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Many young individuals at risk for eating disorders spend time on social media and frequently search for information related to their body image concerns. In a large randomized study, we demonstrated that a guided chat-based intervention could reduce weight and shape concerns and eating disorder pathology. The goal of the current study was to determine if a modified single session mini-course, derived from the aforementioned chat-based intervention, could reduce body image concerns among individuals using eating disorder related search terms on a social media platform. Over a two-month period of prompting individuals, 525 people followed the link to the web-based application where the intervention was hosted and subsequently completed the mini-course. This resulted in a significant improvement on the one-time body image satisfaction question pre-to post intervention (p .001) with a moderate effect size (Cohen's d = 0.54). Additionally, individuals completing the program showed significant improvement on motivation to change their body image (p .001) with a small effect size (Cohen's d = 0.28). Additionally, users reported that the program was enjoyable and easy to use. These results suggest that a single session micro-intervention, offered to individuals on social media, can help improve body image.

Relapse following acute treatment for anorexia nervosa (AN) is common. Evidence suggests cognitive-behavioral therapy (CBT) may be useful in the post-acute period, but few patients have access to trained providers. mHealth technologies have potential to increase access to high-quality care for AN, including in the post-acute period. The aim of this study is to estimate the preliminary feasibility and effectiveness of a CBT-based mobile intervention plus treatment as usual (TAU), offered with and without an accompanying social networking feature.In the current pilot randomized controlled trial, women with AN who have been discharged from acute treatment in the past 2 months (N = 90) will be randomly assigned to a CBT-based mobile intervention plus treatment as usual (TAU), a CBT-based mobile intervention including social networking plus TAU, or TAU alone. We will examine feasibility, acceptability, and preliminary effectiveness of the three conditions in terms of reducing eating disorder psychopathology, reducing frequency of eating disorder behaviors, achieving weight maintenance, reducing depression and suicidal ideation, and reducing clinical impairment. We will examine rehospitalization and full recovery rates in an exploratory fashion. We will also examine whether the mobile intervention and social networking feature change the proposed targets and whether changes in targets are associated with benefit, as well as conduct exploratory analyses to identify within-mobile intervention predictors and moderators of outcome.Ultimately, this research may lead to increased access to evidence-based treatment for individuals with AN and prevention of the extreme negative consequences that can result from this serious disorder.Relapse after acute treatment for anorexia nervosa is common, and few patients have access to trained providers to support them following acute care. This study will pilot a coached mobile app, including a social networking component, for this population. If ultimately successful, our approach could greatly increase access to evidence-based treatment for individuals with anorexia nervosa and ultimately prevent the extreme negative consequences that can result from this serious disorder.

To explore predictors of treatment seeking and uptake among individuals following an online eating disorders (EDs) screen in the U.S. disseminated by the National Eating Disorders Association.Respondents who screened at risk or positive for a probable ED from 04/2019 to 05/2021 (N = 263,530) were eligible to complete a 2-month follow-up survey that assessed treatment seeking and uptake after being offered referral options following screening. Analyses were conducted using chi-square tests or logistic regressions.Sixty thousand thirty-four respondents (22.8%) opted-in to the follow-up survey, of whom 2276 (3.8%) completed it. Of the final analytic sample (n = 1922), 35.7% of respondents reported seeking and 22.4% reported receiving treatment. Treatment seeking and uptake were more common among respondents who were female, White, or 24 years of age; uptake was more common among respondents who were non-Hispanic or higher income. Elevated shape/weight concerns were significantly, albeit modestly, associated with reduced likelihood to receive treatment.Demographic differences in treatment seeking and uptake highlight the need to optimize ED screening tools/feedback to meet the needs of underserved groups and to address stereotypes and structural barriers that may interfere. Research is also needed to identify barriers to uptake among those with elevated shape/weight concerns.Relatively low rates of treatment seeking and uptake were observed, particularly among underserved groups, 2 months following a widely disseminated online eating disorders screen. Optimization of online eating disorder screening tools and delivery of feedback and referral information may be needed to increase health care utilization.

