Evidence-informed practices in the real-world treatment of people with eating disorders

Inpatient treatments for adults with anorexia nervosa: a systematic review of literature

PURPOSE

Anorexia nervosa (AN) is a mental disorder for which hospitalization is frequently needed in case of severe medical and psychiatric consequences. We aim to describe the state-of-the-art inpatient treatment of AN in real-world reports.

METHODS

A systematic review of the literature on the major medical databases, spanning from January 2011 to October 2023, was performed, using the keywords: "inpatient", "hospitalization" and "anorexia nervosa". Studies on pediatric populations and inpatients in residential facilities were excluded.

RESULTS

Twenty-seven studies (3501 subjects) were included, and nine themes related to the primary challenges faced in hospitalization settings were selected. About 81.48% of the studies detailed the clinical team, 51.85% cited the use of a psychotherapeutic model, 25.93% addressed motivation, 100% specified the treatment setting, 66.67% detailed nutrition and refeeding, 22.22% cited pharmacological therapy, 40.74% described admission or discharge criteria and 14.81% follow-up, and 51.85% used tests for assessment of the AN or psychopathology. Despite the factors defined by international guidelines, the data were not homogeneous and not adequately defined on admission/discharge criteria, pharmacological therapy, and motivation, while more comprehensive details were available for treatment settings, refeeding protocols, and psychometric assessments.

CONCLUSION

Though the heterogeneity among the included studies was considered, the existence of sparse criteria, objectives, and treatment modalities emerged, outlining a sometimes ambiguous report of hospitalization practices. Future studies must aim for a more comprehensive description of treatment approaches. This will enable uniform depictions of inpatient treatment, facilitating comparisons across different studies and establishing guidelines more grounded in scientific evidence.

LEVEL OF EVIDENCE

Level I, systematic review.

In-person versus virtual therapy in outpatient eating-disorder treatment: A COVID-19 inspired study

OBJECTIVE

Findings show virtual therapy (conducted using internet-based videoconferencing techniques) to be a viable alternative to in-person therapy for a variety of mental-health problems. COVID-19 social-distancing imperatives required us to substitute virtual interventions for in-person sessions routinely offered in our outpatient eating disorder (ED) program-and afforded us an opportunity to compare the two treatment formats for clinical efficacy.

METHODS

Using self-report assessments, we compared outcomes in a historical sample of 49 adults with heterogeneous EDs (treated in-person over 10-14 weeks in individual and group therapies) to those of 76 patients receiving comparable virtual treatments, at distance, during the COVID-19 outbreak. Linear mixed models were used to study symptom changes over time and to test for differential effects of treatment modality.

RESULTS

Participants in both groups showed similar improvements on eating symptoms, levels of weight gain (in individuals in whom gain was indicated), and satisfaction with services.

DISCUSSION

Our results suggest that short-term clinical outcomes with virtual and in-person ED therapies are comparable, and point to potentials of virtual therapy for situations in which geographical distance or other barriers impede physical access to trained therapists or specialized treatments.

Why Do Women with Eating Disorders Decline Treatment? A Qualitative Study of Barriers to Specialized Eating Disorder Treatment

Despite the fact that eating disorders (EDs) are conditions that are potentially life-threatening, many people decline treatment. The aim of this study was to investigate why women decline specialized ED treatment, including their viewpoints on treatment services. Eighteen semi-structured qualitative interviews were conducted with women who had declined inpatient or outpatient specialized ED treatment. A thematic analysis revealed five main themes: (1) Disagreement on treatment needs, (2) rigid standard procedures, (3) failure to listen, (4) deprivation of identity, and (5) mistrust and fear. The women had declined ED treatment because they believed that treatment was only focused on nutritional rehabilitation and that it failed to address their self-identified needs. From their perspectives treatment was characterized by rigid standard procedures that could not be adapted to their individual situations and preferences. They felt that the therapists failed to listen to them, and they felt deprived of identity and reduced to an ED instead of a real person. This investigation is one of the first of its kind to provide clues as to how treatment could be moderated to better meet the needs of women who decline specialized ED treatment.

