Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa (ANDI): a multicentre, randomised, open-label, non-inferiority trial

Effectiveness of home treatment in children and adolescents with psychiatric disorders-systematic review and meta-analysis

BACKGROUND

Home treatment in child and adolescent psychiatry offers an alternative to conventional inpatient treatment by involving the patient's family, school, and peers more directly in therapy. Although several reviews have summarised existing home treatment programmes, evidence of their effectiveness remains limited and data synthesis is lacking.

METHODS

We conducted a meta-analysis on the effectiveness of home treatment compared with inpatient treatment in child and adolescent psychiatry, based on a systematic search of four databases (PubMed, CINAHL, PsychINFO, Embase). Primary outcomes were psychosocial functioning and psychopathology. Additional outcomes included treatment satisfaction, duration, costs, and readmission rates. Group differences were expressed as standardised mean differences (SMD) in change scores. We used three-level random-effects meta-analysis and meta-regression and conducted both superiority and non-inferiority testing.

RESULTS

We included 30 studies from 13 non-overlapping samples, providing data from 1795 individuals (mean age: 11.95 ± 2.33 years; 42.5% female). We found no significant differences between home and inpatient treatment for postline psychosocial functioning (SMD = 0.05 [- 0.18; 0.30], p = 0.68, I2 = 98.0%) and psychopathology (SMD = 0.10 [- 0.17; 0.37], p = 0.44, I2 = 98.3%). Similar results were observed from follow-up data and non-inferiority testing. Meta-regression showed better outcomes for patient groups with higher levels of psychopathology at baseline and favoured home treatment over inpatient treatment when only randomised controlled trials were considered.

CONCLUSIONS

This meta-analysis found no evidence that home treatment is less effective than conventional inpatient treatment, highlighting its potential as an effective alternative in child and adolescent psychiatry. The generalisability of these findings is reduced by limitations in the existing literature, and further research is needed to better understand which patients benefit most from home treatment.

TRIAL REGISTRATION

Registered at PROSPERO (CRD42020177558), July 5, 2020.

Adaptive design trials in eating disorder research: A scoping review

OBJECTIVE

This scoping review sought to map the breadth of literature on the use of adaptive design trials in eating disorder research.

METHOD

A systematic literature search was conducted in Medline, Scopus, PsycInfo, Emcare, Econlit, CINAHL and ProQuest Dissertations and Theses. Articles were included if they reported on an intervention targeting any type of eating disorder (including anorexia nervosa, bulimia nervosa, binge-eating disorder, and other specified feeding or eating disorders), and employed the use of an adaptive design trial to evaluate the intervention. Two independent reviewers screened citations for inclusion, and data abstraction was performed by one reviewer and verified by a second.

RESULTS

We identified five adaptive design trials targeting anorexia nervosa, bulimia nervosa and binge-eating disorder conducted in the USA and Australia. All employed adaptive treatment arm switching based on early response to treatment and identified a priori stopping rules. None of the studies included value of information analysis to guide adaptive design decisions and none included lived experience perspectives.

DISCUSSION

The limited use of adaptive designs in eating disorder trials represents a missed opportunity to improve enrolment targets, attrition rates, treatment outcomes and trial efficiency. We outline the range of adaptive methodologies, how they could be applied to eating disorder research, and the specific operational and statistical considerations relevant to adaptive design trials.

PUBLIC SIGNIFICANCE

Adaptive design trials are increasingly employed as flexible, efficient alternatives to fixed trial designs, but they are not often used in eating disorder research. This first scoping review identified five adaptive design trials targeting anorexia nervosa, bulimia nervosa and binge-eating disorder that employed treatment arm switching adaptive methodology. We make recommendations on the use of adaptive design trials for future eating disorder trials.

[New aspects in etiology and treatment of adolescent anorexia nervosa-a postulated bio-psycho-social model and the impact of the COVID-19 pandemic]

Anorexia nervosa is one of the most frequent chronic disorders of adolescence associated with a high mortality. During the COVID-19-pandemic, the number of hospitalized children and adolescents with anorexia nervosa significantly increased. This article outlines new research findings to decode the etiology of this serious disorder, especially a genetic disposition and changes of metabolism. Against the background of increasing rates during the COVID-19 pandemic, the importance of the gene-environment interaction is discussed, and new treatment forms are described. Besides the development of new biological treatment strategies, there is also some important progress in psychotherapeutic interventions. Carers should always be integrated when treating children and adolescents with anorexia nervosa, which is especially emphasized in the new "home treatment" setting. The new concept of anorexia nervosa as a metabo-psychiatric disorder gives us hope for new research ideas and treatment strategies in this often-debilitating disorder of childhood and adolescence.

The Diagnosis and Treatment of Anorexia Nervosa in Childhood and Adolescence

BACKGROUND

Anorexia nervosa (AN) is a serious disease with a lifetime prevalence of up to 3.6% in women and 0.3% in men. Abnormally low weight and the associated starvation partly account for its somatic and mental manifestations.

METHODS

This review is based on publications retrieved by a selective search concerning AN in childhood and adolescence.

RESULTS

The peak age of onset of AN is 15.5 years. The frequency of inpatient treatment for AN rose by 40% during the COVID pandemic, indicating the importance of environmental factors; the heritability of AN is estimated at 0.5. The ICD-11 sets the threshold for AN-associated underweight at the fifth percentile for age of the body mass index, as long as the remaining diagnostic criteria are met. The main goal of the multiprofessional treatment of AN is the return to normal body weight, which is a central prerequisite for regaining somatic and mental health. The mean duration of AN is 3.4 years, and approximately twothirds of patients recover from the disease over the long term.

CONCLUSION

Marked weight loss in childhood and adolescence can trigger AN in the presence of a predisposition to this disease. Patients and their families should receive psychoeducation regarding the symptoms of starvation and their overlap with those of AN. Important objectives are to shorten the duration of the illness, minimize mortality and the risk of chronic illness, and to identify pharmacological approaches to treatment.

What is day hospital treatment for anorexia nervosa really like? A reflexive thematic analysis of feedback from young people

BACKGROUND

A significant proportion of young people do not respond to the NICE recommended treatment for anorexia nervosa: Family Therapy. Whilst historically these young people would be admitted to inpatient services, which are associated with greater treatment cost, greater risk of relapse, and worse outcome, more recently evidence is building for the effectiveness of day programmes. One day programme that has been found to be effective is the Intensive Treatment Programme (ITP) of the Maudsley Centre for Child & Adolescent Eating Disorders in London, UK. However, to-date no studies have investigated how young people experience such a day programme.

METHOD

Anonymous feedback was completed via online survey by 51 young people over a 5-year period (2018-2023) on discharge from ITP.

RESULTS

Four main themes were identified: (1) Support-young people expressed the importance of boundaries but also of feeling validated, and encouraged; (2) Uniqueness: an experience like no other-ITP was described as different to any other treatment received before (both outpatient and inpatient); (3) Relationships - young people valued connecting with others in a similar situation and reflected that relationships at home changed throughout treatment; (4) Self-development - learning skills, developing independence, and exploring an identity outside of the eating disorder was valued.

CONCLUSIONS

It is hoped that the reflections from these young people can help to inform clinicians working in DPs and those hoping to set up novel DPs about key aspects of treatment.

Involuntary Treatment for Child and Adolescent Anorexia Nervosa-A Narrative Review and Possible Advances to Move Away from Coercion

BACKGROUND

Children and adolescents with psychiatric disorders frequently experience hospital treatment as coercive. In particular, for patients with severe anorexia nervosa (AN), clinical and ethical challenges often arise if they do not voluntarily agree to hospital admission, often due to the ego-syntonic nature of the disorder. In these cases, involuntary treatment (IVT) might be life-saving. However, coercion can cause patients to experience excruciating feelings of pressure and guilt and might have long-term consequences.

METHODS

This narrative review aimed to summarize the current empirical findings regarding IVT for child and adolescent AN. Furthermore, it aimed to present alternative treatment programs to find a collaborative method of treatment for young AN patients and their families.

RESULTS

Empirical data on IVT show that even though no inferiority of IVT has been reported regarding treatment outcomes, involuntary hospital treatment takes longer, and IVT patients seem to struggle significantly more with weight restoration. We argue that more patient- and family-oriented treatment options, such as home treatment, might offer a promising approach to shorten or even avoid involuntary hospital admissions and further IVT. Different home treatment approaches, either aiming at preventing hospitalization or at shortening hospital stays, and the results of pilot studies are summarized in this article.

Day hospital program for anorexia nervosa in children and adolescents: Assessment, management and specific focus on early onset anorexia nervosa

INTRODUCTION

The French day hospital program specialized in eating disorders (ED) opened in January 2018. Our study presents preliminary data on clinical profiles of patients with anorexia nervosa (AN). We describe more specifically clinical characteristics of patients with early onset AN and according to their therapeutics orientations. Then, we compare the weight gain of patients managed only in day-patient (DP) treatment with those managed initially inpatient (IP) treatment and relays in DP.