Objectives: In a national sample of college students, this study aimed to evaluate whether barriers to mental health treatment varied by race and ethnicity. Methods: Data were drawn from a large multicampus study conducted across 26 US colleges and universities. The sample (n = 5841) included students who screened positive for at least one mental health disorder and who were not currently receiving psychotherapy. Results: Black and Hispanic/Latine individuals showed a greater willingness to seek treatment than White individuals. However, Black and Hispanic/Latine individuals faced more financial barriers to treatment, whereas Hispanic/Latine individuals also showed a lower perceived importance of mental health. Asian American individuals preferred to handle their issues on their own or with support from family/friends and had lower readiness, willingness, and intentions to seek help than White individuals, with greater financial barriers as well.Conclusions: Disparities in unmet treatment need may arise from both distinct and common barriers, and point to the potential benefits of tailored intervention approaches to address the unique needs of students of color from varying racial/ethnic backgrounds. Policy implications: Addressing barriers to treatment may require policies that cater to the unique needs of different racial/ethnic groups.Keywords: barriers to treatment, mental health, unmet need, students of color, health disparities

Digital guided self-help for eating disorders (GSH-ED) can reduce treatment disparities. Understanding program participants’ interests throughout the program can help adapt programs to the service users’ needs. Participants were 383 college students receiving a digital GSH-ED, who were each assigned a coach to help them better utilize the intervention through text correspondence. A thematic and affective analysis of the texts participants had sent found they primarily focused on: strategies for changing their ED-related cognitions, behaviors, and relationships; describing symptoms without expressing an active endeavor to change; and participants’ relationship with their coach. Most texts also expressed affect, demonstrating emotional engagement with the intervention. Findings suggest that participants in GSH-ED demonstrate high involvement with the intervention, and discuss topics that are similar to those reported in clinician-facilitated interventions. The themes discussed by digital program participants can inform future iterations of GSH-ED, thereby increasing scalability and accessibility of digital evidence-based ED interventions. Digital guided self-help for eating disorders (GSH-ED) can reduce treatment disparities. Understanding program participants’ interests throughout the program can help adapt programs to the service users’ needs. Participants were 383 college students receiving a digital GSH-ED, who were each assigned a coach to help them better utilize the intervention through text correspondence. A thematic and affective analysis of the texts participants had sent found they primarily focused on: strategies for changing their ED-related cognitions, behaviors, and relationships; describing symptoms without expressing an active endeavor to change; and participants’ relationship with their coach. Most texts also expressed affect, demonstrating emotional engagement with the intervention. Findings suggest that participants in GSH-ED demonstrate high involvement with the intervention, and discuss topics that are similar to those reported in clinician-facilitated interventions. The themes discussed by digital program participants can inform future iterations of GSH-ED, thereby increasing scalability and accessibility of digital evidence-based ED interventions.

BACKGROUND Therapeutic homework is a core element of cognitive and behavioral interventions, and greater homework compliance predicts improved treatment outcomes. To date, research in this area has relied mostly on therapists’ and clients’ self-reports or studies carried out in academic settings, and there is little knowledge on how homework is used as a treatment intervention in routine clinical care. OBJECTIVE This study tested whether a machine learning (ML) model using natural language processing could identify homework assignments in behavioral health sessions. By leveraging this technology, we sought to develop a more objective and accurate method for detecting the presence of homework in therapy sessions. METHODS We analyzed 34,497 audio-recorded treatment sessions provided in 8 behavioral health care programs via an artificial intelligence (AI) platform designed for therapy provided by Eleos Health. Therapist and client utterances were captured and analyzed via the AI platform. Experts reviewed the homework assigned in 100 sessions to create classifications. Next, we sampled 4000 sessions and labeled therapist-client microdialogues that suggested homework to train an unsupervised sentence embedding model. This model was trained on 2.83 million therapist-client microdialogues. RESULTS An analysis of 100 random sessions found that homework was assigned in 61% (n=61) of sessions, and in 34% (n=21) of these cases, more than one homework assignment was provided. Homework addressed practicing skills (n=34, 37%), taking action (n=26, 28.5%), journaling (n=17, 19%), and learning new skills (n=14, 15%). Our classifier reached a 72% F1-score, outperforming state-of-the-art ML models. The therapists reviewing the microdialogues agreed in 90% (n=90) of cases on whether or not homework was assigned. CONCLUSIONS The findings of this study demonstrate the potential of ML and natural language processing to improve the detection of therapeutic homework assignments in behavioral health sessions. Our findings highlight the importance of accurately capturing homework in real-world settings and the potential for AI to support therapists in providing evidence-based care and increasing fidelity with science-backed interventions. By identifying areas where AI can facilitate homework assignments and tracking, such as reminding therapists to prescribe homework and reducing the charting associated with homework, we can ultimately improve the overall quality of behavioral health care. Additionally, our approach can be extended to investigate the impact of homework assignments on therapeutic outcomes, providing insights into the effectiveness of specific types of homework.

