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A randomized controlled trial of internet-based cognitive-behavioural therapy for bulimia nervosa or related disorders in a student population
Abstract
Background: Bulimic eating disorders are common among female students, yet the majority do not access effective treatment. Internet-based cognitive-behavioural therapy (iCBT) may be able to bridge this gap. Method: Seventy-six students with bulimia nervosa (BN) or eating disorder not otherwise specified (EDNOS) were randomly assigned to immediate iCBT with e-mail support over 3 months or to a 3-month waiting list followed by iCBT [waiting list/delayed treatment control (WL/DTC)]. ED outcomes were assessed with the Eating Disorder Examination (EDE) at baseline, 3 months and 6 months. Other outcomes included depression, anxiety and quality of life. Results: Students who had immediate iCBT showed significantly greater improvements at 3 and 6 months than those receiving WL/DTC in ED and other symptoms. Conclusions: iCBT with e-mail support is efficacious in students with bulimic disorders and has lasting effects.
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“Internet-based interventions have proved their efficacy in reducing ED-related symptoms in a number of Randomised Controlled Trials (RCTs) [17–19].”
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“This research is in its infancy, and additional studies with stronger methodology are needed, as the majority compared Internet-based CBT for eating disorders to a waitlist control.”
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Cognitive–behavioral guided self-help for eating disorders: Effectiveness and scalability
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“This might explain why most content analyzed from trials of BIT support falls into a few themes (e.g., Paxling et al., 2013; S anchez-Ortiz et al., 2011).”
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“Three other studies reported on cognitive behavioral therapy (CBT) delivered via e-mail (Robinson & Serfaty, 2001; Robinson & Serfaty, 2003; Robinson et al., 2008), hereafter referred to as e-mail therapy.”
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Self-citationDoes internet-based prevention reduce the risk of relapse for anorexia nervosa?
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Self-citationThe First Episode Rapid Early Intervention for Eating Disorders ‐ Upscaled study: Clinical outcomes
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“The second is the First Episode Rapid Early Intervention for Eating Disorders (FREED) which was developed for emerging adults aged 18–25 with any ED and a DUED 3 years (Schmidt et al., 2016).”
BackgroundSelf-citationInternet-based interventions for eating disorders in adults: a systematic review
Dölemeyer, R., Tietjen, A., Kersting, A., & Wagner, B. (2013) · BMC Psychiatry · doi:10.1186/1471-244x-13-207 · Cited by 99
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“This was unclear in five studies (DeBar et al., 2011; Heinicke et al., 2007; Ljotsson et al., 2007; Sanchez-Ortiz et al., 2011; Wagner et al., 2013), because either full information was not reported or they only included those who returned pre-assessment or postassessment questionnaires.”
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Self-citationScreening for Eating Disorders in Adolescents and Adults
Feltner, C., Peat, C. M., Reddy, S., Riley, S., Berkman, N. D., Middleton, J. C., Balio, C. P., Coker-Schwimmer, M. J. L., & Jonas, D. E. (2022) · JAMA · doi:10.1001/jama.2022.1807 · Cited by 98
“of participants) % (95% CI) LR+ (95% CI) LR– (95% CI) Sensitivity Specificity SCOFF ≥3 Any 7 (2749) Pooled: 69 (56-80) Pooled: 90 (69-98) Pooled: 7.”
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“This model has been used in a number of published book and online self-help resources and has also been found to be effective in previous RCTs for depression [31], medically unexplained symptoms [32], and eating disorders [33].”
MethodSelf-citationCouturier, J. L., Pellegrini, D., Miller, C., Bhatnagar, N., Boachie, A., Bourret, K., Brouwers, M. C., Coelho, J. S., Dimitropoulos, G., Findlay, S. M., et al. (2021) · Journal of Eating Disorders · doi:10.1186/s40337-021-00394-9 · Cited by 87
“Sanchez-Ortiz et al. 2011 [74] Qualitative 18–25 years BN, EDNOS n = 9 Internet CBT-based guided self-help (Overcoming Bulimia Online) Program received positively as a way of fitting treatment into busy lives.”