METHODS

Ninety-two patients with AN, aged between 8 and 18 years, were evaluated with several questionnaires (EDI-2, EDE-Q, BSQ, EDS-R, CDI, STAI-Y, VSP-A, EPN-13).

RESULTS

Patients with early onset AN, n = 23 (25.3%), presented more restrictive behaviors, less marked dietary symptomatology, a lower degree of clinical perfectionism and a less marked feeling of ineffectiveness than adolescent patients with AN. Regarding the choice of hospitalization modality (DP alone or IP-DP), the only difference highlighted was the severity of patient undernutrition. Among the patients who were treated (IP-DP n = 27 vs DP alone n = 25), the weight evolution after one month and at discharge was favorable for both groups.

CONCLUSION

These preliminary data suggest the effectiveness of DP in the care of AN in children and adolescents.

Anorexia Nervosa With Comorbid Severe Depression: A Systematic Scoping Review of Brain Stimulation Treatments

ABSTRACT

Major depressive disorder (MDD) is highly prevalent in individuals with anorexia nervosa (AN) and is a predictor of greater clinical severity. However, there is a limited amount of evidence supporting the use of psychotropic medications for its management. A systematic scoping review was conducted to assess the current literature on brain stimulation treatments for AN with comorbid MDD, with a specific focus on MDD treatment response and weight restoration. This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the PubMed, PsycInfo, and MEDLINE databases were searched until July 2022 using specific key words related to AN and brain stimulation treatments. A total of 373 citations were identified, and 49 treatment studies that met the inclusion criteria were included in the review. The initial evidence suggests that electroconvulsive therapy, repetitive transcranial magnetic stimulation, and deep-brain stimulation may be effective in managing comorbid MDD in AN. Emerging evidence suggests that transcranial direct current stimulation may have a positive effect on body mass index in individuals with severe to extreme AN. However, there is a need for the development of better measurement techniques for assessing the severity of depression in the context of AN. Controlled trials that are adequately designed to account for these limitations are highly warranted for deep-brain stimulation, electroconvulsive therapy, and repetitive transcranial magnetic stimulation and hold promise for providing clinically meaningful results.

Comparison between continued inpatient treatment versus day patient treatment after short inpatient care in early onset anorexia nervosa (COTIDEA trial): a study protocol for a non-inferiority randomised controlled trial

BACKGROUND

In children with early-onset anorexia nervosa (first symptoms before 13 years old, EO-AN), experts recommend initial outpatient treatment but in-patient treatment (IP) is frequently indicated due to acute medical instability or for those who have not improved with outpatient treatment. This IP can target either a partial weight restauration or a total weight normalization (return to the previous BMI growth trajectory). There are no evidence in the literature on which is the better therapeutic option in EOAN. But as long length of stay induce social isolation, with elevated costs, we wonder if a stepped-care model of daypatient treatment (DP) after short IP stabilisation may be a treatment option as effective as full-time IP to target weight normalization. We designed a two-arm randomised controlled trial testing the non-inferiority of a stepped-care model of DP after short IP stabilisation versus full-time IP.

METHODS

Eighty-eight children aged 8 to 13 years suffering from EOAN with initial severe undernutrition will be randomly allocated to either IP treatment as usual or a stepped care DP model both targeting weight normalization. Assessments will be conducted at inclusion, somatic stabilization, weight normalization, 6 months and 12 months post randomisation. The primary outcome will be BMI at 12 months post-randomisation. Secondaries outcomes will included clinical (tanner stage), biological (prealbumin, leptin, total ghrelin and IGF1) and radiological (bone mineralization and maturation) outcomes, eating symptomatology and psychiatric assessments, motivation to change, treatment acceptability and quality of life assessments, cost-utility and cost-effectiveness analyses.

DISCUSSION

COTIDEA will provide rigorous evaluation of treatment alternative to full-time inpatient treatment to allow a reduction of social iatrogenic link to hospital length of stay and associated costs.

TRIAL REGISTRATION

Trial is registered on ClinicalTrials.gov (NCT04479683).

Inpatient Treatment Outcome in a Large Sample of Adolescents with Anorexia Nervosa

Anorexia nervosa is an illness affecting primarily adolescent girls and young women. Clinical guidelines recommend early intervention, with inpatient treatment for more severe cases. We present an evaluation of a multi-modal cognitive-behavioral inpatient treatment (CBT-E) involving carers in specialized units for adolescents. Routine data of 962 adolescent inpatients (26 boys) (mean age 15.48 [1.26]; range 12-17 years) were analyzed. Predictors of good body weight outcome (achieving a discharge BMI of at least 18.5 kg/m2) were identified by logistic regression analysis. Mean inpatient treatment lasted 96.69 (45.96) days. The BMI increased significantly from 14.93 (1.38) kg/m2 at admission to 17.53 (1.58) kg/m2 at discharge (z = 26.41; p < 0.001; d = 1.708). Drive for thinness decreased from 29.08 (9.87) to 22.63 (9.77; z = 18.41; p < 0.001; d = 0.787). All other subscores of the Eating Disorder Inventory also decreased significantly, with small to medium effect sizes. General psychopathology also showed significant decreases. The Beck Depression Inventory-II score decreased from 26.06 (11.74) to 16.35 (12.51; z = 18.41; p < 0.001; d = 0.883). A good body weight outcome was predicted by a higher BMI at admission (OR = 1.828), age at onset at 15 years or higher (OR = 1.722), and higher Somatization (OR = 1.436), Anxiety (OR = 1.320), and Bulimia (OR = 1.029) scores. CBT-E involving carers is an efficient intervention for adolescents with anorexia nervosa.

Change processes during intensive day programme treatment for adolescent anorexia nervosa: a dyadic interview analysis of adolescent and parent views

Background

Day programmes for adolescent anorexia nervosa (AN) can function as an alternative to inpatient admissions and/or an increase in outpatient treatment intensity. Processes of change during treatment for AN are currently poorly understood. This study aimed to explore how adolescents with AN and their parents understood the helpful and unhelpful factors and processes that impacted them during day programme treatment.

Method

A critical realist paradigm was used to qualitatively explore the views of 16 participants. Participants were recruited from the Intensive Treatment Programme (ITP) at the Maudsley Center for Child and Adolescent Eating Disorders (MCCAED) at the end of treatment. Dyadic Interview Analysis (DIA) was used to compare and contrast the narratives of the seven adolescent-parent pairs after two inductive reflexive thematic analyses were conducted for the group of eight adolescents and the group of eight parents separately.

Results

Eight subthemes across three themes were identified: 1) "Like me she didn't feel so alone anymore"-families connect with staff, peers, and each other; 2) "You have to eat because ITP say so"-the programme provides families with containment through its structure and authority; and 3) "I found that I was using the skills I learnt there like in multiple aspects of my life, not just around food"-families take in new ideas and generalize these into their lives. These interconnected themes generated hope and change. However, helpful elements individually could be unhelpful if one or more of the other factors were missing. For example, staff firmness, which participants often found helpful (theme two), could be experienced as harshness when adolescents did not feel related to as individuals (theme one).

Conclusion

The findings can be conceptualized within recent descriptions regarding the therapeutic change, including epistemic trust and mentalization. Treatment characteristics, such as intensity and containment, as well as illness-specific factors and processes, such as control and collaboration, the role of peer support, and the potential for family members to experience the impact of the adolescent's AN and treatment non-response as traumatic, are equally important to consider.

Eating disorder treatment in routine clinical care: A descriptive study examining treatment characteristics and short-term treatment outcomes among patients with anorexia nervosa and bulimia nervosa in Germany and Switzerland

This descriptive study examined patient characteristics, treatment characteristics, and short-term outcomes among patients with Anorexia Nervosa (AN) and Bulimia Nervosa (BN) in routine clinical care. Results for patients receiving full-time treatment were contrasted with results for patients receiving ambulatory treatment. Data of a clinical trial including 116 female patients (18-35 years) diagnosed with AN or BN were subjected to secondary analyses. Patients were voluntarily admitted to one of nine treatment facilities in Germany and Switzerland. Patients received cognitive-behavioral interventions in accordance with the national clinical practice guidelines for the treatment of EDs under routine clinical care conditions, either as full-time treatment or ambulatory treatment. Assessments were conducted after admission and three months later. Assessments included a clinician-administered diagnostic interview (DIPS), body-mass-index (BMI), ED pathology (EDE-Q), depressive symptoms (BDI-II), symptoms of anxiety (BAI), and somatic symptoms (SOMS). Findings showed that treatment intensity differed largely by setting and site, partly due to national health insurance policies. Patients with AN in full-time treatment received on average 65 psychotherapeutic sessions and patients with BN in full-time treatment received on average 38 sessions within three months. In comparison, patients with AN or BN in ambulatory treatment received 8-9 sessions within the same time. Full-time treatment was associated with substantial improvements on all measured variables for both women with AN (d = .48-.83) and BN (d = .48-.81). Despite the relatively small amount of psychotherapeutic sessions, ambulatory treatment was associated with small increases in BMI (d = .37) among women with AN and small improvements on all measured variables among women with BN (d = .27-.43). For women with AN, reduction in ED pathology were positively related to the number of psychotherapeutic sessions received. Regardless of diagnosis and treatment setting, full recovery of symptoms was rarely achieved within three months (recovery rates ranged between 0 and 4.4%). The present study shows that a considerable amount of patients with EDs improved after CBT-based ED treatment in routine clinical care within three months after admission. Intensive full-time treatment may be particularly effective in quickly improving ED-related pathology, although full remission of symptoms is typically not achieved. A small amount of ambulatory sessions may already produce considerable improvements in BN pathology and weight gain among women with AN. As patient characteristics and treatment intensity differed largely between settings, results should not be interpreted as superiority of one treatment setting over another. Furthermore, this study shows that treatment intensity is quite heterogeneous, indicating the possibility for increasing effectiveness in the treatment of EDs in routine clinical care.

