Pathways into treatment for eating disorders: A quantitative examination of treatment barriers and treatment attitudes

Visual art- and music-based interventions as adjuvants in the treatment of eating disorders: a systematic review and a theoretical model

AIM

To assess the effect of visual art- and music-based interventions in the treatment of eating disorders.

METHODS

This study was registered in PROSPERO (CRD42020161503). Six databases (CINAHL, EMBASE, Lilacs, PsycINFO, PubMed and The Cochrane Library) were consulted. The searches were performed on 19 June 2019, and updated on 18 March 2022. No restriction on language, date, or publication status was applied. Methodological quality was assessed using Joanna Briggs Institute's instruments. All steps were performed by two independent reviewers and a third participated in the event of disagreement.

RESULTS

Eight studies were included. Few statistically significant results were found. Overall, both interventions might help to reduce negative emotional states.

CONCLUSION

Visual art- and music-based interventions present limited and inconclusive scientific evidence in patients with eating disorders and therefore their effectiveness is currently unknown. A theoretical model is proposed to guide future research. Further studies are needed to clarify their clinical relevance.

Views of German mental health professionals on the use of digital mental health interventions for eating disorders: a qualitative interview study

INTRODUCTION

Digital mental health interventions (DMHIs) are getting increasingly important for mental health care. In the case of eating disorders (EDs), DMHIs are still in early stages. Few studies so far investigated the views of mental health professionals for EDs on the integration of DMHIs in routine care.

OBJECTIVE

To gain insights into the experiences, perspectives, and expectations of mental health professionals for EDs regarding DMHIs and to identify requirements for the future integration of DMHIs into routine care.

METHODS

Semi-structured qualitative telephone interviews with 24 German mental health professionals treating patients with EDs were conducted. A content analysis following a deductive-inductive approach asked for experiences, advantages and chances, disadvantages and boundaries, desired functions and properties, target groups, and general conditions and requirements for DMHIs for patients with EDs.

RESULTS

Only few professionals reported experiences with DMHIs besides video-based psychotherapy during the pandemic. From the therapists' point of view, DMHIs have the potential to deliver low-threshold access for patients with EDs. Useful functionalities were seen in digital meal records, skills training, and psychoeducation. However, a stable therapeutic alliance was reported as an important prerequisite for the successful integration into care. Therapists expressed concerns in case of severe anorexia nervosa or suicidality. The participants felt to be informed inadequately on recent developments and on the evidence base of DMHIs.

CONCLUSIONS

Mental health professionals for EDs show positive attitudes towards DMHIs, however many barriers to the integration in routine care were observed. The highest potential was seen for the use of DMHIs in addition to outpatient care and in aftercare. Specific requirements for DMHIs are related to different areas of the healthcare spectrum and for the different symptom profiles in anorexia nervosa, bulimia nervosa and binge eating disorder. Targeted DMHIs are needed and appropriate especially for concepts of blended care.

An intervention mapping adaptation framework to develop a self-help intervention for athletes with eating disorder symptoms

OBJECTIVE

This research forum describes the use of the intervention mapping for adaptation (IMA) framework to develop and evaluate a novel intervention for athletes with mild eating disorder (ED) symptoms.

METHODS

The six IMA steps were followed. In step 1 (needs assessment), we conducted a systematic review of athlete ED interventions and held interviews/focus groups with athletes and sports professionals to inform intervention format and delivery. In step 2 (intervention search), needs assessment information guided the search for an evidence-based intervention suitable for adaptation to athletes. In steps 3 and 4 (intervention development), the identified intervention was adapted and feedback sought from athletes and sport professionals. In steps 5 and 6 (implementation and evaluation), a feasibility study was conducted with athletes (n = 35; females: n = 27; Mage  = 27.1).

RESULTS

The review highlighted poor evidence for the acceptability and relative efficacy of existing interventions, which were all delivered face-to-face in groups. Interview/focus group data suggested a need for more accessible intervention formats (e.g., self-help). One non-athlete self-help intervention was determined suitable for adaptation to athletes, and adaptations were made. Initial feedback suggested the adapted intervention was relevant within sport settings. The feasibility study revealed that the intervention (MOPED-A: Motivational and Psycho-Educational Self-Help Programme for Athletes with Mild Eating Disorder Symptoms) can be feasibly implemented, is acceptable to athletes and shows potential for reducing ED symptoms.

DISCUSSION

IMA is a useful framework for developing participant-centered and evidence-based interventions. The findings and approach taken provide a framework for other researchers and clinicians in developing similar interventions in the ED domain.

PUBLIC SIGNIFICANCE

The novel self-help intervention described in this article was developed using intervention mapping and provides promise as a tool for reducing eating disorder symptoms in athletes. We describe how adopting and systematically following a health intervention development approach, such as intervention mapping, can ensure that eating disorder interventions are participant-centered, contextually relevant, and evidence-based, which in turn could help to maximize their reach and effectiveness.

Barriers and facilitators affecting treatment uptake behaviours for patients with eating disorders: A systematic review synthesising patient, caregiver and clinician perspectives

OBJECTIVE

A significant treatment gap exists between persons affected by eating disorders (ED), and those engaging with treatment services. This systematic review aims to provide a thorough understanding of the barriers and facilitators affecting eating disorder treatment engagement, including a synthesis of the perspectives of patients, caregivers and healthcare professionals.

METHOD

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were retrieved from three databases (PubMed, PsycInfo, Web of Science) and were screened and assessed independently by two raters. A thematic analysis was completed to determine the key barriers and facilitators reported by the included studies.

RESULTS

A total of 73 studies were included. From these studies, 12 barriers and 13 facilitators were identified. Patients reported stigma, shame and guilt as the most prominent barrier affecting their engagement with treatment services. Meanwhile, caregivers and healthcare professionals reported a lack of eating disorder knowledge of clinicians as the most important barrier. Positive social support was cited as the most prominent facilitator to promote help-seeking.

