Care experiences of young people with eating disorders and their parents: qualitative study

Patient and clinician perspectives on supported mealtimes as part of anorexia nervosa treatment: A systematic review and qualitative synthesis

OBJECTIVE

To systematically review the literature on clinicians' and patients' experiences of supported mealtimes in the treatment of anorexia nervosa.

METHOD

This systematic review was conducted in accordance with PRISMA guidelines and registered on PROSPERO (CRD42022372565). PsycINFO, MEDLINE and Embase were searched up to the 20th of November 2023 for qualitative articles investigating the perspectives of healthcare professionals and patients on clinician-supported meals across all clinical settings. Data were analysed using thematic synthesis. The Critical Appraisal Skills Programme was used to evaluate the quality of selected studies.

RESULTS

This review comprised of 26 studies; eight concerned with the perspectives of clinicians only, 16 addressing patients' views, and two studies exploring the views of both groups. Experiences of both groups were generally negative, and three overlapping themes were identified: lack of consistency in care provided, high levels of negative emotions and an uncomfortable power dynamic.

CONCLUSIONS

This review suggests that supported mealtimes are experienced more positively by patients when rules are clear and consistently enforced, and when clinicians make informal conversation and supportive comments. Our findings highlight the need for best practice guidelines and clinician training to improve the delivery of supported mealtimes. Such guidelines and training should be coproduced in collaboration with patients and carers.

Outcomes and associated clinical features of people with eating disorders participating in residential treatment facilities: a scoping review

Residential treatment programs for eating disorders (EDs) have gained popularity in recent years, expanding beyond the United States to countries such as Canada, Italy, and the United Kingdom. These programs offer a "home-like" environment where individuals reside for several weeks or months, emphasising both physical restoration and psychological recovery. This scoping review aimed to provide an update since the most recent reviews on the literature regarding outcomes of residential treatment programs for EDs and to explore clinical features that were associated with these outcomes. Methods used followed the Joanna Briggs Institute guidelines for scoping reviews. A systematic search of electronic databases was conducted, and 12 studies met the inclusion criteria. All studies reported improvements in various outcomes from admission to discharge, including changes in eating psychopathology, weight restoration, depression, anxiety, and quality of life. Additionally, three studies reported positive outcomes at intervals after discharge and three predictive factors (self-compassion, personality organisation, and resistance to emotional vulnerability) were reported in a small number of studies. While residential treatment facilities consistently showed positive outcomes, the review highlights the need for randomised controlled studies to establish the efficacy of these programs for EDs. Future research should include controlled studies comparing residential facilities to other treatment settings and incorporate long-term follow-up outcomes and further studies of emergent predictive factors identified in this review.

The experiences of having a sibling with an eating disorder: A systematic review of the literature

OBJECTIVE

Research on carers in the context of eating disorders (EDs) has predominantly focused on parents and offspring, overlooking the adverse effects EDs have on the lives of siblings. This study aims to shift the paradigm by reviewing the literature in this area. To the authors' knowledge, this is the first review of the literature that broadly captured the lived experiences of siblings without being limited by specific search terms such as coping strategies and levels of psychopathology.

METHOD

Six databases (ERIC, MEDLINE, PsycInfo, Pubmed, Scopus, and Web of Science) were searched using predetermined search strings. Quantitative, qualitative, and mixed methods studies were included as long as they were focused on siblings' experiences of having a brother or sister with an ED. No publication date restrictions were applied, and thorough quality assessments were initially carried out before a qualitative analysis of the data was conducted.

RESULTS

Twenty-one studies were eligible for inclusion, thematic synthesis yielded six core themes, and 17 subthemes related to the inter- and intrapersonal impacts of the ED on siblings' lives. These themes and sub-themes include fragmentation in family relationships, parentification, and competition and jealousy.

CONCLUSION

It is of utmost importance to gain a better understanding of siblings' experiences and needs in relation to EDs. The findings are discussed in relation to the existing literature and theoretical and clinical implications, for example, tailored approaches accounting for siblings' experiences.

