Consumer involvement in the appraisal of treatments for people with eating disorders: a neglected area of research?

Co-producing principles to guide health research: an illustrative case study from an eating disorder research clinic

BACKGROUND

There is significant value in co-produced health research, however power-imbalances within research teams can pose a barrier to people with lived experience of an illness determining the direction of research in that area. This is especially true in eating disorder research, where the inclusion of co-production approaches lags other research areas. Appealing to principles or values can serve to ground collaborative working. Despite this, there has not been any prior attempt to co-produce principles to guide the work of a research group and serve as a basis for developing future projects.

METHODS

The aim of this piece of work was to co-produce a set of principles to guide the conduct of research within our lived experience led research clinic, and to offer an illustrative case for the value of this as a novel co-production methodology. A lived experience panel were recruited to our eating disorder research group. Through an iterative series of workshops with the members of our research clinic (composed of a lived experience panel, clinicians, and researchers) we developed a set of principles which we agreed were important in ensuring both the direction of our research, and the way in which we wanted to work together.

RESULTS

Six key principles were developed using this process. They were that research should aim to be: 1) real world-offering a clear and concrete benefit to people with eating disorders, 2) tailored-suitable for marginalised groups and people with atypical diagnoses, 3) hopeful-ensuring that hope for recovery was centred in treatment, 4) experiential-privileging the 'voice' of people with eating disorders, 5) broad-encompassing non-standard therapeutic treatments and 6) democratic-co-produced by people with lived experience of eating disorders.

CONCLUSIONS

We reflect on some of the positives as well as limitations of the process, highlighting the importance of adequate funding for longer-term co-production approaches to be taken, and issues around ensuring representation of minority groups. We hope that other health research groups will see the value in co-producing principles to guide research in their own fields, and will adapt, develop, and refine this novel methodology.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

An Attentional Bias Modification Task, through Virtual Reality and Eye-Tracking Technologies, to Enhance the Treatment of Anorexia Nervosa

Mirror exposure therapies (METs) have been shown to be effective in reducing body image disturbances through the habituation process. Virtual reality (VR) combined with eye-tracking techniques can provide innovative solutions to some of METs’ limitations reported with patients with anorexia nervosa (AN), especially the negative influence of body-related attentional bias (AB). This pilot study aimed to assess the preliminary efficacy of a new VR-based AB modification task (ABMT) among healthy women and the procedure’s user experience. AB levels towards weight- and non-weight-related body parts, using complete fixation time (CFT) and number of fixations (NF), were assessed throughout the ABMT procedure (300 trials). The user experience was evaluated at the end of the procedure. The results showed that VR-based ABMT was effective in reducing AB significantly after 150 trials for both CFT- and NF-based measures, although 225 trials were necessary to get the same result for women with an NF initially more oriented towards weight-related body parts. Overall, the software received a “C-rating” on a scale from “A” (most usable) to “F” (least usable). These results provide evidence of the opportunity to use a VR-based ABMT procedure to reduce AB and improve existing treatments for AN.

Subjective evaluation of outpatient treatment for adolescent patients with anorexia nervosa

BACKGROUND

The current study investigates determinants of treatment evaluation by adolescent outpatients with anorexia nervosa (AN) and the accordance with their parents' and psychotherapists' evaluation.

SAMPLING AND METHODS

The sample included 50 female adolescent outpatients (mean age: 16.9 ± 1.8) with AN (DSM-IV). They were randomly assigned to either cognitive-behavior therapy (CBT) or dialectical-behavior therapy (DBT). Before (T1) and after treatment (T2) diagnostic interviews as well as self-report questionnaires were administered measuring eating disorder-specific and general psychopathology. The subjective evaluation of the therapy was assessed by a self-report questionnaire. Data on the evaluation of treatment of 42 parents were considered as well as treatment evaluations of the therapists for 48 patients.

RESULTS

Our results revealed significant correlations of treatment satisfaction between parents and therapists, whereas patients and therapists as well as patients and parents did not agree in their treatment evaluation. The change in body mass index (BMI) was a significant predictor of the patients' treatment satisfaction.

CONCLUSION

Adolescent patients displaying high severity of AN at the beginning of treatment put little emphasis on the importance of body weight even after treatment. Satisfaction ratings of this special group of patients could be heavily distorted and have to be interpreted carefully.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Patients' experiences of brief cognitive behavioral therapy for eating disorders: A qualitative investigation

OBJECTIVE

Although it is important to analyze the effectiveness of new therapies, it is also necessary to consider how patients experience them. This is particularly important if we are to maximize treatment acceptability and reduce attrition. This study examined patient experiences of a new 10-session cognitive-behavioral therapy (CBT-T), using a qualitative approach.

METHOD

The sample was 17 patients with a diagnosis of bulimia nervosa who had received CBT-T (including treatment completers and non-completers) within the previous 2 years. Sample size was determined by saturation of the emergent themes. Responses were analyzed using a six-step thematic analysis process.