DISCUSSION

Patients, caregivers and healthcare professionals experience a variety of barriers and facilitators to treatment uptake for ED. Interventions addressing barriers and facilitators could increase treatment engagement, including anti-stigma campaigns and positive peer-support interventions.

Enhanced recovery support for people with eating disorders during the COVID-19 pandemic: quality improvement using a web-based, stepped-care programme in Canada

BACKGROUND

Throughout the COVID-19 pandemic, the number of individuals struggling with eating disorders (EDs) increased substantially. Body Brave (a not-for-profit) created and implemented a web-based stepped-care Recovery Support Programme (RSP) to improve access to community-based ED services. This quality improvement study describes the RSP and assesses its ability to deliver timely access to treatment and platform engagement.

METHODS

We conducted a retrospective cohort study comparing access to, and use of Body Brave services 6 months before and 12 months after implementation of the RSP platform (using 6-month increments for two postimplementation periods). Primary programme quality measures included registration requests, number of participants onboarded and time to access services; secondary measures included use of RSP action plans, attendance for recovery sessions and workshops, number of participants accessing treatment and text-based patient experience data.

RESULTS

A substantial increase in registration requests was observed during the first postimplementation period compared with the preimplementation period (176.5 vs 85.5; p=0.028). When compared with the preimplementation period, the second postimplementation observed a significantly larger percentage of successfully onboarded participants (76.6 vs 37.9; p<0.01) and a reduction in the number of days to access services (2 days vs 31 days; p<0.01). Although participant feedback rates were low, many users found the RSP helpful, easy to access, user-friendly and were satisfied overall. Users provided suggestions for improvement (eg, a platform instructional video, offer multiple times of day for live sessions and drop-in hours).

CONCLUSIONS

Although clinical benefit needs to be assessed, our findings demonstrate that the RSP enabled participants to quickly onboard and access initial services and have informed subsequent improvements. Understanding initial programme effects and usage will help assess the feasibility of adapting and expanding the RSP across Canada to address the urgent need for low-barrier, patient-centred ED care.

Psychotherapies for eating disorders: findings from a rapid review

BACKGROUND

Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development.

METHODS

The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper.

RESULTS

281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence.

CONCLUSIONS

Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.

Towards an understanding of help-seeking behaviour for disordered eating: Refinement of a barriers to help-seeking measure

AIM

Early intervention in eating disorders (EDs) is hampered by a lack of validated measures of barriers to treatment seeking. The present study examined the factor structure of the Perceived Barriers to Psychological Treatment scale (PBPT) and a combination of PBPT and Barriers to Seeking Help for ED items (BATSH-ED) with respect to treatment-seeking for an ED.

METHOD

Participants were 456 female university students aged 17-25 reporting a wide range of disordered eating severity. Confirmatory factor analyses were conducted with the whole sample followed by correlational and regression analyses with a high-risk sample to assess validity of the selected questionnaire items.

RESULTS

Four models were tested. First, we replicated the original PBPT 8-factor structure in our sample with comparable fit indices. Second, the addition of six ED items comprising a Denial and Ambivalence subscale improved model fit. Third and fourth, when only significant subscales predicting treatment seeking were retained, with removal of items with weak loadings, a 15-item six-factor solution provided a best fit. A range of psychosocial measures had relationships in the expected directions with the questionnaire subscales. In addition to disordered eating, the denial subscale was uniquely associated with treatment seeking.

CONCLUSIONS

While the present study contributes to refining the assessment of barriers to help-seeking, future studies should consider co-design with lived experience to further improve the model fit of the questionnaire and improve predictiveness of help-seeking.

Pathways to improve early intervention for eating disorders: Findings from a systematic review and meta-analysis

OBJECTIVE

Treatment-seeking rates among eating disorder (ED) populations are relatively low, with only one in four individuals seeking help. Previous research has identified many factors that might be associated with help-seeking in EDs, but to date no review has investigated the quantitative association between these factors and actual help-seeking behavior. The aim of the current review was to synthesize the relevant quantitative literature on factors (i.e., perceived barriers, characteristics associated with treatment seeking, demographic variables) associated with help-seeking using meta-analytic strategies, as well as provide recommendations on future early intervention research strategies to promote early help-seeking.

METHOD

Overall, 19 studies were included, identifying 141 perceived barriers (e.g., stigma) or individual characteristics (e.g., BMI, duration of illness) and 56 demographic variables (e.g., ethnicity), which were synthesized into 24 unique variables.

RESULTS

Less help-seeking was predicted by higher levels of denial and less perceived ability of others to provide help.

DISCUSSION

Given the small number of studies these results should be considered preliminary. Future studies should consider barriers to help-seeking when creating early intervention approaches. To improve help-seeking rates we suggest the use of targeted psychoeducational materials and co-design with people with lived experience when developing new strategies.

PUBLIC SIGNIFICANCE

The present study addresses a significant gap in the literature by synthesizing factors associated with help-seeking, with the aim of informing early intervention strategies to promote early help-seeking in eating disorder populations. Denial of illness and perceived inability of others to provide help were associated with lower help-seeking. Future studies should consider barriers to help-seeking and co-design with people with lived experience when creating new early intervention strategies.

Perceptions and experiences with eating disorder treatment in the first year of COVID-19: A longitudinal qualitative analysis

OBJECTIVE

The COVID-19 pandemic created significant challenges in accessing and receiving treatment for individuals with eating disorders (EDs). The purpose of this study is to explore perceptions of and experiences with ED treatment during the first year of the pandemic among individuals with past and self-reported EDs in the United States.

METHODS

Online surveys were administered to adults (N = 510) with a past or current self-reported ED at 13 timepoints between April 2020 and May 2021. Using longitudinal qualitative analysis, 5651 free-text responses were examined to capture experiences with ED treatment and generate inferences of change over time.