The importance of individualised care, good communication and trust for reducing nasogastric tube feeding under physical restraint: qualitative multi-informant study

BACKGROUND

Nasogastric tube (NGT) feeding against a patient's consent is an intervention that clinicians working in specialist mental health in-patient units may need to implement from time to time. Little research has explored clinician, patient and carer perspectives on good practice.

AIMS

To use qualitative data from people with lived experience (PWLE), parents/carers and clinicians, to identify components of best practice when this intervention is required.

METHOD

PWLE and parents/carers were recruited via BEAT UK's eating disorder charity. Clinicians were recruited via a post on The British Eating Disorders Society's research page. Semi-structured interviews were administered, transcribed and thematically analysed.

RESULTS

Thirty-six interviews took place and overlapping themes were identified. Participants spoke in relation to three themes: first, the significance of individualised care; second, the importance of communication; third, the impact of staff relationships. Sub-themes were identified and explored.

CONCLUSIONS

Good care evolved around positive staff relationships and individualised care planning rather than standard processes. The centrality of trust as an important mediator of outcome was identified, and this should be acknowledged in any service that delivers this intervention.

Adolescent-perceived parent-child negative body talk and disordered eating: Evidence for behavior-specific affective mediators

INTRODUCTION

This study examined the mediating role of general negative affect and body-specific negative affect between the association between negative body talk occurring within the mother-daughter relationship and restrained and disinhibited disordered eating.

METHODS

Adolescent girls (N = 100; Mage = 14.25; 49.5% White) completed self-report measures of general negative affect (depression and anxiety), body-specific negative affect (body dissatisfaction), and perceptions of the frequency that negative body talk occurred in interactions with their mother (initiated by the mother or daughter) as part of a cross-sectional study. While the same set of questionnaires was administered to both mothers and daughters, only the data reported by the daughters were analyzed and included in this study. Data were gathered in the Ann Arbor/Ypsilanti area of Michigan, USA, around the year 2015.

RESULTS

Path analysis showed that general negative affect, but not body-specific negative affect, mediated the association from mother-daughter negative body talk to disinhibited eating behaviors (emotional and external eating). Conversely, body-specific negative affect, but not general negative affect, mediated the association from negative body talk to restrained eating behaviors.

CONCLUSIONS

Our findings suggest there are distinct affective mechanisms that mediate the relationship between mother-daughter negative body talk and restrained versus disinhibited eating behavior. Future work should continue to explicate the role of general and body-related negative affect in different eating behaviors.

"The third wing of the plane": Fathers' perceptions of their role in the treatment process for daughters with eating disorders

Eating disorders are complex mental health conditions exacerbated by high mortality rates. International and national guidelines recommend family involvement in the treatment process, recognising the family as an important source of support to young people. Research suggests fathers engage less in the process compared to mothers. In studies exploring parental perspectives, most samples consisted of mothers, with fathers minimally represented. Few studies explore family involvement from the perspective of fathers. This study aimed to explore the experiences of fathers regarding their involvement in the treatment process. Qualitative descriptive methods were used, involving focus group interviews of seven fathers. Interviews were assisted by a semi-structured interview guide. A qualitative content analysis approach was used to analyse the data regarding paternal experiences of engagement in the treatment process. Fathers understood the importance of the whole family working together but viewed mothers as taking a more central role in the treatment process, with fathers more at the periphery. Gender emerged as an influencing factor in paternal involvement, with mothers primarily taking on responsibility for the child with the eating disorder and fathers providing secondary support. Healthcare providers need to be aware of the contribution of gendered roles within the family system and consider this when working with families within the treatment process. Consequently, mental health nurses have an important role in encouraging fathers to become actively involved in the treatment process.

Parents' perspectives of anorexia nervosa treatment in adolescents: a systematic review and metasynthesis of qualitative data

BACKGROUND

Studies have established the central role of the family in the recognition, treatment, and recovery of anorexia nervosa. The objective of this study was to review, synthesize, and critically appraise the literature on parents' views on the treatment and recovery process of anorexia nervosa in their adolescent child.

