psychology paper

Mobile Therapy: Use of Text-Messaging in the Treatment of Bulimia Nervosa Jennifer R. Shapiro, PhD 1* Stephanie Bauer, PhD 2 Ellen Andrews, BA 1 Emily Pisetsky, BA 1 Brendan Bulik-Sullivan 1 Robert M. Hamer, PhD 1,3 Cynthia M. Bulik, PhD 1,4 ABSTRACT Objective: To examine a text-messaging program for self-monitoring symptoms of bulimia nervosa (BN) within the context of cognitive-behavioral therapy (CBT). Method: Thirty-one women partici- pated in 12 weekly group CBT sessions and a 12 week follow-up. Participants submitted a text message nightly indicat- ing the number of binge eating and purging episodes and rating their urges to binge and purge. Automatic feedback messages were tailored to their self- reported symptoms. Results: Fully 87% of participants adhered to self-monitoring and reported good acceptability. The number of binge eating and purging episodes as well assymptoms of depression (BDI), eating disorder (EDI), and night eating (NES) decreased signiﬁcantly from baseline to both post-treatment and follow-up. Discussion: Given the frequent use of mobile phones and text-messaging glob- ally, this proof-of-principle study sug- gests their use may enhance self-moni- toring and treatment for BN leading to improved attendance, adherence, engagement in treatment, and remis- sion from the disorder. VVC2009 by Wiley Periodicals, Inc. Keywords: bulimia nervosa; treatment; technology; text messaging (Int J Eat Disord 2010; 43:513–519) Introduction Bulimia nervosa (BN) is characterized by recurrent binge-eating followed by inappropriate compensa- tory behaviors such as self-induced vomiting or misuse of laxatives. Individuals with BN place undue emphasis on weight and shape. BN com- monly occurs in women of normal body weight, has a typical onset in adolescence or early adult- hood, and afﬂicts 1–3% of young adult women. 1 CBT is a multimodal intervention that includes techniques such as psychoeducation, recognizing, and modifying responses to antecedent cues, chal- lenging automatic thoughts, thought restructuring,problem solving, exposure with response preven- tion, and relapse prevention. 2Self-monitoring of food intake, binges, and purges is a central element of therapy. Treatment is most commonly adminis- tered in individual or group therapy over 16–20 ses- sions, although substantial clinical change can occur in as few as eight sessions.

3,4 Group therapy represents a more parsimonious use of therapist time, is an effective treatment, and ultimately is more cost-effective, 5although the time course to recovery may be somewhat slower and abstinence rates lower. 6 Although CBT is effective for 40–67% of patients, 7–10 efforts are required to augment and improve treatment to better serve individuals who drop out (0–33%), 11,12 fail to engage (14%), 12 or relapse (33%). 8The highest risk period for relapse is in the 6 months after treatment, 13 with risk declining at 4-year follow-up. 8After 10 years, 11% of individuals originally diagnosed with BN contin- ued to meet full diagnostic criteria for BN and 18.5% met criteria for eating disorder not otherwise speciﬁed. 7,8 Due to these substantial concerns, a recent systematic review of the treatment of eating disorders has highlighted the importance of explor- ing adaptations of technology to further enhance CBT or ﬂuoxetine treatment. 14 Various means of information technology (e.g., web-based treatment, text messaging, personal Accepted 28 June 2009 1Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 2Center for Psychotherapy Research, University of Heidelberg, Heidelberg, Germany 3Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 4Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina*Correspondence to:J.R. Shapiro, University of North Carolina at Chapel Hill, Department of Psychiatry, CB 7160, Chapel Hill, North Carolina 27599. E-mail: [email protected] by Mental Health Initiative (A Foundation for Mental Health and an Alexander von Humboldt Stiftung German-Ameri- can Trans-Coop grant).