RESULTS

We categorized results into four sequential, temporal quarters and identified patterns that explained participants' perceptions of facilitators, barriers, and experiences with ED treatment over time: Quarter 1. Treatment Disruption and Reorienting Recovery; Quarter 2. Accumulating COVID-19 Stress and Virtual Treatment Woes; Quarter 3. A Continuation of Inadequate Care; and Quarter 4. Ongoing Adaptation and Adjustment to Uncertainty. Participant experiences were marked by numerous barriers to accessing care, challenges adjusting to virtual treatment, unmet treatment needs, and beginning acceptance of telehealth.

DISCUSSION

Our findings present a timeline to help evaluate challenges related to navigating the switch to virtual care which created significant disruption to ED recovery. Participants spent much of the first year trying to adjust to unemployment, loss of insurance, and lack of access to in-person treatment. Future research should identify additional strategies to improve the receipt and experience of care for EDs.

PUBLIC SIGNIFICANCE

Our findings suggest that individuals with eating disorders were significantly challenged by accumulating COVID-19 stress, worsening symptomatology, and limited access to effective treatment during the first year of the pandemic. This knowledge can guide clinicians, treatment centers, and policy makers in addressing the behavioral health needs of individuals impacted by disordered eating amidst emergent public health crises.

Traumatic stress, body shame, and internalized weight stigma as mediators of change in disordered eating: a single-arm pilot study of the Body Trust® framework

To enhance access to evidence-based treatment it is increasingly important to evaluate scalable virtual programs that support the needs of those struggling with disordered eating. This study described a scientifically grounded, trauma-informed framework known as Body Trust,® and aimed to pilot test the preliminary effectiveness and mechanisms of change in a Body Trust® program to improve disordered eating. Using quality outcomes data, we examined 70 mostly white (87%) female-identifying (97%) individuals enrolled in a 6-module online program based in the Body Trust® framework (M_age = 45.5 ±10.9; M_BMI = 33.7 ±8.0). Putative mediators included traumatic stress, internalized weight stigma, and body shame. Outcomes were objective and subjective binge episodes, overvaluation of weight and shape, and eating concerns. Generalized estimating equations were applied to determine pre-to-post changes. We applied Montoya's MEMORE macro, the joint-significance test, and calculated 95% Monte Carlo confidence intervals to assess mediation. Significant pre-to-post improvements with medium to large effect sizes were detected for all outcomes and mediators (ps<.008). All hypothesized mechanisms supported mediation. Using the Body Trust® framework shows early promise for alleviating disordered eating symptoms through targeting traumatic stress, body shame, and internalized weight stigma. Given the program's use of mindfulness techniques, future research should test target mechanisms like interoception.

Informing mHealth and Web-Based Eating Disorder Interventions: Combining Lived Experience Perspectives With Design Thinking Approaches

BACKGROUND

App-based interventions designed to prevent and treat eating disorders have considerable potential to overcome known barriers to treatment seeking. Existing apps have shown efficacy in terms of symptom reduction; however, uptake and retention issues are common. To ensure that apps meet the needs and preferences of those for whom they were designed, it is critical to understand the lived experience of potential users and involve them in the process of design, development, and delivery. However, few app-based interventions are pretested on and co-designed with end users before randomized controlled trials.

OBJECTIVE

To address the issue, this study used a highly novel design thinking approach to provide the context and a lived experience perspective of the end user, thus allowing for a deeper level of understanding.

METHODS

In total, 7 young women (mean age 25.83, SD 5.34, range 21-33 years) who self-identified as having a history of body image issues or eating disorders were recruited. Participants were interviewed about their lived experience of body image and eating disorders and reported their needs and preferences for app-based eating disorder interventions. Traditional (thematic analysis) and novel (empathy mapping; visually depicting and empathizing with the user's personal experience) analyses were performed, providing a lived experience perspective of eating disorders and identifying the needs and preferences of this population in relation to app-based interventions for eating disorders. Key challenges and opportunities for app-based eating disorder interventions were also identified.

RESULTS

Findings highlighted the importance of understanding and identifying problematic eating disorder symptoms for the user, helpful practices for recovery that identify personal values and goals, the role of social support in facilitating hope, and aspects of usability to promote continued engagement and recovery.

CONCLUSIONS

Practical guidance and recommendations are described for those developing app-based eating disorder interventions. These findings have the potential to inform practices to enhance participant uptake and retention in the context of app-based interventions for this population.

Social media and eating disorder recovery: An exploration of Instagram recovery community users and their reasons for engagement

OBJECTIVE

Online recovery communities offer support for people with eating disorders who may not otherwise seek professional help. Instagram is a popular platform that is widely used for eating disorder recovery, but little is known about the population that uses it or its potential benefits.

METHOD

A mixed-methods study surveyed 163 users of the Instagram recovery community to identify their descriptive characteristics, their reasons for using the community, and what they perceived to be helpful or unhelpful about the platform.

RESULTS

The community included users who were diverse in gender, ethnicity and eating disorder presentation and severity, with cases of potential anorexia nervosa, bulimia nervosa and binge eating disorder identified. Reasons for engaging in the community included to see representations of diverse individuals and as an alternative to professional treatment. Results indicate that the community may provide benefits for recovery such as social support and validation, but that its lack of moderation and potential for harmful content can also prevent recovery.

CONCLUSIONS

These findings highlight the need for better recognition of diverse eating disorder presentations and improved accessibility to professional treatment in the wider community. Moderated use of the platform should be considered in order to minimize risks and increase benefits.

Perspectives on barriers to treatment engagement of people with eating disorder symptoms who have not undergone treatment: a qualitative study

BACKGROUND

Many people with an eating disorder (ED) never engage with an evidence-based ED treatment. Of the few studies that have qualitatively explored barriers to receiving treatment, some do so in relation to mental health conditions in general, and others focus on participants who have already undergone treatment. This study aims to address this gap in the literature by exploring the barriers to ED treatment engagement from the perspectives of individuals in the community with an ED (either self-identified or professionally diagnosed) and had not received ED treatment/s.

