Translating evidence-based treatment for digital health delivery: a protocol for family-based treatment for anorexia nervosa using telemedicine

Comparing family-based treatment with inpatient treatment in youth with anorexia nervosa eligible for hospitalization: A 12-month feasibility study

OBJECTIVE

Family-based treatment (FBT) for youth with anorexia nervosa (AN), has not been compared to inpatient, multimodal treatment (IMT).

METHOD

Prospective, non-randomized pilot feasibility study of adolescents with AN receiving FBT (n = 31), and as a reference point for exploratory outcome comparisons IMT (n = 31), matched for baseline age and percent median BMI (%mBMI). Feasibility of FBT in youth fulfilling criteria for IMT was assessed via study recruitment and retention rates; acceptability via drop-out and caregiver strain; safety via adverse events; preliminary treatment effectiveness between groups was assessed via a change in %mBMI, AN psychopathology (Eating Disorder Examination-Questionnaire, EDE-Q), and hospital days, over 12 months with intent-to-treat, mixed models repeated measures analyses covering post-intervention usual care until 12 months.

RESULTS

Taking into account that 8 FBT patients (25.8%) crossed over to IMT due to lack of weight gain or psychiatric concerns, FBT and IMT were similarly feasible, acceptable, and safe, apart from more physical antagonism toward others in FBT (p = .010). FBT lasted longer (median [interquartile range, IQR]; 33.6 [17.4, 49.9] vs. 17.3 [14.4, 24] weeks, p < .001), but required fewer hospital days than IMT (median, [IQR], FBT = 1 [0, 16] vs. IMT = 123 [101, 180], p < .001). Baseline comorbidity-adjusted changes over 12 months did not differ between groups in %mBMI (FBT = 12.6 ± 11.9 vs. IMT = 13.7 ± 9.1; p = .702) and EDE-Q global score (median, [IQR]; FBT = -1.2 [-2.3, 0.2] vs. IMT = -1.3 [-2.8, -0.4]; p = .733).

DISCUSSION

Implementing FBT in this pilot study was feasible, acceptable, and safe for youth eligible for IMT according to German S3 guidelines. Non-inferiority of FBT versus IMT requires confirmation in a sufficiently large multicenter RCT.

PUBLIC SIGNIFICANCE

This pilot study with 62 adolescent patients with anorexia nervosa demonstrated that for 2/3rd of patients eligible for a long hospitalization in the German health care system, outpatient, Family-based treatment (FBT) was a safe and feasible treatment alternative. Over 12 months, FBT lead to similar weight gain and reduction in eating disorder cognitions as inpatient treatment with fewer hospital days. This pilot study needs to be followed up by a larger, multicenter trial.

Improving programme-led and focused interventions for eating disorders: An experts' consensus statement-A UK perspective

OBJECTIVE

Eating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Greater use of programme-led and focused interventions that are less resource-intensive might be part of the solution to this demand-capacity mismatch.

METHOD

In October 2022, a group of predominantly UK-based clinical and academic researchers, charity representatives and people with lived experience convened to consider ways to improve access to, and efficacy of, programme-led and focused interventions for eating disorders in an attempt to bridge the demand-capacity gap.

RESULTS

Several key recommendations were made across areas of research, policy, and practice. Of particular importance is the view that programme-led and focused interventions are suitable for a range of different eating disorder presentations across all ages, providing medical and psychiatric risk are closely monitored. The terminology used for these interventions should be carefully considered, so as not to imply that the treatment is suboptimal.

CONCLUSIONS

Programme-led and focused interventions are a viable option to close the demand-capacity gap for eating disorder treatment and are particularly needed for children and young people. Work is urgently needed across sectors to evaluate and implement such interventions as a clinical and research priority.

The use of technology in the treatment of youth with eating disorders: A scoping review

BACKGROUND

Adolescence and young adulthood is a high-risk period for the development of eating disorders. In recent years, there has been an increase in use of technology-based interventions (TBIs) for the treatment of eating disorders. The objective of this study was to determine the types of technology used for eating disorder treatment in youth and their effectiveness.

METHODS

A scoping review was conducted according to PRISMA-ScR guidelines. Four databases were searched. Eligible articles included: (1) a TBI (2) participants with a mean age between 10- and 25-years and meeting DSM-IV or DSM-5 criteria for any eating disorder and (3) qualitative or quantitative designs. Quantitative and qualitative studies were assessed for quality.

RESULTS

The search identified 1621 articles. After screening of titles and abstracts, 130 articles were read in full and assessed for eligibility by two raters. Forty-nine (29 quantitative and 20 qualitative, observational, or mixed methods studies) met inclusion criteria. Quality ratings indicated that 78% of quantitative studies had a low risk of bias and 22% had a moderate risk. Technologies reviewed in our study included videoconference therapy, mobile applications, and online self-help. We considered interventions used both within sessions with clinicians as well as those used in between sessions by patients alone. Fifteen of 18 (83%) quantitative studies found that TBIs reduce eating disorder symptomatology, with nine of those reporting medium-to-large effect sizes. Qualitative data was of high quality and suggested that virtual interventions are acceptable in this population.

CONCLUSIONS

Although identified studies are of high quality, they are limited in number. More research is needed, particularly regarding videoconferencing and mobile applications. Nonetheless, TBIs show promise for the treatment of eating disorders in youth.

TRIAL REGISTRATION

Not applicable.