BackgroundInfluentialWagner, G., Penelo, E., Wanner, C., Gwinner, P., Trofaier, M., Imgart, H., Waldherr, K., Wöber, C., & Karwautz, A. F. K. (2012) · The British Journal of Psychiatry · doi:10.1192/bjp.bp.111.098582 · Cited by 86
Quality of life in anorexia nervosa, bulimia nervosa and eating disorder not-otherwise-specified
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“Additionally, online interventions such as “ Overcoming Bulimia Online ”— which has been evaluated in an RCT (Sánchez-Ortiz et al., 2011) — might in principle be an option, but unfortunately are not available in German.”
ter Huurne, E. D., de Haan, H. A., Postel, M. G., van der Palen, J., VanDerNagel, J. E., & DeJong, C. A. (2015) · Journal of Medical Internet Research · doi:10.2196/jmir.3946 · Cited by 78
“Additionally, the process of seeking help or knowing that treatment would start shortly could also have contributed to the improvement, as some other studies showed similar results [39,40].”
ResultLinardon, J., Shatte, A. B. R., Rosato, J., & Fuller‐Tyszkiewicz, M. (2020) · Psychological Medicine · doi:10.1017/s0033291720003426 · Cited by 78
“The effect sizes observed from our self-guided app were comparable to the effect sizes reported in previous RCTs of therapistguided computerized interventions for EDs (e.g. Sánchez-Ortiz et al., 2011; Wagner et al., 2016).”
ResultCognitive-Behavioral Therapy for Weight Management and Eating Disorders in Children and Adolescents
Wilfley, D. E., Kolko, R. P., & Kass, A. E. (2011) · Child and Adolescent Psychiatric Clinics of North America · doi:10.1016/j.chc.2011.01.002 · Cited by 77
Barakat, S., Maguire, S., Smith, K. E., Mason, T. B., Crosby, R. D., & Touyz, S. (2019) · International Journal of Eating Disorders · doi:10.1002/eat.23131 · Cited by 77
Online Cognitive–Behavioural Treatment of Bulimic Symptoms: A Randomized Controlled Trial
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“CD-ROMs, internet, e-mail, telemedicine, telephone, short message service (SMS).(34-41) Some strategies have”
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Shingleton, R. M., Richards, L. K., & Thompson‐Brenner, H. (2013) · Psychotherapy · doi:10.1037/a0031815 · Cited by 58
“…were abstinent or reached subclinical levels of bulimic symptomatology as compared with one-third in the delayed treatment condition at 3 months follow-up; Sánchez-Ortiz et al., 2011), and patients reported appreciating the flexibility of the program (Sanchez-Ortiz, Munro, & Schmidt, 2007).”
Current and Emerging Directions in the Treatment of Eating Disorders
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Evolution of cognitive-behavioral therapy for eating disorders
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“Finally, in a post-treatment qualitative interview, livery. participants noted that they liked the flexibility that Internet treatment offered (S anchez-Ortiz et al., 2011) allowing, for example, access to treatment during evening and weekend hours when clinic appointments are not usually available.”
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“Several internet-based interventions have been developed for people suffering from an eating disorder or for their carers (Grover et al. 2011; Gulec et al. 2011; Sánchez-Ortiz et al. 2011; Ruwaard et al. 2013), with promising preliminary results in terms of achieving good outcomes.”
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Self-citationThe effects of cognitive‐behavioral therapy for eating disorders on quality of life: A meta‐analysis
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Internet-based relapse prevention for anorexia nervosa: nine- month follow-up
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“For eating disorders, until recently the few existing studies on internet-based interventions have focused mainly on bulimia nervosa (BN) [15,17-23] and binge eating disorder (BED) [24-27].”
