Predictors of change in perceived burden among caregivers of patients with eating disorders

Remote family education and support program for parents of patients with adolescent and early adulthood eating disorders based on interpersonal psychotherapy: study protocol for a pilot randomized controlled trial

BACKGROUND

In cases of adolescent and early adulthood eating disorders, despite the importance of the patients' relationship with their parents, conflict and confusion frequently occur among them. Interpersonal psychotherapy (IPT) is a present-focused psychotherapy that emphasizes the interpersonal context of symptoms. We developed a remote family education and support program exclusively for parents of patients with eating disorders, based on the principle of IPT. The use of IPT is expected to reduce conflicts in the patient-parent relationship. Consequently, parents will be better able to listen to patients, and patients will be better able to express their thoughts and desires. In this study, we describe the protocol for a randomized controlled trial designed to examine the effectiveness of this program in promoting effective communication in their home based on active listening skills of parents of patients with adolescent and early adulthood eating disorders.

METHODS

Participants will be parents of patients aged 12-29 years with adolescent and early adulthood eating disorders. Individually randomized, parallel-group trial design will be employed. Seventy participants will be allocated to one of two treatment conditions: (1) remote family education and support program (four, 150 min weekly group sessions) for parents plus treatment-as-usual for patients (consultation by physicians or no treatment), or (2) waiting for the control condition (parents will wait to start the program for 8 weeks) plus treatment-as-usual for patients. The primary outcome measure will be parents' active listening ability as measured by the Active Listening Attitude Scale at 8 weeks after randomization. Additionally, perception of social support (Social Provision Scale-10 item), loneliness (UCLA Loneliness Scale), mental health status (K6), family function (Family Assessment Device), and parent-evaluated eating disorder symptoms (Anorectic Behavior Observation Scale) will be assessed. Data from the intention-to-treat sample will be analyzed 8 weeks after randomization.

DISCUSSION

This is the first study to evaluate the effectiveness of a family education and support program for parents of patients with adolescent and early adulthood eating disorders based on IPT. If this type of intervention is effective, although indirect, it could be a new support method for this patient population.

TRIAL REGISTRATION

Clinical Trials. gov ID NCT05840614.

Characteristics, correlates of burden and support service use of a help-seeking carers of loved ones with an eating disorder

OBJECTIVE

Carers, vital in the care of individuals with an eating disorder (ED), experience substantial caregiving burden and unmet needs. This study aims to identify factors which contribute to the burden experienced by carers of a loved one with an ED and their support service usage.

METHOD

Carers (N = 245) completed an online questionnaire assessing demographic, carer-specific, individual and ED factors. Multivariate relationships with caregiving burden were examined using forwards elimination to produce a parsimonious model of carer burden.

RESULTS

The final model, consisting of caregiving factors (e.g., relationship type, skills), carer mental health) and loved one wellbeing (i.e., purging symptoms, depression/self-harm/suicidality) explained a large proportion (62%) of the variance in carers' burden. Carer mental health, caregiving skills and relationship type (e.g., parent, spouse, sibling) were key predictors of carers' burden. Nearly a third of carers had not used any carer support services, yet most carers expressed an interest in such services.

CONCLUSION

Caregiving burden is determined by experiences and skills of the carer as well as the person they are caring for. Carer support services should continue to address the general wellbeing of carers and caregiver skills. Research into the barriers to carer support uptake is needed.

Association between the social support for mothers of patients with eating disorders, maternal mental health, and patient symptomatic severity: A cross-sectional study

BACKGROUND

Although caregivers of patients with eating disorders usually experience a heavy caregiving burden, the effects of social support on caregivers of patients with eating disorders are unknown. This study aimed to investigate how social support for mothers who are caregivers of patients with an eating disorder improves the mothers' mental status and, consequently, the symptoms and status of the patients.

METHODS

Fifty-seven pairs of participants were recruited from four family self-help groups and one university hospital in Japan. Recruitment was conducted from July 2017 to August 2018. Mothers were evaluated for social support using the Japanese version of the Social Provisions Scale-10 item (SPS-10), self-efficacy using the General Self-Efficacy Scale, loneliness using the University of California, Los Angeles Loneliness Scale, listening attitude using the Active Listening Attitude Scale, family functioning using the Family Assessment Device, depression symptoms using the Beck Depression Inventory (Second Edition), and psychological distress using the Kessler Psychological Distress Scale. Patients were evaluated for self-esteem using the Rosenberg Self-Esteem Scale, assertion using the Youth Assertion Scale, and their symptoms using the Eating Disorder Inventory. We divided the mothers and patients into two groups based on the mean score of the SPS-10 of mothers and compared the status of mothers and patients between the high- and low-scoring groups.