Therapeutic outcome and long-term naturalistic follow-up of female adolescent outpatients with AN: clinical, personality and psychopathology evolution, process indicators and outcome predictors

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness of growing prevalence in childhood and adolescence. Despite its severity, there are still no completely satisfactory evidence-based treatments. Follow-up studies represent the most effective attempt to enlighten treatment effectiveness, outcome predictors and process indicators.

METHODS

Seventy-three female participants affected with AN were assessed at intake (T0) and at 6 (T1) and 12 (T2) months of an outpatient multimodal treatment program. Nineteen participants were assessed 15 years after discharge (T3). Changes in diagnostic criteria were compared with the chi-square test. Clinical, personality and psychopathology evolution were tested with ANOVA for repeated measures, using the t-test or Wilcoxon test as post-hoc. T0 features among dropout, stable and healed participants were compared. Healed and unhealed groups at long-term follow-up were compared using Mann-Whitney U test. Treatment changes were correlated to each other and with intake features using multivariate regression.

RESULTS

The rate of complete remission was 64.4% at T2, and 73.7% at T3. 22% of participants maintained a full diagnosis at T2, and only 15.8% at T3. BMI significantly increased at each time-point. A significant decrease of persistence and increase in self-directedness were evidenced between T0 and T2. Interoceptive awareness, drive to thinness, impulsivity, parent-rated, and adolescent-rated general psychopathology significantly decreased after treatment. Lower reward dependence and lower cooperativeness characterized the dropout group. The healed group displayed lower adolescent-rated aggressive and externalizing symptoms, and lower parent-rated delinquent behaviors. BMI, personality and psychopathology changes were related with each other and with BMI, personality and psychopathology at intake.

CONCLUSION

A 12-months outpatient multimodal treatment encompassing psychiatric, nutritional and psychological approaches is an effective approach for the treatment of mild to moderate AN in adolescence. Treatment was associated not only with increased BMI but also with positive personality development, and changes in both eating and general psychopathology. Lower relational abilities may be an obstacle to healing. Approaches to treatment resistance should be personalized according to these finding.

Inpatient target discharge weight for early-onset anorexia nervosa: Restoring premorbid BMI percentile to improve height prognosis

OBJECTIVE

Early-onset anorexia nervosa (EO-AN) is characterized by restricted food intake leading to low body weight, emerging before 14 years old. Most patients reaching a target body mass index (BMI) around the 25th percentile at hospitalization discharge display an incomplete prospective height catch-up. A better understanding of height prognosis determinants is required.

METHODS

In 74 children with an EO-AN, we collected height and weight premorbidly, at hospitalization, and at discharge, 6 months, 12 months, and at longer-term follow-up of 36 months. We defined a height prognosis parameter (HPP) as the difference between the height percentile at follow-up times and the premorbid height percentile. We explored the relationship between weight parameters and height catch-up at follow-up with linear regression analyses.

RESULTS

A higher weight suppression (WS) - i.e., difference between premorbid and current BMI - at admission and discharge was associated with lower HPP - i.e., a greater loss of height - at 12 months and 36 months follow-up. Similarly, a higher premorbid BMI percentile was associated with a lower HPP at 12 and 36 months.

CONCLUSION

Target discharge weight for EO-AN patients should be tailored and based on premorbid BMI trajectory to improve height prognosis.

Day Programs for children and adolescents with eating disorders: A systematic review

Day programs have received significant consideration within psychological literature as part of a continuum of mental health services. With increasing attention on the prevalence of eating disorders in children and adolescents, and the need for early intervention to minimize the costs and burden of the disorder, eating disorder day programs (also referred as partial hospitalization) have begun to emerge around the world. Despite their widespread use, no reviews to date have examined the efficacy of day programs for the treatment of eating disorders in children and adolescents. The current narrative literature review aims to describe and evaluate the efficacy of day programs for children and adolescents. The literature review was conducted according to the PRISMA guidelines and aimed to explore the outcomes and common program elements of day programs to guide clinical practice and service development. The review found variations amongst the day programs related to program elements, measures utilized and outcomes. Overall, the results suggest that day programs for children and adolescents are effective at restoring body weight, reducing eating disorder symptoms and addressing comorbid mental health concerns.

Caregivers in anorexia nervosa: is grief underlying parental burden?

ABSTARCT

PURPOSE: Anorexia Nervosa (AN) is a severe chronic disorder and parents' experience of caregiving is usually marked by emotional distress and burden. Severe chronic psychiatric disorders are known to be linked with the concept of grief. Grief has not been investigated in AN. The aim of this study was to explore parents' and adolescents' characteristics that may be related to parental burden and grief in AN, and the link between these two dimensions.

METHODS

Eighty mothers, 55 fathers and their adolescents (N  =  84) hospitalized for AN participated in this study. Evaluations of clinical characteristics of the adolescent's illness were completed, as well as self-evaluations of adolescent and parental emotional distress (anxiety, depression, alexithymia). Levels of parental burden were evaluated with the Experience of Caregiving Inventory and levels of parental grief with the Mental Illness Version of the Texas Revised Inventory of Grief.

RESULTS

Main findings indicated that the burden was higher in parents of adolescents with a more severe AN; fathers' burden was also significantly and positively related to their own level of anxiety. Parental grief was higher when adolescents' clinical state was more severe. Paternal grief was related to higher anxiety and depression, while maternal grief was correlated to higher alexithymia and depression. Paternal burden was explained by the father's anxiety and grief, maternal burden by the mother's grief and her child's clinical state.

CONCLUSION

Parents of adolescents suffering from AN showed high levels of burden, emotional distress and grief. These inter-related experiences should be specific targets for intervention aimed at supporting parents. Our results support the extensive literature on the need to assist fathers and mothers in their caregiving role. This in turn may improve both their mental health and their abilities as caregivers of their suffering child.

LEVEL OF EVIDENCE

Level III: Evidence obtained from cohort or case-control analytic studies.

Models of care for eating disorders: findings from a rapid review

BACKGROUND

Delayed diagnosis, gaps in services and subsequent delays in specialist care and treatment lead to poorer health outcomes for individuals with eating disorders (EDs) and drive significant government healthcare expenditure. Given the significant disease burden associated with EDs, it is imperative that current implementation research is summarised to identify gaps in care and enable refinement for optimal patient outcomes. This review aimed to provide an updated synthesis on models of care for EDs in developed healthcare systems.

METHODS

This paper was conducted as part of a series of Rapid Reviews (RRs) to be published in a special series in the Journal of Eating Disorders. To provide a current and rigorous review, peer-reviewed articles published in the English language between 2009 and 2021 across three databases (ScienceDirect, PubMed and Ovid/Medline) were searched, with priority given to higher level evidence (e.g., meta-analyses, large population studies, Randomised Control Trials (RCTs)). The current review synthesises data from included studies investigating models of care for people with EDs.

RESULTS

Sixty-three studies (4.5% of the original RR) were identified, which included several diagnostic populations, the most common being Anorexia Nervosa (AN) (30.51%). Across EDs, specialist care was found to improve patient outcomes, with many patients effectively being treated in outpatient or day programs with multi-disciplinary teams, without the need for lengthy inpatient hospitalisation. Few studies investigated the interaction of different ED services (e.g., inpatient, community services, primary care), however stepped care models emerged as a promising approach to integrate ED services in a targeted and cost-effective way. Issues surrounding low treatment uptake, underdiagnosis, long waiting lists and limited hospital beds were also evident across services.

