Does family-based treatment reduce the need for hospitalization in adolescent anorexia nervosa?

Protocol for a randomized clinical trial to confirm the effectiveness of online guided self-help family-based treatment for adolescent anorexia nervosa

BACKGROUND

The leading evidence-based treatment for anorexia nervosa (AN) in adolescents is Family-based Treatment (FBT). However, due to the intensive training requirements and lack of practitioners, it is often difficult for families to access FBT. Thus, innovations that improve access to care are needed. A pilot randomized study of a guided self-help version of Family-based Treatment (GSH-FBT) that utilized approximately 1/4 the amount of therapist time compared to FBT found that the approach was acceptable and appeared to achieve similar outcomes. The study protocol detailed in this manuscript compares the efficiency (clinician time) of GSH-FBT to Family-based Treatment via Videoconferencing (FBT-V) in a fully powered study in achieving clinical outcomes through a multi-site randomized clinical trial across the US and Ontario, Canada.

METHODS

This study will randomize the families of adolescents ages 12-18 (n = 200) who meet DSM-5 criteria for AN to receive either GSH-FBT or FBT-V. Participants will be randomized to 15 sixty-minute sessions of FBT-V or to 10 twenty-minute sessions of online GSH-FBT. Major assessments will be conducted by a masked assessor at baseline, within treatment, at the end of treatment (EOT), and 6 and 12 months after the end of treatment (EOT). The primary outcomes of this study are changes to body weight and eating disorder cognitions relative to clinician time used (relative efficiency of treatment modality).

CONCLUSIONS

The findings of this study may help increase access to care by providing a time efficient, affordable, more scalable intervention for adolescent AN compared to standard FBT.

Clinical Intervention Strategies and Family Dynamics in Adolescent Eating Disorders: A Scoping Review for Enhancing Early Detection and Outcomes

Background: This systematic review investigated the impact of familial factors on individuals aged 10-17 who have clinical signs or symptoms of eating disorders. Simultaneously, it scrutinized the involvement of the family in therapy, as well as other forms of intervention. Methods: The PsycINFO, PubMed, and Scopus databases were used to search for research material comprehensively. After applying specific criteria, 46 articles were deemed suitable and included in the systematic review. The study comprised a cohort of 4794 adolescents who received a diagnosis of either Anorexia Nervosa (AN), Bulimia Nervosa (BN), or Binge-Eating Disorder (BED). In addition, controls were utilized for 1187 adolescents, 1563 parents, 1809 siblings, and 11 other relatives. Results: The connection between family factors and eating disorders is primarily determined by the families' level of functioning, satisfaction with the family dynamic, parents' attitudes toward their children, and the role of food within the family system. Family Therapy was the most used psychotherapeutic approach in the treatment of AN. The incidence of reports in BN closely paralleled that of Cognitive-Behavioral Therapy (CBT) models. Articles about (Enhanced) CBT were exclusively associated with BED. Conclusions: Family-based approaches are crucial in comprehending, preventing, and addressing eating disorders in adolescents. Incorporating the study of family dynamics and actively engaging families in the treatment process can significantly enhance recovery rates and decrease the occurrence of relapses.

Adolescent utilization of eating disorder higher level of care: roles of family-based treatment adherence and demographic factors

BACKGROUND

Outpatient family-based treatment (FBT) is effective in treating restrictive eating disorders among adolescents. However, little is known about whether FBT reduces higher level of care (HLOC) utilization or if utilization of HLOC is associated with patient characteristics. This study examined associations between utilization of eating disorder related care (HLOC and outpatient treatment) and reported adherence to FBT and patient characteristics in a large integrated health system.

METHODS

This retrospective cohort study examined 4101 adolescents who received care for restrictive eating disorders at Kaiser Permanente Northern California. A survey was sent to each medical center to identify treatment teams as high FBT adherence (hFBT) and low FBT adherence (lFBT). Outpatient medical and psychiatry encounters and HLOC, including medical hospitalizations and higher-level psychiatric care as well as patient characteristics were extracted from the EHR and examined over 12 months post-index.

RESULTS

2111 and 1990 adolescents were treated in the hFBT and lFBT, respectively. After adjusting for age, sex, race/ethnicity, initial percent median BMI, and comorbid mental health diagnoses, there were no differences in HLOC or outpatient utilization between hFBT and lFBT. Females had higher odds of any utilization compared with males. Compared to White adolescents, Latinos/Hispanics had lower odds of HLOC utilization. Asian, Black, and Latino/Hispanic adolescents had lower odds of psychiatric outpatient care than Whites.

CONCLUSIONS

Reported FBT adherence was not associated with HLOC utilization in this sample. However, significant disparities across patient characteristics were found in the utilization of psychiatric care for eating disorders. More efforts are needed to understand treatment pathways that are accessible and effective for all populations with eating disorders.