Published online 28 August 2009 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.20744 VVC2009 Wiley Periodicals, Inc. International Journal of Eating Disorders 43:6 513–519 2010 513 REGULAR ARTICLE digital assistants [PDAs]) are currently being used for self-monitoring and treatment delivery. This may increase the frequency of patient-provider contact, reach individuals who may not have access to specialty care, and result in better treatment acceptability in today’s technological society thus leading to increased treatment engagement and decreased attrition. Although self-monitoring is one of the hallmark features of CBT for BN, patients often do not adhere to self- monitoring. 15,16 Grounded in behavioral theory of practice and reinforcement, text messaging may enhance self- monitoring given that behaviors change most when goals are set, and when cueing, support, and posi- tive reinforcement are provided. 17 In contrast to traditional paper diaries, text messaging can be used discretely and quickly and provides time/day stamps so behaviors are recorded immediately and accurately and can be set up to provide individuals with immediate support and feedback to their monitoring behavior. This approach to self-moni- toring is in marked contrast to the potential shame, stigmatization, and drudgery associated with carry- ing around paper self-monitoring diaries, the fre- quent practice of back-ﬁll, and having to wait until your next appointment (if at all) to get feedback on your behaviors. Text messaging has been shown to be acceptable for providing support, effecting behavior change, and/or maintaining treatment gains in diabetes, 18,19 asthma, 20 smoking cessa- tion, 21,22 and monitoring targeted behaviors associ- ated with obesity in children. 23 Bauer and col- leagues developed a text-messaging program to support individuals on a weekly basis after they completed CBT for BN. Results showed that patients found the intervention to be highly con- venient, ﬂexible, and well tolerated. The vast ma- jority rated the program as good or very good, noted that they would recommend the program to others and indicated that they would participate again if they needed additional assistance.

Although most were satisﬁed with weekly check- ins, 39% felt that more frequent interaction would have been valuable. 24,25 In contrast, Robinson et al. 26 found a low use of text messaging for after- care in BN and high attrition and suggested that text messaging required further adaptation to make it a more useful tool. The current proof-of-principle study was designed to expand on these previous investigations to examine the feasibility and acceptability of using a text-messaging program for daily self-monitoring of BN symptoms during CBT. Method Participants Women over the age of 18 with BN were recruited through physician referral, referral from the University of North Carolina Eating Disorders Program, and adver- tisements in the community. Exclusion criteria include diagnosis of anorexia nervosa, developmental learning disorders that could interfere with comprehension of the intervention, current severe depression [score 29 on the Beck Depression Inventory; BDI; 27] or active sui- cidal intent, and inability to speak English ﬂuently.

Individuals taking psychoactive medication were included if their BN symptoms remained stable (i.e., were neither improving not deteriorating) while on medication. A total of 54 women called and left a mes- sage of interest about the study. Of these 54, 11 never responded to a follow-up phone call and 43 underwent the telephone screening. Of these 43, 12 did not advance to a personal meeting due to not living in North Carolina during the treatment (n54), time of group was inconvenient (n54), did not show to inter- view (n52), did not meet diagnostic criteria for BN on the phone (n52). Thus, a total of 31 women pre- sented for the personal interview and completed base- line data. Of these, 29 (93.6%) were Caucasian, 1 (3.2%) was African American, and 1 (3.2%) was Asian. The mean age of participants was 26.368.6 years (range:

17–49 years; note: one person was almost 18 and per- mitted through IRB and parental consent to partici- pate). Nineteen (61.3%) have been previously treated for BN. Procedure Participants ﬁrst underwent a telephone screening (n 543). Those who met preliminary criteria were invited to a personal interview, which included an initial brief semistructured assessment to rule out any exclusion criteria, establish BN diagnosis, and to provide consent to participate. Assessments occurred at baseline, week 12 (post-treatment), and week 24 (follow-up). The study was approved by the Biomedical Institutional Review Board at the University of North Carolina at Chapel Hill.

Measures Height and Weight. Height and weight were assessed in a hospital gown and without shoes using a stadiometer and digital physician’s scale, respectively, calibrated regu- larly according to protocol. BMI (kg/m 2) was calculated. Structured Clinical Interview (SCID) for DSM-IV, Eating Disorders Modules. 28 The eating disorders portion of the SCID was administered to determine BN diagnosis and rule out other eating disorders diagnoses. SHAPIRO ET AL.

