Creating a care pathway for patients with longstanding, complex eating disorders

Clinical care for severe and persistent eating disorders in pediatric populations: Perspectives of health professionals

OBJECTIVE

Models of treatment for adults with severe and enduring eating disorders focus on harm reduction and improving quality of life. However, there is a notable gap in the pediatric literature in this area. The current study set out to assess the perspectives of health professionals regarding clinical care for young people (e.g., ages 10-25 years) with severe and enduring eating disorders, and to explore perceptions about appropriate treatment options for these presentations.

METHODS

Health professionals were invited to complete a two-stage online survey about their experiences with clinical care for pediatric eating disorders through Canadian and Australian professional eating disorder networks. Survey 1 included questions about their experiences in supporting individuals with severe and enduring presentations. Participants who completed Survey 2 reviewed clinical vignettes and shared their perspectives about treatment recommendations and models of care, including for a severe and enduring presentation.

RESULTS

A total of 85 clinicians responded to questions on Survey 1 about severe and enduring eating disorder presentations. A portion of these respondents (n = 25) also participated in Survey 2. The majority of respondents to Survey 1 reported providing clinical care for pediatric severe and enduring eating disorder presentations. Amongst respondents to Survey 2, there was low consensus amongst respondents for the clinical care that would be most appropriate for young people with a severe and enduring eating disorder presentation. Numerous challenges in models of care for severe and enduring presentations in pediatric settings were raised in responses on Survey 2, with clinicians sharing their awareness of models focusing on quality of life, while also raising concerns about the appropriateness of these models for young people.

CONCLUSIONS

The preliminary results of this study demonstrate that the majority of clinicians report that they have provided care to young people with severe and enduring presentations. There is a clear need for establishing guidance for clinicians working in pediatric eating disorder settings around models of care focused on quality of life. Engagement with interested parties, including those with lived experience, can clarify the development of terminology and clinical pathways for severe and enduring presentations of pediatric eating disorders.

Ethical implications of defining longstanding anorexia nervosa

The label severe and enduring anorexia nervosa (SE-AN) is widely used in the literature on longstanding anorexia nervosa (AN). However, the process of constructing the criteria and the use of the label SE-AN has ethical implications that have not been taken into account. Through combining existing literature and lived experience perspective, this paper addresses to what extent the current criteria do and do not reflect the lived experience. Arguments are presented on why the process of constructing the criteria for SE-AN and the application of the label can be both identified as, and give rise to, epistemic injustice. Epistemic injustice is an injustice that is done to a person as an individual with the capacity of acquiring and sharing knowledge. This type of injustice can occur at any stage of an interaction between people in which knowledge is shared with one another. The paper concludes by giving suggestions on how to pursue epistemic justice in the process of defining longstanding AN.

Care pathways for longstanding eating disorders must offer paths to recovery, not managed decline

Eating disorders are historically underserved in healthcare, but are increasingly prevalent and recognised for their high costs regarding mortality, quality of life and the economy. Those with longstanding eating disorders are commonly labelled 'severe and enduring' (SEED), which has been challenged for its conceptual vagueness and potential to discourage patients. Attempts to define individuals from this cohort as having 'terminal' illness have also gained traction in recent years. This paper is grounded in lived/living experience and relevant research. It challenges the logical coherence and utility of SEED, arguing that the word 'enduring' unhelpfully situates intractability of longstanding illness within patients themselves and the nature of their illness. This risks a sense of inevitability and overlooks the important role of contextual factors such as lacking resources and insufficient evidence for withholding active treatment. Recommendations suggest approaches to dismantling unhelpful binaries between early intervention and intensive support, recovery and decline.

Continuity of care for children with anorexia nervosa in the Netherlands: a modular perspective

