Patient and clinician perspectives on supported mealtimes as part of anorexia nervosa treatment: A systematic review and qualitative synthesis

OBJECTIVE

To systematically review the literature on clinicians' and patients' experiences of supported mealtimes in the treatment of anorexia nervosa.

METHOD

This systematic review was conducted in accordance with PRISMA guidelines and registered on PROSPERO (CRD42022372565). PsycINFO, MEDLINE and Embase were searched up to the 20th of November 2023 for qualitative articles investigating the perspectives of healthcare professionals and patients on clinician-supported meals across all clinical settings. Data were analysed using thematic synthesis. The Critical Appraisal Skills Programme was used to evaluate the quality of selected studies.

RESULTS

This review comprised of 26 studies; eight concerned with the perspectives of clinicians only, 16 addressing patients' views, and two studies exploring the views of both groups. Experiences of both groups were generally negative, and three overlapping themes were identified: lack of consistency in care provided, high levels of negative emotions and an uncomfortable power dynamic.

CONCLUSIONS

This review suggests that supported mealtimes are experienced more positively by patients when rules are clear and consistently enforced, and when clinicians make informal conversation and supportive comments. Our findings highlight the need for best practice guidelines and clinician training to improve the delivery of supported mealtimes. Such guidelines and training should be coproduced in collaboration with patients and carers.

Eating disorder hospitalizations among children and youth in Canada from 2010 to 2022: a population-based surveillance study using administrative data

BACKGROUND

Eating disorders (EDs) are severe mental illnesses associated with significant morbidity and mortality. EDs are more prevalent among females and adolescents. Limited research has investigated Canadian trends of ED hospitalizations prior to the COVID-19 pandemic, however during the pandemic, rates of ED hospitalizations have increased. This study examined rates of ED hospitalizations among children and youth in Canada from 2010 to 2022, by sex, age, province/territory, length of stay, discharge disposition and ED diagnosis.

METHODS

Cases of ED hospitalizations among children and youth, ages 5 to 17 years, were identified using available ICD-10 codes in the Discharge Abstract Database from the 2010/11 to 2022/23 fiscal years. The EDs examined in this study were anorexia nervosa (F50.0), atypical anorexia nervosa (F50.1), bulimia nervosa (F50.2), other EDs (F50.3, F50.8) and unspecified EDs (F50.9). Both cases of total and first-time ED hospitalizations were examined. Descriptive statistics and trend analyses were performed.

RESULTS

Between 2010/11 and 2022/23, 18,740 children and youth were hospitalized for an ED, 65.9% of which were first-time hospitalizations. The most frequent diagnosis was anorexia nervosa (51.3%). Females had significantly higher rates of ED hospitalization compared to males (66.7/100,000 vs. 5.9/100,000). Youth had significantly higher rates compared to children. The average age of ED hospitalization was 14.7 years. Rates of ED hospitalizations were relatively stable pre-pandemic, however during the pandemic (2020-2021), rates increased.

INTERPRETATION

Rates of pediatric ED hospitalizations in Canada increased significantly during the pandemic, suggesting that there may have been limited access to alternative care for EDs or that ED cases became more severe and required hospitalization. This emphasizes the need for continued surveillance to monitor how rates of ED hospitalizations evolve post-pandemic.

Inpatient Treatment Outcome in a Large Sample of Adolescents with Anorexia Nervosa

Anorexia nervosa is an illness affecting primarily adolescent girls and young women. Clinical guidelines recommend early intervention, with inpatient treatment for more severe cases. We present an evaluation of a multi-modal cognitive-behavioral inpatient treatment (CBT-E) involving carers in specialized units for adolescents. Routine data of 962 adolescent inpatients (26 boys) (mean age 15.48 [1.26]; range 12-17 years) were analyzed. Predictors of good body weight outcome (achieving a discharge BMI of at least 18.5 kg/m2) were identified by logistic regression analysis. Mean inpatient treatment lasted 96.69 (45.96) days. The BMI increased significantly from 14.93 (1.38) kg/m2 at admission to 17.53 (1.58) kg/m2 at discharge (z = 26.41; p < 0.001; d = 1.708). Drive for thinness decreased from 29.08 (9.87) to 22.63 (9.77; z = 18.41; p < 0.001; d = 0.787). All other subscores of the Eating Disorder Inventory also decreased significantly, with small to medium effect sizes. General psychopathology also showed significant decreases. The Beck Depression Inventory-II score decreased from 26.06 (11.74) to 16.35 (12.51; z = 18.41; p < 0.001; d = 0.883). A good body weight outcome was predicted by a higher BMI at admission (OR = 1.828), age at onset at 15 years or higher (OR = 1.722), and higher Somatization (OR = 1.436), Anxiety (OR = 1.320), and Bulimia (OR = 1.029) scores. CBT-E involving carers is an efficient intervention for adolescents with anorexia nervosa.