514 International Journal of Eating Disorders 43:6 513–519 2010 Eating Disorders Inventory-II (EDI). 29 This self-report instrument contains 91 items used to assess sever- ity of symptomatology on dimensions clinically rel- evant to eating disorders.

Binge-Purge Questionnaire. We created a measure to investigate number of binge eating and purging episodes based on recall. At post-treatment and follow-up, partici- pants responded to two questions ‘‘In the past week, how many binges (and purges) did you have?’’ These numbers were compared with the numbers of weekly binge eating and purge episodes that the participant provided during the interview at baseline. Night Eating Questionnaire. 30 The NEQ is a brief, 14- item questionnaire which evaluates the behavioral and psychological symptoms of NES, including morning hunger, craving, and control of food intake after the evening meal and upon waking at night, evening hyperphagia, nocturnal inges- tions of food, and sleep and mood disturbance. 30 The measure has an acceptable alpha (0.70); convergent and discriminant validity have been established. 30 Beck Depression Inventory-II (BDI). 27 The BDI is one of the most widely used self-report measures of depression. The BDI-II contains 21 items and measures depression on four levels of severity. A score of 29 is deﬁned as severe depression.

Self-Monitoring. Consistent with standard CBT, all par- ticipants were instructed to record their daily food intake (type and amount of food); thoughts, feelings, and situa- tions associated with the eating episode; and binges/ purges each day via paper diaries. At the end of the day, participants were instructed to complete daily responses to the following three items: (1) How many binges did you have today? (2) How many times did you purge today (vomit, restrict, laxative use, excessive exercise)? (3) How strong was your peak urge to binge today (05no urge, 8 5extreme urge)? and (4) How strong was your peak urge to purge today (05no urge, 85extreme urge)? Given that some engage in binge/purge behavior without feel- ing an urge, whereas others feel an urge but do not engage in the behavior, we opted to measure both urges and actual behavior. Participants were encouraged to keep paper and pencil diaries since despite low adher- ence, they remain the ‘‘gold standard’’ of self-monitoring.

The text-messaging program was designed to record the four targeted symptoms described above (i.e., not used as an entire program to monitor meal plans, thoughts, feelings, and cues). Treatment Acceptability. At post-treatment participants completed treatment acceptability Likert scales to address the following questions: (1) How much did the intervention meet your expectations? (2) How likely would you be to recommend the intervention to a friend?(3) How likely would you be to participate in the inter- vention again if necessary? (4) How much did you enjoy the self-monitoring forms? (5) How much did you enjoy using the text-messaging program? A description of the scale was provided such that 05never or not at all or extremely negative and 105extremely positive.

Although this is not a previously validated measure, similar measures have been used in previous studies. 23 Text Messaging Each night participants submitted a text message to the program indicating their numbers of: (1) binge eating episodes, (2) purging episodes, (3) peak urge to engage in binge, and (4) peak urge to engage in a purge (Likert scale 0–8; 05no urge, 85extreme urge) and received an im- mediate feedback message. Hundreds of feedback mes- sages were developed to avoid duplicate messages and included speciﬁc feedback on data as well as suggestions of skills to use; algorithms were based on (1) how many goals were met (the goal was abstinence from binge eat- ing and purging) and (2) enhancement or deterioration from the previous day. An example feedback message consisted of:‘‘Good job with resisting your strong urge to purge today. Try harder not to give into the binge eating tomorrow. Call a friend instead.’’If at 9 am the following morning, there has been no input, participants received a text-message prompt to input their data. Participants began monitoring on treatment day 1 and continued monitoring their symptoms during the 12 week treat- ment phase and an additional 12 weeks for a total of 24 weeks. They then returned to the clinic for a follow-up evaluation. All participants used their own phones and were reimbursed for text-messaging charges during the course of the study.

Treatment Participants met in groups of 5–8 participants for 1.5 h for 12 consecutive weeks. All groups were facilitated by a clinical psychologist. Treatment provided skills and techniques typical of CBT treatment for BN as described earlier.

