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Cliffe C, Cusick M, Vellupillai S, Shear M, Downs J, Epstein S, Pathak J, Dutta R. A multisite comparison using electronic health records and natural language processing to identify the association between suicidality and hospital readmission amongst patients with eating disorders. Int J Eat Disord 2023; 56:1581-1592. [PMID: 37194359 PMCID: PMC10524005 DOI: 10.1002/eat.23980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 04/21/2023] [Accepted: 04/21/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVES To describe and compare the association between suicidality and subsequent readmission for patients hospitalized for eating disorder treatment, within 2 years of discharge, at two large academic medical centers in two different countries. METHODS Over an 8-year study window from January 2009 to March 2017, we identified all inpatient eating disorder admissions at Weill Cornell Medicine, New York, USA (WCM) and South London and Maudsley Foundation NHS Trust, London, UK (SLaM). To establish each patient's-suicidality profile, we applied two natural language processing (NLP) algorithms, independently developed at the two institutions, and detected suicidality in clinical notes documented in the first week of admission. We calculated the odds ratios (OR) for any subsequent readmission within 2 years postdischarge and determined whether this was to another eating disorder unit, other psychiatric unit, a general medical hospital admission or emergency room attendance. RESULTS We identified 1126 and 420 eating disorder inpatient admissions at WCM and SLaM, respectively. In the WCM cohort, evidence of above average suicidality during the first week of admission was significantly associated with an increased risk of noneating disorder-related psychiatric readmission (OR 3.48 95% CI = 2.03-5.99, p-value < .001), but a similar pattern was not observed in the SLaM cohort (OR 1.34, 95% CI = 0.75-2.37, p = .32), there was no significant increase in risk of admission. In both cohorts, personality disorder increased the risk of any psychiatric readmission within 2 years. DISCUSSION Patterns of increased risk of psychiatric readmission from above average suicidality detected via NLP during inpatient eating disorder admissions differed in our two patient cohorts. However, comorbid diagnoses such as personality disorder increased the risk of any psychiatric readmission across both cohorts. PUBLIC SIGNIFICANCE Suicidality amongst is eating disorders is an extremely common presentation and it is important we further our understanding of identifying those most at risk. This research also provides a novel study design, comparing two NLP algorithms on electronic health record data based in the United States and United Kingdom on eating disorder inpatients. Studies researching both UK and US mental health patients are sparse therefore this study provides novel data.
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Affiliation(s)
- Charlotte Cliffe
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London & Maudsley Foundation NHS Trust, London, UK
| | - Marika Cusick
- Division of Population Health Sciences, Cornell University, New York, New York, USA
- Department of Health Policy, Stanford School of Medicine, Stanford, CA, USA
| | - Sumithra Vellupillai
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Matthew Shear
- Department of Psychiatry, Weill Cornell Medicine, New York, New York, USA
- Psychiatry, New York Presbyterian Hospital, White Plains, New York, USA
| | - Johnny Downs
- South London & Maudsley Foundation NHS Trust, London, UK
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Sophie Epstein
- South London & Maudsley Foundation NHS Trust, London, UK
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Jyotishman Pathak
- Division of Population Health Sciences, Cornell University, New York, New York, USA
| | - Rina Dutta
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London & Maudsley Foundation NHS Trust, London, UK
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Yang Y, Conti J, McMaster CM, Hay P. Beyond Refeeding: The Effect of Including a Dietitian in Eating Disorder Treatment. A Systematic Review. Nutrients 2021; 13:nu13124490. [PMID: 34960041 PMCID: PMC8706437 DOI: 10.3390/nu13124490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 11/16/2022] Open
Abstract
Eating disorders are potentially life-threatening mental health disorders that require management by a multidisciplinary team including medical, psychological and dietetic specialties. This review systematically evaluated the available literature to determine the effect of including a dietitian in outpatient eating disorder (ED) treatment, and to contribute to the understanding of a dietitian’s role in ED treatment. Six databases and Google Scholar were searched for articles that compared treatment outcomes for individuals receiving specialist dietetic treatment with outcomes for those receiving any comparative treatment. Studies needed to be controlled trials where outcomes were measured by a validated instrument (PROSPERO CRD42021224126). The searches returned 16,327 articles, of which 11 articles reporting on 10 studies were included. Two studies found that dietetic intervention significantly improved ED psychopathology, and three found that it did not. Three studies reported that dietetic input improved other psychopathological markers, and three reported that it did not. One consistent finding was that dietetic input improved body mass index/weight and nutritional intake, although only two and three studies reported on each outcome, respectively. A variety of instruments were used to measure each outcome type, making direct comparisons between studies difficult. Furthermore, there was no consistent definition of the dietetic components included, with many containing psychological components. Most studies included were also published over 20 years ago and are now out of date. Further research is needed to develop consistent dietetic guidelines and outcome measures; this would help to clearly define the role of each member of the multidisciplinary team, and particularly the role of dietitians, in ED treatment.