Experiences of inpatient eating disorder admissions: A systematic review and meta-synthesis

OBJECTIVE

There has been a significant increase in the number of inpatient admissions for individuals with eating disorders and, with the most critical cases requiring inpatient treatment, it is essential that we continue to improve associated outcomes. The aim of the study was to synthesise the available qualitative literature on the experiences of inpatient admissions for eating disorders to understand individuals' experiences and identify areas that may require further research and/or service development.

METHOD

Searches were performed on the following online databases: PsycINFO, PsycArticles, PsycTherapy MEDLINE, Embase, CINAHL, ASSIA, Scopus and Proquest Open Access Theses. Only papers with qualitative data regarding individuals' experiences of inpatient eating disorder treatment were considered. The CASP qualitative checklist was used to assess studies and relevant data items were extracted. Thematic synthesis was used to integrate the findings in the identified studies. GRADE-CERQual was used to rate the confidence in the findings.

RESULTS

Twenty-eight studies were identified which the CASP assessment considered to be adequate. The synthesis produced 5 main themes; 'Care and control', 'Inpatient bubble', 'Being supported and understood', 'Challenges of living with others' eating disorders' and finally 'Relationship to eating disorder'. The GRADE CERQual framework rated findings with high or moderate confidence.

CONCLUSIONS

Findings reaffirmed the importance of patient-centred care and the significant impact of being separated from normal life with others also experiencing an eating disorder.

Intensive community and home-based treatments for eating disorders: a scoping review study protocol

INTRODUCTION

Institutionally based intensive treatment modalities (inpatient, day patient and residential treatments) for eating disorders (EDs) are associated with high treatment costs and significant challenges for patients and carers, including access difficulties and disruption to daily routines. Intensive community and home-based treatments have been suggested as alternatives to institutionally based intensive treatments for other severe mental illnesses, with promising clinical, social and health economic outcomes. The possible advantages of these treatments have been proposed for EDs, but this emerging area of research has not yet been systematically investigated. This scoping review aims to map the available literature on intensive community and home treatments for EDs, focusing on their conceptualisation, implementation and clinical outcomes.

METHODS

This proposed scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol extension for Scoping Reviews checklist and the Joanna Briggs Institute Reviewer's Manual. This review will include any peer-reviewed study concerning intensive community and home-based treatments for any EDs, with no restrictions on geographical context or study design. Grey literature will also be considered. The literature search will be conducted in four databases: PubMed, PsycInfo, MEDLINE and Web of Science. Two researchers will independently screen the titles, abstracts and text of the returned articles for eligibility. Data charting and analysis will consist of a narrative description of the included studies, quantitative and qualitative findings relative to the aims of this scoping review. Gaps in the literature will be highlighted to inform future research, clinical practice, and policy.

ETHICS AND DISSEMINATION

Ethical approval is not required as all data are available from public sources. The results of this scoping review will be disseminated through peer-reviewed publication, conference presentation, and social media.

Integrated enhanced cognitive behavioural (I-CBTE) therapy significantly improves effectiveness of inpatient treatment of anorexia nervosa in real life settings

BACKGROUND

Inpatient treatment of anorexia nervosa can be lifesaving but is associated with high rates of relapse and poor outcomes. To address this, the Oxford service has adapted the enhanced cognitive behavioural treatment (CBTE) model, first developed for inpatients in Italy to a UK national health service (NHS) setting. In this study, we compared the outcomes from treatment as usual (TAU), integrated CBTE (I-CBTE), and alternative treatment models in routine UK clinical practice.

METHODS

This is a longitudinal cohort study, using routinely collected data between 2017 and 2020 involving all adults with anorexia nervosa admitted to specialist units from a large geographical area in England covering a total population of 3.5 million. We compared TAU with (1) I-CBTE (13 weeks inpatient CBTE, restoration to a healthy weight, combined with 7 weeks day treatment followed by 20 weeks of outpatient CBTE; (2) standalone inpatient CBTE (due to insufficient resources since the pandemic; and (3) 6-8 weeks admission with partial weight restoration as crisis management. Primary outcome measures (min. 1 year after discharge from hospital) were defined as: (1) good outcome: Body Mass Index (BMI) > 19.5 and no abnormal eating or compensatory behaviours; (2) poor outcome: BMI < 19.5 and/or ongoing eating disorder behaviours; (3) readmission; or (4) deceased. Secondary outcomes were BMI on discharge, and length of stay.

RESULTS

212 patients were admitted to 15 specialist units in the UK depending on bed availability. The mean age was 28.9 (18-60) years, mean admission BMI was 14.1 (10-18.3), 80% were voluntary. At minimum 1-year follow up after discharge, 70% of patients receiving I-CBTE and 29% standalone inpatient CBTE maintained good outcomes, in contrast with < 5% TAU and crisis management admission. Readmission rates of I-CBTE were 14.3% vs ~ 50% (χ² < 0.0001) in the other groups. The main predictors of good outcome were reaching healthy BMI by discharge, I-CBTE and voluntary status. Age, psychiatric comorbidity and length of stay did not predict outcomes. BMI on discharge and length of stay were significantly better in the CBTE groups than in TAU.