Parental self-efficacy: Longitudinal impact on clinical outcomes across levels of care in adolescent anorexia nervosa

OBJECTIVE

Parental self-efficacy in the domain of weight restoration for adolescents with restrictive eating disorders is central to success in family-based interventions. We sought to characterize this parental self-efficacy during a brief hospitalization for medical stabilization and follow-up among patients with anorexia nervosa (AN) or atypical AN (AAN) enrolled in the StRONG clinical trial to understand the potential impact of inpatient treatment on caregiver empowerment.

METHODS

Patients were enrolled upon hospital admission and refed per protocol. We examined correlates of the Parents Versus Anorexia (PVA) scale, a measure of parental self-efficacy in the domain of weight restoration, at admission, discharge, 10-days, 1-month, and 3-months post-discharge. Multi-level models evaluated associations among PVA scores and change in %median BMI and Eating Disorder Examination-Questionnaire (EDE-Q) global scores over 3-months post-discharge.

RESULTS

Parents of N = 67 adolescents and young adults M(SD) age 15.79 (2.20) years and 85.00 (11.86) %median BMI participated. PVA scores did not change significantly during hospitalization (p = .053), which lasted on average 10.7 ± 4.5 days. PVA scores increased post-discharge (p = .009), with significant increase between discharge and 1-month post-discharge (p = .045). PVA scores were not associated with subsequent clinical outcomes. Rather, a main effect of time significantly predicted higher %median BMI and improved EDE-Q scores (p < .001).

DISCUSSION

The finding that parental self-efficacy did not deteriorate during the inpatient stay is promising given the medical necessity of hospitalization to ensure short-term safety in some cases and the importance of parental self-efficacy to support long-term recovery.

PUBLIC SIGNIFICANCE

Family-based treatment is the recommended treatment for young people with AN and AAN, serious psychiatric illnesses that may require inpatient medical stabilization. Prior evidence suggests that parental self-efficacy in the outpatient setting is a key component of treatment success. The current study suggests that parental self-efficacy and longer-term treatment outcomes are not undermined by a brief inpatient hospitalization.

Hospital-based higher calorie refeeding and mealtime distress in adolescents and young adults with anorexia nervosa or atypical anorexia nervosa

OBJECTIVE

The StRONG study demonstrated that higher calorie refeeding (HCR) restored medical stability faster in patients hospitalized with anorexia nervosa (AN) and atypical AN (AAN), with no increased safety events compared with standard-of-care lower calorie refeeding (LCR). However, some clinicians have expressed concern about potential unintended consequences of HCR (e.g., greater mealtime distress). The purpose of this study was to examine patient treatment preference and compare mealtime distress, food refusal, and affective states between treatments.

METHOD

Participants (N = 111) in this multisite randomized clinical trial were ages 12-24 years, with AN or AAN, admitted to hospital with medical instability who received assigned study treatment (HCR or LCR). Treatment preference was assessed prior to randomization in the full sample. In a subset of participants (n = 45), linear mixed effect models were used to analyze momentary ratings of mealtime distress (pre, during, and post-meals) and daily affective state during the hospitalization.

RESULTS

About half (55%) of participants reported a preference for LCR. Treatment assignment was not associated with food refusal, mealtime distress, or affective states in the subsample. Food refusal increased significantly over the course of refeeding (p = .018). Individuals with greater depression experienced more negative affect (p = .033), with worsening negative affect over time for individuals with higher eating disorder psychopathology (p = .023).

DISCUSSION

Despite understandable concerns about potential unintended consequences of HCR, we found no evidence that treatment acceptability for HCR differed from LCR for adolescents and young adults with AN and AAN.

PUBLIC SIGNIFICANCE

The efficacy and safety of higher calorie refeeding in hospitalized patients with anorexia nervosa has been demonstrated. However, it is not known whether higher calorie refeeding (HCR) increases meal-time distress. This study demonstrated that HCR was not associated with increased mealtime distress, food refusal, or affective states, as compared with lower calorie refeeding. These data support HCR treatment acceptability for adolescents/young adults with anorexia nervosa and atypical anorexia nervosa.

Systematic review: Exploring the monitoring and reporting of unwanted events in psychotherapy trials for anorexia nervosa

OBJECTIVE

If a psychotherapeutic intervention has the capacity to produce positive change, the "deterioration effect" theory holds that it must also have the potential for negative effects. However, the definition, measurement, and reporting of unwanted events in psychotherapy is a topic of ongoing discussion. At present this area is under-explored in interventions for anorexia nervosa (AN), a severe mental illness associated with high medical and psychiatric risks. The aim of this article was to undertake a systematic review of published randomized controlled trials (RCTs) evaluating psychotherapeutic interventions for AN, and to assess how unwanted events were defined, monitored, and reported alongside the trial's key findings.