Care provision for children with anorexia nervosa is provided by outpatient care teams in hospitals, but the way these teams are organized differs per hospital and hampers the continuity of care. The aim of this study is to explore the organization and continuity of care for children with anorexia nervosa in the Netherlands by using a modular perspective.We conducted a qualitative, exploratory case study and took the healthcare provision for children with anorexia nervosa, provided by outpatient care teams, as our case. We conducted nine interviews with healthcare professionals involved in outpatient care teams from six hospitals. A thematic analysis was used to analyze the data.The modular perspective offered insights into the work practices and working methods of outpatient care teams. We were able to identify modules (i.e. the separate consultations with the various professionals), and components (i.e. elements of these consultations). In addition, communication mechanisms (interfaces) were identified to facilitate information flow and coordination among healthcare professionals. Our modular perspective revealed gaps and overlap in outpatient care provision, consequently providing opportunities to deal with unnecessary duplications and blind spots.   Conclusion: A modular perspective can be applied to explore the organization of outpatient care provision for children with anorexia nervosa. We specifically highlight gaps and overlap in healthcare provision, which in turn leads to recommendations on how to support the three essential parts of continuity of care: informational continuity, relational continuity, and management continuity. What is Known: • Care provision for children with anorexia nervosa requires a network of health care professionals from different organizations, as a result the organization and provision of care faces challenges. What is New: • Modular care provision sheds light on the complexity and organization of outpatient care provision and supports the three dimensions of continuity of care as experienced by children with anorexia nervosa and their parents/caregivers.

Transition support for patients admitted to intensive treatment for anorexia nervosa: qualitative study of patient and carer experiences of a hybrid online guided self-help intervention (ECHOMANTRA)

BACKGROUND

Adults with anorexia nervosa experience high levels of relapse following in-patient treatment. ECHOMANTRA is a novel online aftercare intervention for patients and carers, which provides psychoeducation and support to augment usual care.

AIMS

To explore patient and carer experiences of receiving the ECHOMANTRA intervention.

METHOD

This is part of the process evaluation of the ECHOMANTRA intervention as delivered in the TRIANGLE trial (ISRCTN: 14644379). Semi-structured interviews were conducted with 20 participants randomised to the ECHOMANTRA (ten patients and ten carers). Thematic analysis was used to analyse the interview transcripts.

RESULTS

Five major themes were identified: (1) Mixed experience of the intervention; (2) tailoring the intervention to the stage of recovery; (3) involvement of carers; (4) acceptability of remote support; and (5) impact of self-monitoring and accountability.

CONCLUSIONS

Participants were mostly positive about the support offered. The challenges of using remote and group support were counterbalanced with ease of access to information when needed. Components of the ECHOMANTRA intervention have the potential to improve care for people with eating disorders.

New understandings meet old treatments: putting a contemporary face on established protocols

In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.

Update on the epidemiology and treatment of eating disorders among older people

PURPOSE OF REVIEW

We reviewed the recent literature on the epidemiology and treatment of eating disorders among middle-aged and older women and men.

RECENT FINDINGS

Recent studies show that among older female persons, the prevalence rates with full diagnoses of eating disorders based on DSM-IV or DSM-5 criteria are between 2.1 and 7.7%, and among older men less than 1%. These studies show that the prevalence of eating disorders decreases by age in women, but it does not get towards zero even in very high age. Middle age, with a peak around 50, is also a critical time for the occurrence of eating disorders in men. Women who reported severe menopausal symptoms showed more eating disorder pathology compared with those with low symptoms during menopausal transition.

SUMMARY

Eating disorders do occur in middle and older age of both sexes. Shame and stigmatization have decreased, and medical awareness and explicit assessment of eating behavior in all age groups have developed. What puberty is for eating disorders in adolescence and young age is menopausal transition for midlife women. Also in men, associations with hormonal disturbances are possible. Treatment approaches should consider treatment strategies tailored to older women and men, addressing the context of midlife and aging.

Untreatable or unable to treat? Creating more effective and accessible treatment for long-standing and severe eating disorders

The evidence base for the treatment of severe eating disorders is limited. In addition to improving access to early intervention, there is a need to develop more effective treatments for complex presentations of eating disorders. For patients with long-standing and severe illnesses, particular difficulties might exist with their engagement with treatment and achieving treatment outcomes. Alarmingly, there is an emerging international discourse about a concept labelled as terminal anorexia and about the withdrawal of treatment for people with severe eating disorders, resulting in the death of patients, as a legitimate option. This concept has arisen in the context of vastly overstretched specialist services and insufficient research and funding for new treatments. This Personal View combines multiple perspectives from carers, patients, and mental health professionals based in the UK, highlighting how the risks of current service provision are best alleviated by increasing resources, capacity, and training, and not by a narrowing of the criteria according to which patients with eating disorders are offered the care and support they need.