CONCLUSIONS

Our main finding is that in a real-life setting, I-CBTE has superior short- and minimum 1 year outcomes as compared with alternative inpatient treatment models. Dissemination of I-CBTE across the care pathway has the potential to transform outcomes of inpatient treatment for this high-risk patient population and reduce personal and societal costs.

The clinical effectiveness and cost-effectiveness of a 'stepping into day treatment' approach versus inpatient treatment as usual for anorexia nervosa in adult specialist eating disorder services (DAISIES trial): a study protocol of a randomised controlled multi-centre open-label parallel group non-inferiority trial

Background

Anorexia nervosa (AN) is a serious and disabling mental disorder with a high disease burden. In a proportion of cases, intensive hospital-based treatments, i.e. inpatient or day patient treatment, are required, with day patient treatment often being used as a ‘step-down’ treatment after a period of inpatient treatment. Demand for such treatment approaches has seen a sharp rise. Despite this, the relative merits of these approaches for patients, their families, and the NHS and wider society are relatively unknown. This paper describes the rationale for, and protocol of, a two-arm multi-centre open-label parallel group non-inferiority randomised controlled trial, evaluating the effectiveness and cost-effectiveness of these two intensive treatments for adults with severe AN: inpatient treatment as usual and a stepped care day patient approach (the combination of day patient treatment with the option of initial inpatient treatment for medical stabilisation). The main aim of this trial is to establish whether, in adults with severe AN, a stepped care day patient approach is non-inferior to inpatient treatment as usual in relation to improving body mass index (BMI) at 12 months post-randomisation.

Methods

386 patients with a Diagnostic and Statistical Manual 5th edition diagnosis of severe AN or related disorder, with a BMI of ≤16 kg/m² and in need of intensive treatment will be randomly allocated to either inpatient treatment as usual or a stepped care day patient approach. Patients in both groups will receive treatment until they reach a healthy weight or get as close to this point as possible. Assessments will be conducted at baseline (prior to randomisation), and at 6 and 12 months post-randomisation, with additional monthly symptom monitoring. The primary outcome will be BMI at the 12-month post-randomisation assessment. Other outcomes will include psychosocial adjustment; treatment motivation, expectations and experiences; cost-effectiveness; and carer burden.

Discussion

The results of this study will provide a rigorous evaluation of two intensive treatment approaches which will inform future national and international treatment guidelines and service provision.

Trial registration

ISRCTN ISRCTN10166784. Registered 28 February 2020. ISRCTN is a primary registry of the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) network and includes all items from the WHO Trial Registration Data Set.

Psychological changes in young people with anorexia nervosa during an inpatient treatment: exploration of optimal length of stay predictors

OBJECTIVE

The current study aimed to monitor psychological changes in young people (YP) with anorexia nervosa (AN) during a specialist inpatient treatment in order to explore possible predictors of an optimal length of stay. Outcome measures were analysed to determine if significant changes occur earlier or later on during the treatment.

METHODS

Eating Disorder Examination Questionnaire (EDE-Q), Children's Depression Inventory (CDI), State-Trait Anxiety Inventory (STAI) and Compulsive Exercise Test (CET) measures administered to YP (n = 42) at three time points-admission, 85% ideal body weight (IBW) and discharge-were analysed using linear mixed effects model and regression analysis to determine change between the time points and possible predictors in length of stay.

RESULTS

Significant improvements occurred between admission and the mid time point of 85% IBW in the eating disorder (ED) symptomology outcome measures of EDE‑Q (mean difference [MD] = 1.066 ± 0.259) and CET (MD = 1.743 ± 0.627). A significant improvement occurred in the CDI (MD = 7.714  ± 2.343), and STAI (MD = 5.292 ± 2.121) measures between admission and discharge.

CONCLUSIONS

Psychological changes occur at different stages of treatment. Although it was difficult to determine what factors may predict the length of stay from the variables explored, it was observed that a lower weight at admission impacted negatively on the improvement of ED and anxiety symptoms, which may lead to stay in treatment for longer. Also, higher levels of compulsive exercise and depression were associated to worse outcomes.

LEVEL IV

Evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Adaptation and Implementation of an Intervention Programme on Spanish Carers and Adolescent Patients With an Eating Disorder: Study Protocol of a Randomized Controlled Trial

Introduction: One of the major problems with inpatient treatment of adolescent girls with an eating disorder (ED) is that the strategies learned during their hospital stay are not easily applied or maintained in their daily lives, and this has been related to high rates of relapse and readmission. The ECHOMANTRA programme was developed to optimize outcomes during and following inpatient or day-patient treatment. ECHOMANTRA is based on interventions for carers (Experienced Carers Helping Others, ECHO) and patients (Maudsley Model of Anorexia Nervosa Treatment for Adults, MANTRA) and is developed from the cognitive interpersonal model of anorexia (Schmidt and Treasure, 2006; Treasure and Schmidt, 2013). This study aims to describe the study protocol of a randomized controlled trial (RCT) for evaluating the efficacy of an adaptation of a novel intervention for patients and carers (ECHOMANTRA) to be implemented as an add-on to treatment-as-usual (TAU).

