Survey of regional health care providers on selection of treatment for bulimia nervosa

Towards collaborative care for severe and enduring Anorexia Nervosa - a mixed-method approach

BACKGROUND

Severe and Enduring Eating Disorders (SEED), in particular SEED-Anorexia Nervosa (SE-AN), may represent the most difficult disorder to treat in psychiatry. Furthermore, the lack of empirical research in this patient group, and, consequently the lack of guidelines, call for an urgent increase in research and discussion within this field. Meanwhile experts concur that effective care should be structured in a collaborative manner.

OBJECTIVE

To identify the challenges in providing care to patients with SE-AN in the Dutch healthcare context, and propose a collaborative care treatment model to address these issues.

METHODS

A pragmatic mixed-method approach was used, structured as follows: (1) Identifying perceived barriers and treatment needs from the viewpoint of both patients and eating disorder healthcare professionals through an evaluation questionnaire; (2) Investigating current treatment practices for SEED/SE-AN via benchmarking; (3) Gaining insight into the optimal structure and content of care by interviewing network partners and experts-by-experience. Based on these findings, and drawing from literature on severe and enduring disorders, a treatment model for SE-AN was proposed and implemented.

RESULTS

The key challenges identified included a lack of knowledge about eating disorders among network partners, treatment ambivalence among patients and poor collaboration between professionals. The proposed model enhances self-management and collaborative relationships with healthcare providers, offers user-friendly and practical guidance, and aims at stabilization, reducing relapses, deterioration, and readmissions, thereby being cost-effective. Importantly, the model operates across levels of care (primary, secondary, tertiary).

CONCLUSION

This study, describing a collaborative care program for SE-AN, developed and implemented in a highly specialized treatment center for eating disorders, sets the stage for further explanatory/efficacy research to build on the findings in this study, with the following aims: addressing the critical gap in care for SEED/SE-AN, improving better healthcare organization, reducing relapse rates, and lowering costs for this often overlooked patient group.

To deliver or not to deliver cognitive behavioral therapy for eating disorders: Replication and extension of our understanding of why therapists fail to do what they should do

OBJECTIVE

This study investigated the extent to which therapists fail to apply empirically supported treatments in a sample of clinicians in The Netherlands, delivering cognitive behavioral therapy for eating disorders (CBT-ED). It aimed to replicate previous findings, and to extend them by examining other potential intra-individual factors associated with the level of (non-)use of core CBT-ED techniques.

METHOD

Participants were 139 clinicians (127 women; mean age 41.4 years, range = 24-64) who completed an online survey about the level of use of specific techniques, their beliefs (e.g., about the importance of the alliance and use of pretreatment motivational techniques), anxiety (Intolerance of Uncertainty Scale), and personality (Ten Item Personality Inventory).

RESULTS

Despite some differences with Waller's (2012) findings, the present results continue to indicate that therapists are not reliably delivering the CBT-ED techniques that would be expected to provide the best treatment to their patients. This 'non-delivery' appears to be related to clinician anxiety, temporal factors, and clinicians' beliefs about the power of the therapeutic alliance in driving therapy outcomes.

DISCUSSION

Improving treatment delivery will involve working with clinicians' levels of anxiety, clarifying the lack of benefit of pre-therapy motivational enhancement work, and reminding clinicians that the therapeutic alliance is enhanced by behavioral change in CBT-ED, rather than the other way around.

Implementing Group CBT for Depression Among Latinos in a Primary Care Clinic

Depression in low-income Latino populations can be treated using group cognitive behavioral therapy (GCBT). However, effective delivery of GCBT for depression in primary care settings is often impeded by high dropout rates and poor homework adherence. In this study, we describe the structure, processes, and outcomes (including attendance, homework completion, and symptom measures) of GCBT for Spanish-speaking Latino patients with depression in an urban public sector primary care setting. For this study, 96 Latino patients in a primary care clinic participated in at least 1 session of GCBT. Although depressive symptoms among these patients, as measured by the PHQ-9, significantly decreased during treatment, attendance and homework completion were limited. Even with a strategy in place to allow patients to continue in treatment after missing several sessions, 23% of patients dropped out of therapy following their initial session, and approximately half of all patients completed less than 50% (or 8) therapy sessions. Homework was only completed 23% of the time it was checked. Greater session attendance prospectively predicted lower depressive symptoms over time. We discuss potential strategies to increase engagement, treatment effects, and symptom reduction for depression in primary care settings.