BACKGROUND Most individuals with eating disorders (EDs) do not receive treatment. Leveraging digital tools such as chatbots may be a promising method to mobilize mental health care utilization following ED screening. OBJECTIVE This study examined rates and predictors of uptake of a chatbot aimed to promote mental health services use among adults who screened positive for clinical/subclinical EDs on an online ED screen. METHODS Following screening, eligible individuals (≥18 years, screened positive for a clinical/subclinical ED, not in treatment) were shown the study opportunity. Participants who enrolled were instructed to initiate an SMS conversation with the chatbot. Chi-square tests and logistic regressions explored differences in demographics, ED symptoms, suicidality, and probable ED diagnoses between those who enrolled and engaged with the chatbot versus those who did not. RESULTS Of 6,747 respondents shown the study opportunity, 205 (3.0%) enrolled, of whom 185 (90.2%) subsequently used the chatbot. Chatbot uptake was more common among individuals aged ≥25 versus young adults and less common among individuals engaging in regular dietary restriction. No other differences across demographics or ED presentations were observed. CONCLUSIONS Overall chatbot uptake was low, reflecting a need for additional strategies to promote help-seeking behaviors. However, chatbot uptake was high among those that enrolled and equal across most demographics or ED symptoms. Differences by age and dietary restriction in chatbot uptake indicate a need to better engage those who are younger or report restriction.

OBJECTIVE: There is a lack of research on the prevalence of eating disorders in Singapore. The aims of our study were to (1) estimate the prevalence of eating disorders, risk status, and help-seeking behaviors among adults in Singapore, (2) examine gender differences between eating disorder status groups, and (3) characterize clinical profiles of eating disorder status groups. METHOD: We administered a cross-sectional survey that included a validated eating disorders screening tool to adults in Singapore. RESULTS: A total of 797 Singaporean adults ages 21–77 years completed the eating disorder screen. The majority of participants screened positive for a current DSM-5 clinical eating disorder (6.2%), other specified feeding or eating disorder (37.0%) or at high risk of developing an eating disorder (19.5%). Only 1.6% of those who screened positive for an eating disorder reported currently being in treatment. The ratio of males to females who screened positive for an eating disorder was nearly 1:1. The clinical profiles of eating disorder groups were consistent with the clinical presentations found in Western nations. DISCUSSION: This is the first study in Singapore to estimate the prevalence of eating disorders in a large sample of adults. Results highlight the urgent need for more eating disorder research and expansion of prevention and treatment programs to address the high prevalence of eating disorder psychopathology in Singapore.

OBJECTIVE: To examine eating disorder (ED) symptomatology, related clinical impairment, and comorbid psychopathology in college women with EDs across five racial and two ethnic groups. METHODS: Participants were 690 women from 28 U.S. universities who screened positive for an ED. Thirteen variables assessing ED symptoms, related clinical impairment, and comorbid psychopathology were compared across racial and ethnic groups using analyses of variance (ANOVAs) and independent samples t-tests. RESULTS: Across racial groups, significant differences emerged in binge eating and laxative use. Asian women reported significantly more binge eating than White women (p < .01). Individuals self-identified as the “Other” racial group reported greater laxative use than Asian and White women (ps ≤ .01). No other significant differences emerged across all other variables (ps ≥ .13). Across ethnic groups, Hispanic women reported significantly more laxative use (p < .01), and more comorbid insomnia symptoms (p = .03) than non-Hispanic women. No other significant differences were observed (ps ≥ .24). DISCUSSION: Findings suggest that binge eating, laxative use, and insomnia symptoms differ across racial and ethnic groups in U.S. college women who screened positive for EDs. Findings can inform tailoring of ED screening to reduce current disparities in these underrepresented populations.

