four adolescents with AN was compromised at the start of the COVID-19 quarantine. The use of multi-disciplinary long- distance telemedicine treatment resulted in an improvement in the condition in three of the four adolescents, living in well-organized families, with the motivation and ability to adjust to the new conditions, but not in one adolescent whose family experienced more problems

Qualitative studies

        

Anastasiadou et al. [48]

Qualitative study

1) N = 8, health care providers and mobile health experts, mean age 34 (SD 7.21), psychiatry, psychology and nursing, males and females

2) N = 9 participants of RCT

Mean age = 15 (SD 0.50)

Sex = all females

Diagnosis = any ED, according to DSM-5 criteria

Recruited from RCT participants [24]

Spain

NR

Standard CBT + TCApp, a mobile health intervention including monitoring and chat with therapists (12 weeks)

Hybrid: included both in-person CBT and the online mobile app in between appointments

Online chat support by therapist

Questionnaire assessing services based on effectiveness, user experiences, economic aspects, organizational aspects, sociocultural aspects

Key themes identified by specialists: lack of time, lack of strategic plan, lack of budget, insufficient training, lack of tech support, lack of familiarity and mobile health skills, lack of agreement, insufficient interaction, security/privacy issues. Perceived advantages by patients: ease of use, useful, liked the app design, content appropriate. Perceived disadvantages: problems with design, lack of satisfaction with personalization, some say limited interaction

Brothwood et al. [49]

Qualitative study

14 patients and 19 parents

Age range = 12 -18 years

Mostly females, one male

Diagnosis = AN-R, according to DSM-5 criteria

Recruited via day program at Maudsley center for child and adolescent ED in London

United Kingdom

NR

During the COVID-19 pandemic, day treatment program based on principles of family therapy was delivered online. Online activities included therapy, groups, meal support, and education support. All kinds of therapy, exercises, worksheets, and coaching for meal support, were provided online

Online: treatment online. Urgent appts offered in person if increased physical or psychiatric risks

Mix of clinician support for groups, therapy, and meals. Some exercises were self-help online

User experience questionnaires

Overall experience was positive (slightly more so for parents), quality partly impacted, parents felt more comfortable, young people reported issues with technology. But majority thought could not have done anything differently. Each component rated by majority as somewhat or very helpful. Compared to face to face, varied response but found less helpful (specifically meal support, family sessions and individual sessions). Young people rated that they want those to be in-person in future but would keep medication reviews or dietetic appts virtually. Qualitative data themes: 1) new discoveries 2) lost in translation 3) best of bad situation

Lindgreen et al. [50]

Qualitative study

N = 41

Mean age = 24.0 (age range = 15–41 years, SD 5.9)

Sex: 3 male, 38 female

Diagnoses = anorexia nervosa and bulimia, as diagnosed by clinicians at the specialized ED treatment facility

Recruited = from a specialized ED treatment facility

Denmark

NR

Treatment as usual (for AN: family-based treatment or weekly group/individual sessions; for BN: 10 weekly manualized group sessions followed by an additional group or individual treatment) augmented using Recovery Record (RR) self-monitoring app for eating disorders

Hybrid: in-person sessions augmented by guided self-monitoring smartphone app use

Therapists provided guidance on app usage during in-person therapy sessions

User experience with Recovery Record app

Patient experience with the app depended on its app features, the impact of these features on patients, and their specific app usage. This patient-app interaction affected and was affected by changeable contexts making patients' experiences dynamic

Naccache et al. [51]

Qualitative study

N = 8

Mean age = 15.5 (age range = 12–18, SD 1.07),

Sex = all females

Diagnosis = AN, according to DSM-5 criteria

All enrolled in treatment at Toulouse Teaching Hospital

France

NR

Unguided self-help program app: based on psychoeducation, CBT, and motivational interview strategies. Additional emotional management feature and gamification elements

Online: testing only user experience of the smartphone app

No additional support in relation to the app

UEQ and semi-structured interviews

Patient experience of the app was demonstrated with key themes, including finding coping strategies, information, motivational content helpful. Overall, the app was rated positively, although opinions were mixed regarding novelty, dependability and efficiency. Qualitative data showed that patients and clinicians think the psychoeducation portion is important

Sanchez-Ortiz et al. [52]

Qualitative study (recruited as part of an RCT)

Interview: N = 9

Sex = female

Mean age = 23.2 (SD 3.5)

Diagnoses of BN or EDNOS-BN

Questionnaire: N = 31

All participants were drawn from those participating in RCT on internet CBT and were students recruited from university networks [34]

United Kingdom

NR

Internet-based CBT program called "Overcoming bulimia online" comprised of immediate iCBT with email support from therapist (4 to 8 sessions)