RESULTS

Rated acceptability and effectiveness of CBT-T were high. Five themes emerged, with subthemes. The key elements of patient experience of the therapy were: the therapeutic relationship; the nature of the therapy; its challenging but beneficial aspects; ending therapy; and the overall experience of CBT-T (including comparison with other therapies).

DISCUSSION

The findings build on the effectiveness research for CBT-T, suggesting that it is an acceptable therapy that addresses many of the same themes that matter to patients as other therapies. The findings show that patients were positive about CBT-T relative to other therapies, and offer suggestions as to how CBT-T might be delivered to emphasize the importance of the time-limited nature of the therapy.

Consensus-based perspectives of pediatric inpatient eating disorder services

OBJECTIVE

There are few evidence-based guidelines for inpatient pediatric eating disorders. The aim was to gain perspectives from those providing and receiving inpatient pediatric eating disorder care on the essential components treatment.

METHOD

A modified Delphi technique was used to develop consensus-based opinions. Participants (N = 74) were recruited for three panels: clinicians (n = 24), carers (n = 31), and patients (n = 19), who endorsed three rounds of statements online.

RESULTS

A total of 167 statements were rated, 79 were accepted and reached a consensus level of at least 75% across all panels, and 87 were rejected. All agreed that families should be involved in treatment, and thatpsychological therapy be offered in specialist inpatient units. Areas of disagreement included that patients expressed a desire for autonomy in sessions being available without carers, and that weight gain should be gradual and admissions longer, in contrast to carers and clinicians. Carers endorsed that legal frameworks should be used to retain patients if required, and that inpatients are supervised at all times, in contrast to patients and clinicians. Clinicians endorsed that food access should be restricted outside meal times, in contrast to patients and carers.

DISCUSSION

The findings indicate areas of consensus in admission criteria, and that families should be involved in treatment, family involvement in treatment, while there was disagreement across groups on topics including weight goals and nutrition management. Perspectives from patients, carers, and clinicians may be useful to consider during future revisions of best practice guidelines.

Cognitive Remediation Therapy for Adolescents with Anorexia Nervosa-Treatment Satisfaction and the Perception of Change

Cognitive remediation therapy (CRT) has recently been developed for children and adolescents with anorexia nervosa (AN). It focuses on decreasing rigid cognitions and behaviors, as well as increasing central coherence. Overall, CRT has been proven feasible for young individuals with AN, but little is known regarding the specifics of its feasibility, and the perception of change associated with the intervention. Consequently, the aim of the current study was to explore service users’ perspective on CRT with a specific focus on treatment delivery, treatment content, and perceived change. Twenty adolescents (age 13–18) with AN participated in a 10-session course of CRT. A 20-item treatment evaluation questionnaire was administered at the end of treatment, focusing on four aspects of the intervention: (1) general attitudes towards treatment, (2) treatment specifics, (3) the perception of change and (4) the patient-therapist relation. The main findings suggest high levels of treatment satisfaction, but somewhat limited perceptions of change. The current study is one of the most detailed accounts of adolescents’ perspective on CRT published on eating disorders, and highlights several important aspects of the treatment viewed through the eye of the receiver.

An evaluation of a CAMHS outpatient service for adolescent eating disorders

BACKGROUND

A CAMHS Eating Disorder (ED) service is presented together with cases referred and treated within a 3-year period. An outcome evaluation was conducted for restrictive eating disorders.

METHOD

Case files were analysed to investigate service throughput as well as clinical outcomes for discharged cases (n = 39).

RESULTS

Highly positive End of Treatment (EOT) outcomes were achieved for both anorexia nervosa (AN) and Eating Disorders Not Otherwise Specified (EDNOS). Morgan Russell scores, drop-out and admission rates compared favourably with previous trials. User satisfaction ratings were high.

CONCLUSION

The study offers insight into real-life clinical practice and as outpatient treatment is usually much less expensive than inpatient treatment, this approach has the potential to be cost-effective.

What are the top five essential features of a high quality eating disorder service? A comparison of the views of US and UK eating disorder sufferers, carers and health professionals

OBJECTIVE

The aim of the present study was to identify what are the main features of a high quality eating disorders service and to triangulate the views of patients, carers and health professionals in a cross-national (USA, UK) survey.

METHODS

Data from an internet survey were subjected to content analysis and common themes were identified.

RESULTS

All six stakeholder groups (US and UK patients, carers and health professionals) included the professional qualities of staff amongst their top five quality features. Personal qualities of staff, support for carers and psychological interventions were mentioned by four of the six groups, Support for service users and nutritional assistance was mentioned by three groups. Availability/access and Rapid access to care were mentioned by UK Carers and UK health care personnel. Medical assistance was only mentioned by US health care professionals and flexible care only by UK sufferers.

CONCLUSION

This study suggests many similarities and some differences between different stakeholders from two countries with different health care systems in their views on quality of care.