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Affiliation(s)
- Yive Yang
- Translational Health Research Institute, School of Medicine, Western Sydney University, Campbelltown, NSW 2560, Australia; (Y.Y.); (J.C.)
| | - Janet Conti
- Translational Health Research Institute, School of Medicine, Western Sydney University, Campbelltown, NSW 2560, Australia; (Y.Y.); (J.C.)
- School of Psychology, Western Sydney University, Penrith, NSW 2750, Australia
| | - Caitlin M. McMaster
- University of Sydney Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, Westmead, NSW 2145, Australia;
| | - Phillipa Hay
- Translational Health Research Institute, School of Medicine, Western Sydney University, Campbelltown, NSW 2560, Australia; (Y.Y.); (J.C.)
- Camden and Campbelltown Hospitals, South Western Sydney Local Health District, Sydney, NSW 2560, Australia
- Correspondence:
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McMaster CM, Wade T, Franklin J, Waller G, Hart S. Impact of patient characteristics on clinicians' decisions to involve dietitians in eating disorder treatment. J Hum Nutr Diet 2021; 35:512-522. [PMID: 34908196 DOI: 10.1111/jhn.12980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/06/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND & AIMS Dietetic involvement in eating disorder (ED) treatment is often initiated by other members of a patient's treating team. This study aimed to examine the impact of patient characteristics on clinicians' decisions to involve a dietitian in a patient's ED treatment, as well as the influence of clinician characteristics on their decision-making. METHODS ED clinicians were recruited to complete an online survey, which used case vignettes to assess their likelihood of referring patients to a dietitian or consulting with a dietitian for guidance. Questions were also included measuring clinician anxiety, beliefs about the therapy they deliver, beliefs about dietitians and views on evidence-based practice, to determine if these were related to their responses to case vignettes. RESULTS Fifty-seven clinicians completed the survey, with the largest group being clinical psychologists (n=22, 39%). ED diagnosis, weight status, medical co-morbidities and progress in treatment were all shown to be influential on whether clinicians involved dietitians in ED treatment. Clinician characteristics and their beliefs about dietitians were generally not correlated with the likelihood of seeking dietetic input. CONCLUSIONS This study indicates that clinicians' decisions to involve dietitians in ED treatment are systematic rather than random decisions influenced by individual clinician characteristics. Clinicians require further education on the potential for malnutrition regardless of patients'ED diagnosis or weight status, and the dietitian's role in addressing this. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Caitlin M McMaster
- Boden Collaboration for Obesity, Nutrition, Exercise and Eating Disorders, University of Sydney, Sydney, New South Wales, Australia
| | - Tracey Wade
- Blackbird Initiative, Órama Institute, Flinders University, Adelaide, South Australia, Australia
| | - Janet Franklin
- Metabolism and Obesity Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Glenn Waller
- Department of Psychology, University of Sheffield, Sheffield, United Kingdom
| | - Susan Hart
- Boden Collaboration for Obesity, Nutrition, Exercise and Eating Disorders, University of Sydney, Sydney, New South Wales, Australia.,Nutrition and Dietetics Department, St Vincent's Hospital, Sydney, New South Wales, Australia