Background ICare represents a consortium of European Investigators examining the effects of online mental health care for a variety of common mental health disorders provided in a variety of settings. This article provides an overview of the evidence of effectiveness for Internet-based treatment for four common mental health disorders that are the focus of much of this work: depression, anxiety, substance abuse and eating disorders. Methods The overview focused primarily on systematic reviews and meta-analyses identified through PubMed (Ovid) and other databases and published in English. Given the large number of reviews specific to depression, anxiety, substance abuse and/or eating disorders, we did not focus on reviews that examined the effects of Internet-based interventions on mental health disorders in general. Each article was reviewed and summarized by one of the senior authors, and this review was then reviewed by the other senior authors. We did not address issues of prevention, cost-effectiveness, implementation or dissemination, as these are addressed in other reviews in this supplement. Results Across Internet-based intervention studies addressing depression, anxiety, substance abuse and eating disorders primarily among adults, almost all reviews and meta-analyses found that these interventions successfully reduce symptoms and are efficacious treatments. Generally, effect sizes for Internet-based interventions treating eating disorders and substance abuse are lower compared with interventions for depression and anxiety. Conclusions Given the effectiveness of Internet-based interventions to reduce symptoms of these common mental health disorders, efforts are needed to examine issues of how they can be best disseminated and implemented in a variety of health care and other settings.

Objective Eating disorders (EDs) compromise the health and functioning of affected individuals, but it can often take them several years to acknowledge their illness and seek treatment. Early identification of individuals with EDs is a public health priority, and innovative approaches are needed for such identification and ultimate linkage with evidence-based interventions. This study examined whether Internet activity data can predict ED risk/diagnostic status, potentially informing timely interventions. Method Participants were 936 women who completed a clinically validated online survey for EDs, and 231 of them (24.7%) contributed their Internet browsing history. A machine learning algorithm used key attributes from participants' Internet activity histories to predict their ED status: clinical/subclinical ED, high risk for an ED, or no ED. Results The algorithm reached an accuracy of 52.6% in predicting ED risk/diagnostic status, compared to random decision accuracy of 38.1%, a relative improvement of 38%. The most predictive Internet search history variables were the following: use of keywords related to ED symptoms and websites promoting ED content, participant age, median browsing events per day, and fraction of daily activity at noon. Discussion ED risk or clinical status can be predicted via machine learning with moderate accuracy using Internet activity variables. This model, if replicated in larger samples where it demonstrates stronger predictive value, could identify populations where further assessment is merited. Future iterations could also inform tailored digital interventions, timed to be provided when target online behaviors occur, thereby potentially improving the well-being of many individuals who may otherwise remain undetected.

INTRODUCTION: Generalized anxiety disorder (GAD) is prevalent among college students. Smartphone-based interventions may be a low-cost treatment method. METHOD: College students with self-reported GAD were randomized to receive smartphone-based guided self-help (n = 50), or no treatment (n = 50). Post-treatment and six-month follow-up outcomes included the Depression Anxiety Stress Scales-Short Form Stress Subscale (DASS Stress), the Penn State Worry Questionnaire (PSWQ-11), and the State-Trait Anxiety Inventory-Trait (STAI-T), as well as diagnostic status assessed by the GAD-Questionnaire, 4th edition. RESULTS: From pre- to post-treatment, participants who received guided self-help (vs. no treatment) experienced significantly greater reductions on the DASS Stress (d = −0.408) and a greater probability of remission from GAD (d = −0.445). There was no significant between-group difference in change on the PSWQ-11 (d = −0.208) or STAI-T (d = −0.114). From post to six-month follow-up there was no significant loss of gains on DASS Stress scores (d = −0.141) and of those who had remitted, 78.6% remained remitted. Yet rates of remitted participants no longer differed significantly between conditions at follow-up (d = −0.229). CONCLUSION: Smartphone-based interventions may be efficacious in treating some aspects of GAD. Methods for improving symptom reduction and long-term outcome are discussed.

Eating disorders (EDs) are debilitating health conditions and common across cultures. Recent reports suggest that about 14.0% of university students in Malaysia are at risk for developing an ED, and that prevalence may differ by ethnicity and gender. However, less is known about the prevalence of EDs in nonuniversity populations.The current study seeks to (1) estimate the prevalence of EDs and ED risk status among adults in Malaysia using an established diagnostic screen; (2) examine gender and ethnic differences between ED diagnostic/risk status groups; and (3) characterize the clinical profile of individuals who screen positive for an ED.We administered the Stanford-Washington University Eating Disorder Screen, an online ED screening tool, to adults in Malaysia in September 2020.ED risk/diagnostic categories were assigned to 818 participants (ages 18-73 years) of which, 0.8% screened positive for anorexia nervosa, 1.4% for bulimia nervosa, 0.1% for binge-ED, 51.4% for other specified feeding or ED, and 4.8% for avoidant/restrictive food intake disorder. There was gender parity in the high risk and the overall ED categories. The point prevalence of positive eating pathology screening among Malays was significantly higher than Chinese but no different from Indians.This is the first study to estimate the prevalence of EDs using a diagnostic screen in a population-based sample of Malaysians. It is concerning that over 50% of Malaysians reported symptoms of EDs. This study highlights the need to invest more resources in understanding and managing eating pathology in Malaysia.This study estimates the prevalence of EDs among adults in Malaysia using an online EDs screen. Over 50% of Malaysians report symptoms of EDs. The study highlights the need for more resources and funding to address this important public health issue through surveillance, prevention, and treatment of EDs in Malaysia.