METHOD

Fifty-six of 772 participants in an online Eating Disorders Treatment Experience survey had self-identified as having symptoms consistent with an ED, or had received a diagnosis of an ED and indicated that they had never undergone treatment for an ED. They were asked to share the reasons for which they did not receive treatment with an open-ended question. Qualitative analysis of survey responses was completed using the Framework Method to generate overarching themes that encapsulated the diverse participant accounts.

RESULTS

The thematic analysis generated two main themes, each with two subthemes. The first theme was the negotiation of the need for treatment within oneself (intrapersonal factors; theme 1). The second theme explored interpersonal contexts that shaped the participant's decision not to seek treatment (interpersonal/external factors; theme 2). Two cross-cutting subthemes of fear and health literacy were also generated that demonstrated a high degree of overlap with the aforementioned main themes.

CONCLUSIONS

The process by which individuals decide whether or not to engage with ED treatment services is complex and involves intra- and interpersonal negotiations intertwined with health literacy and fear. A factor not prominent in previous research was negative self-perceptions and the belief of being undeserving of treatment. These factors have implications for ongoing community and clinical interventions to further address barriers to ED treatment engagement.

The experiential perspectives of siblings and partners caring for a loved one with an eating disorder in the UK

BACKGROUND

Caring for a loved one with an eating disorder typically comes with a multitude of challenges, yet siblings and partners are often overlooked. It is important to understand if current clinical guidance for supporting carers are effective and being utilised for these groups, to help meet their needs.

AIMS

To identify the experiential perspectives of siblings and partners of a loved one with an eating disorder compared with guidance for improving the adequacy of support provided to carers published by Beat and Academy for Eating Disorders.

METHOD

Three online focus groups were held for ten siblings and five partners from across the UK (12 females and three males). Carers had experience of caring for a loved one with anorexia nervosa (13 carers) or bulimia nervosa (two carers), across a range of therapeutic settings. Focus group transcriptions were analysed with thematic analysis.

RESULTS

Four key themes were identified: (a) role-specific needs, (b) challenges encountered by siblings and partners, (c) generic needs and helpful strategies or approaches, and (d) accounts of service provision and family support.

CONCLUSIONS

Overall, the majority of experiences reported by siblings and partners did not meet the published guidance. Consequently, clinical practice recommendations were identified for services, alongside the charity sector, to take a proactive approach in detecting difficulties, providing skills training and emotional/practical support, adapting/tailoring peer support groups and supporting online facilitation. Our findings part-informed the design of our national online survey on loved ones' experiences of care in eating disorders.

Understanding treatment delay: Perceived barriers preventing treatment-seeking for eating disorders

OBJECTIVE

Only a small proportion of individuals with an eating disorder will receive targeted treatment for their illness. The aim of this study was to examine the length of delay to treatment-seeking and determine the barriers preventing earlier access and utilisation of eating disorder treatment for each diagnostic group - anorexia nervosa, bulimia nervosa, binge eating disorder and other specified feeding or eating disorder.

METHOD

Participants were recruited as part of the TrEAT multi-phase consortium study. One hundred and nineteen Australians (13-60 years; 96.9% female) with eating disorders currently accessing outpatient treatment for their illness completed an online survey comprised of self-report measures of eating disorder severity, treatment delay and perceived barriers to treatment-seeking. The treating clinician for each participant also provided additional information (e.g. body mass index and diagnosis).

RESULTS

Overall, the average length of delay between onset of eating disorder symptoms and treatment-seeking was 5.28 years. Controlling for age, latency to treatment-seeking was significantly longer for individuals with bulimia nervosa and binge eating disorder compared to anorexia nervosa. However, when perceived barriers to treatment-seeking were investigated, there were no significant differences between the diagnostic groups in regard to the perceived barriers they experienced. Stigma was rated as the most impactful barrier for each diagnostic group.

CONCLUSION

Findings suggest that individuals with eating disorders face substantial delays in accessing appropriate treatment and that latency to treatment-seeking is often magnified for counter-stereotypical eating disorder presentations. Further research is required to investigate other factors contributing to this delay.

A retrospective investigation of the prodromal stages of eating disorders and use of health services in young patients the year prior to the diagnosis

AIM

The aim of this study was to analyse the characteristics and the frequency of medical consultations in the year prior to the diagnosis and the intervention onset of the Eating Disorder, as well as the different prodromal symptoms. The final aim was to understand the origin of all referrals and their possible influence on the duration of untreated illness.

METHODS

We selected 99 young patients (15-25 years) and 61 healthy controls. Their primary and specialized care medical records were both studied retrospectively.

RESULTS

87.6% of patients attended different consultations (primary care, specialized care and emergency department) the year prior compared to 67.2% of the controls (p = .002). The average number of consultations was 3.59 in the case group and 1.57 in the control group (p < .001). These consultations were related to prodromal symptoms in 57.4% compared to 16.4% for the controls (p < .001). They ranged from 29.8% of unspecific digestive symptoms, 22.8% of psychological symptoms, 19.3% of gynaecologic symptoms, 11.9% of weight variation, 8.8% of analytical changes, to 5.3% of malnutrition symptoms. Patients were mainly referred by Primary Care (42.7%). Overall, the mean of the Duration of Untreated Illness was of 7.45 months.

CONCLUSIONS

The majority of reasons for consultation were related to symptoms that could be prodromal symptoms, but the patients were not diagnosed with an eating disorder. These findings highlight the importance of professionals understanding how to identify the warning signs of an eating disorder, so they can refer patients to a specialized unit to establish an early treatment.

