Clinical course and short-term outcome of hospitalized adolescents with eating disorders: the success of combining adolescents and adults on an eating disorders unit

Adolescent Eating Disorder Day Programme Treatment Models and Outcomes: A Systematic Scoping Review

Background: Adolescent eating disorder day programmes (DP), or partial hospitalization programs, are becoming increasingly widespread worldwide. They typically function as an alternative to inpatient care and/or a step up or down in treatment intensity. There has been an increase in the number of publications within the last 5 years investigating DP outcomes. While there are now numerous programmes operating internationally, there is large variability in the content, structure and theoretical underpinnings of each programme. This makes it difficult to compare programme outcomes, and the impact the therapeutic model may have. Aims: To review existing literature on adolescent eating disorder DP treatment models and outcomes. Methods: A systematic scoping review was conducted. Four databases (PsychInfo, EMBASE, Medline, CENTRAL) were searched for relevant peer-reviewed journal articles and book chapters investigating adolescent eating disorder DPs that function as alternatives to inpatient treatment. No restrictions on study methodology were imposed. Studies were first mapped by location, study characteristics and day programme treatment characteristics, then narratively synthesized. Results: Forty nine studies were included in this review. All used a quantitative methodology. One study also included qualitative methods. The majority of studies included describe DPs in the USA (69%). Seventy-six percent of the studies described DPs that operate 5-days per week and most (57%) either only admit or only report on outcomes for restrictive eating disorders. Two-thirds (69%) reported on DPs that had a family focused treatment model, the remainder had a more integrated treatment model informed mostly by individual psychotherapeutic models. Generally, DP treatment is associated with weight gain and improvements in eating disorder and comorbid psychopathology. The studies that include follow-up data (27%) reveal improvements are usually maintained from 3 months to 2 years post-treatment. Early weight gain, early psychological change and early therapeutic alliance are associated with improved end of treatment outcomes. Findings regarding other potential predictors of outcome are mixed. Conclusions: Current evidence suggests day programmes are an effective alternative to inpatient treatment that lead to sustained improvements. DPs tend to either be young-person-only with a family-focused treatment model or all age with a more integrative model. Controlled, empirical investigations into the impact of the therapeutic model on outcomes are needed, as are investigations into treatment mechanisms and the individual and parent experience of day programme treatment.

Canadian practice guidelines for the treatment of children and adolescents with eating disorders

OBJECTIVES

Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline.

METHODS

Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders.

RESULTS

Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed.

CONCLUSIONS

Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.

Outcomes of inpatient psychological treatments for children and adolescents with eating disorders at time of discharge: a systematic review

BACKGROUND

Recommended first line treatment for children and adolescent eating disorders is outpatient therapy. However, a significant number of children and adolescents with eating disorders continue to require inpatient treatment during the course of their illness. The effect of psychological treatments in an inpatient setting on outcomes at the time of discharge remains unclear. This paper presents the results of a review of the literature on outcomes at the time of discharge following inpatient psychological treatment for children and adolescents with eating disorders.

MAIN BODY

The majority of studies found were observational and of low quality. The most consistently reported positive outcome of inpatient treatment is weight gain. Results related to symptom change and motivation vary between studies. Within the inpatient setting, there is considerable heterogeneity in the types of treatments offered, goals of treatment, length of stay and outcomes measured.

CONCLUSION

There remains a paucity of high-quality studies examining the effect of psychological treatments provided to children and adolescents in an inpatient setting. The significant heterogeneity between studies makes it not possible to compare across studies. Future research should aim to resolve these deficiencies in order to better determine the specific factors that contribute to positive outcomes of inpatient treatment for children and adolescents with eating disorders.

An evidence synthesis of risk identification, assessment and management for young people using tier 4 inpatient child and adolescent mental health services

Background

Inpatient child and adolescent mental health services are one part of a complex system, and exist to meet the needs of young people with the greatest mental health difficulties.

Objectives

The research question was ‘What is known about the identification, assessment and management of risk (where “risk” is broadly conceived) in young people (aged 11–18 years) with complex mental health needs entering, using and exiting inpatient child and adolescent mental health services in the UK?’

Data sources

The two-phase Evidence for Policy and Practice Information and Co-ordinating Centre approach was used. In phase 1, scoping searches were made using two databases with an end date of March 2013. Phase 2 centred on the search for citations relating to the risks to young people of ‘dislocation’ and ‘contagion’. Searches were made using 17 databases, with time limits from 1995 to September 2013. Websites were searched, a call for evidence circulated and references of included citations reviewed.