Statistical Analyses This study was designed to be a proof-of-principle study to explore the feasibility of using text messaging as a self-monitoring tool in the treatment of BN. The pri- mary outcome measure in this study was adherence to self-monitoring; secondary outcome measures included treatment acceptability, and change in symptoms of BN over time after participating in CBT. Primary analyses used descriptive statistics, change scores from baseline to post-treatment and baseline to follow-up, with signiﬁ- cance testing performed using single-groupt-tests on the change scores.pvalues should be interpreted with MOBILE PHONE TEXT MESSAGING FOR BULIMIA NERVOSA International Journal of Eating Disorders 43:6 513–519 2010 515 caution due to the exploratory nature of this study. Anal- yses were conducted with SAS, version 9.1.3. 31 Results Attrition Dropouts were deﬁned as those who stopped coming to treatment sessions and stopped moni- toring. The dropout date is whichever was later (date of last treatment visit or last monitoring date). Of the 31 who interviewed, all met inclusion criteria but only 25 actually showed upto the ﬁrst group session. A total of 15 completed the treat- ment and post-treatment questionnaires (48.4% of the total sample and 60% of those who began treat- ment). The average number of sessions attended was 7/12 (range: 0–12) for the full 31 sample and 8/ 12 (range: 1–12) for the 25 who began treatment.

Self-Monitoring Adherence Frequency of monitoring was calculated by counting the number of days self-monitoring was done divided by the number of days between the participant’s ﬁrst scheduled monitoring day and last scheduled monitoring day or drop out date.

Due to slight variations in the exact number of days that different waves of the study were expected to monitor, a more accurate comparison is percentage of total monitoring days rather than actual number of days monitored. Self-monitoring binge eating and purging behavior was calculated on 18 partici- pants who had monitoring behavior over at least a 2-week period, the ﬁrst week and a nonoverlapping last week, even if a participant dropped out before the post-treatment evaluation.

Participants demonstrated 87% adherence to self-monitoring. Furthermore, two of the partici- pants asked if they could continue to use the pro- gram even after the study ended as it helped them with their recovery.

Treatment Acceptability The treatment acceptability measure asked par- ticipants to rate various aspects about the program on a 0–10 Likert scale with 0 indicating the most negative response and 10 indicating an extremely positive response. The questions and the ratings are as follows (mean6SD): (1) How much did the intervention meet your expectations? (7.162.0), (2) How likely would you be to recommend this intervention to a friend? (7.961.6), (3) How likely would you be to participate in this interventionagain if necessary? (7.762.8), (4) How much did you enjoy the self-monitoring forms? (5.062.4), and (5) How much did you enjoy using the text- messaging program? (6.362.4). Thus, participants rated all aspects of the program including text mes- saging as above average other than self-monitoring forms which were rated as average. Preliminary Effectiveness Table 1presents baseline, post-treatment, and follow-up scores on the various measures as well as text-messaging data. Preliminary effectiveness was assessed in completers only. As can be seen in the table, participants signiﬁcantly improved in their self-reported binge and purge episodes obtained via paper measures. Notably, participants reported an average of six binge episodes in the past week at baseline and 2.5 at post-treatment (p\0.01); they reported an average of 14.5 purges in the past week at baseline and 4.3 at post-treatment (p\0.05). In addition, participants’ scores on all other outcome measures (BDI, EDI, NEQ) signiﬁcantly improved from baseline to post-treatment and follow-up.

We also calculated the number of binges, num- ber of purges, peak urge to binge, and peak urge to purge reported during the ﬁrst week of self-moni- toring and during the last week of self-monitoring.

To do this, we had to follow an algorithm. First, a participant had to have self-monitored for at least 2 weeks, or the ﬁrst and last week would overlap, which would make deﬁning change problematic.

We then counted number of binges, purges, urges to binge, urges to purge in the ﬁrst week and in the last week of self-monitoring. Thus, we were able to calculate self-monitoring statistics on only a subset of participants. text-messaging results showed that only the mean number of purges signiﬁcantly reduced from the ﬁrst week of monitoring to the last week of monitoring.