CONCLUSION

Findings suggested further research into alternatives to traditional inpatient care is needed, with partial and shorter 'hospitalisations' emerging as promising avenues. Additionally, to tackle ongoing resource issues and ensure timely detection and treatment of EDs, further research into novel alternatives, such as active waiting lists or a greater role for primary care clinicians is needed. This paper is part of a larger Rapid Review series carried out to guide Australia's National Eating Disorders Research and Translation Strategy 2021-2031. Rapid reviews aim to thoroughly summarise an area of research over a short time period, typically to help with policymaking in this area. This Rapid Review summarises the evidence relating to how we care for people with eating disorders in Western healthcare systems. Topics covered include inpatient/hospital care, residential care, day programs, outpatient/community care, and referral pathways. Findings suggested specialist eating disorder services may enhance detection, referral, and patient care. Stepped care models presented as a cost-effective approach which may help with linkage between different eating disorder services. There was a trend towards shorter hospital stays and approaches which allow for greater connection with the community, such as day programs. Evidence was also found of treatment delays, due to system issues (long waiting lists, lack of accurate assessment and diagnosis) and patient-related barriers (stigma, recognition). Upskilling and involving primary care clinicians in diagnosis and referral as part of a stepped care model may help to address some of these concerns. Further efforts to improve mental health literacy and de-stigmatise help-seeking for eating disorders are needed.

Long-term follow-up of a randomized controlled trial comparing systemic family therapy (FT-S) added to treatment as usual (TAU) with TAU alone in adolescents with anorexia nervosa

BACKGROUND

Randomized controlled trials showed the efficacy of family therapy for anorexia nervosa during adolescence, but studies examining its long-term beneficial effect are still needed. This article presents the results of a 54-month post-randomization follow-up of a previously reported randomized controlled trial that compared two post-hospitalization outpatient treatment programs: Treatment As Usual alone versus Systemic Family Therapy added to Treatment As Usual.

METHODS

A consecutive series of 60 female adolescents with anorexia nervosa (DSM-IV) were randomized (30 per group). During the first 18 months, in the Treatment As Usual group, subjects received a multidisciplinary treatment. In the other group, Systemic Family Therapy sessions targeting intra-familial dynamics were added to Treatment As Usual. At 54 months, the primary outcome was defined using the Morgan and Russell global Outcome Categories (Good or Intermediate versus Poor). Secondary outcomes were the Global Outcome Assessment Schedule score, body mass index, amenorrhea, number of hospitalizations, eating disorder symptoms, psychopathological features, and family functioning. Analyses were carried out using an Intention-To-Treat with the Last Observation Carried Forward procedure. Data of 59/60 subjects were available.

RESULTS

At 54 months, significant effects in favor of adding Systemic Family Therapy to Treatment As Usual were shown for the Global Outcome Categories (60% of Good/Intermediate versus 31% in the control group, p = .026), mean body mass index (p = .048), resumption of menses (70.0% vs. 40% p = .020), and mental state score (p = .010). Family cohesion scores were lower in the Systemic Family Therapy group (p = .040).

CONCLUSIONS

Adding Systemic Family Therapy focusing on intra-familial dynamics to a multidimensional outpatient treatment program appeared to lead to a better long-term outcome in young women who suffered from severe anorexia nervosa during adolescence.

Comparing randomized controlled trials of outpatient family-based or inpatient multimodal treatment followed by outpatient care in youth with anorexia nervosa: Differences in populations, metrics, and outcomes

OBJECTIVE

Various approaches exist to treat youth with anorexia nervosa (AN). Family-based treatment (FBT) has never been compared to long inpatient, multimodal treatment (IMT) in a randomized controlled trial (RCT). The aim of this study was to compare data on body weight trajectories, change in eating disorder psychopathology, hospital days and treatment costs in RCTs delivering FBT or IMT.

METHOD

Review of RCTs published between 2010 and 2020 in youth with AN, delivering FBT or IMT.

RESULTS

Four RCTs delivering FBT (United States, n = 2; Australia, n = 2), one RCT delivering Family Therapy for AN (United Kingdom) and two RCTs delivering IMT (France, n = 1; Germany, n = 1) were identified from previous meta-analyses. The comparison of studies was limited by (1) significant differences in patient baseline characteristics including pretreated versus non-pretreated patients, (2) use of different psychometric and weight measures and (3) different initial velocity of weight recovery. Minimal baseline and outcome reporting standards for body weight metrics and nature/dose of interventions allowing international comparison are needed and suggestions to developing these standards are presented.

DISCUSSION

An RCT should investigate, whether FBT is a viable alternative to IMT, leading to comparable weight and psychopathology improvement with less inpatient time and costs.

Implementing service transformation for children and adolescents with eating disorders across England: the theory, politics, and pragmatics of large-scale service reform

BACKGROUND

Eating disorders are among the most serious mental health problems affecting children and young people and without appropriate treatment often have a protracted course with high levels of morbidity and mortality. While considerable progress has been made in recent years in developing effective evidence-based outpatient treatments, these are not always readily available. In England, until recently, the usual care pathway for young people with an eating disorder was referral from primary care to local generic Child and Adolescent Mental Health Services with varying levels of expertise in eating disorders and a mix of outpatient treatments available. Poor treatment progress or physical deterioration would usually result in inpatient admission. Admission rates were high, with children and young people with an eating disorder accounting for nearly a quarter of all child and adolescent psychiatric hospital admissions. Inpatient treatment is costly and has high relapse rates with some evidence that it may contribute to poorer long-term outcomes in eating disorders. Accumulating clinical and research evidence that early expert outpatient treatment can significantly reduce the need for inpatient care indicates,+ that investing in dedicated community-based eating disorders services is likely to be both clinically and economically beneficial.

OVERVIEW OF PAPER

This paper describes a large-scale transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community-based eating disorders services for children and young people.

Integrated enhanced cognitive behavioural (I-CBTE) therapy significantly improves effectiveness of inpatient treatment of anorexia nervosa in real life settings

BACKGROUND

Inpatient treatment of anorexia nervosa can be lifesaving but is associated with high rates of relapse and poor outcomes. To address this, the Oxford service has adapted the enhanced cognitive behavioural treatment (CBTE) model, first developed for inpatients in Italy to a UK national health service (NHS) setting. In this study, we compared the outcomes from treatment as usual (TAU), integrated CBTE (I-CBTE), and alternative treatment models in routine UK clinical practice.

METHODS

This is a longitudinal cohort study, using routinely collected data between 2017 and 2020 involving all adults with anorexia nervosa admitted to specialist units from a large geographical area in England covering a total population of 3.5 million. We compared TAU with (1) I-CBTE (13 weeks inpatient CBTE, restoration to a healthy weight, combined with 7 weeks day treatment followed by 20 weeks of outpatient CBTE; (2) standalone inpatient CBTE (due to insufficient resources since the pandemic; and (3) 6-8 weeks admission with partial weight restoration as crisis management. Primary outcome measures (min. 1 year after discharge from hospital) were defined as: (1) good outcome: Body Mass Index (BMI) > 19.5 and no abnormal eating or compensatory behaviours; (2) poor outcome: BMI < 19.5 and/or ongoing eating disorder behaviours; (3) readmission; or (4) deceased. Secondary outcomes were BMI on discharge, and length of stay.

RESULTS

212 patients were admitted to 15 specialist units in the UK depending on bed availability. The mean age was 28.9 (18-60) years, mean admission BMI was 14.1 (10-18.3), 80% were voluntary. At minimum 1-year follow up after discharge, 70% of patients receiving I-CBTE and 29% standalone inpatient CBTE maintained good outcomes, in contrast with < 5% TAU and crisis management admission. Readmission rates of I-CBTE were 14.3% vs ~ 50% (χ² < 0.0001) in the other groups. The main predictors of good outcome were reaching healthy BMI by discharge, I-CBTE and voluntary status. Age, psychiatric comorbidity and length of stay did not predict outcomes. BMI on discharge and length of stay were significantly better in the CBTE groups than in TAU.

CONCLUSIONS

Our main finding is that in a real-life setting, I-CBTE has superior short- and minimum 1 year outcomes as compared with alternative inpatient treatment models. Dissemination of I-CBTE across the care pathway has the potential to transform outcomes of inpatient treatment for this high-risk patient population and reduce personal and societal costs.

The effects of polyunsaturated fatty acid (PUFA) administration on the microbiome-gut-brain axis in adolescents with anorexia nervosa (the MiGBAN study): study protocol for a longitudinal, double-blind, randomized, placebo-controlled trial

Background

Anorexia nervosa (AN) is a severe psychiatric disease that often takes a chronic course due to insufficient treatment options. Emerging evidence on the gut-brain axis offers the opportunity to find innovative treatments for patients with psychiatric disorders. The gut microbiome of patients with AN shows profound alterations that do not completely disappear after weight rehabilitation. In previous studies, the administration of polyunsaturated fatty acids (PUFA) resulted in effects that might be beneficial in the treatment of AN, affecting the microbiome, body weight and executive functions. Therefore, the MiGBAN study aims to examine the effects of a nutritional supplementation with PUFA on the gut microbiome and body mass index (BMI) in patients with AN.