Review methods

Priority risk areas for phase 2 were decided in collaboration with stakeholders including through consultations with young people and the mother of a child who had been in hospital. All types of evidence relating to outcomes, views and experiences, costs and cost-effectiveness, policies, and service and practice responses in the areas of ‘dislocation’ and ‘contagion’ for young people (11–18 years) using inpatient mental health services were considered. A staged approach to screening was used. Data were extracted into tables following guidance from the Centre for Reviews and Dissemination or tables developed for the review. Quality was assessed using appraisal checklists from the Effective Public Health Practice Project or the Critical Skills Appraisal Programme or devised by previous reviewers. No papers were excluded on the grounds of quality, and all materials identified were narratively synthesised.

Results

In phase 1, 4539 citations were found and 124 included. Most were concerned with clinical risks. In phase 2, 15,662 citations were found and 40 addressing the less obvious risks of ‘dislocation’ and ‘contagion’ were included, supplemented by 20 policy and guidance documents. These were synthesised using these categories: Dislocation: Normal Life; Dislocation: Identity; Dislocation: Friends; Dislocation: Stigma; Dislocation: Education; Dislocation: Families; and Contagion. No studies included an economic analysis or economic evaluation. The importance to stakeholders of these less obvious risks contrasted with the limited quantity and quality of research capable of informing policy, services and practice in these areas.

Limitations

Included studies were of variable quality. Data derived could not be used to inform an economic modelling of NHS costs or to analyse cost-effectiveness. Other limitations were the search for only English-language materials and the use of umbrella concepts (‘dislocation’ and ‘contagion’).

Conclusions

The less obvious risks are important, but little evidence exists to support their identification, assessment and management. This has implications for services, and a programme of research is recommended to generate new knowledge.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Effectiveness of a multimodal inpatient treatment for adolescents with anorexia nervosa in comparison with adults: an analysis of a specialized inpatient setting : treatment of adolescent and adult anorexics

OBJECTIVE

There is evidence for an increased prevalence and an earlier onset of anorexia nervosa (AN) in adolescents. Early specialized treatment may improve prognosis and decrease the risk of a chronic course. The current study evaluates the effectiveness of a multimodal inpatient treatment for adolescent AN patients treated in a highly specialized eating disorder unit for adults.

METHOD

177 adolescents and 1,064 adult patients were included. The evaluation focused on eating behavior, depressive symptoms and general psychopathology.

RESULTS

All measured variables decreased significantly in both groups during inpatient treatment. No differences were found concerning weight gain, improvement of global eating disorder symptomatology as well as depressive symptoms. However, adults showed a higher psychological distress and in this regard also a greater improvement.

CONCLUSION

Results indicate that treating adolescent AN patients in a highly specialized eating disorder unit for adults can be an effective treatment setting for these patients.

Salient components of a comprehensive service for eating disorders

Eating disorders are challenging and difficult to treat, because of the necessity of a multidisciplinary treatment team for effective outcomes and the high mortality rate of anorexia nervosa. An adequate initial assessment and evaluation requires a psychiatric assessment, a medical history and medical examination, a social history and an interview of family members or collateral informants. A comprehensive eating disorder treatment team includes a psychiatrist coordinating the treatment and appropriate medical physician specialists, nutritionists, and psychotherapists. An adequate outpatient eating disorder clinic needs to provide individual psychotherapy with cognitive behavioral techniques specific for anorexia nervosa and bulimia nervosa, family therapy, pharmacological treatment and the resources to obtain appropriate laboratory tests. Eating disorder patients requiring inpatient care are best treated in a specialized eating disorder inpatient unit. A cognitive behavioral framework is most useful for the overall unit milieu. Medical management and nutritional rehabilitation are the primary goals for inpatient treatment. Various group therapies can cover common core eating disorder psychopathology problems and dialectical behavior therapy groups can be useful for managing emotional dysregulation. Residential, partial hospitalization and day treatment programs are useful for transitioning patients from an inpatient program or for patients needing some monitoring. In these programs, at least one structured meal is advisable as well as nutritional counseling, group therapy or individual counseling sessions. Group therapies usually address issues such as social skills training, social anxiety, body image distortion or maturity fears. Unfortunately there is s paucity of evidence based randomized control trials to recommend the salient components for a comprehensive service for eating disorders. Experienced eating disorder clinicians have come to the conclusion that a multidisciplinary team approach provides the most effective treatment.