METHOD

Using a systematic review methodology, this article identified 23 RCTs through database searches meeting eligibility criteria. Results are presented using a narrative summary approach.

RESULTS

Unwanted event reporting varied widely, both regarding definitions of key unwanted events (such as non-compliance or symptom deterioration) and in the amount of detail captured in each paper.

DISCUSSION

The review identified two key issues: firstly, a lack of consistent definitions and unclear causality made it difficult to distinguish between unwanted events, and adverse events caused by the interventions. Secondly, it highlighted the difficulty of defining unwanted events where different studies have different populations and goals. Recommendations are made around how the area of defining, monitoring, and reporting unwanted events in RCTs for AN can be taken forward.

PUBLIC SIGNIFICANCE

Whilst psychotherapies can be effective in treating mental health conditions, negative or unwanted events can sometimes occur. This review explored how RCTs examining psychotherapy for AN report how they monitor the safety of participants, and how they report unwanted events. We found that the reporting was often inconsistent or hard to interpret, and we have made recommendations for how this can be improved in the future.

A scoping review of non-specific predictors, moderators, and mediators of family-based treatment for adolescent anorexia and bulimia nervosa: a summary of the current research findings

PURPOSE

This scoping review presents an up-to-date synthesis of the current evidence base for non-specific predictors, moderators, and mediators of family-based treatment (FBT) for adolescent anorexia and bulimia nervosa.

METHODS

We identify ways in which end-of-treatment outcomes have been shown to differ based upon baseline clinical features and person-specific factors and explore psychological mechanisms that may explain differences in treatment response. We draw from this evidence base to outline recommendations for clinical practice, as well as directions for future clinical eating disorder research.

RESULTS

Noted findings from review include that early response in weight gain and parental criticism may be particularly influential in treatment for anorexia nervosa. Further, for adolescents with either anorexia or bulimia nervosa, eating-related obsessionality may be a key intervention target to improve outcomes.

CONCLUSION

In addition to highlighting a need for attention to specific patient- and caregiver-level factors that impact treatment response, recommendations for research and clinical practice include testing whether certain targeted treatments (e.g., exposure-based approaches) may be suitable within the context of FBT for eating disorders.

LEVEL OF EVIDENCE

Level I: Evidence obtained from: at least one properly designed randomized controlled trials; experimental studies.

From efficacy to effectiveness: child and adolescent eating disorder treatments in the real world (part 1)-treatment course and outcomes

BACKGROUND

Findings from randomised control trials inform the development of evidence-based eating disorder (ED) practice guidelines internationally. Only recently are data beginning to emerge regarding how these treatments perform outside of research settings. This study aimed to evaluate treatment pathways and outcomes for a specialist child and adolescent ED service across a five-year period.

METHODS

All consecutive referrals between August 2009 and January 2014 seen at the Maudsley Centre for Child and Adolescent Eating Disorders in London were included. Data are reported on for all young people who were offered treatment (N = 357).

RESULTS

Most young people referred to the service were diagnosed with anorexia nervosa (AN)/Atypical AN (81%). Treatment for AN/Atypical AN (median 11 months) was predominantly ED focused family therapy (99%). Treatment for bulimia nervosa (BN)/Atypical BN (median seven months) was most commonly a combination of cognitive behavioural therapy and ED focused family therapy (87%). At discharge, 77% of the AN/Atypical AN group had a good or intermediate outcome and 59% of the BN/Atypical BN group reported no or fewer than weekly bulimic episodes. 27% of the AN/Atypical AN group had enhanced treatment with either day- and/or inpatient admissions (AIM group). The %mBMI at 3 months of treatment was strongest predictor of the need for treatment enhancement and more modestly EDE-Q and age at assessment. The AIM group at assessment had significantly lower weight, and higher ED and comorbid symptomatology and went on to have significantly longer treatment (16 vs. 10 months). At discharge, this group had significantly fewer good and more poor outcomes on the Morgan Russell criteria, but similar outcomes regarding ED and comorbid symptoms and quality of life. When analysis was adjusted for %mBMI at assessment, 1 and 3 months of treatment, differences in Morgan Russell outcomes and %mBMI were small and compatible with no difference in outcome by treatment group.

CONCLUSIONS

This study shows that outcomes in routine clinical practice in a specialist community-based service compare well to those reported in research trials. The finding from research trials that early weight gain is associated with improved outcomes was also replicated in this study. Enhancing outpatient treatment with day treatment and/or inpatient care is associated with favourable outcome for most of the young people, although a longer duration of treatment is required.

Feasibility of conducting a randomized controlled trial comparing family-based treatment via videoconferencing and online guided self-help family-based treatment for adolescent anorexia nervosa

OBJECTIVE

This report describes the feasibility, acceptability, and outcomes from a pilot randomized clinical trial (RCT) comparing an online guided self-help program version of family-based treatment (GSH-FBT) for parents with a child with DSM-5 anorexia nervosa (AN) to FBT delivered via videoconferencing (FBT-V).