Discussion This study was the ﬁrst study to investigate whether a novel technology of text messaging could be used as a self-monitoring tool within the context of out- patient group CBT. Results showed that partici- pants generally accepted the text-messaging pro- gram and adhered to self-monitoring 87% of the time, which is higher than many published self- monitoring adherence rates. 32 These results are consistent with Stone et al. who found a 94% ad- herence to the PDA and only an 11% adherence to SHAPIRO ET AL.

516 International Journal of Eating Disorders 43:6 513–519 2010 paper diaries. 15 Because self-monitoring is associ- ated with increased adherence to goals, increasing the frequency of self-monitoring could be expected to lead to higher remission rates. In addition, par- ticipants improved on paper and pencil self- reported measures of binge eating and purging epi- sodes from baseline to post-treatment as well as improvements in depression, and both eating dis- order and night eating symptoms. Interestingly, when looking at the text-messaging data, only the number of purging episodes was signiﬁcantly reduced from baseline to post-treatment. Speciﬁ- cally, at both baseline and post-treatment, the number of binge episodes over the past week reported via the binge-purge questionnaire was similar to those reported via text messaging (i.e., results were similar across measurement method).

The number of purges over the past week reported at baseline was also consistent across measure- ment methods. However, at post-treatment, the number of purges reported via text messaging was greater (7 per week) than that reported via the binge-purge questionnaire (4 per week). Thus, it is unclear which data collection method is more accurate. If the daily time stamped text-messaging technique is more accurate than retrospective weekly recall, then it is plausible that participants are signiﬁcantly underreporting (either accidentally or purposefully) their symptoms when asked to report retrospectively. This inaccuracy is important for research and clinical purposes; errors may be made when individuals are asked to recall the number of binge/purge episodes on a weekly basis but also if they back-ﬁll their self-monitoring forms (i.e., complete weekly forms retrospectively before meeting with the provider).Although this study was designed as a proof-of- principle study, we nonetheless must discuss limi- tations. Appreciation of these limitations will assist with designing subsequent trials that incorporate text-messaging components for self-monitoring.

First, the initial sample size was small. Second, attrition was high but notably not much higher than the reported 33% drop out rate reported in previous studies. 11,12 A large portion of participants in most studies of BN fail to engage in treatment and/or drop out. Thus, it is important to enhance treatment in such ways that are likely to increase acceptance, usability, and completion. As society becomes more technologically savvy, researchers and clinicians must utilize such modes of commu- nication as they are increasingly being shown to increase treatment acceptability. This pilot study was the ﬁrst to show that participants accepted and adhered to a text messaging self-monitoring pro- gram within the context of outpatient CBT for BN.

Future studies should continue to enhance treat- ments to reduce attrition; however, we found that text messaging may be one vehicle to enhance self- monitoring for those individuals who remain in an intervention program. Third, this was a within group design and we did not compare results to a traditional paper diary group. Thus, we are unable to determine if text messaging would signiﬁcantly improve treatment acceptability, adherence, effec- tiveness, and completion relative to a control group. However, our results are promising in that 87% of participants adhered to self-monitoring, which is much higher than adherence rates to tra- ditional paper and pencil based self-monitoring. 15 Fourth, when comparing the number of binge eat- ing and purging episodes, the baseline data were TABLE 1. Scores on baseline and post-treatment outcome measures Baseline: Entire Sample Baseline: Completers Only Post-Treatment (Week 12) Follow-Up (Week 24) Height (inches) Mean6SD (n) 65.263.1 (31) N/A N/A N/A Weight (pounds) Mean6SD (n) 137.0630.0 (31) 131.2614.1 (13) 133.5614.1 (13) 133.9615.3 (13) BDI Mean6SD (n) 24.6611.0 (31) 23.1610.7 (15) 11.469.6 (15)**** 8.869.4 (14)*** EDI (total score) Mean6SD (n) 108.9641.4 (31) 102.9635.4 (15) 58.7634.5 (15)*** 52.6618.8 (14)** NEQ Mean6SD (n) 20.166.6 (31) 21.166.9 (15) 16.966.9 (15)** 14.267.6 (14)*** # Binges in past week: Mean6SD (n) 5 (30) 5.864.8 (15) 2.561.9 (15)** 2.9 (14)* # Purges in past week Mean6SD (n) 7 (30) 14.5619.4 (15) 4.365.4 (15)* 4.465.7 (14)* Text-messaging data a Mean per day per week6SD (n) # Binges N/A 0.860.9 (18) 0.760.6 (18) N/A # Purges N/A 1.962.4 (18) 1.061.2 (18)* N/A Urge to Binge N/A 4.762.3 (18) 4.262.6 (18) N/A Urge to Purge N/A 5.062.4 (18) 4.062.5 (18) N/A BDI, Beck depression inventory; EDI, eating disorders inventory; NEQ, night eating questionnaire.

