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Invited Commentary
August 31, 2020

Increasing Access for the Treatment of Eating Disorders Among College Students

Author Affiliations
  • 1New York University Grossman School of Medicine, New York
  • 2Department of Child & Adolescent Psychiatry, NYU Langone Health, New York, New York
JAMA Netw Open. 2020;3(8):e2016117. doi:10.1001/jamanetworkopen.2020.16117

In recent years, psychiatry has gained a deeper understanding of the breadth of eating disorders and rightly expanded the definition to include a broad spectrum of difficulties, including atypical anorexia nervosa, avoidant/restrictive food intake disorder, and binge eating disorder. These disorders frequently cause just as much psychological distress and functional impairment as their better-known cousins, anorexia nervosa and bulimia nervosa.1 This is not your grandmother’s eating disorder.

Eating disorders are highly chronic, often lasting for years, and they exact an enormous toll on those who experience them. Eating disorders interfere with interpersonal, occupational, and academic functioning, and they greatly increase the risk of comorbid difficulties, such as anxiety, depression, and suicide. Eating disorders typically emerge in adolescence, with one large study of college students demonstrating a prevalence of 13.5% among women and 3.6% among men.2 Unfortunately, only a minority of adolescents and young adults receive treatment for these problems, which is why Fitzsimmons-Craft and colleagues’3 contribution is so very important at this time.

Although the current study is not the first to successfully utilize a manualized, digital cognitive-behavior therapy (CBT) program to treat eating disorders,4 Fitzsimmons-Craft and colleagues3 are the first to use a digital CBT self-help methodology across a large national assortment of universities, students, and eating disorder diagnoses (excluding anorexia nervosa) with long-term follow-up demonstrating a broad range of clinical findings. Students who engaged in the Student Bodies-EDs (SB-ED) program experienced greater reductions in not only eating disorder psychopathology, as compared to those referred to usual care, but also in binge eating, compensatory behaviors, depression, anxiety, and overall clinical impairment. Notably, and in contrast to study aims, the authors found no difference between intervention and control groups in abstinence from all eating disorder behaviors, and no difference between groups on academic impairment.

Fitzsimmons-Craft and colleagues3 used stringent criteria to define academic impairment in their study (eg, “withdrawn from a course due to academic difficulties caused by an eating disorder” or “taken a leave of absence from a college due to eating related issues”). Thankfully, relatively few students met those benchmarks. However, among college students nationally who reported a diagnosis of an eating disorder within the past 12 months on the National College Health Assessment in 2019, 25% noted that their disorder negatively impacted their academic performance, which is more in line with what would be expected.5 Eating disorders have a vast and commonly sustained impact upon those affected, so it is not surprising that there were no differences between intervention and control groups in abstinence from all eating disorder behaviors. Subthreshold symptoms of eating disorders, in fact, typically persist far longer than their diagnoses.6

Throughout the duration of the study, improvement was observed among both the students who received the SB-ED intervention and those assigned to the control condition, who received feedback about their diagnosis and treatment referrals. Given that the control group did not wholly remain static, the observed improvements among intervention students become even more meaningful. Furthermore, a large majority of the students who were assigned to the intervention group (83%) completed at least some portion of the intervention, whereas only 28% of controls reported receiving at least some treatment for their eating disorder. As all clinicians well know, simply getting patients into treatment is half the battle when it comes to mental illness, which is, perhaps, the most important reason that accessible, well-structured, and personally coached interventions like SB-ED must become a vital component of our treatment toolbox. Finally, among the 83% within the intervention group who initiated the SB-ED program, they completed only 31% of the content offered on average, yet they still reaped substantial benefit from the intervention. We might wonder how much more improvement would be seen if more of the treatment protocol were completed.

The need for mental health services on college campuses has grown dramatically in recent years. College students are a young and vulnerable population facing numerous stressors. Anxiety, mood, substance dependence, psychotic disorders, and eating disorders often blossom during these years and are challenging to treat, in large part because campus-based mental health programs have insufficient services to meet the needs of their students.7 Fitzsimmons-Craft and colleagues3 have presented us with not only a specific tool for the treatment of eating disorders, but also more evidence that online, manualized, and easily accessible therapeutic tools can help stem the rising tide of mental illness among college students. Now is the time for all good mental health practitioners to embrace these and similar therapeutic tools and come to the aid of our college students.

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Article Information

Published: August 31, 2020. doi:10.1001/jamanetworkopen.2020.16117

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Shatkin JP. JAMA Network Open.

Corresponding Author: Jess P. Shatkin, MD, MPH, NYU Department of Child & Adolescent Psychiatry, One Park Ave, 7th Floor, New York, NY 10016 (jess.shatkin@nyumc.org).

Conflict of Interest Disclosures: None reported.

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American College Health Association.  American College Health Association-National College Health Assessment III: Reference Group Executive Summary Fall 2019. American College Health Association; 2020.
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