Factors influencing the utilization of empirically supported treatments for eating disorders

This study expands upon previous research investigating the use of empirically supported treatments (ESTs) for eating disorders by surveying a large sample of clinicians who specialize in treating eating disorders. Surveys developed for this study were sent to 698 members of a large, professional, eating disorder organization who were listed as treatment providers on the organization's website. Despite clinicians reporting frequently using CBT techniques, most identified something other than CBT or IPT as their primary approach to treatment. In contrast with previous research, the majority had received prior training in the use of manual-based treatments. However, consistent with previous investigations, most denied regular use of such treatments. Although manual-based CBT and IPT are referred to as "treatments of choice," professional clinicians in the field are not consistently using them. Responses suggest several barriers to the utilization of ESTs in practice.

Who is providing what type of psychotherapy to eating disorder clients? A survey

OBJECTIVE

Little is known about the psychotherapies delivered to eating-disordered clients by community therapists. We sought to describe the education and training of psychotherapists working with eating-disordered clients, the psychotherapeutic approaches used, and the reasons for use.

METHOD

Eligible Calgary clinicians were identified and asked to complete a 25-item telephone interview.

RESULTS

The response rate was 74%. Educational backgrounds and fields of specialization of clinicians who completed the survey (n = 52) varied widely, as did the psychotherapies used. The most common primary therapeutic orientations of respondents were eclectic therapy (50%), cognitive-behavioral therapy (CBT; 33%), and addiction-based therapy (6%). Most clinicians (87%) reported frequently using CBT techniques with eating-disordered clients. The reasons given for using primary therapeutic approaches varied by clinicians' preferred therapeutic approach and education level.

CONCLUSION

Clinicians generally choose to tailor treatment to individual needs rather than base decisions on the level of empirical support. These findings have implications for dissemination of empirically supported psychotherapies.

Psychological Treatment of Eating Disorders

Manual-based cognitive behavior therapy (CBT) is presently the most effective treatment of bulimia nervosa. Its efficacy is limited, however. Different strategies for improving upon current manual-based CBT are discussed, including combining CBT with antidepressant medication, integrating CBT with alternative psychological therapies, and expanding the scope and flexibility of manual-based CBT. CBT is underutilized in clinical practice. Dissemination of evidence-based treatment is a priority. Research on anorexia nervosa is minimal. Effective treatments have yet to be developed, although the Maudsley method of family therapy has shown the most promise in the treatment of adolescents. The most commonly seen eating disorders in clinical practice are those classified as "eating disorder not otherwise specified." With the exception of binge eating disorder (BED), however, they have been neglected by researchers. Several psychological therapies have been shown to be effective in treating BED. Controversy exists over whether treatment-specific effects have been identified. Whereas treatments have proved effective in eliminating binge eating and associated eating disorder psychopathology, achieving clinically significant weight loss remains a challenge.

Eating disorders guidelines from NICE

CONTEXT

January, 2004, marked the publication of NICE guidelines for the treatment of eating disorders, a series of recommendations from a multidisciplinary, comprehensive, and rigorous process. The recommendations are assigned a grade from A (strong empirical support from well-conducted randomised trials) to C (expert opinion without strong empirical data). Over 100 recommendations were made, most of which were given a C grade. No specific recommendations were made for anorexia nervosa. Cognitive behavioural therapy for bulimia nervosa was assigned grade A because of the evidence showing that it is superior to other psychological and drug treatments. Antidepressants for bulimia nervosa were given grade B. No specific recommendations were made for atypical eating disorders except for binge-eating disorder (cognitive behavioural therapy was recommended [A]).

STARTING POINT

The methodological rigour of the NICE guidelines is in contrast with the current Practice Guideline for Eating Disorders (PGED) of the American Psychiatric Association. PGED does not detail criteria for evaluating supporting research. Instead of making clear recommendations, PGED is uncritically inclusive and emphasises subjective judgment of individual clinicians. The NICE guidelines balance recommending specific treatments against the importance of clinical judgment when guideline recommendations are not readily applicable.

WHERE NEXT

Evidence-based guidelines are limited by the quality of the available research and its clinical relevance. The NICE guidelines underscore the absence of sufficient evidence for guidance in several important areas, such as atypical eating disorders (eating disorders not otherwise specified) which are the most common. Research on the treatment of these atypical eating disorders is needed. Evidence-based psychological treatments are not routinely implemented in general practice. Dissemination of these demonstrably effective treatments poses a challenge, and learning how to implement evidence-based psychological treatments and monitor their use is a research priority.