Online: intervention provided completely online via platform + email

Therapist support via weekly emails

Semi-structured and questionnaires on iCBT treatment experience

Experiences of treatment were summarised in five categories: confidentiality/privacy, flexibility, ease of use, feeling supported, and content of programme. As for impact of treatment, overall positive impression, categorized into: (1) expectations about outcome, (2) effectiveness – reported change in ED symptoms, (3) effectiveness—other changes, and (4) tools for coping in future. As for all RCT participants impressions: struggled to find motivation to continue treatment, knowledge and confidence grew, most useful aspects = weekly emails, problems with access to treatment/technical difficulties, most common suggestion = more support and some face to face*

Shaw et al. [53]

Qualitative

N = 43 participants; 19 parents/carers, 12 members of staff, 12 patients, all < 18 years of age

Diagnosis = typical or non-typical AN, BN, or BED

recruited from a hospital ED service

United Kingdom

NR

Describes experience of adaptations made in response to COVID-19 pandemic

Hybrid: in-person physical examinations with all other appointments online

No additional support outside of primary treatment

Healthcare service usage (hospitalizations, referrals, admissions); user satisfaction, narrative analysis

More referrals accepted in 2020 than 2019, higher % increase for urgent vs. routine consultations (150% vs 129%, respectively); Qualitative results: Using virtual platforms improved ease of access but altered relational experiences

Case studies

        

Hellner et al. [54]

Case series

N = 2

Female

Age = 20 and 15, respectively

Diagnosis = AN or atypical AN

Recruited by Equip providers through postings

USA

NR

Videoconference delivered multidisciplinary treatment based on FBT, CBT, and DBT. Patient met with each provider weekly or more

Online: all done through telehealth and unlimited messages on the telehealth platform

Team support (family therapist, dietitian, peer mentor and family mentor) via chat

Weight gain, EDE-Q short form

Both patients gained at least one pound per week. Scores for EDE-Q decreased by 7–12 point

Duncan et al. [ 55]

Case study

N = 1

Sex = female

Age = 14 years

Diagnosis = EDNOS

Recruited from rural tele-psychological clinic in her community

USA

NR

Videoconference delivered therapy, based on cognitive behavioral strategies

Online: all sessions done over videoconferencing platform. 1 appointment was done in person

No additional support outside of primary treatment

n/a

At the end of the 12 sessions of therapy, Mila increased food intake, fell within normal range on growth chart, and scores on CDI no longer elevated

Study protocols*

        

Anderson et al. [56]

Case series

N = 10 (target)

Age range = 13–18 years

Sex = no specification

Diagnosis = DSM-5 criteria for AN or atypical AN

Recruited = by referrals and through community

USA

NR

Videoconference delivered Family-Based Treatment consisting of weekly family meetings with therapist (20 sessions over 6 months)

Online: intervention delivered completely via telehealth platform

No additional support outside of primary treatment

Feasibility/Acceptability of FBT via Telemedicine

Protocol only

Barakat et al. [57]

Multi-site three-arm RCT

N = 110 (target)

Gender will be reported

Age range ≥ 16 years

Diagnosis = DSM-5 criteria for BN or OSFED with bulimic behaviors

Recruited = from general population via advertisement and referrals from health professional

Australia

Income, and cultural background/ethnicity will be reported

Online CBT-based self-help program completed independently vs. completed with therapist guidance (= weekly telemedicine sessions) vs. waitlist control

Online: either online self-help platform or secure videoconference platform

For self-help group with guidance only: weekly 30 min videoconference session with therapist

Frequency of objective binge episodes (EDE-Q)

Protocol only

Bulik et al. [58]

RCT

N = 180 (target)

Sex: no specification

Age range ≥ 18 years old

Diagnosis = criteria for DSM-IV BN

Recruited from within local health services and via ads

USA

NR

Group CBT delivered via the internet versus face-to-face

Online: online modules with text-based chat group (without audio/video)

Therapist-led chat groups or in-person therapist support in groups

EDE

Protocol only

de Zwaan et al. [59]

Multicenter RCT

N = 178 (target)

Age range ≥ 18 years old

Diagnosis = DSM-IV criteria for BED or subsyndromal BED

Recruited = via ads

Germany and Switzerland

NR

Internet-based guided self-help vs. individual in-person CBT

Hybrid: 2 in-person meetings with therapist + internet-based email-guided self help

Therapist support by email

Difference in number of days with OBEs over the past 28 days (assessed by EDE)

Protocol only

Hambleton et al. [60]

Uncontrolled trial

Goal is 41 families

Age range = 12–18 years

Gender will be reported

Diagnosis = criteria for AN according to DSM-5

Recruited from regional or rural health district via referral

Australia

SES will be reported

Family-based treatment delivered via videoconference (18 session over 9 months) via telemedicine

Online: via videoconferencing platform (or via telephone if technical difficulties)