BackgroundCognitive Behavioral Therapy for the Eating Disorders
Agras, W. S., & Bohon, C. (2021) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-081219-110907 · Cited by 41
Self-Help Treatment of Eating Disorders
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Self-citationE-mental health – a land of unlimited possibilities
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“8% displayed abstinence from bulimic behaviours following engagement in an eight-session online CBT-based program [21].”
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“However, that study and the randomized controlled trial (RCT) from which participants were drawn focused on students [6].”
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“These interventions yield moderate to large treatment effects [6-14].”
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Bulik, C. M., Marcus, M. D., Zerwas, S. C., Levine, M. D., Hofmeier, S. M., Trace, S. E., Hamer, R. M., Zimmer, B., Moessner, M., & Kordy, H. (2012) · Contemporary Clinical Trials · doi:10.1016/j.cct.2012.05.008 · Cited by 35
“Successful computer-based programs and the use of online anonymous environments have been reported for a number of problems including obsessive compulsive disorder, sexual abuse, anxiety, depression, obesity, smoking, and eating disorders [47–55].”
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“To date, the effects of Internet-based interventions as a stand-alone treatment for BN and BED have only been evaluated in a small number of trials (Aardoom et al., 2016a; Carrard et al., 2011a,c; Ruwaard et al., 2013; Sanchez-Ortiz et al., 2011; ter Huurne et al., 2015) and considered in recent systematic reviews wit…”
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“We identified four trials testing internet-based self-help programs utilizing CBT principles such as self-monitoring, stimulus control, operant conditioning methods, exposure treatment, and cognitive restructuring [26, 27, 34, 36].”
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“Internet-based interventions have been found to be effective in prevention and treatment of a range of psychiatric disorders, including depression [10], anxiety [11], posttraumatic stress disorder [12], and eating disorders [13].”
Self-citationMol, M., Dozeman, E., Provoost, S., van Schaik, A., Riper, H. M., & Smit, J. H. (2018) · Journal of Medical Internet Research · doi:10.2196/jmir.9890 · Cited by 30
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“in self-induced vomiting and laxative use for the self-help and clinician supported arms, respectively (Aardoom et al., 2016; Ruwaard et al., 2013; Sánchez-Ortiz et al., 2011; Wagner et al., 2013).”
BackgroundResultTreating eating disorders using the internet
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“Moreover, most studies involve self-help or minimal contact interventions [31-34], whereas research has shown that intensive contact with a therapist is more effective [8,13,35-37].”
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Cost-Effectiveness of Internet-Based Cognitive-Behavioral Treatment for Bulimia Nervosa
Watson, H. J., McLagan, N. B., Zerwas, S. C., Crosby, R. D., Levine, M. D., Runfola, C. D., Peat, C. M., Moessner, M., Zimmer, B., Hofmeier, S. M., et al. (2017) · The Journal of Clinical Psychiatry · doi:10.4088/jcp.16m11314 · Cited by 26
Grammer, A. C., Fitzsimmons‐Craft, E. E., Laing, O., DePietro, B., & Wilfley, D. E. (2020) · Current Psychopharmacologye · doi:10.2174/2211556009999200416153022 · Cited by 25
Merkouris, S. S., Rodda, S. N., Austin, D., Lubman, D. I., Harvey, P., Battersby, M., Cunningham, J., Lavis, T., Smith, D., & Dowling, N. A. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-014226 · Cited by 21
Pellizzer, M. L., Waller, G., & Wade, T. D. (2018) · Clinical Psychologist · doi:10.1111/cp.12170 · Cited by 22
Efficacy of technology-based eating disorder treatment: A meta-analysis
Haderlein, T. P. (2019) · Current Psychology · doi:10.1007/s12144-019-00448-x · Cited by 21
Rodgers, R. F., & Paxton, S. J. (2014) · Journal of Eating Disorders · doi:10.1186/s40337-014-0030-2 · Cited by 36
“Sánchez [50] N intervention =38; N control =38; F 23.”