Purpose The COVID-19 pandemic has heightened the need for mental healthcare that can be delivered remotely and at scale to college students. This study evaluated the efficacy of online self-help for stress among students during the pandemic. Method College students with moderate or higher stress (N = 585) were recruited between November 2020 and February 2021, when COVID-19 was having a major impact on colleges. Participants were randomly assigned to receive either online self-help using cognitive-behavioral therapy and positive psychology principles to support resilience and coping with pandemic-related stressors (n = 301) or referral to usual care (n = 284). Stress (primary outcome), depression, and anxiety (secondary outcomes) were assessed at pre-treatment, one-month post-treatment, and three-month follow-up. Results Participants in the online self-help condition experienced significantly larger reductions in stress (d = -0.18, p = .035) and depression (d = -0.20, p = .018) from pre-treatment to post-treatment than participants in the referral group. Reductions in stress from pre-treatment to follow-up were also larger in the treatment vs. referral group (d = -0.23, p = .005). Groups did not differ in change in anxiety. More time using the self-help program predicted greater improvement in depression at post-treatment (d = -0.41, p = .001) and follow-up (d = -0.32, p = .007), though usage was unrelated to change in stress or anxiety. Conclusion Online self-help targeting resilience and coping during the pandemic appears efficacious for long-term alleviation of stress and short-term alleviation of depression symptoms among college students. Registration: ClinicalTrials.gov (NCT04762173).

Background Although preventive interventions for eating disorders in general have shown promise, interventions specifically targeting individuals at risk for anorexia nervosa (AN) are lacking. Objective The aim of this study was to determine the efficacy of a guided, indicated web-based prevention program for women at risk for AN. Methods We conducted a randomized controlled efficacy trial for women at risk for AN. Assessments were carried out at baseline (before the intervention), after the intervention (10 weeks after baseline), and at 6- and 12-month follow-ups (FUs). A total of 168 women with low body weight (17.5 kg/m2≤BMI≤19 kg/m2) and high weight concerns or with normal body weight (19 kg/m2 Results Data were available for 81.5% (137/168) of the women after the intervention and for 69% (116/168) of the women at 12-month FU. At 12-month FU, the IG participants showed larger decreases in Eating Disorder Examination total scores (38/48, 79% vs 33/58, 57%) than the CG participants and the IG participants who were underweight also showed larger clinically relevant increases in BMI (15/31, 49% vs 10/32, 32%) than the CG participants, but these differences were not significant. In addition, after the intervention and at 12-month FU, we found a significant increase in continuously measured BMI for the participants who were underweight and significant improvements in disordered eating attitudes and behaviors (eg, restrained eating as well as weight and shape concerns). At all time points, the rates of new-onset eating disorder cases were (nonsignificantly) lower in the IG than in the CG and the reductions in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition–based eating disorder syndromes were (nonsignificantly) higher in the IG than in the CG. Conclusions SB-AN is the first preventive intervention shown to significantly reduce specific risk factors for, and symptoms of, AN and shows promise for reducing full-syndrome AN onset. Trial Registration ISRCTN Registry ISRCTN70380261; https://www.isrctn.com/ISRCTN70380261