No additional support outside of primary treatment

Remission (increase in %mBMI to ≥ 85%)

Protocol only

Jenkins et al. [61]

RCT

N = 51 (target)

Sex not specified

Age range ≥ 17.5 years

Diagnosis = regular binge eating in the context of an ED

Recruited = clinical referrals

United Kingdom

NR

Self-help delivered face-to-face versus via e-mail versus delayed treatment control condition

Hybrid: first guidance session provided in-person

Therapist support via email, up to twice weekly

Frequency of objective bulimic episodes assessed by EDE-Q

Protocol only

Kolar et al. [62]

RCT

N = 30 (target)

Sex = female

Age range = 12–19 years

Diagnosis = AN

Germany

NR

In-person consultations with smartphone app vs. in-person consultations alone

Hybrid: in-person therapy + smartphone app use

Therapist support in-person

Weight gain

Protocol only

Kolar et al. [63]

Multi-center RCT

N = 30 (target)

Sex = female

Age range = 12–19 years

Diagnosis = AN or atypical AN confirmed by EDE structured interview

Recruited = from waiting list from 3 child & adolescent psychiatry centers

Germany

NR

Face-to-face supportive psychiatric follow-up augmented by therapist-guided use of a DBT-informed smartphone application, (Jourvie) vs. TAU (supportive therapy by psychiatrist)

Hybrid: face-to-face therapy + guided smartphone app use

In-person therapy sessions will include guidance on use of the smartphone app

BMI-SDS, EDI-2

Protocol only

Rohrbach et al. [64]

RCT (two-by-two factorial design with repeated measures)

N = 352 (target)

Sex not specified

Age range ≥ 16 years

Diagnosis = at least mild self-reported ED symptoms on standardized questionnaire

Recruitment = community Dutch e-community ED website

Netherlands

NR

(1) Featback, a fully automated self-guided Internet-based monitoring and feedback intervention augmented by weekly chat/email support from an expert patient was compared to (2) Featback without expert patient support, (3) expert patient support only, and (4) waiting list

Online: unguided internet psychoeducation with or without chat/email support

Weekly expert patient support via chat and email (in 2/4 conditions), no additional support in 2/4 conditions

EDE-Q

Protocol only

Schlegl et al. [65]

RCT

N = 186 participants (target)

Sex = female

Age range = 12–60 years

Diagnosis = diagnosis of AN at hospital admission, according to DSM-5 criteria

Recruited = at an ED clinic

Germany

NR

Therapist-guided smartphone-based aftercare (Recovery Record) + TAU vs. TAU alone

Hybrid: therapist-guided use of smartphone app w/in-app therapist feedback + face-to-face therapy (TAU)

Psychotherapists provide individual feedback via-in app messages

EDE

Protocol only

ter Huurne et al. [66]

RCT

N = 252 (target)

Age range ≥ 18 year

Sex = female

Diagnosis = DSM-IV criteria for BN, BED, or EDNOS

Recruited = self-selection via targeted ads

The Netherlands

NR

CBT-based internet self-help compared to waiting list control group

Online: intervention and therapist support via online treatment platform

Therapist support by email twice weekly; Forum for peer support

EDE-Q

Protocol only

  1. NR not reported, n/a not applicable, ED eating disorder, AN anorexia nervosa, AAN atypical anorexia nervosa, AN-R anorexia nervosa restricting type, ARFID avoidant/restrictive food intake disorder, BN bulimia nervosa, BED binge-eating disorder, EDNOS eating disorder not otherwise specified OSFED other specified feeding or eating disorders, ICD-10 international classification of diseases 10th revision, DSM-IV diagnostic and statistical manual of mental disorders fourth edition, DSM-5 diagnostic and statistical manual of mental disorders fifth edition, SES socioeconomic status, CBT cognitive behavioral therapy, DBT dialectical behavior therapy, RCT randomized controlled trial, TAU treatment as usual, SCID-5: SEED Short evaluation of eating disorders, %mBMI Percent median BMI, EDE-Q eating disorder examination-questionnaire, EDE eating disorder examination, EDI-2 eating disorder inventory-2, SCL-90R symptom checklist-90-revised instrument, BMI body mass index, %EBW percent expected mean body weight, BAT body attitude test, BIATQ body image automatic thoughts questionnaire, BASS body areas satisfaction scale, SIBID situational inventory of body image dysphoria, BITE bulimic investigatory test, EAT eating attitudes test, BDI Beck depression inventory, GenPsy of SIAB-EX general psychopathology of the structured interview for anorexic and bulimic disorders, TCI-R temperament and character inventory revised, BNSOCQ bulimia nervosa stages of change questionnaire, UEQ user experience questionnaire, BMI body mass index, USA United States of America
  2. *Note that we included these study protocols on the basis that they had the potential of having a sample mean age that fit our inclusion criteria considering their target population