Impact of patient characteristics on clinicians' decisions to involve dietitians in eating disorder treatment

BACKGROUND & AIMS

Dietetic involvement in eating disorder (ED) treatment is often initiated by other members of a patient's treating team. This study aimed to examine the impact of patient characteristics on clinicians' decisions to involve a dietitian in a patient's ED treatment, as well as the influence of clinician characteristics on their decision-making.

METHODS

ED clinicians were recruited to complete an online survey, which used case vignettes to assess their likelihood of referring patients to a dietitian or consulting with a dietitian for guidance. Questions were also included measuring clinician anxiety, beliefs about the therapy they deliver, beliefs about dietitians and views on evidence-based practice, to determine if these were related to their responses to case vignettes.

RESULTS

Fifty-seven clinicians completed the survey, with the largest group being clinical psychologists (n=22, 39%). ED diagnosis, weight status, medical co-morbidities and progress in treatment were all shown to be influential on whether clinicians involved dietitians in ED treatment. Clinician characteristics and their beliefs about dietitians were generally not correlated with the likelihood of seeking dietetic input.

CONCLUSIONS

This study indicates that clinicians' decisions to involve dietitians in ED treatment are systematic rather than random decisions influenced by individual clinician characteristics. Clinicians require further education on the potential for malnutrition regardless of patients'ED diagnosis or weight status, and the dietitian's role in addressing this. This article is protected by copyright. All rights reserved.

Do orthorexia and intolerance of uncertainty mediate the relationship between autism spectrum traits and disordered eating symptoms?

PURPOSE

Autism spectrum disorder traits have been implicated in the psychopathology of eating disorders and may also be relevant for the development of orthorexia symptoms. Further, intolerance of uncertainty (IUS) may indirectly contribute to the development of disordered eating, as the displacement of anxiety onto food may help achieve a sense of control and maximise certainty. We examined a new cognitive model of eating pathology which assessed the role of IU and orthorexia symptoms as potential mediators of the relationship between autistic traits and disordered eating in a community sample.

METHODS

Three-hundred-and-ninety-six female participants (M = 20.07, SD = 4.52 years old) completed an online self-report questionnaire which assessed the variables of interest.

RESULTS

Despite finding significant bivariate correlations, our model results showed that autistic traits did not directly predict disordered eating or orthorexia symptoms. Significant indirect relationships were found between autistic traits and eating disorder symptoms through both IU and orthorexia symptoms.

CONCLUSION

The findings provide partial support for our proposed model suggesting that autistic traits may increase the vulnerability for disordered eating, not directly, but through their associations with mechanisms such as IU and the development of problematic eating behaviours typical of orthorexia. Future research should focus on whether targeting IU may assist in preventing the development of disordered eating.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

The implementation of large-scale health system reform in identification, access and treatment of eating disorders in Australia

BACKGROUND

It seems to be a truth universally acknowledged that pathways to care for people with eating disorders are inconsistent and difficult to navigate. This may, in part, be a result of the complex nature of the illness comprising both mental and medical ill-health across a broad range of severity. Care therefore is distributed across all parts of the health system resulting in many doors into the system, distributed care responsibility, without well developed or integrated pathways from one part of the system to another. Efforts in many parts of the world to redesign health service delivery for this illness group are underway, each dependent upon the local system structures, geographies served, funding sources and workforce availability.

METHODS

In NSW-the largest populational jurisdiction in Australia, and over three times the size of the UK-the government embarked six years ago on a program of whole-of-health system reform to embed identification and treatment of people with eating disorders across the lifespan and across the health system, which is largely publicly funded. Prior to this, eating disorders had not been considered a 'core' part of service delivery within the health system, meaning many patients received no treatment or bounced in and out of 'doorways'. The program received initial funding of $17.6 million ($12.5 million USD) increasing to $29.5 million in phase 2 and the large-scale service and workforce development program has been implemented across 15 geographical districts spanning almost one million square kilometres servicing 7.75 million people.

CONCLUSIONS

In the first five years of implementation there has been positive effects of the policy change and reform on all three service targets-emergency departments presentations, hospital admissions and community occasions of service as well as client hours. This paper describes the strategic process of policy and practice change, utilising well documented service design and change strategies and principles with relevance for strategic change within health systems in general.

Eating disorders treatment experiences and social support: Perspectives from service seekers in mainland China

OBJECTIVE

This study explored treatment experiences and social support among individuals with eating disorders (EDs) in mainland China.

METHOD

Subscribers of a Chinese online social media platform (WeChat) focused on EDs were invited to complete a screening questionnaire that included the Eating Disorder Diagnostic Scale for the DSM-5. Of the 116 questionnaire responses, 31 met inclusion criteria for follow-up interviews. Individuals who never sought treatment were not eligible for follow-up interviews, but provided brief explanations about why they did not seek treatment. All eligible participants (n = 31) completed a semi-structured interview about their experiences with ED treatment and social support. Qualitative data from the interviews and survey responses regarding not seeking treatment were subjected to inductive data-driven thematic analysis with deductive coding to illuminate treatment and social support experiences or reasons for not seeking treatment.

RESULTS

Themes emerged from interviews revealed positive inpatient treatment experiences for anorexia nervosa, but negative outpatient treatment experiences, unaffordable care, and ineffective psychopharmacological treatments. Parents, friends, and partners were sources of social support, but participants largely felt misunderstood or blamed by these same entities. Shame, not recognizing ED as an illness, and financial constraints were listed as the primary reasons for not seeking treatment.

DISCUSSION

The importance of hearing patients' perspectives, improving ED literacy in China, increasing knowledge of culturally specific manifestations of EDs, and developing culturally responsive services and dissemination of treatment resources are emphasized.

Psychological and eating disorder symptoms as predictors of starting eating disorder treatment

OBJECTIVE

Little is known about the treatment uptake rate for adults diagnosed with an eating disorder through formal assessment. This study aimed to identify psychological and eating disorder symptoms that predict whether individuals with diagnosed eating disorders start treatment after receiving a diagnostic assessment and recommendation to begin treatment. Identifying barriers to starting treatment can inform interventions to improve the uptake of treatment.