Methods

This is a longitudinal, double-blind, randomized, placebo-controlled trial. Within 2 years, 60 adolescent patients aged 12 to 19 years with AN will receive either PUFA or placebo for 6 months additional to treatment as usual. After 1 year, the long-term effect of PUFA on the gut microbiome and consecutively on BMI will be determined. Secondary outcomes include improvement of gastrointestinal symptoms, eating disorder psychopathology, and comorbidities. Additionally, the interaction of the gut microbiome with the brain (microbiome-gut-brain axis) will be studied by conducting MRI measurements to assess functional and morphological changes and neuropsychological assessments to describe cognitive functioning. Anti-inflammatory effects of PUFA in AN will be examined via serum inflammation and gut permeability markers. Our hypothesis is that PUFA administration will have positive effects on the gut microbiota and thus the treatment of AN by leading to a faster weight gain and a reduction of gastrointestinal problems and eating disorder psychopathology.

Discussion

Due to previously heterogeneous results, a systematic and longitudinal investigation of the microbiome-gut-brain axis in AN is essential. The current trial aims to further analyse this promising research field to identify new, effective therapeutic tools that could help improve the treatment and quality of life of patients. If this trial is successful and PUFA supplementation contributes to beneficial microbiome changes and a better treatment outcome, their administration would be a readily applicable additional component of multimodal AN treatment.

Trial registration

German Clinical Trials Register DRKS00017130. Registered on 12 November 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06413-7.

The clinical effectiveness and cost-effectiveness of a 'stepping into day treatment' approach versus inpatient treatment as usual for anorexia nervosa in adult specialist eating disorder services (DAISIES trial): a study protocol of a randomised controlled multi-centre open-label parallel group non-inferiority trial

Background

Anorexia nervosa (AN) is a serious and disabling mental disorder with a high disease burden. In a proportion of cases, intensive hospital-based treatments, i.e. inpatient or day patient treatment, are required, with day patient treatment often being used as a ‘step-down’ treatment after a period of inpatient treatment. Demand for such treatment approaches has seen a sharp rise. Despite this, the relative merits of these approaches for patients, their families, and the NHS and wider society are relatively unknown. This paper describes the rationale for, and protocol of, a two-arm multi-centre open-label parallel group non-inferiority randomised controlled trial, evaluating the effectiveness and cost-effectiveness of these two intensive treatments for adults with severe AN: inpatient treatment as usual and a stepped care day patient approach (the combination of day patient treatment with the option of initial inpatient treatment for medical stabilisation). The main aim of this trial is to establish whether, in adults with severe AN, a stepped care day patient approach is non-inferior to inpatient treatment as usual in relation to improving body mass index (BMI) at 12 months post-randomisation.

Methods

386 patients with a Diagnostic and Statistical Manual 5th edition diagnosis of severe AN or related disorder, with a BMI of ≤16 kg/m² and in need of intensive treatment will be randomly allocated to either inpatient treatment as usual or a stepped care day patient approach. Patients in both groups will receive treatment until they reach a healthy weight or get as close to this point as possible. Assessments will be conducted at baseline (prior to randomisation), and at 6 and 12 months post-randomisation, with additional monthly symptom monitoring. The primary outcome will be BMI at the 12-month post-randomisation assessment. Other outcomes will include psychosocial adjustment; treatment motivation, expectations and experiences; cost-effectiveness; and carer burden.

Discussion

The results of this study will provide a rigorous evaluation of two intensive treatment approaches which will inform future national and international treatment guidelines and service provision.

Trial registration

ISRCTN ISRCTN10166784. Registered 28 February 2020. ISRCTN is a primary registry of the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) network and includes all items from the WHO Trial Registration Data Set.

The Impact of Inpatient Multimodal Treatment or Family-Based Treatment on Six-Month Weight Outcomes in Youth with Anorexia Nervosa: A Naturalistic, Cross-Continental Comparison

In the USA, family-based treatment (FBT) with inpatient medical stabilization as needed is the leading evidence-based treatment for youth with anorexia nervosa (AN). In continental Europe, typically inpatient multimodal treatment targeting weight recovery followed by outpatient care (IMT) is standard care, if prior outpatient treatment was not sufficient. Our aim was to compare weekly weight gain and hospital days over six months for adolescents receiving FBT (USA) versus IMT (Germany) using naturalistic treatment data. To yield similar subgroups of youth aged 12−18 years, inclusion criteria were a percent median BMI (%mBMI) between 70−85 and the restrictive AN subtype. Weight gain and hospital days were compared, adjusted further in a multiple linear regression analysis (MLRA) for baseline group differences. Samples differed on baseline %mBMI (FBT [n = 71], 90.5 ± 12.8; IMT [n = 29], 78.3 ± 9.1, p < 0.05). In subgroups with comparable baseline %mBMI, the weekly weight gain over 6 months was similar (FBT [n = 21]: 0.35 ± 0.18 kg/week; IMT [n = 20]: 0.30 ± 0.18, p = 0.390, p = 0.166 after MLRA), but achieved fewer hospital days in FBT (FBT [n = 7]: 4 ± 6 days, IMT [n = 20]: 121 ± 42 days, p < 0.0001 before and after MLRA). FBT may be effective for a subgroup of adolescents with AN currently receiving IMT, but head-to-head studies in the same healthcare system are needed.

Adolescent inpatients with anorexia nervosa can roughly predict their own weight trajectories after discharge

Most adolescents with anorexia nervosa (AN) gain a substantial amount of weight during inpatient treatment, but many relapse after discharge. Therefore, there is a need to identify variables that predict weight changes after treatment. The current study tested whether such a variable may be patients' own predictions about their future weight. Data of 120 female adolescent inpatients with AN were available at discharge and one-year follow-up. Patients' own predictions about their future weight trajectories predicted their actual weight change after discharge: those who indicated that they would gain weight, gained weight, those who indicated that they would lose weight, lost weight, and those who indicated to maintain their weight, had no weight change on average. Similarly, expected weight change in kilograms correlated positively with actual weight change after discharge. Thus, patients who expect that they will lose weight again should receive intensified aftercare that fosters motivation to change.

Considerations for Athletes with Eating Disorders Based on Levels of Care

ABSTRACT

This article provides an overview of levels of care for eating disorders (EDs) and considerations that are specific to elite athletes. We discuss the following levels of care in terms of ED pathology and treatment aspects that may be unique to athletes: 1) inpatient and residential care, 2) intensive outpatient and partial hospitalization treatment, and 3) outpatient. Illustrative case studies also are presented to highlight distinctions between levels of care and athlete-specific nuances to treatment approaches and health care teams. Finally, we review aspects of return to play plans for elite athletes with EDs.

Clinicians' perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has significantly affected intensive treatment settings (i.e., inpatient [IP] and day patient [DP]) in specialist eating disorder services. However, the impact on clinicians working in these services is largely unknown. We therefore explored the perspectives of those supporting individuals with severe anorexia nervosa (AN) in intensive treatment settings during the pandemic.

METHODS

Between May 2020 and June 2021, we interviewed clinicians (n = 21) who delivered IP and/or DP treatment to patients with severe AN in four specialist eating disorder services in the United Kingdom. Data relating to experiences during COVID-19 were analysed using reflexive thematic analysis.

RESULTS

We identified six themes: Disruptions to Routine Treatment; Introduction of Virtual Treatment; Separation from Treatment, Others and the World; Impact on Recovery; Impact on Staff; and Pressure on Referral Pathways. COVID-19 posed significant challenges to IP and DP services: forcing closures, operating with restrictions and virtual treatment, and impacting delivery of essential treatment components, referral pathways, clinician wellbeing, risk management, and patient isolation and recovery trajectories. Opportunities arose, in particular in DP services offering virtual support.

CONCLUSIONS

COVID-19 challenged the continuation of multidisciplinary treatment. The findings underline the necessity for medical, psychological, practical, and nutritional support, as well as carer involvement and fostering social connections to remain at the forefront of intensive treatment for severe AN. They also emphasise the uncertainty surrounding which intensive treatment may be best suited to which patient when, particularly within the context of virtual DP support.

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.

Eating Disorder Day Programs: Is There a Best Format?

The use of a Day Program (DP) format (i.e., intensive daily treatment with no overnight admission) has been shown to be an effective treatment for eating disorders (EDs). The disadvantages, however, include higher cost than outpatient treatment (including costs of meals and staff), greater disruption to patients’ lives, and the use of a highly structured and strict schedule that may interrupt the development of patients’ autonomy in taking responsibility for their recovery. This study investigated whether reducing costs of a DP and the disruption to patients’ lives, and increasing opportunity to develop autonomy, impacted clinical outcomes. Three sequential DP formats were compared in the current study: Format 1 was the most expensive (provision of supported dinners three times/week and extended staff hours); Format 2 included only one dinner/week and provision of a take-home meal. Both formats gave greater support to patients who were not progressing well (i.e., extended admission and extensive support from staff when experiencing feelings of suicidality or self-harm). Format 3 did not provide this greater support but established pre-determined admission lengths and required the patient to step out of the program temporarily when feeling suicidal. Fifty-six patients were included in the analyses: 45% were underweight (body mass index (BMI) < 18.5), 96.4% were female, 63% were given a primary diagnosis of anorexia nervosa (or atypical anorexia nervosa), and mean age was 25.57 years. Clinical outcomes were assessed using self-reported measures of disordered eating, psychosocial impairment, and negative mood, but BMI was recorded by staff. Over admission, 4- and 8-week post-admission, and discharge there were no significant differences between any of the clinical outcomes across the three formats. We can tentatively conclude that decreasing costs and increasing the opportunities for autonomy did not negatively impact patient outcomes, but future research should seek to replicate these results in other and larger populations that allow conclusions to be drawn for different eating disorder diagnostic groups.