BackgroundYager, J., Devlin, M. J., Halmi, K. A., Herzog, D. B., Mitchell, J. C., Powers, P. S., & Zerbe, K. J. (2014) · Cited by 21
Wiberg, A.-C., Ghaderi, A., Danielsson, H. B., Safarzadeh, K., Parling, T., Carlbring, P., Jansson, M., & Welch, E. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100570 · Cited by 22
Anastasiadou, D., Lupiañez-Villanueva, F., Faulí, C., Arcal Cunillera, J., & Serrano-Troncoso, E. (2018) · BMC Psychiatry · doi:10.1186/s12888-018-1664-4 · Cited by 16
Plateau, C. R., Brookes, F. A., & Pugh, M. (2017) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2017.08.004 · Cited by 17
“Low levels of motivation may also be due to discrepancies between patient expectations of treatment and the treatment provided (Murray et al., 2003; Sanchez-Ortiz et al., 2011a).”
Using Technology to Improve Treatment Outcomes for Children and Adolescents with Eating Disorders
Darcy, A. M., & Lock, J. (2016) · Child and Adolescent Psychiatric Clinics of North America · doi:10.1016/j.chc.2016.07.010 · Cited by 16
Barakat, S., Touyz, S., Maloney, D., Russell, J., Hay, P., Cunich, M., Lymer, S., Kim, M., Madden, S., Miskovic-Wheatley, J., et al. (2021) · Journal of Eating Disorders · doi:10.1186/s40337-021-00482-w · Cited by 14
“[45] significant improvements were reported in a sample of 75 patients with full or subthreshold BN following completion of an eight-session online CBT-based program.”
BackgroundHamid, N. (2023) · PsyCh Journal · doi:10.1002/pchj.715 · Cited by 15
“Co-interventions such as stable dose of antidepressants was not prevented in three studies, which is aligned with routine clinical practice, but may possibly confound results (Carrard et al., 2011; Ruwaard et al., 2013; S (cid:2) anchez-Ortiz et al., 2011).”
BackgroundResultInfluentialZhong, J., Zhang, Y., Sun, Y., Wang, Q., Dong, G., & Li, X. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.06.084 · Cited by 18
Vaz, A. R., Conceição, E., & Machado, P. P. P. (2013) · Psychotherapy Research · doi:10.1080/10503307.2013.796424 · Cited by 19
Clinton, D. N., Almlöf, L., Lindström, S., Manneberg, M., & Westin, L. (2014) · Eating Disorders · doi:10.1080/10640266.2014.912553 · Cited by 15
Bruns, J., Meier, M., & Jansen, K. (2025) · International Journal of Eating Disorders · doi:10.1002/eat.24519 · Cited by 17
Sasseville, M., LeBlanc, A., Tchuente, J., Boucher, M., Dugas, M., Mbemba, G. I. C., Barony, R., Chouinard, M., Beaulieu, M., Beaudet, N., et al. (2023) · Systematic Reviews · doi:10.1186/s13643-023-02241-1 · Cited by 16
“Sanchez [85] 2011 United Kingdom Bulimia 76 Internet or website/email (SMS) Depression/anxiety”
BackgroundCandela, C. G. (2017) · Nutrición Hospitalaria · doi:10.20960/nh.1562 · Cited by 20
The rise of artificial intelligence for cognitive behavioral therapy: A bibliometric overview
Vanhée, L., Andersson, G., Garcia, D., & Sikström, S. (2025) · Applied Psychology Health and Well-Being · doi:10.1111/aphw.70033 · Cited by 14
“…an extensive empirical demonstration of its relevance for an array of therapeutic aims, including depression (Andersson, 2024b), bulimia (S (cid:1) anchez-Ortiz et al., 2011), insomnia (Trauer et al., 2015), anxiety disorders (Bandelow et al., 2015), chronic fatigue syndrome (Malouff et al.,…”
Barakat, S., & Maguire, S. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph20010119 · Cited by 17
Wagner, G., Wagner, G., Penelo, E., Nobis, G., Mayerhofer, A., Schau, J., Spitzer, M., Imgart, H., & Karwautz, A. F. K. (2013) · Neuropsychiatrie · doi:10.1007/s40211-013-0062-x · Cited by 13
A scoping review of therapist behaviors in guided digital mental health interventions
González-Robles, A., Miguel, C., Richards, D., Duffy, D., & Enrique, Á. (2024) · Internet Interventions · doi:10.1016/j.invent.2024.100751 · Cited by 12
“A pioneering study addressing the guidance content of an internet-delivered treat-ment was conducted by S ´ anchez-Ortiz et al. (2011a, 2011b).”
