Can adolescents with eating disorders be treated in primary care? A retrospective clinical cohort study

Does embedding pediatric eating disorder treatment in primary care bridge the access gap?

Given the numerous barriers to accessing child and adolescent eating disorder treatment, there is a need for innovation in how this care is delivered. Primary care-based eating disorder treatment has established proof-of-concept, yet it is unclear whether this model can bridge the treatment-access gap. This retrospective chart review study compared demographic and illness characteristics of 106 adolescents (M age = 15.1 years)  SD = 1.8 consecutively evaluated in a primary care-based eating disorder clinic with 103 adolescent patients (M age = 15.2 years)  SD = 2.2 seen consecutively in a specialty eating disorder clinic at the same medical center. Relative to adolescents in specialty care, those in the primary care group presented at a significantly higher BMI percentile, had less weight suppression, a shorter illness duration, lower rates of amenorrhea and lower scores on the EDE-Q Dietary Restraint subscale. In addition, more patients in the primary care group identified as non-white and had government/public assistance insurance compared to those in the specialty group. The results suggest that, compared to traditional specialty care clinics, embedded eating disorder treatment in primary care may reach a more racially and socioeconomically diverse group of adolescents when they are earlier in the course of their illness. Future research determining the relative effectiveness of this model as compared to interventions delivered in specialty care is needed.

Adapting Behavioral Treatments for Primary Care Using a Theory-Based Framework: The Case of Adolescent Eating Disorders

Evidence-based treatments have been developed for a range of pediatric mental health conditions. These interventions have proven efficacy but require trained pediatric behavioral health specialists for their administration. Unfortunately, the widespread shortage of behavioral health specialists leaves few referral options for primary care providers. As a result, primary care providers are frequently required to support young patients during their lengthy and often fruitless search for specialty treatment. One solution to this treatment-access gap is to draw from the example of integrated behavioral health and adapt brief evidence-based treatments for intra-disciplinary delivery by primary care providers in consultation with mental health providers. This solution has potential to expand access to evidence-based interventions and improve patient outcomes. We outline how an 8-step theory-based process for adapting evidence-based interventions, developed from a scoping review of the wide range of implementation science frameworks, can guide treatment development and implementation for pediatric behavioral health care delivery in the primary care setting, using an example of our innovative treatment adaptation for child and adolescent eating disorders. After reviewing the literature, obtaining input from leaders in eating disorder treatment research, and engaging community stakeholders, we adapted Family-Based Treatment for delivery in primary care. Pilot data suggest that the intervention is feasible to implement in primary care and preliminary findings suggest a large effect on adolescent weight gain. Our experience using this implementation framework provides a model for primary care providers looking to develop intra-disciplinary solutions for other areas where specialty services are insufficient to meet patient needs.

The Role of Primary Care in Bridging Adolescents Awaiting Eating Disorder Treatment

The striking rise in adolescent eating disorders since the severe acute respiratory coronavirus syndrome 2 pandemic has amplified demands for specialty eating disorders services and contributed to protracted delays in care. In the context of these delays, patients are at risk for increased weight loss, medical instability, escalating disease progression and poor prognosis. Primary care providers (PCPs) are frequently the first point of contact for young patients with eating disorders and are often left to bridge the gap while families struggle to establish specialty care. Yet, beyond case detection and medical comanagement, there are no evidence-based guidelines that can assist PCPs to prepare families for treatment, halt disease progression, and begin the lengthy process of weight and nutritional restoration in efforts to reduce medical complications and support a favorable prognosis. We present the case of a 13-year-old girl with a restrictive eating disorder to illustrate how PCPs can use intervention principles and strategies derived from evidence-based eating disorder treatment to successfully manage adolescent patients until they can access specialty treatment. We offer concrete guidelines for decision-making, as well as suggested behavioral and medical interventions for the PCP. With evidence-based tools, PCPs are well-positioned to support young patients with restrictive eating disorders and their family members as they begin the process of recovery from an eating disorder.

Description of patients with eating disorders by general practitioners: a cohort study and focus on co-management with depression

BACKGROUND

International guidelines often state that general practitioners (GPs) provide early management for most patients with eating disorders (EDs). GP management of EDs has not been studied in France. Depressive disorders are often a comorbidity of EDs. The aims of this study were to describe in France the characteristics of people with all subcategories of EDs (Anorexia Nervosa, Bulimia Nervosa, ED Not Otherwise Specified) managed by their GPs and to study the management temporality between depression and all subcategories of EDs.