METHOD

After a diagnostic assessment at an eating disorder specialty clinic, 223 adults were recommended to begin treatment and completed self-report measures of psychological functioning, clinical impairment, and eating psychopathology. Patient attendance was assessed to determine rates and predictors of starting treatment within 3 months of the assessment.

RESULTS

Of the 223 patients recommended to begin treatment, approximately two-third started treatment within 3 months of the assessment. Logistic regression identified greater avoidance of eating, greater laxative use frequency, more social eating concerns, and lower weight dissatisfaction as predicting lower likelihood of beginning treatment after assessment. A chi-square test for independence found no significant differences between diagnostic groups on starting treatment.

DISCUSSION

Findings identify eating disorder symptoms that predict treatment enrollment after diagnostic assessment and recommendation to begin treatment. Assessing for these symptoms at the diagnostic assessment stage is recommended to address potential treatment barriers. Future research should identify strategies that increase treatment uptake at this stage of the process.

Practitioner eating disorder detection: The influence of health mindset, thin-ideal internalization, orthorexia and gender role

AIMS

The current study sought to determine what factors inhibited psychologists, naturopaths and fitness instructors from detecting an eating disorder (ED), and the discipline differences across these factors.

METHODS

Participants of the online study were 115 health practitioners who consisted of 35 psychologists, 50 naturopathic and 30 fitness practitioners. A vignette describing a female experiencing a sub-threshold bulimic variant without purging was presented alongside ED mental health literacy items such as assessing one's ability to detect a problem. Additional items examined factors that may inhibit detection, including practitioners' level of: thin-ideal internalization, orthorexia, health or fitness mindset (a newly developed scale measuring health and fitness obsessiveness) and gender role identity.

RESULTS

A significant number of naturopaths and fitness instructors (20% and 33.3%, respectively) were found to have elevated orthorexia scores. Similarly, psychologists had the greatest tendency to internalize the thin-ideal (M = 3.60), which was comparable to levels seen in recent research for 20- to 21-year-old females with EDs. The two largest factors inhibiting ED detection were the strength of a health mindset and gender role identity. Practitioners who had higher health mindset scores or who associated with gender identities higher in masculinity traits (ie, either androgynous or masculine gender roles) were more likely to miss detecting an ED.

CONCLUSIONS

While many present ED studies focus upon assessing and changing client cognitions, this study emphasizes the need for further research regarding training interventions to address practitioner cognitions and gender role biases, which may in turn improve ED detection.

The Brazilian version of the SCOFF questionnaire to screen eating disorders in young adults: cultural adaptation and validation study in a university population

Objective:

This study translated, culturally adapted, and validated a Brazilian Portuguese version (SCOFF-BR) of the Sick, Control, One Stone, Fat, Food Questionnaire (SCOFF) to screen eating disorders in young adults.

Methods:

This study used back-translation to culturally adapt the questionnaire according to International Society of Pharmacoeconomics and Outcome Research principles. The SCOFF-BR validation process involved a sample of men and women aged 18-32 years from a university community. After the participants completed the SCOFF-BR questionnaire, pre-trained researchers interviewed them with the Mini International Neuropsychiatric Interview (MINI). The presence of eating disorders was determined according to DSM-5 criteria.

Results:

Of the 361 subjects, 9.7% had an eating disorder (2.2% anorexia nervosa, 5% bulimia nervosa, and 2.5% binge-eating disorder). Using a cutoff point of two positive responses, we obtained a sensitivity of 80% and a specificity of 71.5%, with an accuracy of 72.3%. The positive and negative predictive values were 23.1% and 97.1%, respectively.

Conclusion:

This study demonstrated that the Brazilian version of the SCOFF questionnaire presents satisfactory accuracy and reliability to screen eating disorders among young adults in the Brazilian university community.

Facilitators and barriers in anorexia nervosa treatment initiation: a qualitative study on the perspectives of patients, carers and professionals

BACKGROUND

An early psychotherapeutic treatment of anorexia nervosa (AN) is crucial for a good prognosis. In order to improve treatment initiation, knowledge about facilitators and barriers to treatment is needed.

OBJECTIVE

Against this background, we aimed to identify facilitators and barriers from the perspectives of patients, carers and professionals using a qualitative approach.

METHOD

To this end, semi-structured interviews were conducted in triads of female patients with AN aged 14 years and older at the beginning of their first psychotherapeutic treatment, their carers, and referring health care professionals. A modified Grounded Theory approach was used for analysis.

RESULTS

In total, 22 interviews were conducted (n = 6 adults, n = 4 adolescents, 4 full triads). The duration of untreated AN ranged between 30 days and 25.85 years (M = 3.06 ± 8.01 years). A wide spectrum of facilitators and barriers within the patient, the social environment, the health care system and the society were identified. Most prominent factors were 'recognizing and addressing' by close others, 'waiting times and availability' and 'recommendations and referrals' by health care professionals. 'Positive role models for treatment' were perceived as a specific facilitative social influence. Facilitators were more frequently mentioned than barriers and most of the factors seem to hold potential for modifiability.

CONCLUSION

Overall, the findings suggest that early intervention approaches for AN should not only address patients and the health care system, but may also involve carers and successfully treated former patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03713541 .

Dietary restraint patterns and eating disorder help-seeking

OBJECTIVE

Determine whether gender differences exist in associations among central barriers to and facilitators of eating disorder (ED) help-seeking-ED stigma, negative affect, perceived ED treatment need-as a function of individuals' probability of classification within empirically derived groups characterized by different dietary restraint patterns.

METHOD

As part of the cross-sectional, multi-institute Healthy Bodies Study, women (n = 2215) and men (n = 986) attending three colleges and universities in 2015 completed measures of ED symptoms, affect, and ED help-seeking in an online survey. Structural equation mixture modeling was used to (1) classify women and men, separately, into distinct classes characterized by unique dietary restraint patterns and (2) test associations among the three ED help-seeking barriers and facilitators within each class.

