Treatment engagement in eating disorders: who exits before treatment?

An exploration of patient experiences of transitioning to a remote day programme following inpatient treatment in an adult eating disorder service

WHAT IS KNOWN ON THE SUBJECT?: Traditionally, treatment for eating disorders (EDs) has been provided on an inpatient or outpatient basis, but more recently other levels of treatment provision to include, day care (DC) and community outreach programmes, have been developed. There is limited research exploring the experience of patients who have transitioned from inpatient ED treatment to a remote DC treatment. This lack of knowledge can impact mental health nurses' understanding of what that experience is like for patients and hence may influence the efficacy of collaboration and inclusion between patients and nurses. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This research addresses this dearth of knowledge and adds to our understanding of patients' experiences of attending a remote DC programme following a period of inpatient treatment for an ED. This is an important study for nurses and other mental health professionals working with people in ED treatment, as it highlights the specific challenges and anxieties of transitioning from inpatient to a remote DC programme and the individualized supports advisable during this process. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This research provides a basis on which nurses can understand and address the challenges experienced by patients after transitioning to a less intensive supportive ED programme. The understanding of these experiences will enhance the therapeutic alliance between the nurse and patient, which will in turn support the patient in increasing agency as they progress through their recovery. This research provides a foundation on which to develop specific supports that need to be in place to help patients manage the anxieties they experience as they transition to a less intense and remote treatment. Findings from these lived experiences can be used to support the development of similar DC programmes for EDs in other settings.

ABSTRACT

INTRODUCTION: Day care (DC) treatment for people with an eating disorder (ED) provides for an easier transition from hospital to home, along with a treatment milieu where patients can maintain occupational and social functioning and allow for the transfer of newly acquired skills to everyday life.

AIM

To explore patients' experiences of attending a remote day programme following intense inpatient treatment in an adult ED service.

METHOD

A qualitative descriptive methodology informed the study. In-depth semi-structured interviews were conducted with 10 consenting patients. A thematic analysis framework was used to guide the process of data analysis.

RESULTS

Three themes reflected participants' experiences: 'Moving On: Preparing for Change', 'Navigating a New Support System' and 'Increasing Agency'.

DISCUSSION

An underlying issue for participants was an ongoing but changing experience of anxiety. While anticipatory anxiety is evident in preparing for discharge, this is replaced with a real-time anxiety as they endeavour to negotiate an effective support network.

IMPLICATIONS FOR PRACTICE

The findings from this study provide a basis on which mental health nurses can develop timely and effective treatment and support systems with patients who are transitioning from a high support inpatient ED programme to a less intensive ED remote DC programme.

Psychotherapies for eating disorders: findings from a rapid review

BACKGROUND

Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development.

METHODS

The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper.

RESULTS

281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence.

CONCLUSIONS

Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.

Pharmacotherapy, alternative and adjunctive therapies for eating disorders: findings from a rapid review

BACKGROUND

The current review broadly summarises the evidence base for pharmacotherapies and adjunctive and alternative therapies in the treatment of eating disorders and disordered eating.

METHODS

This paper forms part of a Rapid Review series examining the evidence base in the field of eating disorders. This was conducted to inform the Australian National Eating Disorder Research and Translation Strategy 2021-2030. ScienceDirect, PubMed and Ovid/Medline were searched for included studies published between 2009 and 2021 in English. High-level evidence such as meta-analyses, large population studies and randomised control trials were prioritised, and grey literature excluded. Data from included studies relating to pharmacotherapy, and to adjunctive and alternative therapies in eating disorders, were synthesised and disseminated in the current review.

RESULTS

A total of 121 studies were identified, relating to pharmacotherapy (n = 90), adjunctive therapies (n = 21) and alternative therapies (n = 22). Some of the identified studies involved combinations of the above (e.g. adjunctive pharmacotherapy). Evidence of efficacy of interventions across all three categories was very limited with few relevant high quality clinical trials. There was a particular scarcity of evidence around effective treatments for anorexia nervosa (AN). With treatment of bulimia nervosa (BN), fluoxetine has exhibited some efficacy leading to regulatory approval in some countries. With binge eating disorder (BED), recent evidence supports the use of lisdexamfetamine. Neurostimulation interventions show some emerging efficacy in the treatment of AN, BN and BED but some, such as deep brain stimulation can be highly invasive.