RESULTS

High social support for mothers of patients with eating disorders was significantly associated with lower scores for loneliness and depression of these mothers. We found no significant differences in any patient scores based on mothers' level of social support.

CONCLUSIONS

For patients with eating disorders, social support for a caregiver cannot be expected to improve their symptoms, but it may help prevent caregiver depression and loneliness.

Living with someone with an eating disorder: factors affecting the caregivers' burden

We focused on carers of subjects suffering from eating disorders (ED), and studied the characteristics that mostly expose them to high levels of stress, anxiety, depression and expressed emotion, favoring the accommodation of the family system to the cared person. We administered the accommodation and enabling scale for eating disorders (AESED) questionnaire, the family questionnaire (FQ) and the depression, anxiety and stress scale (DASS-21) questionnaire to 97 carers of 62 ED patients, and investigated the carer's characteristics associated with the scores in the three questionnaires. A personal history of ED, being the primary carer, and caring for a person with a diagnosis of anorexia nervosa are the characteristics that contribute most to aggravate the carers' burden in terms of stress, anxiety, depression, accommodation and enabling. Our findings may help doctors to provide effective support to caregivers and eventually improve the treatment of subjects with ED.

Partners' experiences of living with a person with an eating disorder: A grounded theory study

AIM

To explore the experiences of intimate partners of people with an eating disorder.

DESIGN

Qualitative grounded theory study.

METHODS

In-depth interviews were conducted with 18 partners of people with an eating disorder from 2013-2016. Data were analysed using the principles of classic grounded theory including, concurrent data collection and analysis, theoretical sampling, constant comparative analysis and memo writing.

RESULTS

Partners encounter disruptions to their lives when their significant other experiences an eating disorder. As a result, partners engage in a four-stage cyclical process involving: encountering a disruption; becoming an informed self; countering the disruption and reclaimed livability. By engaging in this process partners learn to support their significant other, remain committed to the relationship and recover their own lives. The process is drawn together and defined as the theory of 'Reconstructing Livability'.

CONCLUSION

The theory of 'Reconstructing Livability' provides a unique conceptualization of the experiences of partners who are living with a person with an eating disorder. It highlights the challenges faced by partners when supporting the recovery of their significant other and the intimate relationship, while reclaiming their own lives.

IMPACT

This study addresses the dearth of knowledge and understanding of partners' experiences. Partners engage in a process to enable them support recovery of their significant other and their own lives, but this is hindered by the challenges and unmet needs they experience. The theory provides a basis on which nurses can provide effective and timely supports to partners.

From eHealth to iHealth: Transition to Participatory and Personalized Medicine in Mental Health

Clinical assessment in psychiatry is commonly based on findings from brief, regularly scheduled in-person appointments. Although critically important, this approach reduces assessment to cross-sectional observations that miss essential information about disease course. The mental health provider makes all medical decisions based on this limited information. Thanks to recent technological advances such as mobile phones and other personal devices, electronic health (eHealth) data collection strategies now can provide access to real-time patient self-report data during the interval between visits. Since mobile phones are generally kept on at all times and carried everywhere, they are an ideal platform for the broad implementation of ecological momentary assessment technology. Integration of these tools into medical practice has heralded the eHealth era. Intelligent health (iHealth) further builds on and expands eHealth by adding novel built-in data analysis approaches based on (1) incorporation of new technologies into clinical practice to enhance real-time self-monitoring, (2) extension of assessment to the patient's environment including caregivers, and (3) data processing using data mining to support medical decision making and personalized medicine. This will shift mental health care from a reactive to a proactive and personalized discipline.

Predictors of change in psychosocial impairment secondary to an eating disorder

Eating disorders (ED) can significantly impair psychosocial health in patients. However, no published studies have so far used a standardized and specific instrument to evaluate predictive factors in ED-related psychosocial impairment. This prospective cohort study involved 177 patients receiving outpatient treatment for an ED at baseline and 115 patients at the 1-year follow-up. Patients completed three self-administered questionnaires: the Clinical Impairment Assessment (CIA), the Eating Attitudes Test-12 (EAT-12), and the Health-Related Quality of Life in ED-short form (HeRQoLED-s). Descriptive statistics, ANOVA, chi-square, and Fisher's exact test were applied to examine intervariable relationships. Multivariate linear regression was used to determine predictors of change in CIA scores. An improvement was reported by patients with restrictive anorexia nervosa (AN) compared to those with purgative AN. In the multivariate analysis, employment status, subtype of ED, and the bulimia and food preoccupation factor of the EAT-12 were significant predictors of change in the CIA scores.