BackgroundMethodInfluentialBohrer, B. K., Chen, Y., Christensen, K. A., Forbush, K. T., Thomeczek, M. L., Richson, B. N., Chapa, D. A. N., Jarmolowicz, D. P., Gould, S. R., Negi, S., et al. (2023) · International Journal of Eating Disorders · doi:10.1002/eat.23987 · Cited by 11
Dalton, B., Davies, M. R., Flynn, M., Hutchings-Hay, C., Potterton, R., O’Byrne, E. B., Kilonzo, C., Belli, S. R., Gallop, L., Gordon, G., et al. (2024) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465823000607 · Cited by 10
Self-citationNaini, R., Wibowo, M. E., & Mulawarman, M. (2021) · Islamic Guidance and Counseling Journal · doi:10.25217/igcj.v4i1.1280 · Cited by 10
“Research conducted by Sánchez-Ortiz et al. (2011) indicates that online cognitive behavior therapy can promote behavioral change effectively.”
BackgroundComputerised cognitive behavioural therapy: helping Ireland log on
Twomey, C., O'Reilly, G., & Byrne, M. (2013) · Irish Journal of Psychological Medicine · doi:10.1017/ipm.2012.5 · Cited by 11
Metadata
- Authors
- Sánchez-Ortiz, V. C., Munro, C., Stahl, D., House, J., Startup, H., Treasure, J., Williams, C., & Schmidt, U.
- Affiliations
- King's College London (GB)
- South London and Maudsley NHS Foundation Trust (GB)
- University of Glasgow (GB)
- Corresponding author
- Schmidt, U.
- Venue
- Psychological Medicine
- Publisher
- Cambridge University Press (CUP)
- Published
- 2010-04-21
- Volume
- 41
- Issue
- 2
- Pages
- 407-417
- ISSN
- 0033-2917 (ISSN-L)
- 1469-8978
- OpenAlex
- W2079542203
- Cited by
- 154
- References
- 43
- Citations by year
- 2026: 3 · 2025: 7 · 2024: 13 · 2023: 15 · 2022: 9 · 2021: 9 · 2020: 8 · 2019: 7 · 2018: 8 · 2017: 16 · 2016: 6 · 2015: 7 · 2014: 14 · 2013: 17 · 2012: 9
- FWCI
- 11.22
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Psychological Medicine (publishedVersion)
- PubMed (publishedVersion)
- ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (submittedVersion)
- Research Portal (King's College London) (submittedVersion)
- Funders
- NIHR Biomedical Research Centre, Royal Marsden NHS Foundation Trust/Institute of Cancer Research
- Consejo Nacional de Ciencia y Tecnología
- National Institutes of Health
- Topics
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Health Sciences › Nursing › Nutrition and Dietetics › Nutrition, Health and Food Behavior
- Keywords
- bulimia nervosa, eating disorder not otherwise specified, internet-based cognitive behavioral therapy, university students, female students, waitlist control, depression, anxiety, quality of life, treatment efficacy
- MeSH terms
- Adult, Feeding and Eating Disorders, Female, Humans, London, Therapy, Computer-Assisted, Waiting Lists, Cognitive Behavioral Therapy, Remote Consultation, Internet, Electronic Mail, Bulimia Nervosa
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