CONCLUSION

Despite widespread use of medications, this Rapid Review has identified a lack of effective medications and adjunctive and alternative therapies in the treatment of EDs. An intensification of high-quality clinical trial activity and drug discovery innovation are required to better assist patients suffering from EDs.

Why Do Women with Eating Disorders Decline Treatment? A Qualitative Study of Barriers to Specialized Eating Disorder Treatment

Despite the fact that eating disorders (EDs) are conditions that are potentially life-threatening, many people decline treatment. The aim of this study was to investigate why women decline specialized ED treatment, including their viewpoints on treatment services. Eighteen semi-structured qualitative interviews were conducted with women who had declined inpatient or outpatient specialized ED treatment. A thematic analysis revealed five main themes: (1) Disagreement on treatment needs, (2) rigid standard procedures, (3) failure to listen, (4) deprivation of identity, and (5) mistrust and fear. The women had declined ED treatment because they believed that treatment was only focused on nutritional rehabilitation and that it failed to address their self-identified needs. From their perspectives treatment was characterized by rigid standard procedures that could not be adapted to their individual situations and preferences. They felt that the therapists failed to listen to them, and they felt deprived of identity and reduced to an ED instead of a real person. This investigation is one of the first of its kind to provide clues as to how treatment could be moderated to better meet the needs of women who decline specialized ED treatment.

Gender and help-seeking for an eating disorder: findings from a general population sample

PURPOSE

This study aimed to compare gender differences in eating disorder (ED) features and to examine the role of gender as a predictor of ED help-seeking controlling for other putative determinants, namely weight/shape overvaluation, age, BMI, and impairment in role functioning.

METHODS

Demographic, ED symptoms, and related data were collected during household interviews of individuals aged ≥ 15 years. One hundred and forty-eight participants (164 after data were weighted) with an ED syndrome were identified.

RESULTS

Compared to women, men with an ED were younger and had lower levels of purging and overvaluation. However, men and women with an ED had similar levels of functional impairment, binge eating and strict dieting. In univariate analyses, males in general, but not males with an ED, were significantly less likely than females to seek help for an ED. In multivariate analysis of people with an ED, only BMI was significantly associated with treatment-seeking.

CONCLUSION

Functional health impairment and common ED behaviours were similar for men and women with EDs. Gender may not be a primary reason to be more or less likely to seek help for an ED. Rather, other features, most notably, a higher BMI, appear to be stronger predictors of ED-specific help-seeking.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Characteristics of patients in an eating disorder sample who dropped out: 2-year follow-up

OBJECTIVE

This manuscript explores the characteristics of individuals diagnosed with an eating disorder who dropped out of treatment, compared with those who completed it.

METHOD

The participants were 196 patients diagnosed with eating disorders (according to DSM-IV-TR criteria) who consecutively began treatment for the first time in an eating disorders unit. They were assessed at baseline with a set of questionnaires evaluating eating habits, temperament, and general psychopathology. During the follow-up period, patients who dropped out were re-assessed via a telephone interview.

RESULTS

In the course of a 2-year follow-up, a total of 80 (40.8%) patients were labeled as dropouts, and 116 (59.2%) remaining subjects were considered completers. High TCI scores in the character dimensions of Disorderliness (NS4) (p < .01) and total Novelty Seeking (NST), along with low scores in Dependency (RD4), were significantly associated with dropout in the course of 2 years. Once the results were submitted to logistic regression analysis, dropout only remained associated with high scores in Disorderliness (NS4) and, inversely, with an initial Anorexia Nervosa (AN) diagnosis (p < .05). Reasons for dropout stated by the patients included logistic difficulties, subjective improvement of their condition, and lack of motivation.

DISCUSSION

Clinicians should handle the first therapeutic intervention with particular care in order to enhance their understanding of clients and their ability to rapidly identify those who are at risk of dropping out of treatment.

LEVEL OF EVIDENCE

Level III: Cohort Study.

Depressive symptoms, alcohol and other drug use, and suicide risk: Prevention and treatment effects from a two-country online eating disorder risk reduction trial

OBJECTIVE

Eating disorders are known to have high comorbidity, and the current report outlines the impact of an online eating disorder risk reduction program on brief, self-report measures of depressive symptoms, alcohol and other drug use, and suicidality.