Service users' views of eating disorder services: an international comparison

OBJECTIVE

To perform a United States-United Kingdom cross-national comparison of service users' perspectives on eating disorder (ED) treatments and services.

METHOD

Qualitative, exploratory study. One hundred forty-four US and 150 UK ED service users completed a questionnaire developed by the Academy for Eating Disorders. Data were analyzed using conventional content analysis.

RESULTS

Both samples identified the following as essential aspects of care: good therapeutic relationship, holistic approach, individual psychotherapy/counseling, specialized treatment, client-centered care, and support. In the US sample, the main concerns involved lack of financial accessibility to services and problems with insurance coverage. In the UK sample, lack of and inequity of availability of services were highlighted and three main barriers to accessing care were identified.

DISCUSSION

US and UK service users' views suggest that neither country provides early intervention and comprehensive care for EDs at present, although due to dissimilar health care systems the barriers to care differ.

Support for parents of children with anorexia: what parents want

Parents' encounters with health professionals can influence their ability to cope with having a daughter with anorexia nervosa. Using qualitative analysis of in-depth interviews with 24 parents, we examine the question "What support do parents of teenage girls with anorexia want from clinicians?" The analysis shows that parents wanted clinicians to include them in treatment, support and guide them in their daughters' care, and demonstrate positive attitudes toward them. The implications for clinicians are discussed, including being sensitive to parents' vulnerability, ensuring congruence between clinicians' and parents' expectations about treatment, and strengthening formal channels of communication.

Treatment perception in adolescent onset anorexia nervosa: retrospective views of patients and parents

OBJECTIVE

To investigate perception of treatment in former patients with anorexia nervosa (AN) and their parents, and to determine whether this was related to outcome and treatment characteristics. Client satisfaction is important for treatment engagement and adherence.

METHOD

Forty-six (of 55) girls with adolescent onset AN, 33 mothers and 26 fathers participated in a follow-up study conducted 8.8 (SD 3.3) years after start of treatment. The former patients were assessed using diagnostic interviews. Only nine participants (19%) had an eating disorder (ED) at follow-up. Perception of treatment was assessed by questionnaires.

RESULTS

Parents reported having an overall positive perception of treatment. However, reports from former patients were significantly more negative than from the parents. In former patients, the "perception of therapists" total score and the items "therapists' knowledge of ED" and "usefulness of pediatric inpatient treatment" correlated with ED symptoms at follow-up. The perception of therapists' scores of the parents were not associated with the ED outcome of their daughters. More family therapy sessions were associated with the former patients' satisfaction with the therapists, while higher age at admission was associated with their mothers' satisfaction.

CONCLUSION

In spite of good ED outcome, former patients were only moderately satisfied with their treatment, whereas parental satisfaction was high.

Management of child and adolescent eating disorders: the current evidence base and future directions

Although eating disorders in children and adolescents remain a serious cause of morbidity and mortality, the evidence base for effective interventions is surprisingly weak. The adult literature is growing steadily, but this is mainly with regard to psychological therapies for bulimia nervosa and to some extent in the field of pharmacotherapy. This review summarises the recent research literature covering management in three areas, namely physical management, psychological therapies, and service issues, and identifies prognostic variables. Findings from the adult literature are presented where there is good reason to believe that these might be applied to younger patients. Evidence-based good practice recommendations from published clinical guidelines are also discussed. Suggestions for future research are made, focusing on 1) the need for trials of psychological therapies in anorexia nervosa, 2) applications of evidence-based treatments for adult bulimia nervosa to the treatment of adolescents, and 3) clarification of the benefits and costs of different service models.

The place of inpatient care in the treatment of anorexia nervosa: questions to be answered

BACKGROUND

The chance that an anorexia nervosa patient will be hospitalized depends more on circumstantial rather than on scientifically based factors. Although there is a lot of information on the treatment of anorexia nervosa patients in a residential setting, answers to questions relating to the "when," "where," and "how" of treatment are subjective. There is no clinical consensus and the paucity of controlled research is hampering the development of an evidence-based practice.

RESULTS

Increasing economic restraints through managed care policies limit the length of inpatient treatment, which leads to early discharge at a lower body weight, which leads to a higher likelihood of readmissions, which leads to increasing costs.

DISCUSSION

We will highlight important issues in the ongoing debate between economic demands and clinical challenges. Our goal is to stimulate critical reflections and systematic research.

What can we learn from consumer studies and qualitative research in the treatment of eating disorders?

The aim of this paper is to review all qualitative research and questionnaire surveys with people who have experienced an eating disorder or received treatment for it. Studies were identified on PubMed and PsychInfo. Twenty-three studies were identified and key findings are reviewed. Support and understanding are critical aspects of treatment perceived as helpful. Empathic relationships, whether professional or non-professional, were reported as essential to recovery. Psychological interventions (counselling and therapy) are the most popular and perceived as the most helpful. Many patients report that "medical interventions" were unhelpful. Interventions which focus exclusively on weight are reported negatively and many studies identify the importance of addressing wider issues than food and weight in treatment.