Method: In a multi−center pilot RCT, 80 female adolescent patients with a DSM-5 diagnosis of an ED and their carers will be invited to participate in the study. They will then be randomized to receive either the ECHOMANTRA intervention as an add-on to TAU or TAU alone. A repeated measures design will be conducted across four time points. Primary outcomes will be patient psychological well-being and eating disorder symptoms, and secondary outcomes will include body mass index, obsessive-compulsive symptoms, perfectionism, motivation to change and psychosocial adjustment. For carers, outcome variables will include psychological well-being, expressed emotion, accommodation and enabling behaviors, burden, and care skills.

Discussion: The results from this trial will establish the effectiveness of ECHOMANTRA and may reveal whether and to what extent this novel intervention can optimize outcomes during and following inpatient treatment. This study will also provide the adaptation of the ECHOMANTRA in the Spanish context for inpatient/day-care treatment.

[What factors explain the length of hospitalization for anorexia nervosa: A systematic review]

OBJECTIVES

The cost of hospital treatment for anorexia nervosa (AN) is very high given its duration. Identifying factors related to length of hospital stay (LOS) would make it possible to consider targeted therapeutic strategies that, by optimizing care, would reduce their duration and costs. The objective of this work is to identify the factors related (predictive and associated) to LOS for AN.

METHODS

Systematic review of existing literature up to October 2020, based on Pubmed, according to PRISMA recommendations (Preferred Reported Items for Systematic reviews and Meta-Analysis). Factors related to LOS have been described in two categories: factors related to clinical aspects ; and factors related to therapeutic aspects and management modalities. We distinguished predictive factors (identified as pre-hospitalization or contemporaneous with hospital admission) and associated factors (observed during hospitalization) for each category.

RESULTS

Thirteen articles were selected. Samples from the selected studies ranged from 35 to 381 subjects, mostly women with restrictive type AN (R-AN), but some samples included all types of AN, or focused on purging-type forms. The mean age at admission ranged from 13.6 years (Standard Deviation-SD:±1.6) to 30.3 years (SD :±13.9), corresponding to adolescent, adult or mixed samples. Mean body mass indices at admission ranged from 12.3 (SD±1.4) to 16.6 (SD:±2.1). The duration of disease progression ranged from 11.7 months±2.2 to 9.7 years. Mean LOS are short for studies conducted in pediatrics or in medical services (ranging from 13.0 days [SD±7.3] to 22.1 days [SD±9.4]); they are more variable for studies conducted in psychiatry: from 15.6 days (SD±1.0) to 150.2 days (SD±80.8). Among the factors related to an increase in LOS, clinical predictors included: older age at onset or admission; longer duration of the disorder; low minimum body weight during AN; low BMI at admission; purgative form of anorexia nervosa; and high levels of dietary symptoms (asceticism and ineffectiveness dimensions on Eating Disorder Inventory-2). Therapeutic and management modality predictive factors were: a higher number of hospitalizations for AN; the use of enteral nutrition (nasogastric or percutaneous gastric tube) on admission or during hospitalization; the use of intravenous renutrition coupled with oral renutrition; hospitalization far from the patient's home; absence of hospital care in psychiatry after medical stabilization in a somatic unit; compulsory hospitalization. Associated factors were: the presence of psychiatric comorbidities; greater weight gain during hospitalization. Among the factors related to a decrease in LOS, the clinical predictive factor were: greater self-confidence at admission (measured by the Eating Disorder Recovery Self-Efficacy Questionnaire). Therapeutic and management modality predictors included: increased caloric intake of oral renutrition on admission; intake of oral nutritional supplements on admission; and hospitalization in urban areas. The associated factor was: compliance with the weight contract in the adolescent population.

DISCUSSION

Factors related to an increase in LOS are explained by: higher resistance to treatment, higher severity of the disease, the time required for weight gain in services using cognitive-behavioural therapy, complications associated with renutrition modalities such as parenteral renutrition, difficulties in organising outpatient follow-up which require better consolidation of inpatient treatment and the lack of multidisciplinary care in medical services. Factors related to a decrease in LOS are due to: faster weight gain, the presence of a greater number of outpatient follow-up structures close to the hospital and better adherence to treatment to complete the weight contract.

CONCLUSIONS

Taking these factors into account during hospitalization for AN would help optimize care, duration and costs. This situation therefore requires the development of therapeutic trials targeting the identified factors in order to reduce LOS in the treatment of AN.

Length of stay for anorexia nervosa: Systematic review and meta-analysis

OBJECTIVE

Evidence regarding global trends in length of stay for patients with anorexia nervosa is limited. The aim of this study is to conduct a meta-analysis examining the length of stay for anorexia nervosa patients globally, and to investigate moderators of the variance.

METHOD

Medline, EMBASE and PsycINFO were searched for studies published up to January 2019. Two independent reviewers assessed the eligibility of each report based on predefined inclusion criteria. A meta-analysis was performed to calculate a pooled mean length of stay using the random-effects model. Subgroup analyses and meta-regression were conducted to explore potential sources of heterogeneity between studies.