Eating Disorders, Heredity and Environmental Activation: Getting Epigenetic Concepts into Practice

Epigenetic mechanisms are believed to link environmental exposures to alterations in gene expression, and in so doing, to provide a physical substrate for the activation of hereditary potentials by life experiences. In keeping with this idea, accumulating data suggest that epigenetic processes are implicated in eating-disorder (ED) etiology. This paper reviews literature on putative links between epigenetic factors and EDs, and examines ways in which epigenetic programming of gene expression could account for gene-environment interactions acting in the EDs. The paper also presents evidence suggesting that epigenetic processes link malnutrition and life stresses (gestational, perinatal, childhood, and adult) to risk of ED development. Drawing from empirical evidence and clinical experience, we propose that an epigenetically informed understanding of ED etiology can benefit patients, caregivers, and clinicians alike, in the sense that the perspective can reduce judgmental or blameful attitudes on the part of clinicians and caregivers, and increase self-acceptance and optimism about recovery on the part of those affected.

A longitudinal, epigenome-wide study of DNA methylation in anorexia nervosa: results in actively ill, partially weight-restored, long-term remitted and non-eating-disordered women

Background

This study explored state-related tendencies in DNA methylation in people with anorexia nervosa.

Methods

We measured genome-wide DNA methylation in 75 women with active anorexia nervosa (active), 31 women showing stable remission of anorexia nervosa (remitted) and 41 women with no eating disorder (NED). We also obtained post-intervention methylation data from 52 of the women from the active group.

Results

Comparisons between members of the active and NED groups showed 58 differentially methylated sites (Q < 0.01) that corresponded to genes relevant to metabolic and nutritional status (lipid and glucose metabolism), psychiatric status (serotonin receptor activity) and immune function. Methylation levels in members of the remitted group differed from those in the active group on 265 probes that also involved sites associated with genes for serotonin and insulin activity, glucose metabolism and immunity. Intriguingly, the direction of methylation effects in remitted participants tended to be opposite to those seen in active participants. The chronicity of Illness correlated (usually inversely, at Q < 0.01) with methylation levels at 64 sites that mapped onto genes regulating glutamate and serotonin activity, insulin function and epigenetic age. In contrast, body mass index increases coincided (at Q < 0.05) with generally increased methylation-level changes at 73 probes associated with lipid and glucose metabolism, immune and inflammatory processes, and olfaction.

Limitations

Sample sizes were modest for this type of inquiry, and findings may have been subject to uncontrolled effects of medication and substance use.

Conclusion

Findings point to the possibility of reversible epigenetic alterations in anorexia nervosa, and suggest that an adequate pathophysiological model would likely need to include psychiatric, metabolic and immune components.

Is stage of change enough? Confidence as a predictor of outcome in inpatient treatment for eating disorders

OBJECTIVE

While stage of change has been shown to be a robust predictor of eating disorder treatment outcome, little attention has been paid to the role of confidence. This study sought to better understand the role of confidence and the possible interaction it may have with stage of change in promoting eating disorder symptom change.

METHOD

Participants were adult women in inpatient treatment for eating disorders. They completed measures of motivation for change, which assessed precontemplation, action, confidence and internality (changing for oneself vs. others) and eating disorder symptom severity at pretreatment (N = 159) and posttreatment (n = 59). Only treatment completer analyses were used.

RESULTS

Precontemplation and confidence had significant effects on pretreatment and posttreatment symptom severity, while action only had a significant effect on pretreatment symptoms. Confidence was shown to moderate relations between both measures of stage of change (i.e., precontemplation and action) and symptoms posttreatment. Follow-up analyses indicated that high precontemplation was associated with poor outcome, irrespective of confidence, however, low precontemplation was associated with better outcome at high levels of confidence. The interaction between confidence and action was also significant at very high levels of confidence. That is, among individuals who had high action at baseline, those with low confidence had significantly poorer outcomes relative to those with high confidence.

DISCUSSION

Findings indicate that stage of change and confidence are both important prognostic factors and suggest that early behavior change in the absence of confidence may not guarantee best outcomes in inpatient eating disorder treatment.

Psychometric properties of the "Autonomous and Controlled Motivation for Treatment Questionnaire" in women with eating disorders

OBJECTIVE

To validate the Autonomous and Controlled Motivation for Treatment Questionnaire (ACMTQ) for use in women with an eating disorder (ED).

METHOD

Data were available for 463 individuals. We assessed factor structure, internal reliability, test-retest reliability, convergent/divergent validity, and incremental predictive validity.

RESULTS

Our data showed acceptable fit to our hypothesized model (comparative fit index = 0.92, root mean square error of approximation = 0.09, standardized root mean square residual = 0.09). We found test-retest reliability of 0.73 for both the autonomous (α = 0.85) and controlled (α = 0.80) subscales. Autonomous scores were more strongly associated with motivation measures (β = 0.37; 0.46) than with ED severity measures (β = -0.10; -0.18). Associations between autonomous motivation and symptom improvement over time supported predictive validity. Controlled motivation was associated with lower motivation (β = 0.02; -0.31) and with higher ED severity (β = 0.12; 0.47).