METHODS

Retrospective cohort study of patients with EDs visiting French GPs. Data collected from 1994 through 2009 were extracted from the French society of general electronic health record. A descriptive analysis of the population focused on depression, medication such as antidepressants and anxiolytics, and the management temporality between depression and EDs.

RESULTS

1310 patients aged 8 years or older were seen at least once for an ED by a GP participating in the database out of 355,848 patients, with a prevalence rate of 0.3%. They had a mean age of 35.19 years, 82.67% were women. 41.6% had anorexia nervosa, 26.4% bulimia nervosa, and 32% an ED not otherwise specified. Overall, 32.3% had been managed at least once for depression, and 18.4% had been prescribed an antidepressant of any type at least once. Benzodiazepines had been prescribed at least once for 73.9% of the patients treated for depression. Patients with an ED seen regularly by their GP ("during" profile) received care for depression more frequently than those with other profiles. 60.9% had a single visit with the participating GP for their ED Treatment and management for depression did not precede care for EDs.

CONCLUSIONS

Data extracted from the French society of general practice were the only one available in France in primary care about EDs and our study was the only one on this topic. The frequency of visits for EDs was very low in our general practice-based sample. Depressive disorders were a frequent comorbidity of EDs. GPs could manage common early signs of depression and EDs, especially if they improved their communication skills and developed collaborative professional management.

How best to support parents of children with an eating disorder: A commentary on Wilksch (2023)

Wilksch (2023) uses survey data to characterize the perspective of caregivers of children who have undergone treatment for an eating disorder. With this framework, the author presents an evocative view of both the challenges these parents experience in acquiring needed specialty treatment, as well as the negative impact that the caregiving role may have on their own well-being. Altogether, this Forum underscores the unquestionable importance of not overlooking the practical and emotional needs of caregivers of youth with eating disorders, and presents a compelling call to action for our field to better support parents who navigate treatment for these challenging illnesses.

Adoption of inpatient family-based treatment for anorexia nervosa: A case report

Background

Family-based treatment (FBT) is effective for the treatment of anorexia nervosa (AN) in children and adolescents. However, its availability in Japan is limited because it requires adherence to specific guidelines, commitment of sufficient time for frequent outpatient treatment, as well as the entire family's participation. We present a case of a patient with AN who was treated with modified FBT during hospitalization.

Case Presentation

Our patient was a 14-year-old girl with AN. She was hospitalized for malnutrition and dehydration, and was introduced to FBT during this period. After discharge, she continued FBT on an outpatient basis and was in remission 1 year later.

Conclusion

This case shows that initiation of FBT during hospitalization may be useful in patients with physically severe AN. Flexible adaptation to each of the diverse healthcare systems and cultural differences may be necessary for the widespread use of FBT.

MC, Bidika E. A Clinical Overview of Anorexia Nervosa and Overcoming Treatment Resistance

Anorexia nervosa (AN) is a type of eating disorder that has been increasing in incidence and has been encountered more commonly by physicians in their daily practice. Both environmental and genetic risk factors paired along with a more susceptible neurobiology are at play in the emerging resistance to treatment in AN. Preoccupations with intense fear of weight gain, dietary restrictions, excessive exercise, and how the individual is perceived by society mixed with underlying psychopathology all further add to the issue. Many patients who fall into this cycle of obsessive and restrictive patterns refuse to get treatment. As clinicians, it is essential we recognize the early signs of both eating disorders during the initial primary care appointments.

To review the literature on the etiology of AN, possible misdiagnosis leading to inappropriate management of this condition, and understand the treatment-resistant AN and its management. Additionally, it will explore possible reasons that contribute to the resistance to treatment, the underlying psychopathology of anorexics, its genetic predisposition, psychiatric comorbidities, identification of the early signs and symptoms, and timely prevention.

Early recognition by a physician includes a thorough history and physical examination, pertinent laboratory, and electrolyte studies, and identifying comorbid psychiatric conditions. The treatment of AN is intricate and requires a holistic approach. Treatment includes multiple modalities such as nutritional rehabilitation and psychosocial and pharmacological therapies. An interdisciplinary team of medical professionals for managing chronic AN is recommended.