METHOD

Between August 2019 and October 2020, 40 adolescents ages 12-18 years with DSM-5 AN and their families were recruited at two sites and randomized to either twelve 20-min guided sessions of GSH-FBT for parents or fifteen 60-min sessions of FBT-V for the entire family. Recruitment, retention, and acceptability of treatment were the primary outcomes. Secondary outcomes were changes in weight, eating disorder examination (EDE), parental self-efficacy, weight remission, full remission, and outcome efficiency (therapist time needed to achieve treatment outcomes).

RESULTS

Descriptive data are reported. Recruitment and retention rates are similar to RCTs using in-person treatments. Both treatments received similar acceptability rates. Medium and large effect sizes (ES) related to improvements in weight, EDE, parental self-efficacy, and remission were achieved in both treatments and were maintained at a 3-month follow-up. Clinical outcomes between groups were associated with a small ES. Differences in efficiency (outcome/therapist time) were associated with a large ES difference favoring GSH-FBT.

DISCUSSION

These data support the feasibility of conducting an adequately powered RCT comparing online GSH-FBT to FBT-V to determine which approach is more efficient in achieving improvements in clinical outcomes in adolescents with AN.

Lower rates of readmission following integration of family-based treatment in a higher level of care

There has been a growing effort to incorporate the evidence-based practices of family-based treatment (FBT) into higher levels of care, such as day-treatment programs. This study tracked the effects of integrating the principles and strategies of FBT into a partial hospitalization program (PHP) for youth with eating disorders. Following retrospective chart review, rates of readmission to the PHP were measured for three years before (2011-2014) and after (2014-2017) FBT was incorporated into the hospital programming. Patients (N = 326) were primarily adolescents with anorexia nervosa. Rates of readmission were significantly lower for those who received care during the implementation of FBT-based PHP programming (2.95%) as compared to the prior traditional PHP (11.7%). Patterns of readmission to the PHP before and after FBT implementation suggest that FBT can be adapted for higher levels of care, and may reduce readmissions and promote continuity of care.

Provisional posttraumatic stress disorder is associated with greater severity of eating disorder and comorbid symptoms in adolescents treated in residential care

OBJECTIVE

Past traumatic events, subsequent posttraumatic stress disorder (PTSD) and related psychiatric comorbidities are commonly associated with eating disorders (EDs) in adults but remain understudied in adolescents.

METHODS

Adolescent participants (mean [SD] age = 15.1 ± 1.5 years, 96.5% female) with EDs entering residential treatment (n = 647) at six sites in the United States completed validated self-report assessments of ED, PTSD, major depression, anxiety disorders and quality of life. Provisional DSM-5 PTSD diagnoses (PTSD+) were made via the Childhood Trauma Questionnaire, admission interviews and the PTSD Symptom Checklist for DSM-5.

RESULTS

PTSD+ occurred in 35.4% of participants, and those with ED-PTSD+ had significantly higher scores on all assessments (p ≤ 0.001), including measures of ED psychopathology, major depression, anxiety disorders and quality of life, as well as significantly higher rates of all forms of childhood trauma. Those with PTSD+ also exhibited a significantly higher percent median body mass index for age and sex and a lower propensity toward anorexia nervosa, restricting type.

CONCLUSIONS

Results confirm that adolescent patients in residential treatment with ED-PTSD+ are more symptomatic and have worse quality of life than their ED counterparts without PTSD. Integrated treatment approaches that effectively address ED-PTSD+ are greatly needed in ED programs that treat adolescents.

The value of including families in the treatment of anorexia nervosa

The aim of this paper is to consider family and wider carer involvement in the treatment of anorexia nervosa, and how this can be used to add value to services. We discuss widely adopted interventions involving the family that have been manualised and studied in trials that have outcome measures that are of relevance to illness costs. The therapeutic targets of these interventions range from a focus on feeding to the wellbeing of the whole family. The theoretical models that underpin interventions involving the family/wider carers include both intra and interpersonal processes, with the exception of family-based therapy, which in its original form holds an agnostic stance towards aetiology. Although formal evaluation of the cost effectiveness of these interventions is minimal, there is evidence that involving the family can reduce bed use and improve the wellbeing of both patients and family members. Moreover, for the most part, these interventions are acceptable to patients and carers. Finally, we consider how these approaches can be disseminated and scaled up more widely into services.