RESULTS

Five dietary restraint symptoms (food amount limiting attempts, fasting, food avoidance, following food/diet rules, desiring an empty stomach) clustered within four classes among women and three classes among men, which were characterized by qualitative and quantitative similarities and differences. Further, opposite patterns were generally found in associations among the ED help-seeking barriers and facilitators for women versus men as a function of the way dietary restraint symptoms clustered within each class. For example, bivariate associations between worse ED stigma and negative affect relative to greater perceived ED treatment need were both significant only among women in their lowest restraint severity class, whereas these associations were both significant among men in their highest severity class.

DISCUSSION

These findings can help to increase the reach of ED intervention efforts, including increasing ED help-seeking rates.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Credentialing for eating disorder clinicians: a pathway for implementation of clinical practice standards

Advances are needed to ensure safe and effective treatment is available for people with eating disorders. Recently developed clinical practice and training standards for mental health professionals and dietitians represent a significant step in this direction by providing a consensus statement on eating disorder treatment as a foundation on which to build competent practice. This commentary argues that a credentialing system could promote implementation of these practice standards through formal recognition of qualifications, knowledge, training and professional activities to meet minimum standards for delivery of safe and effective eating disorder treatment. Drivers for credentialing include the imperative to provide safe and effective care, promotion of workforce development in eating disorder practice and, importantly, readily available and transparent information for referrers, consumers, and carers to identify health professionals credentialed to provide eating disorder treatment. However, a number of factors must be considered to ensure that credentialing does not restrict access to care, such as prohibitively narrow criteria to become credentialed, absence of pathways for education, training, or professional development opportunities, and lack of consultation with or endorsement by stakeholders of the credentialing criteria, application and approval processes, and ways of identifying credentialed practitioners. Further work, including development of credentialing criteria and aligned training opportunities, currently being undertaken by the Australia & New Zealand Academy for Eating Disorders and the National Eating Disorders Collaboration in consultation with stakeholders in the eating disorders sector and health professions will advance understanding of the feasibility of a system of credentialing for eating disorders within Australia and New Zealand. The availability of clinical practice and training standards, supported by implementation pathways, including credentialing of eating disorders practitioners, aim to improve quality of life, reduce financial burden, and close the treatment gap.

Therapist-guided smartphone-based aftercare for inpatients with severe anorexia nervosa (SMART-AN): Study protocol of a randomized controlled trial

OBJECTIVE

Inpatient treatment for patients with anorexia nervosa (AN) is recommended in extreme or severe cases after failure of outpatient treatment and is highly effective. However, a number of patients show symptom increase and relapse after discharge. The aim of this study is to evaluate the efficacy of a therapist-guided smartphone-based aftercare intervention for inpatients with AN to support symptom stabilization.

METHOD

A total of 186 female patients with a DSM-5 diagnosis of AN (307.1) will be randomized either to receive a 16-week smartphone-based aftercare intervention with therapist feedback as add-on to treatment as usual (TAU) or TAU alone. Data will be assessed at discharge (= baseline, T0), after 16 weeks (= end of the aftercare intervention, T1) and after 10 months (= 6-month follow-up, T2). Primary outcome will be overall eating disorder symptomatology (Eating Disorder Examination Global score). Secondary outcome measures will include body mass index, depression, motivation to change, self-efficacy, patient satisfaction with and adherence to the smartphone-based aftercare intervention as well as rehospitalization rate.

DISCUSSION

This study will be the first randomized controlled trial to examine a therapist-guided smartphone-based aftercare intervention for inpatients with AN. Results may reveal whether and to which extent this novel intervention can support symptom stabilization after inpatient treatment.

What prevents young adults from seeking help? Barriers toward help-seeking for eating disorder symptomatology

OBJECTIVES

The aim of this study was to investigate help-seeking attitudes, intentions, and behaviors, and to systematically explore perceived barriers to help-seeking for eating, weight, or shape concerns among young adults. Differences in perceived barriers as a function of type of eating disorder symptomatology were also examined.

METHOD

Data were collected using an online survey among individuals (aged 18-25 years) in Australia. Overall, 291 young adults with varying levels of eating disorder symptoms completed measures of disordered eating, weight or shape concerns, help-seeking barriers, attitudes, intentions, and behaviors. According to their self-reported symptoms, participants were classified into four subgroups (i.e., anorexia nervosa [AN] symptoms, bulimia nervosa [BN] symptoms, binge-eating disorder [BED] symptoms, and other eating disorder symptoms).

RESULTS

Despite the belief that help-seeking is useful, only a minority of participants with elevated symptoms, namely those with AN, BN, and BED symptoms, believed they needed help. Across the sample, the most frequently cited barriers to seeking help for eating disorder symptoms were: concern for others, self-sufficiency, fear of losing control, denial and failure to perceive the severity of the illness, and stigma and shame.

DISCUSSION

The findings highlight the need to educate young adults about the severity of eating disorders and the importance of seeking help, and to increase the awareness of help-seeking barriers among those designing public health interventions as well as clinicians. Our findings suggest that help-seeking barriers may differ depending on the type of eating disorder symptomology.

A systems thinking perspective on the barriers to treatment access for people with eating disorders

Treatment access remains low for people with eating disorders. In addressing the complexity inherent in this challenge, this article introduces systems thinking and argues that it could provide new insights. Systems thinking views behavior as an emergent property of a system and considers the relationships between technical, organizational, and social components. Several methods used in safety science incorporate this thinking. For example, AcciMap draws focus to the influence of decisions and actions made across hierarchical levels of a system, including those by government, regulatory bodies, management, services, and individuals. By examining the findings of the existing literature on barriers to eating disorder treatment access according to these levels, it is evident that most identified barriers relate to individuals and that further research is needed to consider the influence of high-level stakeholders. Research using systems thinking should consider the causal networks of influence from government, regulatory, and organizational decisions and actions through to outcomes for clinicians and individuals. The understanding of how barriers operate within specific healthcare systems also warrants investigation. Systems thinking is yet to be formally applied in the area of eating disorders and thus represents an opportunity to inform the development and implementation of more effective, system wide interventions.