Concerns and recommendations for using Amazon MTurk for eating disorder research

OBJECTIVE

Our original aim was to validate and norm common eating disorder (ED) symptom measures in a large, representative community sample of transgender adults in the United States. We recruited via Amazon Mechanical Turk (MTurk), a popular online recruitment and data collection platform both within and outside of the ED field. We present an overview of our experience using MTurk.

METHOD

Recruitment began in Spring 2020; our original target N was 2,250 transgender adults stratified evenly across the United States. Measures included a demographics questionnaire, the Eating Disorder Examination-Questionnaire, and the Eating Attitudes Test-26. Consistent with current literature recommendations, we implemented a comprehensive set of attention and validity measures to reduce and identify bot responding, data farming, and participant misrepresentation.

RESULTS

Recommended validity and attention checks failed to identify the majority of likely invalid responses. Our collection of two similar ED measures, thorough weight history assessment, and gender identity experiences allowed us to examine response concordance and identify impossible and improbable responses, which revealed glaring discrepancies and invalid data. Furthermore, qualitative data (e.g., emails received from MTurk workers) raised concerns about economic conditions facing MTurk workers that could compel misrepresentation.

DISCUSSION

Our results strongly suggest most of our data were invalid, and call into question results of recently published MTurk studies. We assert that caution and rigor must be applied when using MTurk as a recruitment tool for ED research, and offer several suggestions for ED researchers to mitigate and identify invalid data.

Clinicians' perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings

BACKGROUND

Admissions to intensive treatment (i.e., inpatient [IP] and/or day patient [DP]) for individuals with severe anorexia nervosa (AN) are common. Growing literature indicates potential risks and benefits of each intensive treatment approach; however, existing research has focused on patient and carer perspectives of these treatments. Also, there is scant empirical evidence available for guiding the parameters of intensive treatments for AN. We therefore explored clinicians' perspectives and experience of supporting adults with severe AN in intensive settings.

METHODS

We conducted twenty one semi-structured interviews with clinicians who deliver intensive treatments (i.e., IP and/or DP) for individuals with severe AN across four specialist Eating Disorder Services in the United Kingdom between May 2020 and June 2021. We asked clinicians about their views and experiences of supporting individuals with severe AN in intensive treatment settings and the challenges and opportunities associated with IP and DP treatment. Data were analysed using reflexive thematic analysis supported by NVivo software.

RESULTS

Five broad and interrelated themes were identified: (1) Intensive Support; (2) The Severity of Patients' Illnesses; (3) Hope and Recovery; (4) Which Treatment When; (5) Limited Resources; and (6) Carer Burden. We identified various similarities between the two intensive treatment approaches, including the value of intensive and multidisciplinary support and carer involvement, and the challenge of managing complex and unique needs in resource-limited intensive settings. We also found differences in the relationship of treatment to patients' home environments, the necessity of patient motivation, and the management of risk.

CONCLUSIONS

Both intensive treatment settings are valued by clinicians; however, there are unique challenges and opportunities for supporting individuals with severe AN within each. Our findings suggest DP treatment may be used as an alternative to IP treatment for individuals with severe AN. However, clear questions remain over which intensive treatment setting is best suited to which patient when and should be the focus of future research.

Gender-related differences in health-care and economic costs for eating disorders: A comparative cost-development analysis for anorexia and bulimia nervosa based on anonymized claims data

OBJECTIVE

Anorexia nervosa (AN) and bulimia nervosa (BN) impose a significant financial burden and immense sufferings on affected individuals. Yet little is known about the differences between how each disorder affects males and females, respectively.

METHOD

We performed a retrospective cost-development analysis of anonymized claims data from the German statutory health-insurance system. Insured persons who suffered from an onset of AN (F50.0; N = 1,242 females and 71 males) or BN (F50.2; N = 1,104 females and 64 males) were analyzed for cost-of-illness over a 5-year period, beginning 2 years before the index diagnosis.

RESULTS

In total, all groups incurred similar distributions of total costs over the 5-year observation period, with roughly 14,000-20,000 EUR median costs. About two-thirds of the total costs for females and males with AN are associated with mental illness, whereas for females and males with BN, this applies to approximately half the total costs. Analyses revealed differences between disorders and genders for single outcomes. AN is associated with a stronger increase in costs within a short period following onset and higher inpatient treatment costs, whereas BN entails more instances of incapacity to work before and after onset. Compared to females, males incurred lower costs in outpatient treatments.

DISCUSSION

Our study adds evidence as to the disparities in health-care utilizations and costs over the course of illness, in outcome ratios, and between genders, for both AN and BN.

Lessons learned developing and testing family-based interoceptive exposure for adolescents with low-weight eating disorders

BACKGROUND

Anorexia nervosa (AN) usually develops in early adolescence and is characterized by high rates of morbidity and mortality. Family-based therapy (FBT) is the leading evidence-based treatment for adolescents with AN, but not all patients experience sufficient improvement. The purpose of this manuscript is to describe the development and subsequent experience with a Family-Based Interoceptive Exposure (FBT-IE) for adolescents with a broader form of low-weight eating disorders.

METHODS

The novel IE-based behavioral intervention is a six-session family-based treatment module designed to directly target and modify disgust by altering the prefrontal regulation of the insula response to aversive stimuli by decreasing visceral sensitivity (e.g., bloating). Each session teaches a new skill regarding tolerating distress to visceral sensations associated with disgust and an in-vivo "IE exercise," in which the family is provided with a meal replacement shake of unknown content and caloric density.

RESULTS

In this novel treatment, the patient learns to tolerate disgust in the context of a challenging food stimulus as a way to increase consumption of restricted foods outside of session.

CONCLUSION

We discuss successes and challenges executing this treatment with patients with low-weight eating disorders and propose future directions for the intervention.

BDNF levels in adolescent patients with anorexia nervosa increase continuously to supranormal levels 2.5 years after first hospitalization

BACKGROUND

Brain-derived neurotrophic factor (BDNF) influences brain plasticity and feeding behaviour, and it has been linked to anorexia nervosa in numerous studies. Findings in mostly adult patients point to reduced serum BDNF levels in the acute stage of anorexia nervosa and rising levels with weight recovery. However, it is unclear whether this increase leads to normalization or supranormal levels, a difference that is potentially important for the etiology of anorexia nervosa and relapse.

METHODS

We measured serum BDNF at admission (n = 149), discharge (n = 130), 1-year follow-up (n = 116) and 2.5-year follow-up (n = 76) in adolescent female patients with anorexia nervosa hospitalized for the first time, and in healthy controls (n = 79). We analyzed associations with body mass index, eating disorder psychopathology and comorbidities.

RESULTS

Serum BDNF was only nominally lower at admission in patients with anorexia nervosa compared to healthy controls, but it increased continuously and reached supranormal levels at 2.5-year follow-up. BDNF was inversely associated with eating disorder psychopathology at discharge and positively associated with previous weight gain at 1-year follow-up.

LIMITATIONS

We compensated for attrition and batch effects using statistical measures.

CONCLUSION

In this largest longitudinal study to date, we found only nonsignificant reductions in BDNF in the acute stage of anorexia nervosa, possibly because of a shorter illness duration in adolescent patients. Supranormal levels of BDNF at 2.5-year follow-up could represent a pre-existing trait or a consequence of the illness. Because of the anorexigenic effect of BDNF, it might play an important predisposing role for relapse and should be explored further in studies that test causality.

Short-Term Outcome of Inpatient Treatment for Adolescents with Anorexia Nervosa Using DSM-5 Remission Criteria

This study evaluated the short-term outcome of a multimodal inpatient treatment concept for adolescents with anorexia nervosa (AN). In this prospective observational study, a cohort of 126 female adolescents with AN (age range: 11–17, mean age: 14.83) was longitudinally followed from admission to discharge (average duration of stay: 77 days). We used gold-standard clinical interviews and self-report data, as well as DSM-5 remission criteria, to evaluate the treatment outcome. From admission to discharge, body-mass-index (BMI) significantly improved by 2.6 kg/m². Data from clinical interviews and self-reports yielded similar improvements in restraint eating and eating concerns (large effects). Lower effects were observed for variables assessing weight/shape concerns and drive for thinness. At discharge, 23.2% of patients showed full remission of AN, 31.3% partial remission, and 45.5% no remission according to DSM-5 criteria. Differences in remission groups were found regarding AN severity, age at admission, and use of antidepressant medication. Living with both parents, longer duration of inpatient treatment and the use of antipsychotic medication were significantly associated with higher BMI change. The findings provide evidence for the short-term effectiveness of our inpatient treatment concept. We recommend using DSM-5 based remission criteria to evaluate the treatment outcome to improve the comparability of studies.