Toward A Greater Understanding of the Ways Family-Based Treatment Addresses the Full Range of Psychopathology of Adolescent Anorexia Nervosa

Family-based treatment (FBT) for anorexia nervosa (AN) is an empirically supported treatment for this disorder. Derived from several different schools of family therapy, it is a highly focused approach that initially targets weight restoration under parental management at home. However, the view that manualized FBT is solely a behavioral therapy directing parents to refeed their children AN with the single purpose of weight gain is a common but misleading over simplification of the therapy. Indeed, weight restoration is the main goal only in phase 1 of this 3-phase treatment. When practiced with fidelity and skill, FBT's broadest aim is to promote adolescent development without AN thoughts and behaviors interfering and disrupting these normal processes. Although weight restoration is a key starting point in FBT, the entire course of treatment takes into consideration the ongoing impact of starvation, cognitions, emotions, and behaviors on adolescent development. These factors associated with maintaining low weight are viewed in FBT as interfering with the adolescent being able to take up the tasks of adolescence and thus must be overcome before fully turning to those broader adolescent tasks. In addition, FBT recognizes that adolescence takes place in the context of family and community and respects the importance of learning in a home environment both for weight gain as well as related developmental tasks to have a lasting effect. Specifically, in this article we describe how the current FBT manualized approach addresses temperament/personality traits, emotional processing, cognitive content and process, social communication and connections, psychiatric comorbidity, and family factors. This report makes no claim to superiority of FBT compared to other therapies in addressing these broader concerns nor does it add interventions to augment the current manual to improve FBT.

Moderators and mediators of outcome in treatments for anorexia nervosa and bulimia nervosa in adolescents: A systematic review of randomized controlled trials

OBJECTIVE

To critically appraise papers reporting on moderators and mediators of recommended psychological treatments for anorexia nervosa (AN) and bulimia nervosa (BN) in adolescents.

METHOD

A systematic search of databases was conducted including PsycINFO, Embase, MEDLINE, AMED, CINAHL, and the Cochrane Library. Studies were included where a randomized controlled trial (RCT) compared therapies for AN or BN and reported on moderators or mediators of treatment effect. Twenty-one eligible papers were included, all based on data from eight RCTs.

RESULTS

Family therapies were dominant in the literature. Individual or separated treatment appeared superior for families with more difficult relationships, whereas conjoint family treatment appeared to be superior where good family relationships were reported. Where there was greater eating disorder psychopathology in AN, including eating disorder-related obsessions and compulsions, the response was better to a family approach than to individual therapies. There was some evidence that a family treatment was superior for those engaging in purging behaviors in BN. Measures of family relationships, parental self-efficacy, and early change emerged as possible mediators; however, the quality of evidence was mixed and the findings, in some cases, arguably circular. Moderator and mediator analyses were underpowered in all studies, with multiple, and post-hoc, analyses being run, and a broad range of outcome measures used.

DISCUSSION

This review recommends that emerging findings are explored further in adequately powered trials of the different recommended therapies, with a move toward focusing on effect sizes. A consensus on acceptable definitions of outcome, including remission and recovery, would benefit future research.

Family therapy approaches for anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is characterised by a failure to maintain a normal body weight due to a paucity of nutrition, an intense fear of gaining weight or behaviour that prevents the individual from gaining weight, or both. The long-term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality. 'Family therapy approaches' indicate a range of approaches, derived from different theories, that involve the family in treatment. We have included therapies developed on the basis of dominant family systems theories, approaches that are based on or broadly similar to the family-based therapy derived from the Maudsley model, approaches that incorporate a focus on cognitive restructuring, as well as approaches that involve the family without articulation of a theoretical approach.This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To evaluate the efficacy of family therapy approaches compared with standard treatment and other treatments for AN.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and PsycINFO (OVID) (all years to April 2016). We ran additional searches directly on Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Ovid Embase, and PsycINFO (to 2008 and 2016 to 2018). We searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov, together with four theses databases (all years to 2018). We checked the reference lists of all included studies and relevant systematic reviews. We have included in the analyses only studies from searches conducted to April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of family therapy approaches compared to any other intervention or other types of family therapy approaches were eligible for inclusion. We included participants of any age or gender with a primary clinical diagnosis of anorexia nervosa.

DATA COLLECTION AND ANALYSIS

Four review authors selected the studies, assessed quality and extracted data. We used a random-effects meta-analysis. We used the risk ratio (with a 95% confidence interval) to summarise dichotomous outcomes and both the standardised mean difference and the mean difference to summarise continuous measures.