RESULTS

Of 305 abstracts reviewed, 71 studies met the inclusion criteria, generating 111 datasets. The pooled mean length of stay (95% confidence interval) was 76.3 days (73.3, 79.4) using the random-effects model, with marked variation across countries and time. Heterogeneity between studies was explained by age and admission body mass index.

CONCLUSIONS

This meta-analysis found that although clinical features do contribute to length of admissions for anorexia nervosa, there are also global and temporal variations. Future research should provide an in-depth analysis of why and how this variation exists and what the impact is on the well-being of people with anorexia nervosa.

Evaluating empirically valid and clinically meaningful change in intensive residential treatment for severe eating disorders at discharge and at a 6-month follow-up

PURPOSE

The present study evaluated the statistical and clinical significance of symptomatic change at discharge and after 6 months of an intensive residential treatment for patients with eating disorders (ED), and explored the individual factors that may affect therapeutic outcomes.

METHODS

A sample of 118 female ED patients were assessed at intake and discharge on the following dimensions: BMI, ED-specific symptoms, depressive features, and overall symptomatic distress. A subsample of 59 patients filled out the same questionnaires at a 6-month follow-up after discharge.

RESULTS

Findings evidenced statistically significant changes in all outcome measures at both discharge and follow-up. Between 30.1 and 38.6% of patients at discharge and 35.2-54.2% at the 6-month follow-up showed clinically significant symptomatic change; additionally, 19.8-29.1% of patients at discharge and 22.9-38.3% at follow-up improved reliably. However, 34.9-39.8% remained unchanged and 2-4.8% worsened. At the 6-month follow-up, 21.3-25.9% showed no symptomatic change and 0-3.7% had deteriorated. Unchanged and deteriorated patients had an earlier age of ED onset and were more likely to suffer a comorbid personality pathology and to be following concurrent pharmacological treatment.

CONCLUSIONS

Results suggested that intensive and multimodal residential treatment may be effective for the majority of ED patients, and that therapeutic outcomes tend to improve over time. Prevention strategies should focus on early onset subjects and those with concurrent personality pathology.

LEVEL OF EVIDENCE

Level III, evidence obtained from a longitudinal cohort study.

Mortality and risk assessment for anorexia nervosa in acute-care hospitals: a nationwide administrative database analysis

BACKGROUND

Anorexia nervosa (AN) is a common eating disorder with the highest mortality rate of all psychiatric diseases. However, few studies have examined inpatient characteristics and treatment for AN. This study aimed to characterise the association between mortality and risk factors in patients with AN in acute-care hospitals.

METHODS

We conducted a nationwide, retrospective analysis of the Japanese Diagnosis and Procedure Combination inpatient database. Data extraction occurred from April 2010 to March 2016. We estimated in-hospital mortality and identified independent risk factors, using multivariate logistic regression analysis to examine patient characteristics and physical and psychological comorbidities.

RESULTS

We identified 6937 patients with AN aged ≥12 years in 885 acute-care hospitals. Of these, 361 (5.2%) were male. Male and female participants' median ages at first admission were 34 (17-65) and 28 (17-41) years, respectively. In total, 195 in-hospital patient deaths, including 22 (6.1%) men and 173 (2.6%) women, it was observed that the unadjusted odds ratio of mortality for male patients was more than twice that for female patients (OR: 2.40, 95% CI: 1.45-3.81). Multivariate logistic regression analysis demonstrated an adjusted odds ratio of 2.19 (95% CI: 1.29-3.73). Age at first hospital admission, percentage of ideal body weight, comorbidities, and hypotension were significantly associated with increased mortality risk, but the frequency of hospitalization, bradycardia, and other psychiatric disorders were not. Treatment in a university hospital was associated with lower mortality risk (odds ratio: 0.45, 95% CI: 0.30-0.67).

CONCLUSION

The results highlighted sex differences in mortality rates. Potential risk factors could contribute to improved treatment and outcomes. These retrospective findings indicate a need for further longitudinal examination of these patients.

Physical restraint during inpatient treatment of adolescent anorexia nervosa: frequency, clinical correlates, and associations with outcome at five-year follow-up

BACKGROUND

Studies of the use and effects of physical restraint in anorexia nervosa (AN) treatment are lacking. The purpose of this study was to describe the frequency of physical restraint in a specialized program for adolescents with AN, and to examine if meal-related physical restraint (forced nasogastric tube-feeding) was related to 5-year outcome.

METHOD

Thirty-eight (66% of 58) patients with AN (mean age 15.9, SD = 1.9) admitted to a regional, specialized adolescent eating disorders (ED) inpatient unit. Patient data, including restraint episodes, were obtained from hospital records, and outcome was assessed at a 5-year follow-up.