METHOD

A systematic search of Medline, PsychINFO, CINHAL, EMBASE, Cochrane library, and SSCI was conducted for qualitative studies published regarding parents' views about the treatment of anorexia nervosa. The quality of articles was assessed using the critical appraisal skills program (CASP) and findings were analysed using thematic synthesis.

RESULTS

A total of 25 studies from nine countries reporting the views of 357 parents met the inclusion criteria. Four major themes were developed from the analysis: understanding the child and the disease, experience of services and treatment modalities, the role of professionals, and the experience of recovery.

CONCLUSION

Parents report struggles with delays in finding help, judgmental attitudes of professionals, and uncertainty about the future. Recognition of the challenges faced by parents and families empowers clinicians to build stronger therapeutic relationships essential for long-term recovery from anorexia nervosa.

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.

Acceptability of using a nasogastric refeeding protocol with adult patients with medically unstable eating disorders

RATIONALE, AIMS AND OBJECTIVES

Nasogastric feeding is becoming commonly used to support patients with medically compromised eating disorders. Previous research has demonstrated the safety of this approach, however there is limited evidence as to how adult patients and staff perceive this feeding method. This study aimed to describe the acceptability of a nasogastric refeeding protocol with adult patients with medically unstable eating disorders and the staff involved in their treatment.

METHOD

This was a qualitative exploratory study using semi-structured interviews conducted in acute medical wards of a tertiary hospital where nasogastric nutrition is the sole source of nutrition for the first 7 days of the eating disorder admission. Data were analysed using the Framework method.

RESULTS

Eight patients (100% female, median: 22 years old, n = 6 diagnosed with anorexia nervosa) and 12 staff members (medical n = 5, nursing n = 5, dietitians n = 2; median: 8.5 years clinical experience) were interviewed. Patients reported that nasogastric feeding was tolerable, however concerns were raised regarding communication and the desire for concurrent oral feeding. Acceptability from staff was influenced by perceived competence, confidence, tensions around patient-centred care, and working with stigma and ambivalence.

CONCLUSIONS

Consideration needs to be given as to whether a 'nil by mouth' status during nasogastric feeding further impacts recommencing an oral diet to progress treatment. Improvements are required within the current service, including improved communication, additional educational resources for patients, and allowing patients to partake in decision-making as able.

A lived experience response to the proposed diagnosis of terminal anorexia nervosa: learning from iatrogenic harm, ambivalence and enduring hope

The ethical approach to treatment non-response and treatment refusal in severe-enduring anorexia nervosa (SE-AN) is the source of significant ethical debate, particularly given the risk of death by suicide or medical complications. A recent article proposed criteria to define when anorexia nervosa (AN) can be diagnosed as 'terminal' in order to facilitate euthanasia or physician-assisted suicide (EAS), otherwise known as medical assistance in dying, for individuals who wish to be relieved of suffering and accept treatment as 'futile'. This author utilises their personal lived experience to reflect on the issues raised, including: treatment refusal, iatrogenic harm, suicidality and desire to end suffering, impact of diagnosis/prognosis, schemas, alexithymia, countertransference, ambivalence, and holding on to hope. Within debates as critical as the bioethics of involuntary treatment, end-of-life and EAS in eating disorders, it is crucial that the literature includes multiple cases and perspectives of individuals with SE-AN that represent a wide range of experiences and explores the complexity of enduring AN illness, complex beliefs, communication patterns and relational dynamics that occur in SE-AN.