MAIN RESULTS

We included 25 trials in this version of the review (13 from the original 2010 review and 12 newly-included studies). Sixteen trials were of adolescents, eight trials of adults (seven of these in young adults aged up to 26 years) and one trial included three age groups: one adolescent, one young adult and one adult. Most investigated family-based therapy or variants. Reporting of trial conduct was generally inadequate, so that in a large number of studies we rated the risk of bias as unclear for many of the domains. Selective reporting bias was particularly problematic, with 68% of studies rated at high risk of bias in this area, followed by incomplete outcome data, with 44% of studies rated at high risk of bias in this area. For the main outcome measure of remission there was some low-quality evidence (from only two studies, 81 participants) suggesting that family therapy approaches might offer some advantage over treatment as usual on rates of remission, post intervention (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.49 to 8.23; I² = 0%). However, at follow-up, low-quality evidence from only one study suggested this effect was not maintained. There was very low-quality evidence from only one trial, which means it is difficult to determine whether family therapy approaches offer any advantage over educational interventions for remission (RR 9.00, 95% CI 0.53 to 153.79; 1 study, N = 30). Similarly, there was very low-quality evidence from only five trials for remission post-intervention, again meaning that it is difficult to determine whether there is any advantage of family therapy approaches over psychological interventions (RR 1.22, 95% CI 0.89 to 1.67; participants = 252; studies = 5; I² = 37%) and at long-term follow-up (RR 1.08, 95% CI 0.91 to 1.28; participants = 200; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I² = 0%). There was no indication that the age group had any impact on the overall treatment effect; however, it should be noted that there were very few trials undertaken in adults, with the age range of adult studies included in this analysis from 20 to 27. There was some evidence of a small effect favouring family based therapy compared with other psychological interventions in terms of weight gain post-intervention (standardised mean difference (SMD) 0.32, 95% CI 0.01 to 0.63; participants = 210; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I² = 11%) . Overall, there was insufficient evidence to determine whether there were any differences between groups across all comparisons for most of the secondary outcomes (weight, eating disorder psychopathology, dropouts, relapse, or family functioning measures), either at post-intervention or at follow-up.

AUTHORS' CONCLUSIONS

There is a limited amount of low-quality evidence to suggest that family therapy approaches may be effective compared to treatment as usual in the short term. This finding is based on two trials that included only a small number of participants, and both had issues about potential bias. There is insufficient evidence to determine whether there is an advantage of family therapy approaches in people of any age compared to educational interventions (one study, very low quality) or other psychological therapies (five studies, very low quality). Most studies contributing to this finding were undertaken in adolescents and youth. There are clear potential impacts on how family therapy approaches might be delivered to different age groups and further work is required to understand what the resulting effects on treatment efficacy might be. There is insufficient evidence to determine whether one type of family therapy approach is more effective than another. The field would benefit from further large, well-conducted trials.

The role of self-esteem in the treatment of patients with anorexia nervosa - A systematic review and meta-analysis

OBJECTIVE

We aimed to provide a comprehensive overview of the role of self-esteem in the treatment of patients with anorexia nervosa (AN). Specifically, our objectives were to investigate the differences in self-esteem between individuals with AN and healthy controls, or individuals with other eating disorders, and to examine self-esteem as an outcome, predictor, moderator, and mediator in AN treatment.

METHOD

The databases PsycINFO, PSYNDEXplus, Ovid MEDLINE®, and ProQuest were searched for studies published from 1990 to 2018. To estimate aggregated effect sizes, we performed random-effects meta-analyses.

RESULTS

A screening of 1,596 abstracts and 203 full-texts identified 68 relevant publications. Results suggest a significantly lower global self-esteem in individuals with AN than in healthy controls (d = -1.90, p < .001). In contrast, global self-esteem of AN and bulimia nervosa (BN) patients was found to be comparable (d = 0.05, p = .529). It might be specific to AN patients that negative self-evaluations may not affect scholastic and professional abilities. Significantly moderate self-esteem increases were observed in treated AN patients at the end of treatment (d = 0.56, p < .001), short-term (d = 0.50, p < .001), and long-term (d = 0.75, p < .001) follow-up. Self-esteem did not predict end of treatment remission-or weight-related outcome and treatment dropout. However, small to moderate predictive effects were detected on short-term (r = .15, p = .007) and long-term remission or weight (r = .33, p = .017). Finally, first indications point to self-esteem as a mediator in adult AN inpatient treatment.

DISCUSSION

The review provides insights relevant for theory, research, and practice. Implications concern the overall support for transdiagnostic approaches and the recommendation to consider low initial self-esteem for decisions on after-care.

Pre-treatment patient characteristics as predictors of drop-out and treatment outcome in individual and family therapy for adolescents and adults with anorexia nervosa: A systematic review and meta-analysis

Understanding variables predicting drop-out or unfavourable outcome following treatment for anorexia nervosa (AN) may help to improve upon intervention efforts. However, the current literature has demonstrated sparse and inconsistent significant findings. The current systematic review and meta-analysis summarised the evidence base examining baseline predictors of drop-out and outcome in AN treatment. A literature search was conducted to identify research investigating predictors of drop-out and outcome in individuals treated for AN. Four online databases were searched, and predictors were organised by category and dependent variable (outcome versus drop-out). 27 studies were included. Lower motivation, lower BMI, and having the binge-purge subtype of AN predicted drop-out. Greater ED pathology and poorer motivation predicted poorer outcome. Clinical recommendations include taking particular care during assessment stages to identify patients at risk of drop-out and/or poor outcome based on their clinical profile and level of motivation for recovery. At-risk patients should be receiving tailored treatment to enhance engagement and reduce risk of drop-out. In conclusion, there's some evidence that motivation, BMI, subtype, and ED pathology predicts drop-out and/or outcome in individual and family-based therapy for AN amongst adolescents and adults; however, research incorporating carefully designed multi-site studies is required to further examine these findings.