Adaptation and validation of the Spanish version of the Clinical Impairment Assessment Questionnaire

The Clinical Impairment Assessment (CIA) assesses psychosocial impairment secondary to an eating disorder. The aim of this study was to create and validate a Spanish-language version of the CIA. Using a forward-backward translation methodology, we translated the CIA into Spanish and evaluated its psychometric characteristics in a clinical sample of 178 ED patients. Cronbach's alpha values, confirmatory factor analysis (CFA), and correlations between the CIA and the Eating Attitudes Test-12 and the Health-Related Quality of Life in ED-short form questionnaires evaluated the reliability, construct validity, and convergent validity, respectively. Known-groups validity was also studied comparing the CIA according to different groups; responsiveness was assessed by means of effect sizes. Data revealed a three-factor structure similar to that of the original CIA. Cronbach alpha coefficient of 0.91 for the total CIA score supported its internal consistency and correlations with other instruments demonstrated convergent validity. The total CIA score and factor scores also significantly discriminated between employment status, evidencing known-groups validity. Responsiveness parameters showed moderate changes for patients with restrictive eating disorders. These findings suggest that the CIA can be reliably and validly used in Spain in a number of different clinical contexts, by researchers and clinicians alike.

A systematic review of family caregiving in eating disorders

The objective of the study was to review systematically the available new evidence on family caregiving in eating disorders (ED), updating the study of Zabala, Macdonald, and Treasure (2009). Electronic databases were searched from October 2008 until May 2013. Selected studies included carers of people with ED and employed one or more measures of caregiving experience, accommodation and enabling behaviours, expressed emotion, and/or psychological distress. Twenty-nine studies were identified. Most of the studies examined these features in mothers of patients with anorexia. Only a few studies included a control group. The majority of studies found high levels of negative aspects of caregiving, accommodation and enabling behaviours, expressed emotion and psychological distress in carers of people with ED, although positive aspects and emotions were also reported. These features varied depending on some sociodemographic and clinical characteristics of carers and patients; moreover, interesting preliminary cultural and gender differences emerged. Progress has been made in research on family caregiving in ED and there is evidence that these factors can be associated with the outcome of ED. Theoretical, research and clinical implications of the findings are discussed.

Eating disorders: predictors of change in the quality of life of caregivers

Eating disorders (EDs) have a strong impact on the quality of life (QoL) of caregivers. This study explores the longitudinal changes in the QoL of ED caregivers at 1 (T1; n=109) and 2 years (T2; n=32) follow-up, and identifies predictors of improvement at 1-year follow-up. ED outpatients also completed a battery of tests at T1 (n=69) and T2 (n=11). Multivariate hierarchical linear mixed models were used, in which the caregivers' 1-year changes in QoL, anxiety and depression scores were analysed as the dependent variables. Predictor variables were the caregivers' perception of burden, perception of the severity of the patient's ED, kinship data, and the ED person's scores on QoL, anxiety depression and ED symptoms. Higher scores in mental health and low perception of burden at baseline predicted improved caregiver QoL at 1-year follow-up. The caregivers' QoL improved if the perception of burden decreased over time and if depression of the patient improved. The results suggest that interventions directed to reduce the caregivers' perception of burden and to improve the mental health of the ED patients would lead to improved caregiver QoL. The high attrition rate at T2 made prediction analyses unviable.

Validity and reliability of the Spanish version of the Involvement Evaluation Questionnaire among caregivers of patients with eating disorders

The Involvement Evaluation Questionnaire (IEQ) was developed to evaluate burden among caregivers of patients with schizophrenia. We aimed to examine its psychometric properties among caregivers of patients with eating disorders (ED). A prospective study was carried out, recruiting caregivers of patients with an ED attending two outpatient clinics in Bizkaia, Spain. Caregivers provided sociodemographic information and completed the Involvement Evaluation Questionnaire (IEQ), the Hospital Anxiety and Depression Scale (HADS), the Short-Form 12 (SF-12) and the Anorectic Behaviour Observation Scale (ABOS). The same information was requested one year later. The confirmatory factor analysis (CFA) provided satisfactory fit indexes. Almost all of the factor loadings were above 0.40. Cronbach's alpha coefficients were mostly superior to 0.70. The correlation coefficients between the IEQ domains and the other questionnaires were lower than the Cronbach's alpha coefficients. Known-groups validity was supported by significant differences in the IEQ mean scores according to certain variables, as contact hours, living with the patient, type of caregiver and gender. The indexes employed for the evaluation of responsiveness were between 0.13 and 0.99. The IEQ has good psychometric properties and can be used to evaluate burden among caregivers of patients with ED.