CONCLUSION

Our results suggest that the ACMTQ is valid for use in women with EDs and lend support to the validity of findings from previous ED studies that have used the ACMTQ.

Prognostic value of autonomous and controlled motivation in outpatient eating-disorder treatment

According to Self-Determination Theory, when motivation to reach an objective is fully internal, it is said to be "autonomous"; when driven by external incentives, it is said to be "controlled". Previous research has indicated that autonomously motivated individuals show better response to treatments for eating disorders.

OBJECTIVE

In individuals undergoing different intensities of outpatient treatment for an eating disorder, we sought to assess associations between autonomous and controlled motivations and response to treatment on the one hand, and likelihood of dropping out of treatment, on the other.

METHOD

Seven hundred seventy adults meeting DSM-5 criteria for an eating disorder (216 with Anorexia Nervosa, 282 with Bulimia Nervosa, and 272 with Other Specified Feeding or Eating Disorder) were included in this study. Before an interval of outpatient treatment, individuals completed the Eating Disorder Examination Questionnaire and the Autonomous and Controlled Motivations for Treatment Questionnaire. Participants completed the Eating Disorder Examination Questionnaire again at one or two subsequent timepoints.

RESULTS

After controlling for diagnosis, treatment intensity, and number of previous treatments, analyses showed that higher autonomous motivation was associated with better response on eating-disorder overall symptoms and lower likelihood of dropping out of treatment. In contrast, controlled motivation was not associated with response to treatment.

DISCUSSION

Our results suggest that autonomous motivation has trans-diagnostic influence upon response to various intensities of treatment for an eating disorder. In support of an autonomy supportive approach to treatment, findings link autonomous motivation with more favorable outcome.

Outpatient CBT for Underweight Patients with Eating Disorders: Effectiveness Within a National Health Service (NHS) Eating Disorders Service

Background: Underweight eating disorders (EDs) are notoriously difficult to treat, although a growing evidence base suggests that outpatient cognitive behaviour therapy for EDs (CBT-ED) can be effective for a large proportion of individuals. Aims: To investigate the effectiveness of CBT-ED for underweight EDs in a ‘real-world’ settings. Method: Sixty-three adults with underweight EDs (anorexia nervosa or atypical anorexia nervosa) began outpatient CBT-ED in a National Health Service setting. Results: Fifty-four per cent completed treatment, for whom significant changes were observed on measures of ED symptoms, psychological distress and psychosocial impairment. There was also a large effect on body weight at end-of-treatment. Conclusions: The results suggest that good outcomes can be achieved by the majority of those who complete treatment, although treatment non-completion remains a significant barrier to recovery. Future studies should focus on improving treatment retention, as evidence suggests that CBT-ED in ‘real-world’ settings is effective.

Autonomy support and autonomous motivation in the outpatient treatment of adults with an eating disorder

OBJECTIVE

Across diverse clinical problems, therapists' autonomy support has been found to increase patients' autonomous motivation for change. Being self-motivated has, in turn, been linked to superior treatment response. In people undergoing outpatient eating disorder (ED) treatment, we examined associations among ratings of autonomy support received from therapists and other carers, self-reported engagement in therapy, and clinical outcomes.

METHOD

Ninety-seven women with anorexia nervosa, bulimia nervosa, or a related ED provided measures of motivational status and clinical symptoms at the beginning and end of time-limited (12-16 weeks) segments of specialized treatment. At mid-treatment, patients also rated the extent to which they perceived their individual therapists, group therapists, group-therapy peers, family members, friends, and romantic partners as being autonomy supportive.

RESULTS

Overall, multiple regression analyses indicated autonomy support to moderate (rather than mediate) the link between initial autonomous motivation and later change in autonomous motivation-with results indicating that, independently of ED diagnosis or treatment intensity, greater perceived autonomy support (from therapists and nontherapists alike) coincided with larger increases in autonomous motivation over the course of therapy. In turn, higher autonomous motivation at end-of-therapy coincided with larger reductions in eating symptoms.

DISCUSSION

Findings suggest that the experience of autonomy support (from therapists and nontherapists) is associated with increasing motivation in people undergoing ED treatment, and that becoming self-motivated is linked to better outcomes. Such results indicate that support from therapists, relatives, and peers can favorably influence personal engagement in individuals undergoing ED treatment.