METHOD

An online pragmatic, randomized-controlled trial was conducted with N = 316 young-women (M age = 20.80 years) across Australia and New Zealand. Media Smart-Targeted (MS-T) was a 9-module program released weekly while control participants received positive body image tips. Prevention effects (asymptomatic at baseline) and treatment effects (symptomatic at baseline) were investigated.

RESULTS

MS-T participants were 94% and 91% less likely than controls to develop Moderate or higher depressive symptoms at 6-month (MS-T = 3.3%; controls = 35.4%) and 12-month follow-up (MS-T = 3.4%; controls = 29.4%), respectively. MS-T participants did not commence using recreational drugs at any assessment point, compared to 18.2% of controls at a least one assessment point. Regarding treatment effects, MS-T participants were 84% more likely to no longer be using recreational drugs at 12-month follow-up (MS-T = 60%; controls = 21.1%). Mutitvariate logistic regressions revealed group, depressive symptoms and alcohol use to be significant predictors of elevated suicide risk, where being an MS-T participant, without depressive symptoms and not drinking alcohol, significantly lowered likelihood of developing elevated suicide risk. Disordered eating at post-program mediated the relationship between group and depressive symptoms across post-program to 12-mnoth follow-up.

DISCUSSION

MS-T shows promise as a program with important mental health benefits in addition to previous reports of lowered eating disorder diagnosis, risk and impairment.

Randomized controlled psychotherapy trials in eating disorders: Improving their conduct, interpretation and usefulness

BACKGROUND

While randomized controlled trials (RCTs) inform the efficacy and effectiveness of treatments, we need to understand that even RCTs can be associated with sub-optimal execution. This is of special pertinence to eating disorders given the majority of treatment studies involving cognitive behaviour therapy are of poor quality with respect to managing risk of bias adequately.

METHODS

The current paper outlines the components of a good RCT for psychotherapy, and examines ways to improve the conduct, interpretation, and usefulness of RCTs.

RESULTS

This includes managing reporting bias, recognizing the limits of randomization, applicability, and ethical considerations.

CONCLUSIONS

We highlight a number of strategies for future research, including issues related to utilizing a variety of designs to examine treatment outcomes, integrity, openness and reproducibility.

Treatment seeking for eating disorders: Results from a nationally representative study

OBJECTIVE

Eating disorders (EDs) are associated with substantial morbidity and mortality, yet up to 45% of individuals with EDs never receive treatment for their eating-related problems. This study sought to identify whether comorbidity, suicidality, discrimination, family cohesion, employment status, income, sex, age, marital status, religious belongingness, and ED-specific variables (body mass index and past-year ED diagnoses) were associated with treatment seeking in a nationally representative sample of individuals with EDs (N = 595; 77.8% women; 72.4% ethnic minority).

METHOD

Structural equation modeling was used to identify significant predictors of treatment seeking.

RESULTS

In the full sample, age was associated with a greater probability of treatment seeking, and men had a lower probability of seeking treatment. No variables were significant predictors of treatment seeking among individuals in Hispanic or Caucasian subgroups.

DISCUSSION

To our knowledge, this was the largest study to characterize predictors of treatment seeking in adults with EDs. Results from this study were consistent with existing literature documenting age and sex differences in treatment seeking among adolescents with an ED. Findings suggest a need for improved ED education and outreach-including greater mental health/ED literacy and decreased stigmatization for patients, providers, and the general public-and additional persuasive public-health messages to change community knowledge about treatment options for younger persons and men with EDs.

Recognition and management of eating disorders in children and young people

Eating disorders form a group of mental health conditions characterised by abnormal eating habits and are associated with high mortality rates. This article provides nurses working in various settings with evidence-based strategies to identify, manage and refer children and young people with eating disorders. It explores what eating disorders are, and their association with physical and psychiatric co-morbidities. Eating disorders have a significant effect on children and young people's health and development, and nurses have a vital role in managing them. This article presents a case study that illustrates some of the challenges nurses may experience when managing children and young people with eating disorders.