RESULTS

A total of 201 restraint episodes occurred over 5513 days of inpatient treatment, including 109 meal-related episodes and 56 episodes to avoid self-harm. Twelve (32%) patients experienced at least one restraint episode during the admission, of which eight (21%) experienced meal-related restraint. Four patients represented 91% of all restraint episodes, experiencing 10 or more episodes during admission. Meal-related restraint was significantly associated with a higher rate of persisting ED diagnosis, but not with weight gain during admission, EDE-Q global score or BMI at follow-up.

CONCLUSIONS

Restraint episodes occurred rather infrequently. A small number of patients (n = 4) accounted for a high proportion of episodes (91%). More knowledge is important to reduce the need for restraint in treatment for AN.

Canadian practice guidelines for the treatment of children and adolescents with eating disorders

OBJECTIVES

Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline.

METHODS

Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders.

RESULTS

Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed.

CONCLUSIONS

Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.

Outcomes of inpatient psychological treatments for children and adolescents with eating disorders at time of discharge: a systematic review

BACKGROUND

Recommended first line treatment for children and adolescent eating disorders is outpatient therapy. However, a significant number of children and adolescents with eating disorders continue to require inpatient treatment during the course of their illness. The effect of psychological treatments in an inpatient setting on outcomes at the time of discharge remains unclear. This paper presents the results of a review of the literature on outcomes at the time of discharge following inpatient psychological treatment for children and adolescents with eating disorders.

MAIN BODY

The majority of studies found were observational and of low quality. The most consistently reported positive outcome of inpatient treatment is weight gain. Results related to symptom change and motivation vary between studies. Within the inpatient setting, there is considerable heterogeneity in the types of treatments offered, goals of treatment, length of stay and outcomes measured.

CONCLUSION

There remains a paucity of high-quality studies examining the effect of psychological treatments provided to children and adolescents in an inpatient setting. The significant heterogeneity between studies makes it not possible to compare across studies. Future research should aim to resolve these deficiencies in order to better determine the specific factors that contribute to positive outcomes of inpatient treatment for children and adolescents with eating disorders.

Trends in Psychiatric Hospitalization of Children and Adolescents in Spain between 2005 and 2015

Eating disorders are on top of chronic conditions in children and adolescents, and the most severe cases may require hospitalization. Inpatient psychiatric treatment is one of the most expensive ones and therefore the efforts when treating eating disorders should focus on avoiding and shortening admissions, as well as preventing readmissions. Advances in of eating disorders treatment lie in an accurate knowledge of those patients requiring admission. This study examined the Conjunto Mínimo Básico de Datos-the largest public hospitalization database in Spain-to estimate the prevalence of eating and other psychiatric disorders during childhood and adolescence. It is a cross-sectional study of the hospital discharges in Castilla y León (Spain) from 2005 to 2015, in which patients under 18 years old with a psychiatric diagnosis at discharge were selected. Trends in the rates of hospitalization/1000 hospitalizations per year were studied by joinpoint regression analysis. Conclusions: eating disorders were the only group that presented an upward and continuous trend throughout the study period. This statistically significant increase showed an annual change of 7.8%.

Stationäre Behandlung von Kindern und Jugendlichen mit Anorexia nervosa und Bulimia nervosa

Zusammenfassung. Anorexia nervosa und Bulimia nervosa betreffen vor allem Jugendliche sowie junge Erwachsene, wobei das Ersterkrankungsalter sinkt, und bei Anorexia nervosa bereits 8-Jährige betroffen sein können. Häufig ist der Verlauf chronisch und kann sowohl schwere körperliche als auch psychische Komorbiditäten nach sich ziehen. Schlimmstenfalls enden Essstörungen tödlich (je nach Schweregrad der Erkrankung Mortalitätsraten bis zu 15 % bei Anorexia nervosa). Ein frühzeitiger Therapiebeginn geht mit einer verbesserten Prognose einher, weshalb die rasche Diagnosestellung von großer Bedeutung ist. Wesentlich hierfür ist die sichere Kenntnis der Diagnosekriterien sowie der essstörungstypischen Folgen. Es werden Aspekte der Symptomatik, Diagnostik, Differentialdiagnostik, Epidemiologie, Pathogenese, Funktionalität, sowie Therapiemöglichkeiten und eigene sowie internationale Studienergebnisse mit Schwerpunkt auf der stationären Therapie von Jugendlichen mit Anorexia nervosa und Bulimia nervosa ausgeführt.

Eating disorders-Related hospitalizations in Portugal: A nationwide study from 2000 to 2014

INTRODUCTION

Recent evidence suggests that incidence of Anorexia nervosa (AN) has remained stable over the last decades in Western Europe, while decreasing for Bulimia nervosa (BN). It is well-known that most individuals with an ED (Eating disorder) do not seek medical treatment.

OBJECTIVE

The present study analyses hospitalizations related with EDs held in mainland Portuguese public hospitals between 2000 and 2014.

METHOD

A retrospective observational study was performed gathering all inpatient episodes with primary or secondary diagnosis of ED. Number of patients, gender, mean age at discharge, suicide-attempts related hospitalizations, in-hospital mortality, length of stay, and mean charges were analyzed.