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McMaster CM, Wade T, Franklin J, Hart S. Development of consensus-based guidelines for outpatient dietetic treatment of eating disorders: A Delphi study. Int J Eat Disord 2020; 53:1480-1495. [PMID: 32662177 DOI: 10.1002/eat.23330] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To generate consensus-based guidelines for outpatient dietetic treatment of patients with an eating disorder (ED) using Delphi methodology. METHOD A modified Delphi method was used to develop consensus-based guidelines in several categories: referral to a dietitian; essential components of outpatient dietetic treatment; strategies to promote collaboration between dietitians and other healthcare professionals; and skills dietitians should possess if treating patients with an ED. Participants (n = 162) were coded into three panels: ED specialists (n = 79), non-ED specialists (n = 28), and consumers and carers with lived experience of an ED (n = 55). A total of 122 statements were rated across three rounds. RESULTS Eighty-one statements reached consensus level (66.4%). A high proportion of endorsed statements were consistent with current guidelines for ED treatment, though some statements for which evidence exists were not endorsed as essential components of dietetic treatment. Compared to consumers and carers, ED specialists were less likely to endorse assessment or involvement by a dietitian as a standard component of treatment, and a number of discrepancies between ED specialists and consumers and carers were observed regarding essential components of dietetic treatment. DISCUSSION This study provides consensus-based guidelines in the current absence of clinical practice guidelines for dietetic treatment of EDs. It also highlights the importance of further research into: (a) the effectiveness of different components of dietetic intervention in this population and (b) how dietetic assessment and intervention is best incorporated into outpatient treatment.
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Affiliation(s)
- Caitlin M McMaster
- Boden Collaboration for Obesity, Nutrition, Exercise and Eating Disorders, University of Sydney, Sydney, New South Wales, Australia
| | - Tracey Wade
- Blackbird Initiative, Órama Institute, Flinders University, Adelaide, South Australia, Australia
| | - Janet Franklin
- Metabolism and Obesity Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Susan Hart
- Boden Collaboration for Obesity, Nutrition, Exercise and Eating Disorders, University of Sydney, Sydney, New South Wales, Australia.,Nutrition and Dietetics Department, St Vincent's Hospital, Sydney, New South Wales, Australia
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Hughes EK, Poker S, Bortz A, Yeo M, Telfer M, Sawyer SM. Adolescent and Parent Experience of Care at a Family-Based Treatment Service for Eating Disorders. Front Psychiatry 2020; 11:310. [PMID: 32372986 PMCID: PMC7186319 DOI: 10.3389/fpsyt.2020.00310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 03/27/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Incorporating consumer perspectives is an important but often overlooked opportunity to optimize treatment engagement and outcomes for adolescents with eating disorders. This study explored the experience of care of adolescents and their parents at a multidisciplinary specialist eating disorders service providing family-based treatment (FBT) as first-line treatment. METHOD Eighty-five adolescents and 145 parents who completed FBT at the service between 2013 and 2015 were surveyed in 2017 about their experience of care. A study-designed survey asked respondents to rate on Likert scales their experience of service access, intake assessment, education, support, interactions with the treatment team, recovery, and the discharge process. Open-ended comments on helpful and unhelpful aspects of the service provided further context on the ratings. RESULTS Overall families were very positive about their experience, particularly in regard to assessment, education, interactions with the team, and achieving physical health. Although parents tended to be more satisfied, adolescents also held the service in high regard. Some areas were identified that could be improved, including treatment delays, carer support, therapeutic alliance, and preparation for discharge. CONCLUSIONS Surveying families about their experience of care provides an important opportunity to identify service strengths as well as services gaps. The results indicated several areas that specialist eating disorder services could focus on to ensure that the services provided, including FBT, fully meet the needs of families and optimize adolescents' treatment experiences.
