Adapting family-based treatment for adolescent anorexia nervosa delivered in the home: A novel approach for improving access to care and generalizability of skill acquisition

Interdisciplinary perspectives on accessing specialty evidence-based treatment for Medicaid-insured adolescents with eating disorders

BACKGROUND

Family-based treatment (FBT), the leading intervention for adolescents with anorexia nervosa (AN), is severely understudied in outpatient care settings that serve publicly-insured populations. Many individuals with public insurance are lower-income, racially and ethnically diverse, and experience barriers to accessing evidence-based interventions for eating disorders (EDs).

METHODS

Semi-structured interviews were conducted with ten interdisciplinary providers who provide specialty care to youth with EDs in an inpatient and/or outpatient medical setting. Interview questions were focused on the interdisciplinary providers' experiences of caring for individuals with EDs, with a focus on differences in care for those with private insurance compared to public insurance. The interviews took place two years after training in FBT was delivered to mental health providers in San Francisco County, which created opportunities to explore provider perspectives on collaborating with newly-trained mental health providers in the community implementing FBT with publicly-insured youth.

RESULTS

Content analysis converged on three themes: the critical importance of supporting mental health treatment within the context of medical care, complex challenges when helping patients and their families navigate publicly-funded health care systems, and the overall positive impact of the FBT rollout in San Francisco County. Participants emphasized greater confidence in patient outcomes when collaborating with FBT providers and noted discord when working with providers not trained in EDs or FBT. Referral systems, weight-based stigma, and a lack of appropriate services were highlighted as significant barriers to care. To facilitate treatment engagement in publicly-insured populations, participants stressed the importance of clinicians providing psychoeducation and providing services with a high degree of cultural competence. Participants expressed that patients' ability to access FBT and providers' ability to collaborate on cases markedly improved following the county training, increasing their sense of efficacy in delivering adequate patient care.

CONCLUSIONS

The discussed themes highlight the importance of access to FBT for individuals in underserved communities, which can significantly reduce both provider and patient burden. Despite various barriers to utilizing FBT in publicly-funded settings, clinicians stressed that cultural adaptations increase the implementation of and facilitate family engagement in FBT, which is consistent with previous literature examining evidence-based intervention implementation science.

Quantifying the economic value of earlier and enhanced management of anorexia nervosa for adults in England, Germany and Spain: improving the care pathway

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness. One-third of people develop severe, enduring, illness, adversely impacting quality of life with high health system costs. This study assessed the economic case for enhanced care for adults newly diagnosed with AN.

METHODS

A five-state 312-month-cycle Markov model assessed the economic impact of four enhanced care pathways for adults newly diagnosed with AN in England, Germany, and Spain. Enhancements were halving wait times for any outpatient care, receiving specialist outpatient treatment post-referral, additional transitional support post-referral, and all enhancements combined. Care pathways, estimates of impact, resource use, and costs were drawn from literature. Net monetary benefits (NMBs), impacts on health system costs, and disability-adjusted life years (DALYs) averted were estimated. Parameter uncertainty was addressed in multi-way sensitivity analyses. Costs are presented in 2020 purchasing power parity adjusted Euros.

RESULTS

All four enhanced care pathways were superior to usual care, with the combined intervention scenario having the greatest NMBs of €248,575, €259,909, and €258,167 per adult in England, Germany, and Spain, respectively. This represented maximum NMB gains of 9.38% (€21,316), 4.3% (€10,722), and 4.66% (€11,491) in England, Germany and Spain compared to current care. Healthcare costs would reduce by more than 50%.

CONCLUSIONS

Early and effective treatment can change the trajectory of AN. Reducing the untreated duration of the disorder is crucial. There is a good economic case in different country contexts for measures to reduce waiting times between diagnosis and treatment and increase access to enhanced outpatient treatment.

A qualitative assessment of provider-perceived barriers to implementing family-based treatment for anorexia nervosa in low-income community settings

BACKGROUND

Family-based treatment (FBT) is a front-line empirically supported intervention for adolescent anorexia nervosa, but it is often inaccessible to families from lower income backgrounds, as it is most typically available in specialty research and private practice settings. In preparation for a pilot trial of FBT delivered in the home setting, this study qualitatively examined provider perceptions of implementing FBT in lower-income communities.

METHODS

Eating disorder clinicians working in community clinics (therapists, medical doctors, dietitians, and social workers; n = 9) were interviewed about their experiences using FBT. Interview transcripts were analyzed both deductively, using an approach consistent with applied thematic analysis, and inductively, using the Replicating Effective Programs implementation framework, to examine barriers to FBT implementation.

RESULTS

Prevailing themes included concern about the time and resources required of caregivers to participate in FBT, which may not be feasible for those who work full time, have other caregiving demands, and/or lack family support. Psychosocial problems outside of the eating disorder, such as food insecurity, other untreated mental health concerns (in themselves or other family members), or externalizing behaviors on the part of the adolescent, were also discussed as barriers, and participants noted that the lack of cohesive treatment teams in the community make it difficult to ensure continuity of care.

CONCLUSION

Findings from this qualitative study indicate the need to address systemic socioeconomic barriers to improve the efficacy of implementation of FBT in the community and to understand how provider perceptions of these barriers influence their uptake of FBT.

Involuntary Treatment for Child and Adolescent Anorexia Nervosa-A Narrative Review and Possible Advances to Move Away from Coercion

BACKGROUND

Children and adolescents with psychiatric disorders frequently experience hospital treatment as coercive. In particular, for patients with severe anorexia nervosa (AN), clinical and ethical challenges often arise if they do not voluntarily agree to hospital admission, often due to the ego-syntonic nature of the disorder. In these cases, involuntary treatment (IVT) might be life-saving. However, coercion can cause patients to experience excruciating feelings of pressure and guilt and might have long-term consequences.

METHODS

This narrative review aimed to summarize the current empirical findings regarding IVT for child and adolescent AN. Furthermore, it aimed to present alternative treatment programs to find a collaborative method of treatment for young AN patients and their families.

RESULTS

Empirical data on IVT show that even though no inferiority of IVT has been reported regarding treatment outcomes, involuntary hospital treatment takes longer, and IVT patients seem to struggle significantly more with weight restoration. We argue that more patient- and family-oriented treatment options, such as home treatment, might offer a promising approach to shorten or even avoid involuntary hospital admissions and further IVT. Different home treatment approaches, either aiming at preventing hospitalization or at shortening hospital stays, and the results of pilot studies are summarized in this article.