Family therapy approaches for anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is characterised by a failure to maintain a normal body weight due to a paucity of nutrition, an intense fear of gaining weight or behaviour that prevents the individual from gaining weight, or both. The long-term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality. 'Family therapy approaches' indicate a range of approaches, derived from different theories, that involve the family in treatment. We have included therapies developed on the basis of dominant family systems theories, approaches that are based on or broadly similar to the family-based therapy derived from the Maudsley model, approaches that incorporate a focus on cognitive restructuring, as well as approaches that involve the family without articulation of a theoretical approach.This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To evaluate the efficacy of family therapy approaches compared with standard treatment and other treatments for AN.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and PsycINFO (OVID) (all years to April 2016). We ran additional searches directly on Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Ovid Embase, and PsycINFO (to 2008 and 2016 to 2018). We searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov, together with four theses databases (all years to 2018). We checked the reference lists of all included studies and relevant systematic reviews. We have included in the analyses only studies from searches conducted to April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of family therapy approaches compared to any other intervention or other types of family therapy approaches were eligible for inclusion. We included participants of any age or gender with a primary clinical diagnosis of anorexia nervosa.

DATA COLLECTION AND ANALYSIS

Four review authors selected the studies, assessed quality and extracted data. We used a random-effects meta-analysis. We used the risk ratio (with a 95% confidence interval) to summarise dichotomous outcomes and both the standardised mean difference and the mean difference to summarise continuous measures.

MAIN RESULTS

We included 25 trials in this version of the review (13 from the original 2010 review and 12 newly-included studies). Sixteen trials were of adolescents, eight trials of adults (seven of these in young adults aged up to 26 years) and one trial included three age groups: one adolescent, one young adult and one adult. Most investigated family-based therapy or variants. Reporting of trial conduct was generally inadequate, so that in a large number of studies we rated the risk of bias as unclear for many of the domains. Selective reporting bias was particularly problematic, with 68% of studies rated at high risk of bias in this area, followed by incomplete outcome data, with 44% of studies rated at high risk of bias in this area. For the main outcome measure of remission there was some low-quality evidence (from only two studies, 81 participants) suggesting that family therapy approaches might offer some advantage over treatment as usual on rates of remission, post intervention (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.49 to 8.23; I2 = 0%). However, at follow-up, low-quality evidence from only one study suggested this effect was not maintained. There was very low-quality evidence from only one trial, which means it is difficult to determine whether family therapy approaches offer any advantage over educational interventions for remission (RR 9.00, 95% CI 0.53 to 153.79; 1 study, N = 30). Similarly, there was very low-quality evidence from only five trials for remission post-intervention, again meaning that it is difficult to determine whether there is any advantage of family therapy approaches over psychological interventions (RR 1.22, 95% CI 0.89 to 1.67; participants = 252; studies = 5; I2 = 37%) and at long-term follow-up (RR 1.08, 95% CI 0.91 to 1.28; participants = 200; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 0%). There was no indication that the age group had any impact on the overall treatment effect; however, it should be noted that there were very few trials undertaken in adults, with the age range of adult studies included in this analysis from 20 to 27. There was some evidence of a small effect favouring family based therapy compared with other psychological interventions in terms of weight gain post-intervention (standardised mean difference (SMD) 0.32, 95% CI 0.01 to 0.63; participants = 210; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 11%) . Overall, there was insufficient evidence to determine whether there were any differences between groups across all comparisons for most of the secondary outcomes (weight, eating disorder psychopathology, dropouts, relapse, or family functioning measures), either at post-intervention or at follow-up.

AUTHORS' CONCLUSIONS

There is a limited amount of low-quality evidence to suggest that family therapy approaches may be effective compared to treatment as usual in the short term. This finding is based on two trials that included only a small number of participants, and both had issues about potential bias. There is insufficient evidence to determine whether there is an advantage of family therapy approaches in people of any age compared to educational interventions (one study, very low quality) or psychological therapies (five studies, very low quality). Most studies contributing to this finding were undertaken in adolescents and youth. There are clear potential impacts on how family therapy approaches might be delivered to different age groups and further work is required to understand what the resulting effects on treatment efficacy might be. There is insufficient evidence to determine whether one type of family therapy approach is more effective than another. The field would benefit from further large, well-conducted trials.