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Affiliation(s)
- Elizabeth K Hughes
- Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Suzannah Poker
- Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Amy Bortz
- School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Michele Yeo
- Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Adolescent Medicine, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Michelle Telfer
- Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Adolescent Medicine, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Susan M Sawyer
- Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Adolescent Medicine, Royal Children's Hospital, Melbourne, VIC, Australia
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Mitrofan O, Petkova H, Janssens A, Kelly J, Edwards E, Nicholls D, McNicholas F, Simic M, Eisler I, Ford T, Byford S. Care experiences of young people with eating disorders and their parents: qualitative study. BJPsych Open 2019; 5:e6. [PMID: 30762506 PMCID: PMC6343117 DOI: 10.1192/bjo.2018.78] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Perspectives of young people with eating disorders and their parents on helpful aspects of care should be incorporated into evidence-based practice and service design, but data are limited.AimsTo explore patient and parent perspectives on positive and negative aspects of care for young people with eating disorders. METHOD Six online focus groups with 19 young people aged 16-25 years with existing or past eating disorders and 11 parents. RESULTS Thematic analysis identified three key themes: the need to (a) shift from a weight-focused to a more holistic, individualised and consistent care approach, with a better balance in targeting psychological and physical problems from an early stage; (b) improve professionals' knowledge and attitude towards patients and their families at all levels of care from primary to 'truly specialist'; (c) enhance peer and family support. CONCLUSIONS Young people and parents identified an array of limitations in approaches to care for young people with eating disorders and raised the need for change, particularly a move away from a primarily weight-focused treatment and a stronger emphasis on psychological needs and individualised care.Declaration of interestNone.
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Affiliation(s)
- Oana Mitrofan
- Academic Clinical Lecturer in Child and Adolescent Psychiatry,University of Exeter College of Medicine and Health,University of Exeter,UK
| | - Hristina Petkova
- Health Economist, King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience,King's College London,UK
| | - Astrid Janssens
- Senior Research Fellow,University of Exeter College of Medicine and Health,University of Exeter,UK
| | | | | | | | - Fiona McNicholas
- Professor of Child and Adolescent Psychiatry,School of Medicine,University College Dublin,Ireland
| | - Mima Simic
- Consultant Child and Adolescent Psychiatrist,Child and Adolescent Eating Disorders Service,South London and Maudsley NHS Trust,UK
| | - Ivan Eisler
- Professor of Family Psychology and Family Therapy, Institute of Psychiatry, Psychology and Neuroscience,King's College London,UK
| | - Tamsin Ford
- Professor of Child and Adolescent Psychiatry,University of Exeter College of Medicine and Health,University of Exeter,UK
| | - Sarah Byford
- Professor of Health Economics, King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience,King's College London,UK
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Pettersen G, Rosenvinge JH, Bakland M, Wynn R, Mathisen TF, Sundgot-Borgen J. Patients' and therapists' experiences with a new treatment programme for eating disorders that combines physical exercise and dietary therapy: the PED-t trial. A qualitative study protocol. BMJ Open 2018; 8:e018708. [PMID: 29317417 PMCID: PMC5781017 DOI: 10.1136/bmjopen-2017-018708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Women with bulimia nervosa and binge eating disorder often suffer for many years before they seek professional help. Evidence-based treatments like cognitive-behavioural therapy (CBT) might be poorly accessible, and about 50% of those who receive CBT respond to it. Such outcome may reflect the heterogeneous nature of eating disorders, and addressing this heterogeneity calls for expanding the portfolio of treatment options. In particular, it is important to explore such options' acceptability, tolerability and affordability expressed through experiences with the treatment. This protocol outlines the rationale and design of a qualitative study. It captures experiences from patients and therapists who were involved in a randomised controlled trial (RCT) exploring the efficacy of a new group-based treatment programme combining physical exercise and dietary therapy. METHODS AND ANALYSIS 15 patients with bulimia nervosa or binge eating disorder, 10 therapists (physical trainers and dietitians) and 6-10 patients who dropped out of the RCT will be semistructurally interviewed. All interviews will be analysed using a systematic text condensation approach. ETHICS AND DISSEMINATION Results will be presented in peer-reviewed international journals, and at relevant international conferences. Key findings will be available to study participants as well as to patient organisations and health authorities. The overall study meets the intent and requirements of the Health Research Act and the Declaration of Helsinki. It is approved by the regional committee for medical research ethics (2013/1871). TRIAL REGISTRATION NUMBER NCT02079935; Pre-results.