Use of Telehealth in the Management of Adolescent Eating Disorders: Patient Perspectives and Future Directions Suggested from the COVID-19 Pandemic

Efforts to increase accessibility of eating disorder (ED) treatment via telemedicine have been ongoing for the past decades. However, there has been a recent surge in research focused on remote delivery of interventions since the onset of the novel coronavirus pandemic (COVID-19) in 2020, the related lockdowns, and an exponential increase in ED symptoms in youth secondary to the pandemic worldwide. In the current review, we provide a focused summary of existing literature regarding telehealth for the treatment of EDs in adolescents using a frame of past, present, and future work. Specifically, we begin with a brief overview of research in remote delivery for EDs in youth prior to 2020. Then, we detail more recent studies in this domain, with a focus on research conducted during the COVID-19 pandemic. We close by outlining limitations of the existing data and future steps necessary to expand the rigor and impact of this work. Overall, there are considerable limitations associated with research conducted during the pandemic, but an increase in the acceptability of remote delivery methods and interest in hybrid care appears to be feasible, and likely to be lasting. Future work must replicate more recent research in non-pandemic contexts and prioritize evaluation of factors that will aid in matching patients to the most efficient and effective modalities of care moving forward.

Assessing the Effectiveness of a Telemedicine Initiative in Clinical Management of Children Living with HIV/AIDS in Maharashtra, India

AIMS

To evaluate the effectiveness of telemedicine in the clinical management of children living with HIV/AIDS in resource-limited settings ; Background: Telemedicine is an important mechanism for service delivery in health care settings, both in resource-rich and resource-poor settings. Such service delivery mechanisms have shown to be associated with virologic suppression and higher CD4 counts. These services are also associated with improved access, shorter visiting times, and higher patient satisfaction. ; Objective: We designed the present two-group comparison study to compare the clinical evaluation and management of children in the anti-retroviral therapy (ART) centres linked to telemedicine facility with those who are not linked to this facility in Maharashtra, India. ; Methods: We analysed clinical records from six ART centres in Maharashtra; of these, 250 children were in the linked ART centres and 301 were in the non-linked ART centres. The outcomes were classified according to investigations, management, and monitoring. For management, we evaluated: 1) Initiation of cotrimoxazole prophylaxis; 2) Children not initiated on ART when required; 3) ART regime after appropriate investigations; and 4) Change of regime (if immunologically indicated). For monitoring, we assessed the haematological monitoring of children on ART. ; Results: The mean (SD) ages of children in linked and non-linked ART centres were 10.8 (4.6) and 10.9 (4.6) years, respectively (p=0.80). After adjusting for individual and structural level variables, physical examination (OR: 2.0, 95% CI; 1.2, 3.2), screening for tuberculosis (OR: 12.9, 95% CI: 2.0, 82.9) and cotrimoxazole prophylaxis were significantly more likely in the linked centres compared with non-linked centres (OR: 1.8, 95% CI: 1.4, 2.2). A higher proportion of children eligible for ART were not initiated on treatment in the non-linked centres compared with linked centres (26% vs. 8%, p=0.06). Children were less likely to be initiated on zidovudine-based regimens without baseline haemoglobin or with baseline haemoglobin of less than 9 gm% in linked centres (OR: 0.7, 95% CI: 0.6, 0.8). Similarly, children in the linked centres were less likely to have been started on nevirapine-based regimens without baseline liver enzymes (OR: 0.8, 95% CI: 0.7, 0.9). ; Conclusion: Thus, the overall clinical management of Children Living with HIV/ AIDS (CLHA) was better in ART centres linked with the telemedicine initiative compared with those who were not linked. Children in the linked ART centres were more likely to have a complete baseline assessment (physical, hematological, radiological, and screening for TB); the presence of a pediatrician in the centres was helpful.

What was the impact of a global pandemic (COVID-19) lockdown period on experiences within an eating disorder service? A service evaluation of the views of patients, parents/carers and staff

BACKGROUND

The World Health Organization declared the outbreak of COVID-19 as a global pandemic on the 11th March 2020. As a result, the UK Government imposed severe restrictions on working and social contact as part of "lockdown." Whilst the full extent of the pandemic's impact on eating disorder patients is unknown, the literature suggests that patients with pre-existing mental illness may be more vulnerable to the mental health impacts. In addition, the restrictions greatly reduced the access to mental health services and presented new challenges to service delivery. A service evaluation was carried out to explore how the COVID-19 global pandemic changed service provision in a young person's eating disorder service and how this affected patient, family and staff experiences.

METHODS

An audit was carried out to explore how the lockdown period had impacted referrals and service delivery. Quantitative data was collected in an online survey and qualitative data was collected in two formats: open ended answers as part of the online survey and open-ended focus groups, structured using narrative enquiry. The 43 participants consisted of 12 patients, 19 parents/carers, and 12 staff members. Patients were under the age of 18 and had a diagnosis of an eating disorder.

RESULTS

COVID-19 and lockdown increased the pressure on the service and changed service provision significantly. This has impacted the relational experiences for patients and their carers and staff have been faced with new challenges. Patients, parents/carers and staff all preferred face-to-face appointments over virtual options. There was no difference in service satisfaction before and during COVID-19.

CONCLUSIONS

It is possible to provide an eating disorder service in lockdown restrictions that patients and parents report high satisfaction with. Providing face-to-face appointments at the beginning of treatment and including families in the planning should be prioritised. Staff support is crucial to be able to continue delivering high quality services. The key themes are identified, and clinical recommendations are made to guide service delivery.