Vitamin D Level Trajectories of Adolescent Patients with Anorexia Nervosa at Inpatient Admission, during Treatment, and at One Year Follow Up: Association with Depressive Symptoms

(1) Background: Evidence has accumulated that patients with anorexia nervosa (AN) are at higher risk for vitamin D deficiency than healthy controls. In epidemiologic studies, low 25(OH) vitamin D (25(OH)D) levels were associated with depression. This study analyzed the relationship between 25(OH)D serum levels in adolescent patients and AN and depressive symptoms over the course of treatment. (2) Methods: 25(OH)D levels and depressive symptoms were analyzed in 93 adolescent (in-)patients with AN from the Anorexia Nervosa Day patient versus Inpatient (ANDI) multicenter trial at clinic admission, discharge, and 1 year follow up. Mixed regression models were used to analyze the relationship between 25(OH)D levels and depressive symptoms assessed by the Beck Depression Inventory (BDI-II). (3) Results: Although mean 25(OH)D levels constantly remained in recommended ranges (≥50 nmol/L) during AN treatment, levels decreased from (in)patient admission to 1 year follow up. Levels of 25(OH)D were neither cross-sectionally, prospectively, nor longitudinally associated with the BDI-II score. (4) Conclusions: This study did not confirm that 25(OH)D levels are associated with depressive symptoms in patients with AN. However, increasing risks of vitamin D deficiency over the course of AN treatment indicate that clinicians should monitor 25(OH)D levels.

Cost-effectiveness of specialist eating disorders services for children and adolescents with anorexia nervosa: a national surveillance study

BACKGROUND

Evidence suggests specialist eating disorders services for children and adolescents with anorexia nervosa have the potential to improve outcomes and reduce costs through reduced hospital admissions. This study aimed to evaluate the cost-effectiveness of assessment and diagnosis in community-based specialist child and adolescent mental health services (CAMHS) compared to generic CAMHS for children and adolescents with anorexia nervosa.

METHOD

Observational, surveillance study of children and adolescents aged 8 to 17, in contact with community-based CAMHS in the UK or Republic of Ireland for a first episode of anorexia nervosa. Data were reported by clinicians at baseline, 6 and 12-months follow-up. Outcomes included the Children's Global Assessment Scale (CGAS) and percentage of median expected body mass for age and sex (%mBMI). Service use data included paediatric and psychiatric inpatient admissions, outpatient and day-patient attendances. A joint distribution of incremental mean costs and effects for each group was generated using bootstrapping to explore the probability that each service is the optimal choice, subject to a range of values a decision-maker might be willing to pay for outcome improvements. Uncertainty was explored using cost-effectiveness acceptability curves.

RESULTS

Two hundred ninety-eight children and adolescents met inclusion criteria. At 12-month follow-up, there were no significant differences in total costs or outcomes between specialist eating disorders services and generic CAMHS. However, adjustment for pre-specified baseline covariates resulted in observed differences favouring specialist services, due to significantly poorer clinical status of the specialist group at baseline. Cost-effectiveness analysis using CGAS suggests that the probability of assessment in a specialist service being cost-effective compared to generic CAMHS ranges from 90 to 50%, dependent on willingness to pay for improvements in outcome.

CONCLUSIONS

Assessment in a specialist eating disorders service for children and adolescents with anorexia nervosa may have a higher probability of being cost-effective than assessment in generic CAMHS.

TRIAL REGISTRATION

ISRCTN12676087 . Date of registration 07/01/2014.

Third-wave interventions for eating disorders in adolescence - systematic review with meta-analysis

CONTEXT

Third-wave therapies have demonstrated efficacy as a treatment option for EDs in adulthood. Data on the suitability for EDs in adolescence are lacking.

OBJECTIVE

To estimate the efficacy of third-wave interventions to reduce ED symptoms in adolescents in randomized controlled trials (RCTs) and uncontrolled studies.

DATA SOURCES

We systematically reviewed the databases PubMed (1976-January 2021), PsycINFO (1943-January 2021), and the Cochrane database (1995-January 2021) for English-language articles on third-wave therapies. References were screened for further publications of interest.

STUDY SELECTION

RCTs and pre-post studies without control group, comprising patients aged 11-21 years (mean age = 15.6 years) with an ED diagnosis (anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder not otherwise specified) investigating the efficacy of third-wave psychological interventions were included. Efficacy had to be evaluated according to the Eating Disorder Examination or Eating Disorder Examination-Questionnaire, the Eating Disorder Inventory-2, the Eating Disorder Inventory-3, or the Structured Interview for Anorexic and Bulimic Disorders for DSM-IV and ICD-10. The outcome assessed in the meta-analysis was the EDE total score.

DATA EXTRACTION

Independent extraction of data by two authors according to a pre-specified data extraction sheet and quality indicators.

DATA SYNTHESIS

We identified 1000 studies after removal of duplicates, assessed the full texts of 48 articles for eligibility, and included 12 studies with a total of 487 participants (female 97.3%/male 2.6%) in the qualitative synthesis and seven studies in the meta-analysis. Articles predominantly reported uncontrolled pre-post trials of low quality, with only two published RCTs. Treatments focused strongly on dialectical behaviour therapy (n = 11). We found moderate effects of third-wave therapies on EDE total score interview/questionnaire for all EDs (d = - 0.67; z = - 5.53; CI95% = - 0.83 to - 0.59). Descriptively, the effects appeared to be stronger in patients with BN and BED.

CONCLUSION

At this stage, it is not feasible to draw conclusions regarding the efficacy of third-wave interventions for the treatment of EDs in adolescence due to the low quality of the empirical evidence. Since almost all of the identified studies used DBT, it is unfortunately not possible to assess other third-wave treatments' efficacy.

Moving online: young people and parents' experiences of adolescent eating disorder day programme treatment during the COVID-19 pandemic

BACKGROUND

This study examined the experiences of young people and their parents who attended an intensive day treatment programme for eating disorders online during the global COVID-19 pandemic.

METHODS

Online questionnaires were completed by 14 adolescents (12-18 years) and their parents (n = 19). The questionnaires included a mixture of rating questions (Likert scale) and free text responses. Free text responses were analysed using reflexive thematic analysis.

RESULTS

Three main themes were identified: 1) New discoveries, 2) Lost in translation and 3) The best of a bad situation. This study provides insight into the benefits and pitfalls of online treatment delivery in the adolescent day programme context, which has rapidly had to become part of the everyday therapeutic practice. Results indicate that there are advantages and disadvantages to this, and that parents and young people's views differed.

CONCLUSIONS

This study suggests that the increased accessibility provided by online working does not necessarily translate to increased connection. Given the importance of therapeutic alliance in treatment outcomes, this will be an important consideration for future developments of online intensive treatments.

Specialized post-inpatient psychotherapy for sustained recovery in anorexia nervosa via videoconference - study protocol of the randomized controlled SUSTAIN trial

BACKGROUND

A major barrier to long-term recovery from anorexia nervosa (AN) are early and frequent relapses after inpatient treatment. There is an urgent need for enhanced continuity of specialized care involving effective aftercare interventions and relapse prevention strategies in order to improve the long-term outcome for patients with AN.

METHODS

SUSTAIN is a multi-center, prospective, randomized-controlled trial investigating the efficacy of a novel post-inpatient aftercare intervention for patients with AN as compared to optimized treatment-as-usual (TAU-O). The SUSTAIN aftercare intervention is based on the cognitive-interpersonal maintenance model of AN and specifically tailored to achieve sustained recovery in AN following inpatient treatment. The SUSTAIN aftercare intervention comprises 20 treatment sessions over eight months and will be predominantly delivered via videoconference to overcome discontinuity of care. TAU-O refers to routine outpatient psychotherapy as generally offered in the German health care system. A total number of 190 patients receiving inpatient or day-hospital treatment for AN will be randomized and assessed over a 14-month period following randomization including a 6 months follow-up. Minimum Body Mass Index (BMI) is 15 kg/m² at trial inclusion. The primary efficacy endpoint is the change in BMI between baseline (T0) and end of treatment (T2) adjusted for baseline BMI. Key secondary outcomes comprise eating disorder and general psychopathology, quality of life, proportion of relapse and of weight restoration, and cost-effectiveness.

DISCUSSION

The results of the present trial will provide evidence if the novel aftercare intervention fosters sustained recovery in patients affected by severe courses of AN.

TRIAL REGISTRATION

The SUSTAIN trial was prospectively registered on November 18, 2020, under the registration number DRKS00023372 at the German Clinical Trials Register ( https://www.drks.de/drks_web/ ) which is an acknowledged primary register of the World Health Organization ( http://apps.who.int/trialsearch/ ). Protocol version: 1.2.