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Affiliation(s)
- Gunn Pettersen
- Department of Health and Care Sciences, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway
| | - Jan H Rosenvinge
- Department of Psychology, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Maria Bakland
- Department of Health and Care Sciences, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway
| | - Rolf Wynn
- Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
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Perez M, Van Diest AK, Cutts S. Preliminary examination of a mentor-based program for eating disorders. J Eat Disord 2014; 2:24. [PMID: 25426293 PMCID: PMC4243944 DOI: 10.1186/s40337-014-0024-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 08/14/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND There is a current and pressing need for recovery resources for individuals suffering from eating disorders. Mentoring programs have been useful with other psychiatric disorders such as addictions, and may be useful for individuals recovering from an eating disorder. The present study sought to examine a mentoring program for individuals working towards recovery from an eating disorder. METHODS The study included mentors (i.e., individuals who have recovered from an eating disorder for an extended period of time), and mentees (i.e., individuals who were in the process of recovering from an eating disorder and wanting additional support aside from their treatment team). Participants included 141 participants, consisting of 34 mentors, 58 mentees who matched with a mentor, and 49 mentees searching for a mentor. Participants completed questions assessing eating disorder symptoms, quality of life, motivation towards recovery, and treatment compliance. RESULTS Matched mentees reported higher levels of quality of life on 7 out of 12 domains, and missed fewer appointments with treatment providers when compared to unmatched mentees. There were no differences between matched and unmatched mentees on motivation, energy or confidence towards recovery. CONCLUSIONS Findings suggest a mentor model is beneficial for individuals engaged in the process of recovering from an eating disorder in the areas of quality of life and treatment compliance. Specifically, mentees in a mentoring relationship reported better family and close relationships, future outlook, and psychological, emotional, and physical well-being than unmatched mentees. Mentors reported being positively impacted by the mentoring relationship by strengthening the skills they learned while in recovery, and reminding them of how far they had come in their own recovery. The findings in this study suggest that mentor programs warrant further investigation as ancillary support services for individuals recovering from an eating disorder.
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Affiliation(s)
- Marisol Perez
- />Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX 77843-4235 USA
| | - Ashley Kroon Van Diest
- />Department of Psychology, Texas A&M University, 4235 TAMU, College Station, TX 77843-4235 USA
| | - Shannon Cutts
- />MentorCONNECT, www.mentorconnect-ed.org, Houston, Texas USA
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Schmidt U, Oldershaw A, Sternheim L, Tchanturia K, Treasure J, Jichi F, Landau S, Startup H, Wolff G, Rooney M, McIntosh V, Jordan J. Authors' reply. Br J Psychiatry 2013; 202:384-5. [PMID: 23776953 DOI: 10.1192/bjp.202.5.384a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Koskina A, Arkell J, Butcher G, Currie A, Gowers S, Key A, Millar H, Nicholls D, Ringwood S, Robinson P, Venkatraman L, Wurr K, Schmidt U. Service providers' perceptions of the strengths and prospective improvements in UK eating disorder services: findings from a Royal College survey. EUROPEAN EATING DISORDERS REVIEW 2011; 20:225-31. [PMID: 21809422 DOI: 10.1002/erv.1149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 06/29/2011] [Indexed: 11/08/2022]
Abstract
AIMS AND METHODS This study aims to explore perceptions of eating disorder service strengths and to develop a clearer picture of improvements clinicians would like to see occur in the services they lead. A survey designed by the Royal College of Psychiatrists' Section of Eating Disorders was completed by 83 lead clinicians in both public and private sector services in the UK and Eire. Content analysis was performed, and common themes were identified. RESULTS Five main strengths of a service were identified as follows: quality of treatment (n = 36), staff skills (n = 21), continuity of care (n = 15), family involvement (n = 12) and accessibility and availability (n = 11). These themes also arose when clinicians evaluated areas they wished to develop and improve. CONCLUSIONS Service providers' views were congruent with each other, NICE guidelines and quality standards as proposed by the Royal College. Although clinicians feel that their service fulfils many practice guidelines, there remains areas in which adherence is felt to be lacking.
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