RESULTS

There were a total of 4,485 hospitalizations with an associated ED. AN was the most frequent ED (n = 2,806). Suicide attempt-related hospitalizations were most common among patients with BN (10.1% of BN hospitalizations) or AN (5.2% of AN hospitalizations).

DISCUSSION

AN has higher in-hospital mortality than BN. We observed a higher proportion of suicide related hospitalizations in BN when compared to AN. Although pica, rumination disorder, and psychogenic vomiting represent a smaller portion of all EDs, this study was the first to describe hospitalization trends for this set of EDs for a 15-year period, to the best of our knowledge.

Factors influencing the length of hospital stay of patients with anorexia nervosa - results of a prospective multi-center study

BACKGROUND

The length of stay (LOS) strongly influences anorexia nervosa (AN) inpatient weight outcomes. Hence, understanding the predictors of LOS is highly relevant. However, the existing evidence is inconsistent and to draw conclusions, additional evidence is required.

METHODS

We conducted a prospective, multi-center study including adult female inpatients with AN. Using stepwise linear regression, the following demographic and clinical variables were examined as potential predictors for LOS: admission BMI, AN-subtype, age, age of onset, living situation, partnership status, education, previous hospitalization, self-rated depression, anxiety and somatic symptoms (PHQ-9, PHQ-15, GAD-7), self-rated therapy motivation (FEVER) and eating disorder psychopathology (EDI-2 subscale scores).

RESULTS

The average LOS of the sample (n = 176) was 11.8 weeks (SD = 5.2). Longer LOS was associated with lower admission BMI (ß = -1.66; p < .001), purging AN-subtype (ß = 1.91; p = .013) and higher EDI-2 asceticism (ß = 0.12; p = .030). Furthermore, differences between treatment sites were evident.

CONCLUSIONS

BMI at admission and AN-subtype are routinely assessed variables, which are robust and clinically meaningful predictors of LOS. Health care policies might consider these variables. In light of the differences between treatment sites future research on geographical variations in mental health care seems recommended.

Transition Care in Anorexia Nervosa Through Guidance Online from Peer and Carer Expertise (TRIANGLE): Study Protocol for a Randomised Controlled Trial

TRIANGLE is a multicentre trial investigating whether the addition of a novel intervention for patients and carers (ECHOMANTRA) to treatment as usual (TAU) improves outcomes for people with anorexia nervosa (AN). ECHOMANTRA is based on the cognitive interpersonal model of AN and includes assessments, workbooks, videos, online groups and joint Skype sessions for patients and carers. People receiving intensive hospital treatment (N = 380) will be randomised to TAU or TAU plus ECHOMANTRA. Participants will be assessed over an 18-month period following randomisation. The primary outcome is patient psychological well-being at 12 months postrandomisation. Secondary outcomes include (i) patient's weight, eating disorder symptoms, motivation to change, quality of life and number of days in hospital at 12 months postrandomisation and (ii) carer's psychological well-being, burden and skills at 12 months (some outcomes will be assessed at 18 months postrandomisation). The results from this trial will establish the effectiveness of ECHOMANTRA.

TRIAL REGISTRATION

ISRCTN registry ISRCTN14644379, 08/12/2016. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Predictors of short-term outcome variables in hospitalised female adolescents with eating disorders

OBJECTIVE

Research in eating disorders (EDs) suggests that outcome variables other than that of the ED per se, such as the presence of comorbid disorders and overall functioning at follow-up, may influence the ED condition at that time. We sought to assess the factors potentially predicting these different outcome variables.

METHODS

Eighty-eight female adolescent in-patients with an ED were assessed on admission, discharge, and around one-year post-discharge using clinical interviews and self-rating questionnaires assessing ED and other relevant symptoms.

RESULTS

The mean body mass index (BMI) of patients with anorexia nervosa increased from admission to discharge and was maintained at follow-up. Twenty-eight patients were remitted at follow-up, whereas 48 and 12 patients had intermediate and poor ED-related outcome, respectively. Follow-up BMI was correlated with baseline BMI. Good ED-related outcome at follow-up according to accepted criteria was associated with more lifetime suicide attempts and more severe baseline ED symptomatology. Elevated psychiatric comorbidity at follow-up was associated with elevated baseline anxiety and with re-hospitalisation during the post-discharge follow-up period. Better academic/occupational functioning and social functioning at follow-up were associated with less lifetime suicide attempts, less re-hospitalisation and lower baseline anxiety.

CONCLUSIONS

In EDs, diverse factors may predict different outcome variables.

The medical risks of severe anorexia nervosa during initial re-feeding and medical stabilisation

BACKGROUND & AIMS

Objective evidence about the risks associated with anorexia nervosa and how to manage them, is limited. The aim of this study is to describe the medical risk profile, management and outcomes of a cohort of patients with severe anorexia nervosa (sAN) during medical stabilisation treatment.

METHODS

Retrospective analysis of case records gathered medical risk data for a 90 day high risk period, on 65 patients with sAN admitted to two specialist services. Prospectively established definitions of medical risk variables and significant complications were applied to the data to describe the risk profiles and outcomes.