A novel approach for autism spectrum condition patients with eating disorders: Analysis of treatment cost-savings

OBJECTIVE

In the current economic context, it is critical to ensure that eating disorder (ED) treatments are both effective and cost-effective. We describe the impact of a novel clinical pathway developed to better meet the needs of autistic patients with EDs on the length and cost of hospital admissions.

METHOD

The pathway was based on the Institute for Healthcare's Model of Improvement methodology, using an iterative Plan, Do, Study, Act format to introduce change and to co-produce the work with people with lived experience and with healthcare professionals. We explored the change in length and cost of admissions before and after the pathway was introduced.

RESULTS

Preliminary results suggest that the treatment innovations associated with this pathway have led to reduced lengths of admission for patients with the comorbidity, which were not seen for patients without the comorbidity. Estimated cost-savings were approximately £22,837 per patient and approximately £275,000 per year for the service as a whole.

CONCLUSION

Going forward, our aim is to continue to evaluate the effectiveness and cost-effectiveness of investment in the pathway to determine whether the pathway improves the quality of care for patients with a comorbid ED and autism and is good value for money.

Intensive Treatments in Adolescent Anorexia Nervosa

Approximately one-fifth to one-third of patients with adolescent anorexia nervosa (AN) need intensive care in the course of their illness. This article provides an update and discussion on different levels of intensive care (inpatient treatment (IP), day patient treatment (DP) and home treatment (HoT)) in different health care systems based on recently published literature. Important issues discussed in this article are new recommendations for the refeeding process and the definition of target weight as well as principles of medical stabilization and psychotherapeutic approaches. The pros and cons of longer or shorter hospitalization times are discussed, and the advantages of stepped care and day patient treatment are described. A new promising intensive treatment method involving the patient, their caregivers and the direct home environment is introduced. Parents and caregivers should be included in treatment research to foster collaborative work with the attending clinicians. There is an urgent need to evaluate the mid- to long-term outcomes of various intensive treatment programs to compare their effectiveness and costs across different health care systems. This could help policy makers and other stakeholders, such as public and private insurances, to enhance the quality of eating disorder care.

[What factors explain the length of hospitalization for anorexia nervosa: A systematic review]

OBJECTIVES

The cost of hospital treatment for anorexia nervosa (AN) is very high given its duration. Identifying factors related to length of hospital stay (LOS) would make it possible to consider targeted therapeutic strategies that, by optimizing care, would reduce their duration and costs. The objective of this work is to identify the factors related (predictive and associated) to LOS for AN.

METHODS

Systematic review of existing literature up to October 2020, based on Pubmed, according to PRISMA recommendations (Preferred Reported Items for Systematic reviews and Meta-Analysis). Factors related to LOS have been described in two categories: factors related to clinical aspects ; and factors related to therapeutic aspects and management modalities. We distinguished predictive factors (identified as pre-hospitalization or contemporaneous with hospital admission) and associated factors (observed during hospitalization) for each category.

RESULTS

Thirteen articles were selected. Samples from the selected studies ranged from 35 to 381 subjects, mostly women with restrictive type AN (R-AN), but some samples included all types of AN, or focused on purging-type forms. The mean age at admission ranged from 13.6 years (Standard Deviation-SD:±1.6) to 30.3 years (SD :±13.9), corresponding to adolescent, adult or mixed samples. Mean body mass indices at admission ranged from 12.3 (SD±1.4) to 16.6 (SD:±2.1). The duration of disease progression ranged from 11.7 months±2.2 to 9.7 years. Mean LOS are short for studies conducted in pediatrics or in medical services (ranging from 13.0 days [SD±7.3] to 22.1 days [SD±9.4]); they are more variable for studies conducted in psychiatry: from 15.6 days (SD±1.0) to 150.2 days (SD±80.8). Among the factors related to an increase in LOS, clinical predictors included: older age at onset or admission; longer duration of the disorder; low minimum body weight during AN; low BMI at admission; purgative form of anorexia nervosa; and high levels of dietary symptoms (asceticism and ineffectiveness dimensions on Eating Disorder Inventory-2). Therapeutic and management modality predictive factors were: a higher number of hospitalizations for AN; the use of enteral nutrition (nasogastric or percutaneous gastric tube) on admission or during hospitalization; the use of intravenous renutrition coupled with oral renutrition; hospitalization far from the patient's home; absence of hospital care in psychiatry after medical stabilization in a somatic unit; compulsory hospitalization. Associated factors were: the presence of psychiatric comorbidities; greater weight gain during hospitalization. Among the factors related to a decrease in LOS, the clinical predictive factor were: greater self-confidence at admission (measured by the Eating Disorder Recovery Self-Efficacy Questionnaire). Therapeutic and management modality predictors included: increased caloric intake of oral renutrition on admission; intake of oral nutritional supplements on admission; and hospitalization in urban areas. The associated factor was: compliance with the weight contract in the adolescent population.

DISCUSSION

Factors related to an increase in LOS are explained by: higher resistance to treatment, higher severity of the disease, the time required for weight gain in services using cognitive-behavioural therapy, complications associated with renutrition modalities such as parenteral renutrition, difficulties in organising outpatient follow-up which require better consolidation of inpatient treatment and the lack of multidisciplinary care in medical services. Factors related to a decrease in LOS are due to: faster weight gain, the presence of a greater number of outpatient follow-up structures close to the hospital and better adherence to treatment to complete the weight contract.

CONCLUSIONS

Taking these factors into account during hospitalization for AN would help optimize care, duration and costs. This situation therefore requires the development of therapeutic trials targeting the identified factors in order to reduce LOS in the treatment of AN.

A systematic review of interventions to support transitions from intensive treatment for adults with anorexia nervosa and/or their carers

AIM

In the short term, intensive treatment focusing on restoring weight for anorexia nervosa can remediate many symptoms. However, there is a high level of relapse after discharge. This paper examines interventions developed to bridge the transition from intensive to less intensive forms of treatment for adult anorexia nervosa.

METHOD

We undertook a systematic review of the literature on interventions aimed at providing transition support. The Template for Intervention Description and Replication was used to describe components of the transition interventions. Patient's drop-out rates, weight, eating disorder psychopathology and mood data were extracted at end of treatment and follow-up to describe preliminary efficacy.

RESULTS

Fourteen studies were selected: nine used psychological interventions delivered through face-to-face talking therapy or guided self-help, three examined the use of fluoxetine and two assessed stepped-care approaches. Transition support was delivered to patients in 11 studies, to patients and carers in two studies, and carers alone in another study.

CONCLUSIONS

There was a great heterogeneity in the content and structure of the transition interventions evaluated. Overall, drop-out rates were lower for psychological support than pharmacological interventions or stepped-care approaches. Changes in eating disorder outcomes and mood were small to moderate throughout for studies that included a comparison group.

Can you find the right support for children, adolescents and young adults with anorexia nervosa: Access to age-appropriate care systems in various healthcare systems

OBJECTIVE

Anorexia nervosa (AN) often has its onset in childhood or adolescence. However, there is insufficient knowledge regarding access to and utilisation of age-specific clinical diagnostics and treatment.

METHODS

A literature review covering the last 10 years was conducted to provide a narrative review of the current state of research on the detection and treatment of young patients with AN in primary and secondary care.

RESULTS

Most articles were of Western European or US origin. Timely diagnosis of the eating disorder (ED) and treatment options more often depend on the structure and quality of the national health care system than on scientific evidence. Regular paediatric health check-ups and age-appropriate eating disorder services appear to facilitate early diagnosis. Age-specific treatment that also involves the carers is often associated with a higher continuity of care and a better outcome. Although many adolescents require an extension of treatment into young adulthood, individual and health care system-related obstacles in many countries prevent a smooth transition.

CONCLUSION

To improve outcomes in childhood and adolescent AN, age-specific and timely diagnostic and therapeutic procedures are urgently needed.

Length of stay for anorexia nervosa: Systematic review and meta-analysis

OBJECTIVE

Evidence regarding global trends in length of stay for patients with anorexia nervosa is limited. The aim of this study is to conduct a meta-analysis examining the length of stay for anorexia nervosa patients globally, and to investigate moderators of the variance.

METHOD

Medline, EMBASE and PsycINFO were searched for studies published up to January 2019. Two independent reviewers assessed the eligibility of each report based on predefined inclusion criteria. A meta-analysis was performed to calculate a pooled mean length of stay using the random-effects model. Subgroup analyses and meta-regression were conducted to explore potential sources of heterogeneity between studies.

RESULTS

Of 305 abstracts reviewed, 71 studies met the inclusion criteria, generating 111 datasets. The pooled mean length of stay (95% confidence interval) was 76.3 days (73.3, 79.4) using the random-effects model, with marked variation across countries and time. Heterogeneity between studies was explained by age and admission body mass index.

CONCLUSIONS

This meta-analysis found that although clinical features do contribute to length of admissions for anorexia nervosa, there are also global and temporal variations. Future research should provide an in-depth analysis of why and how this variation exists and what the impact is on the well-being of people with anorexia nervosa.