Prevention of eating disorders (EDs) is of high importance. However, digital programs with human moderation are unlikely to be disseminated widely. The aim of this study was to test whether a chatbot (i.e., computer program simulating human conversation) would significantly reduce ED risk factors (i.e., weight/shape concerns, thin-ideal internalization) in women at high risk for an ED, compared to waitlist control, as well as whether it would significantly reduce overall ED psychopathology, depression, and anxiety and prevent ED onset.Women who screened as high risk for an ED were randomized (N = 700) to (1) chatbot based on the StudentBodies© program; or (2) waitlist control. Participants were followed for 6 months.For weight/shape concerns, there was a significantly greater reduction in intervention versus control at 3- (d = -0.20; p = .03) and 6-m-follow-up (d = -0.19; p = .04). There were no differences in change in thin-ideal internalization. The intervention was associated with significantly greater reductions than control in overall ED psychopathology at 3- (d = -0.29; p = .003) but not 6-month follow-up. There were no differences in change in depression or anxiety. The odds of remaining nonclinical for EDs were significantly higher in intervention versus control at both 3- (OR = 2.37, 95% CI [1.37, 4.11]) and 6-month follow-ups (OR = 2.13, 95% CI [1.26, 3.59]).Findings provide support for the use of a chatbot-based EDs prevention program in reducing weight/shape concerns through 6-month follow-up, as well as in reducing overall ED psychopathology, at least in the shorter-term. Results also suggest the intervention may reduce ED onset.We found that a chatbot, or a computer program simulating human conversation, based on an established, cognitive-behavioral therapy-based eating disorders prevention program, was successful in reducing women's concerns about weight and shape through 6-month follow-up and that it may actually reduce eating disorder onset. These findings are important because this intervention, which uses a rather simple text-based approach, can easily be disseminated in order to prevent these deadly illnesses.OSF Registries; https://osf.io/7zmbv.

The unprecedented COVID-19 crisis presents an imperative for mental health care systems to make digital mental health interventions a routine part of care. Already because of COVID-19, many therapists have rapidly moved to using telehealth in place of in-person contact. In response to this shift, Waller and colleagues compiled a series of expert recommendations to help clinicians pivot to delivering teletherapy to address eating disorders during COVID-19. However, numerous barriers still impede widespread adoption and implementation of digital interventions. In this commentary, we aim to extend the recommendations for clinicians offered by Waller and colleagues by presenting a roadmap of the systems- and policy-level requirements that are needed. We advocate for addressing barriers associated with training, licensing, safety, privacy, payment, and evaluation, as these factors have greatly limited use of these promising interventions. We also indicate that longer-term goals should include introducing truly innovative digital mental health practices, such as stepped-care models and simultaneously providing preventive and self-management services in addition to clinical services, into the health care system. Now is the time to catalyze change and comprehensively address the barriers that have prevented widespread delivery of these efficacious digital services to the millions of people who would benefit.

OBJECTIVE: This study examined the associations between insomnia, anxiety, and depression in college women with eating disorders (EDs). PARTICIPANTS: Six hundred and ninety female students from 28 U.S. colleges who screened positive for an ED were assessed for psychiatric comorbidities. Women were, on average, 22.12 years old, mostly White (60.1%), and undergraduates (74.3%). METHODS: Two mediation models were tested to determine if depression and/or anxiety mediated the relationship between insomnia and ED symptomatology. RESULTS: One-fifth of the sample (21.7%) reported clinically moderate and severe levels of insomnia. Both depression (B=.13, p

Objective The Internet-based Healthy Body Image (HBI) Program, which uses online screening to identify individuals at low risk of, high risk of, or with an eating disorder (ED) and then directs users to tailored, evidence-based online or in-person interventions to address individuals' risk or clinical status, was deployed at 28 U.S. universities as part of a randomized controlled trial. The purpose of this study is to report on: (a) reach of HBI, (b) screen results, and (c) differences across ED status groups. Method All students on participating campuses ages 18 years or older were eligible, although recruitment primarily targeted undergraduate females. Results The screen was completed 4,894 times, with an average of 1.9% of the undergraduate female student body on each campus taking the screen. ED risk in participating students was high-nearly 60% of students screened were identified as being at high risk for ED onset or having an ED. Key differences emerged across ED status groups on demographics, recruitment method, ED pathology, psychiatric comorbidity, and ED risk factors, highlighting increasing pathology and impairment in the high-risk group. Discussion Findings suggest efforts are needed to increase reach of programs like HBI. Results also highlight the increasing pathology and impairment in the high-risk group and the importance of programs such as HBI, which provide access to timely screening and intervention to prevent onset of clinical EDs.