Results are compared with baseline completers only:

*5p\0.05; **5p\0.01; ***p\0.001; ****5p\0.0001.

aAll data on table is based on self-report measures during data collection periods except for text-messaging data, which is a summary of the ﬁrst and last week of text-messaging data. MOBILE PHONE TEXT MESSAGING FOR BULIMIA NERVOSA International Journal of Eating Disorders 43:6 513–519 2010 517 extrapolated from the SCID, whereas the post- treatment data were taken from the binge-purge questionnaire. Thus, although the questions queried the same behaviors, it was asked verbally at baseline and asked via questionnaires at post- treatment and follow-up. However, results showed that participants reported a much higher rate of binge eating and purging episodes at baseline via a clinical interview and fewer episodes at post-treat- ment via a questionnaire. Despite the slight differ- ences in methods of inquiry, we are conﬁdent that they yielded similar results; if social desirability was in effect, one would suspect that the results would have been reverse (i.e., report lower frequen- cies on a verbal interview).

Bearing the limitations in mind, these initial promising results as well as previous studies that have demonstrated a higher adherence rate in elec- tronic diaries versus paper diaries, 15,23 support the further exploration of incorporate text-messaging- based self-monitoring in larger randomized clinical trials comparing traditional therapy with a more enhanced technological version. Although the results of this pilot study do not demonstrate reduced attrition, the text messaging demonstrated a high self-monitoring adherence rate for those who remained in the study.

Independent of the limitations inherent in our study, there are inherent challenges with text mes- saging that may limit generalization and wide- spread use. Providers must have access to a secure server to host the text-messaging program. The server at times may malfunction and not accept incoming or outgoing text messages until it is rebooted. Although the cost of text-messaging plans is relatively inexpensive, it may be inaccessi- ble for individuals without mobile phones and indi- viduals who live in rural areas may have no mobile phone coverage. However, these limitations were infrequent and the beneﬁts strongly outweighed the challenges we encountered.

In sum, the speciﬁc advantages of text messaging include its wide dissemination, low cost, availabil- ity, ﬂexibility, convenience, and interactivity. Men- tal health professionals are currently limited in the services available to patients. In terms of behavioral treatment, patients often do not receive any clinical input beyond the 50 min per week that they meet with their therapist. In addition, after terminating treatment, relapse is common. 8 Text messaging could be used as part of a stepped care approach to maintain more frequent contact with patients after they are discharged from inpatient or partial hospi- talization treatment to maintain contact and helpprevent relapse. Finally, the cost-effectiveness of such programs should be examined in greater detail; text messaging may prove to be a cost-effec- tive method for increasing adherence and effecting behavior change, which could ultimately enhance CBT for those who do not have regular access to treatment providers, need more frequent contact, drop out of treatment, or for treatment nonres- ponders. If effective, this methodology could read- ily be exported to other populations and settings for improving digestive diseases, nutritional disor- ders, and other eating disorders as well as dissemi- nation to remote settings in which access to health-care is limited. The authors greatly appreciate Lauren Reba-Harrelson, MA for facilitating some of the intervention groups.

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