Initial treatment seeking from professional health care providers for eating disorders: A review and synthesis of potential barriers to and facilitators of "first contact"

The objective of this study is to provide a comprehensive review of empirical research exploring barriers to and facilitators of initial treatment seeking ("first contact") from professional health care providers by adults and young adults with eating disorders (EDs). A search of databases PsycINFO and MEDLINE using the terms "treatment" and "eating disorder*" yielded 9,468 peer-reviewed articles published from January 1945 to June 2016. Screening identified 31 articles meeting the following criteria: (1) participants were 16 or older and presented with a self-reported or clinically diagnosed ED; (2) studies focused on (a) initial treatment seeking (b) for an ED (c) from professional health care providers; (3) articles were empirical, and (4) peer reviewed. Quantitative studies revealed few consistent correlates of treatment seeking, perhaps because most variables were examined in only one or two investigations. Variables with some degree of predictive utility (i.e., produced significant results in multiple studies) were age (older), ethnicity (nonethnic minority), ED type (anorexia, purging BN), specific ED-related behaviors (i.e., purging), and time spent on a treatment waitlist following referral (less). Although BMI was one of the most investigated variables, it did not predict treatment seeking. Qualitative studies revealed the following perceived barriers: (1) personal feelings of shame/fear, (2) ED-related beliefs/perceptions, (3) lack of access/availability, and (4) aspects of the treatment process. Perceived facilitators included (1) health-related concerns, (2) emotional distress, and (3) social support. Implications for clinical practice and areas for further research are discussed. Results highlight the need for shared definitions and methodologies across studies of treatment seeking.

Motivo de abandono del tratamiento desde la perspectiva del paciente con un trastorno de la conducta alimentaria

Los tratamientos psicológicos y farmacológicos para los trastornos de la conducta alimentaria comportan costes personales y sanitarios. El propósito de nuestro estudio ha sido identificar los diferentes motivos que pueden estar asociados al abandono en ambos tipos de tratamientos en pacientes diagnosticados de un trastorno de la conducta alimentaria. Método: Se examinaron diversas características (edad, sexo, diagnóstico, motivos y tipos de abandono, y satisfacción respecto a la unidad de trastornos de la conducta alimentaria) en 212 pacientes atendidos en un servicio especializado en el tratamiento de trastornos de la conducta alimentaria durante un periodo de dos años. Resultados: Nuestros datos apoyan la hipótesis de que la causa de abandono de los tratamientos más frecuente ha sido la mejoría del trastorno de la conducta alimentaria. Conclusiones: Nuestros resultados indican que los motivos de abandono son heterogéneos. Se pueden establecer dos perfiles diferenciados de abandonos, uno ligado a la mejoría y a los impedimentos físicos temporales, y otro relacionado con motivos diversos.

Personality predicts drop-out from therapist-guided internet-based cognitive behavioural therapy for eating disorders. Results from a randomized controlled trial

Internet-based guided self-help cognitive behavioural therapy (ICBT) seems a promising way of delivering eating disorder treatment. However, treatment drop-out is a common problem and little is known about the correlates, especially in clinical settings. The study aimed to explore prediction of drop-out in the context of a randomized controlled trial within specialized eating disorder care in terms of eating disorder symptomatology, personality traits, comorbidity, and demographic characteristics. 109 outpatients diagnosed with bulimia nervosa or similar eating disorder were randomized to two types of ICBT. Participants were assessed with several clinical- and self-ratings. The average drop-out rate was 36%. Drop-out was predicted by lower scores in the personality traits Dutifulness and Assertiveness as measured by the NEO Personality Inventory Revised, and by higher scores in Self-affirm as measured by the Structural Analysis of Social Behaviour. Drop-out was also predicted by therapist factors: one therapist had significantly more drop-outs (82%) than the other three (M = 30%). Theoretical and clinical implications of the impact of the predictors are discussed.

Clinical characteristics associated with premature termination from outpatient psychotherapy for anorexia nervosa

AIM

The literature on clinical characteristics associated with premature termination of treatment (PTT) is beset with conflicting and non-replicated findings. This study explores clinical characteristics potentially associated with PTT in a randomised controlled outpatient psychotherapy trial for anorexia nervosa (AN).

METHODS

Participants were 56 women aged 17-40 years with spectrum AN. The completer group (n = 35) included those completing at least 15/20 planned sessions with the remainder of the sample comprising the PTT group (n = 21). Variables examined included demographic factors, psychosocial functioning, psychiatric history, lifetime comorbidity, temperament and eating disorder characteristics. Logistic regression was used to examine significant variables. A Kaplan-Meier survival curve was used to illustrate time taken to PTT.

RESULTS

The mean number of sessions in the PTT group was 8.1. Lower self-transcendence scores on the Temperament and Character Inventory were associated with PTT.

CONCLUSIONS

Recognising and addressing personality factors have the potential to enhance retention in treatment.