(1) Background: The current study leveraged social media to connect with teens with EDs to identify population specific characteristics and to gather feedback on an mHealth intervention. (2) Methods: We recruited teens with EDs from social media in two phases: (1) Discovery Group, (2) Testing Group. The Discovery Group (n = 14) participants were recruited from Facebook/Instagram and were asked to review the app for up to one week and provide qualitative feedback. After incorporating feedback from the Discovery Group, we refined our social media outreach methods to connect with 30 teens with EDs to pilot this mobile app. Recruitment from a variety of platforms on social media was successful, with the majority of enrolled participants in the Testing Group coming from Snapchat (60%) and a large percentage of participants belonging to gender and sexual minority groups (63%). (3) Results: Participants from both groups experienced extremely high rates of depression (100% Discovery, 90% Testing) and/or anxiety symptoms (100% Discovery, 93% Testing) in addition to ED symptoms, and noted this as a possible barrier to app engagement. (4) Conclusion: Use of social media for recruitment of teens with EDs is feasible and may connect with groups who may be more difficult to reach using traditional recruitment methods. Among the Discovery Group there was high acceptability of and interest in an app to support ED recovery, and characteristics of both groups demonstrated need for support in other mental health domains. Future studies should evaluate the preliminary efficacy of such tools among teens to determine the effects of such interventions on ED symptoms and other mental health outcomes.

Background The COVID-19 pandemic could affect college students’ mental health. We examined screening rates for psychological disorders before and during the pandemic. Methods Undergraduates were surveyed before (n = 3643) or during the pandemic (n = 4970). Logistic regression adjusting for participant demographics was conducted. Results Frequencies of depression [OR 1.32, 95% CI (1.17, 1.48)], alcohol use disorder [OR 1.70, 95% CI (1.50, 1.93)], bulimia nervosa/binge-eating disorder [OR 1.54, 95% CI (1.28, 1.85)], and comorbidity [OR 1.19, 95% CI (1.04, 1.35)] were greater during (vs. before) the pandemic. Frequencies of posttraumatic stress disorder were lower during the pandemic [OR 0.86, 95% CI (0.75, 0.98)]. The upward trend in alcohol use disorder was stronger among women than men [OR 1.47, 95% CI (1.18, 1.83)]. The upward trend in depression was stronger among Black students than White students [OR 1.72, 95% CI (1.19, 2.49)]. Anxiety disorders, insomnia, anorexia nervosa, and suicidality showed no significant trends. Conclusions Depression, alcohol use disorder, bulimia nervosa/binge-eating disorder, and comorbidity were higher, whereas posttraumatic stress disorder was lower during the pandemic. Women and Black students could face especially heightened risk for alcohol use disorder and depression, respectively, during the pandemic.

Background Eating disorders (EDs) are complex mental illnesses with debilitating, pervasive psychological and physiological consequences when left untreated. Unfortunately, patients may face barriers to receiving treatment, such as stereotypes surrounding EDs, denial of illness severity, lack of motivation for treatment, and lack of knowledge about treatment resources. Barriers such as these result in a large treatment gap: only 20% of those with EDs will ever receive treatment. Digital tools like chatbots show potential to disseminate mental health–related interventions to large populations while offering a user-friendly, cost-effective, accessible, and anonymous means of tackling patient concerns. Objective This study developed and evaluated the usability of a chatbot designed for pairing with online ED screening. The tool aimed to promote mental health service utilization by improving motivation for treatment and self-efficacy among individuals with EDs. Methods A chatbot prototype, Alex, was designed using decision trees and theoretically informed components: psychoeducation, motivational interviewing, personalized recommendations, and repeated administration. Usability testing was conducted over 4 iterative cycles, with user feedback informing refinements to the next iteration. Postintervention, participants (N=21) completed the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), and a semistructured interview. This process aimed to create an optimized chatbot by the final cycle for use in a randomized trial. Results Interview feedback detailed chatbot aspects participants enjoyed and aspects necessitating improvement. Feedback converged on four themes: user experience, chatbot qualities, chatbot content, and ease of use. Following refinements, users described Alex as humanlike, supportive, and encouraging. Content was perceived as novel and personally relevant. USE scores across domains were generally above average (~5 out of 7), and SUS scores indicated “good” to “excellent” usability across cycles, with the final iteration receiving the highest average SUS score. Conclusions Overall, participants responded well in interactions with Alex, including the initial version. Refinements between cycles further improved user experiences. This study provides preliminary evidence of the feasibility and acceptance of a chatbot designed to promote motivation for and use of services among individuals with EDs. Alex is the first chatbot designed for pairing with an ED or other mental health–related online screen, with the goal of ultimately increasing service utilization. Acknowledgments This research was supported by K08 MH120341 from the National Institute of Mental Health. Availability of Data, Materials, and Code The data will be made available by reasonable request to the corresponding author. Authors’ Contributions EEFC conceptualized and designed the study. OL and BD conducted the investigation process. BD and JS assisted with data curation and conducted formal thematic analyses. JS conducted formal statistical analyses. JS wrote the original manuscript, with contribution from BD. EEFC, CBT, DEW, and SSS designed the data collection instruments, and coordinated and supervised data collection, in addition to reviewing and editing the manuscript with LS, LMF, LAF, and LD. Conflicts of Interest None declared.