RESULTS

Amongst this population with an average initial BMI of 12.8 kg/m², 74% developed no significant medical complications. Oral re-feeding over 60 days achieved an increase in mean BMI to 14.4 kg/m² and mean weight gain of 4 kg. No patients developed severe hypophosphatemia (<0.45 mmol/L) or any other indicators of a re-feeding syndrome. All the medical complications that arose were temporary.

CONCLUSIONS

Initial re-feeding and medical stabilisation of patients with severe AN can be managed safely in specialist inpatient and community settings with slow re-feeding. Although the prevalence of complications was shown to be low, slight worsening of medical risk markers and increased incidence of complications did occur during initial re-feeding. The limited comparable published data appears to support slower rates of re-feeding, showing fewer abnormal results and complications. There is however a need for a definitive prospective multi-centre observational cohort study to investigate risks factors, and the effects of treatment on medical outcomes, in a large sample with varied rates of re-feeding.

Inpatient Treatment for Adolescents with Anorexia Nervosa: Clinical Significance and Predictors of Treatment Outcome

This study evaluated the clinical significance as well as predictors of outcome for adolescents with severe anorexia nervosa (AN) treated in an inpatient setting. Body mass index (BMI), eating disorder (ED) symptoms [Eating Disorder Inventory-2 (EDI-2)], general psychopathology and depression were assessed in 238 patients at admission and discharge. BMI increased from 14.8 + 1.2 to 17.3 + 1.4 kg/m(2). Almost a fourth (23.6%) of the patients showed reliable changes, and 44.7% showed clinically significant changes (EDI-2). BMI change did not significantly differ between those with reliable or clinically significant change or no reliable change in EDI-2. Length of stay, depression and body dissatisfaction were negative predictors of a clinically significant change. Inpatient treatment is effective in about two thirds of adolescents with AN and should be considered when outpatient treatment fails. About one third of patients showed significant weight gain, but did not improve regarding overall ED symptomatology. Future studies should focus on treatment strategies for non-responders.

Comparison between enteral nutrition and intravenous hyperalimentation in patients with eating disorders: results from the Japanese diagnosis procedure combination database

OBJECTIVE

Eating disorders (EDs) are some of the most common chronic disorders in adolescent girls, and have some of the worst prognoses among psychiatric diseases. However, reported data on mortality and morbidity of ED patients are scarce, and no previous studies have compared the short-term outcomes of enteral nutrition (EN) and intravenous hyperalimentation (IVH) in patients with EDs.

METHOD

Using the Diagnostic Procedure Combination database, a national inpatient database in Japan, we searched for ED patients who received EN or IVH. We investigated the backgrounds, complications, and in-hospital mortality for all ED patients. We compared the length of stay between the EN and IVH groups using the Cox regression model. In-hospital mortality was compared between the groups using propensity score matching and inverse probability weighting.

RESULTS

We identified 3,611 patients with EDs from 540 hospitals. The mean body mass index was 13.1 ± 1.9 kg/m(2); 41 (1.1 %) patients died. The mean length of stay was 61.7 days. Compared with the EN-alone group (n = 634), the IVH-alone group (n = 278) showed significantly higher proportions of sepsis (0.5 vs. 5.8 %; p < 0.001) and disseminated intravascular coagulation (0.5 vs. 2.9 %; p = 0.005). The Cox regression showed no significant difference in hospital discharge between the two groups. Propensity-matched analysis evidenced lower in-hospital mortality in the EN group than the IVH group (0.4 vs. 3.0 %; p = 0.019).

DISCUSSION

ED patients treated with IVH were significantly more likely to have higher in-hospital mortality and morbidity than those receiving EN.

Specialized inpatient treatment of adult anorexia nervosa: effectiveness and clinical significance of changes

BACKGROUND

Previous studies have predominantly evaluated the effectiveness of inpatient treatment for anorexia nervosa at the group level. The aim of this study was to evaluate treatment outcomes at an individual level based on the clinical significance of improvement. Patients' treatment outcomes were classified into four groups: deteriorated, unchanged, reliably improved and clinically significantly improved. Furthermore, the study set out to explore predictors of clinically significant changes in eating disorder psychopathology.

METHODS

A total of 435 inpatients were assessed at admission and at discharge on the following measures: body-mass-index, eating disorder symptoms, general psychopathology, depression and motivation for change.

RESULTS

20.0-32.0% of patients showed reliable changes and 34.1-55.3% showed clinically significant changes in the various outcome measures. Between 23.0% and 34.5% remained unchanged and between 1.7% and 3.0% deteriorated. Motivation for change and depressive symptoms were identified as positive predictors of clinically significant changes in eating disorder psychopathology, whereas body dissatisfaction, impulse regulation, social insecurity and education were negative predictors.

CONCLUSIONS

Despite high rates of reliable and clinically significant changes following intensive inpatient treatment, about one third of anorexia nervosa patients showed no significant response to treatment. Future studies should focus on the identification of non-responders as well as on the development of treatment strategies for these patients.