Reach Out and Recover: Intentions to seek treatment in individuals using online support for eating disorders

OBJECTIVE

The aim of this study was to explore characteristics and treatment-seeking intentions of consumers accessing an online resource for eating disorders support, Reach Out and Recover (ROAR). Factors associated with treatment-seeking intent among visitors to ROAR were also examined.

METHOD

Participants were 200 visitors to the website aged 18 to 60 plus. The majority of participants (93.5%) identified as women. Responses to self-report questions assessing treatment-seeking intention, eating disorder symptoms and their impact on health, and attitudes to treatment were collected.

RESULTS

Participants experienced a range of eating disorder symptoms, yet the majority (86.0%) was not receiving treatment. Importantly, of those not in treatment, the majority (82.6%) indicated that they planned to get treatment. In addition, more than half of participants (52.9%) downloaded a report to present to their health practitioner to facilitate communication with a health professional. Intention to seek treatment and download of the report were positively associated with motivation to change, confidence to achieve change, greater frequency of binge eating, and greater recognition of the impact of eating disorder symptoms on relationships and well-being but not with stigma or ambivalence.

DISCUSSION

Study findings indicated that the ROAR website was accessed by individuals for whom it was designed, namely those experiencing eating disorder symptoms who are not receiving treatment. Encouragingly, participants had strong intentions to seek treatment, and the majority downloaded a report that could be used to facilitate the first step toward treatment. Greater focus on enhancing motivation and confidence to change may further promote treatment-seeking.

Weighty decisions: How symptom severity and weight impact perceptions of bulimia nervosa

OBJECTIVE

The current study examined whether variations in patient weight and eating-disorder behavior frequency influenced the recognition of bulimia nervosa (BN) and the perception that it is a serious mental health concern.

METHOD

Participants (N = 320) were randomly assigned to one of six conditions in which they read a vignette describing a young woman with BN. Each vignette was identical except for the variables of interest: weight status (underweight, healthy-weight, and overweight), and symptom frequency (daily or weekly binge-eating episodes and purging).

RESULTS

Participants were more likely to have negative attitudes toward and blame the patient with overweight. Participants were less likely to believe that the patient with overweight was experiencing mental illness and that her problems were too serious to handle on her own. There were no significant differences by symptom frequency.

DISCUSSION

Findings suggest the presence of weight stigma and that overweight might impede the recognition of eating disorders.

A randomized controlled trial of an Internet-based intervention for eating disorders and the added value of expert-patient support: study protocol

Background

E-mental health has become increasingly popular in interventions for individuals with eating disorders (EDs). It has the potential to offer low-threshold interventions and guide individuals to the needed care more promptly. Featback is such an Internet-based intervention and consists of psychoeducation and a fully automated monitoring and feedback system. Preliminary findings suggest Featback to be (cost-)effective in reducing ED symptomatology. Additionally, e-mail or chat support by a psychologist did not enhance the effectiveness of Featback. Support by an expert patient (someone with a lived experience of an ED) might be more effective, since that person can effectively model healthy behavior and enhance self-efficacy in individuals struggling with an ED. The present study aims to replicate and build on earlier findings by further investigating the (cost-)effectiveness of Featback and the added value of expert-patient support.

Methods

The study will be a randomized controlled trial with a two-by-two factorial design with repeated measures. The four conditions will be (1) Featback, in which participants receive automated feedback on a short monitoring questionnaire weekly, (2) Featback with weekly e-mail or chat support from an expert patient, (3) weekly support from an expert patient, and (4) a waiting list. Participants who are 16 years or older and have at least mild self-reported ED symptoms receive a baseline measure. Subsequently, they are randomized to one of the four conditions for 8 weeks. Participants will be assessed again post-intervention and at 3, 6, 9, and 12 months follow-up. The primary outcome measure will be ED psychopathology. Secondary outcome measures are experienced social support, self-efficacy, symptoms of anxiety and depression, user satisfaction, intervention usage, and help-seeking attitudes and behaviors.

Discussion

The current study is the first to investigate e-mental health in combination with expert-patient support for EDs and will add to the optimization of the delivery of Internet-based interventions and expert-patient support.

Trial registration

Netherlands Trial Register, NTR7065. Registered on 7 June 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3574-2) contains supplementary material, which is available to authorized users.

Updates in the treatment of eating disorders in 2018: A year in review in eating disorders: The Journal of Treatment & Prevention

Current evidence suggests that the majority of patients with eating disorders will not fully recover during treatment, and little doubt can exist around the urgent need for improved treatment outcomes across the field of eating disorders. While empirical efforts are underway to optimize outcomes, this article reviews treatment-related research findings published in Eating Disorders: The Journal of Treatment & Prevention during 2018. Importantly, this review encapsulates research addressing (i) barriers to access and the uptake of empirically supported treatments, (ii) research assessing the delivery of empirically supported treatments across the full spectrum of patient care, and (iii) research aiming to isolate treatment mechanisms and optimize treatment outcomes across a transdiagnostic array of eating disorders. Ultimately, while much ground has been covered in 2018, further research is needed to enhance the accessibility and uptake existing treatments, since only a fraction of those with eating disorders are currently engaged in treatment. Further, with the expanding scope of non-outpatient eating disorder treatment settings, further research is required to adapt and assess the implementation of empirically supported treatments in higher levels of patient care. Lastly, in aiming to optimize patient outcomes, treatment outcome research must seek to identify (i) mechanisms that underlie illness eating disorder psychopathology, and (ii) the active mechanisms of existing treatments.