Background Women experience poorer health outcomes following acute coronary syndrome (ACS). Heart rate (HR) and heart rate variability (HRV) have emerged as sensitive and cost-effective markers of autonomic function and prognostic risk factors of poor cardiac outcomes. The aim of the current study was to investigate whether sex-specific differences existed across HR and five parameters of HRV, at 1 and 12 months following ACS diagnosis. Methods Between January 2013 and June 2014, a sample of 416 ACS patients was enrolled in the Anxiety Depression & Heart Rate Variability in cardiac patients: Evaluating the impact of Negative emotions on functioning after Twenty four months (ADVENT) longitudinal cohort study. At 1 and 12 months following discharge, patient HR and HRV (root mean square of successive differences [RMSDD], standard deviation of RR intervals [SDRR], high frequency power [HF], low frequency power [LF], very low frequency power [VLF]) was measured via three-lead electrocardiogram. Results At 1 month post-ACS, sex was a significant predictor of HR and VLF power in fully- adjusted models. At 12 months post-ACS, sex was a predictor of HR, SDRR and VLF power in fully-adjusted models. Conclusion Sex-specific differences in resting HR and HRV were observed in the year following ACS, whereby women had higher HR and lower HRV, suggestive of poorer autonomic function. Further large-scale cohort studies examining autonomic function as a driver of sex-specific outcomes following ACS are required.

Objective We compared eating disorder (ED) characteristics and treatment seeking behaviors between self-identified competitive athletes and non-athletes in a large, community-based sample. Method During the 2018 National Eating Disorders Awareness Week, 23,920 respondents, 14.7% of whom identified as competitive athletes, completed the National Eating Disorders Association online screen. Data were collected on demographics, disordered eating behaviors, probable ED diagnosis/risk, treatment history, and intent to seek treatment. Results The sample was predominantly White (81.8%), female (90.3%), and between 13 and 24 years (82.6%). Over 86% met criteria for an ED/subthreshold ED, and of those, only 2.5% were in treatment. Suicidal ideation was reported in over half of the sample. Athletes reported a significantly greater likelihood of engaging in and more frequent excessive exercise episodes than non-athletes. Athletes also reported a significantly lower likelihood of engaging in and less frequent binge-eating episodes compared with non-athletes. Athletes were more likely to screen positive for an ED/subthreshold ED than non-athletes, but percentages across all probable ED diagnoses were similar. No significant differences between athletes and non-athletes emerged on treatment history or intention to seek treatment post-screen (less than 30%). Discussion Although the distribution of probable ED diagnoses was similar in athletes and non-athletes, symptom profiles related to disordered eating behavior engagement and frequency may differ. Athletes may be less likely to seek treatment due to stigma, accessibility, and sport-specific barriers. Future work should directly connect survey respondents to tailored treatment tools and increase motivation to seek treatment.

Objective To characterize disordered eating behaviors, eating disorder (ED) risk and diagnosis, and treatment seeking behaviors in active-duty military personnel/veterans compared with civilians. Method Self-selecting participants (n = 113,388; 1744 were military personnel/veterans) 18+ years old completed the National Eating Disorders Association's online screen. Engagement in and frequencies of disordered eating behaviors were compared across military/veteran and civilian groups and were stratified by gender. ED risk and diagnosis and treatment seeking behaviors were also compared. Results Individuals in the military/veteran group were more likely to engage in diuretic/laxative use and excessive exercise compared with civilians. Compared with civilians, the military/veteran group had a lower percentage who screened “at risk for an ED” and a higher percentage who screened for “no risk”. Females in the military/veteran group were more likely to engage in diuretic/laxative use, excessive exercise, and fasting compared with female civilians; males in the military/veteran group were more likely to engage in excessive exercise and less likely to engage in vomiting than male civilians. Of the self-identified military personnel/veterans who screened positive for any ED, 86% had never received treatment, which did not differ significantly from civilians. Notably, 56.7% of those (54.1% of military/veteran group; 56.7% of civilians) who completed an optional item on intention to seek treatment (n = 5312) indicated they would not seek treatment. Conclusions Disordered eating and ED profiles, but not treatment seeking, may differ between military personnel/veterans and civilians who complete an online ED screen. Future work should emphasize treatment options and connecting respondents directly to tailored resources.