Adaptation and implementation of family-based treatment enhanced with dialectical behavior therapy skills for anorexia nervosa in community-based specialist clinics

Although family-based therapy (FBT) is a well-established treatment for anorexia nervosa, its implementation and effectiveness in clinical settings has been neglected. A group of seven therapists at a community-based eating disorders clinic were trained in skills-enhanced FBT and provided treatment to 11 youth with anorexia nervosa. Family-based skills training, which borrowed heavily from dialectical behavior therapy, was introduced in four additional sessions and then integrated throughout the remainder of FBT. FBT was perceived as appropriate and acceptable by all participants. Therapists reported high treatment fidelity. There was a large improvement in weight and moderate improvement in caregiver-reported eating disorder psychopathology but no clinically significant change by youth report. This study provides preliminary data on the implementation and effectiveness of FBT in the community.

Are parental self-efficacy and family flexibility mediators of treatment for anorexia nervosa?

OBJECTIVE

Family-based treatment (FBT) for adolescent anorexia nervosa (AN) promotes faster weight restoration when compared to other treatments. However, the mechanisms through which this occurs are not clarified. This study explored the trajectories of parental self-efficacy and perceived family flexibility during FBT and systemic family therapy (SyFT). We also explored whether parental self-efficacy mediates the effects of treatment on weight gain early in treatment.

METHOD

158 adolescents (12-18 years old; 89% girls) and their parents were randomized to FBT or SyFT. Parental self-efficacy as well as adolescents' and parental perceptions of the family's flexibility were collected at baseline and at sessions 2, 4, 6, and 8.

RESULTS

Over time, only parents in FBT reported significantly greater self-efficacy. The change in maternal self-efficacy over the first 8 weeks of treatment was a significant mediator of session 10 weight gain. There were no significant group differences in perceived flexibility by session 8.

DISCUSSION

Both parents in FBT and mothers in SyFT understand early the need to change their family's rules and roles. However, the specific strategies of FBT appear to mediate early weight gain in AN.

Family-based treatment for transition age youth: parental self-efficacy and caregiver accommodation

BACKGROUND

Family-Based Treatment (FBT) is the first line of care in paediatric treatment while adult programs focus on individualized models of care. Transition age youth (TAY) with Anorexia Nervosa (AN) are in a unique life stage and between systems of care. As such, they and their caregivers may benefit from specialized, developmentally tailored models of treatment.

METHODS

The primary purpose of this study was to assess if parental self-efficacy and caregiver accommodation changed in caregivers during the course of FBT-TAY for AN. The secondary aim was to determine if changes in parental self-efficacy and caregiver accommodation contributed to improvements in eating disorder behaviour and weight restoration in the transition age youth with AN. Twenty-six participants (ages 16-22) and 39 caregivers were recruited. Caregivers completed the Parents versus Anorexia Scale and Accommodation and Enabling Scale for Eating Disorders at baseline, end-of-treatment (EOT), and 3 months follow-up.

RESULTS

Unbalanced repeated measures designs for parental self-efficacy and caregiver accommodation towards illness behaviours were conducted using generalized estimation equations. Parental self-efficacy increased from baseline to EOT, although not significantly (p = .398). Parental self-efficacy significantly increased from baseline to 3 months post-treatment (p = .002). Caregiver accommodation towards the illness significantly decreased from baseline to EOT (p = 0.0001), but not from baseline to 3 months post-treatment (p = 1.000). Stepwise ordinary least squares regression estimates of eating disorder behaviour and weight restoration did not show that changes in parental-self efficacy and caregiver accommodation predict eating disorder behaviour or weight restoration at EOT or 3 months post-treatment.

CONCLUSIONS

Our findings demonstrate, albeit preliminary at this stage, that FBT-TAY promotes positive increases in parental self-efficacy and assists caregivers in decreasing their accommodation to illness behaviours for transition age youth with AN. However, changes in the parental factors did not influence changes in eating and weight in the transition age youth.

Key factors that influence government policies and decision making about healthcare priorities: Lessons for the field of eating disorders

Worldwide, the demand for healthcare exceeds what individuals and governments are able to afford. Priority setting is therefore inevitable, and mental health services have often been given low priority in the decision-making process. Drawing on established economic criteria, and specifically the work of Philip Musgrove, key factors which influence government decision-making about health priorities are reviewed. These factors include the size of the health burden, the availability of cost-effective interventions to reduce the burden, whether private markets can provide the necessary treatment efficiently, whether there are "catastrophic costs" incurred in accessing treatment, whether negative externalities arise from not providing care, and if the "rule of rescue" applies. Beyond setting priorities for resource allocation, governments also become involved where there is a need for regulation to maintain quality in the delivery of healthcare. By providing field-specific examples for each factor, we illustrate how advocates in the eating disorder field may use evidence to inform government policy about resource allocation and regulation in support of individuals with an eating disorder.