Ethical tensions in the treatment of youth with severe anorexia nervosa

Treatment of anorexia nervosa poses a moral quandary for clinicians, particularly in paediatrics. The challenges of appropriately individualising treatment while balancing prospective benefits against concomitant harms are best highlighted through exploration and discussion of the ethical issues. The purpose of this Viewpoint is to explore the ethical tensions in treating young patients (around ages 10-18 years) with severe anorexia nervosa who are not capable of making treatment-based decisions and describe how harm reduction can reasonably be applied. We propose the term AN-PLUS to refer to the subset of patients with a particularly concerning clinical presentation-poor quality of life, lack of treatment response, medically severe and unstable, and severe symptomatology-who might benefit from a harm reduction approach. From ethics literature, qualitative studies, and our clinical experience, we identify three core ethical themes in making treatment decisions for young people with AN-PLUS: capacity and autonomy, best interests, and person-centred care. Finally, we consider how a harm reduction approach can provide direction for developing a personalised treatment plan that retains a focus on best interests while attempting to mitigate the harms of involuntary treatment. We conclude with recommendations to operationalise a harm reduction approach in young people with AN-PLUS.

"I'm not alone": a qualitative report of experiences among parents of children with eating disorders attending virtual parent-led peer support groups

BACKGROUND

The treatment for children with eating disorders (EDs) requires extensive involvement of parents. The parents of children with EDs have voiced a need for greater support, including connecting with other parents with lived experience of caring for a child with an ED. We aimed to qualitatively explore parental experiences of these groups, including their benefits and areas for improvement.

METHODS

This study examined the delivery of four virtual parent-led peer support groups in Ontario, Canada for parents of children with EDs with approximately 10 parent participants per group and two parent facilitators leading each group. Parents (n = 44) were asked to attend 12 bi-weekly support group sessions over 6 months, and then complete an individual end-of-study qualitative interview. Interview data were analyzed using content analysis, following the qualitative description design.

RESULTS

Thirty-six parents completed the end-of-study qualitative interview. Participants shared their experiences and impressions related to the group's structure and content. Notable helpful aspects of the group included being able to receive support from those with similar experiences, access to education and resources about EDs, and being able to support others. Suggestions for improvements were made, which included organizing groups according to the child's ED diagnosis or duration of illness.

CONCLUSION

The findings indicate that this intervention is acceptable to parents and is perceived as helpful. Future research is needed to strengthen this support group model and to study its effects for parents in different settings and for parents of children with various EDs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04686864.

Potential Triggers for Risking the Development of Eating Disorders in Non-Clinical Higher-Education Students in Emerging Adulthood

Nowadays, eating disorders (ED) among individuals during emerging adulthood have become a crucial challenge to public health, taking into account the fact that the global prevalence of the ED risk in student-aged populations already stands at 10.4% and has been sharply increasing during the COVID-19 pandemic. In all, from 50% to 80% of all the ED cases go undetected or are not correctly diagnosed; moreover, these individuals do not receive specialized treatment. Therefore, early diagnosis detected via screening questionnaires for ED is highly recommended. This study aimed to identify the triggers for ED risk development in emerging-adulthood individuals and to reveal the factors significant not only for ED prevention but also for assessing individuals with subthreshold symptoms. This cross-sectional study provides the results for the ED symptom screening in 1716 Lithuanian higher-education students aged 21.2 ± 3.9, during emerging adulthood. According to the results of this study, 19.2% of students were at risk for ED. Potential risk factors such as sex (odds ratio (OR): 3.1, 95% CI: 1.9–4.9), body weight (self-reported body mass index) (adjusted (A) OR: 1.4; 95% CI: 1.2–1.7) and comorbidities such as smoking (AOR: 2.1; 95% CI: 1.6–2.8), and perceived stress during the pandemic (AOR: 1.4; 95% CI: 1.1–1.8) are involved in anticipating the symptomatology of ED during emerging adulthood. Regular initial screenings with universally adopted questionnaires and further referral to a psychiatrist must be applied to promote both the diagnosis of early-onset symptomatology and the treatment of these ED in student-aged populations. Preventive programs for reducing the prevalence of overweight or obesity among students during emerging adulthood should focus on integration directions for the development of a positive body image.

Patient perspectives on premature termination of eating disorder treatment: a systematic review and qualitative synthesis

BACKGROUND

High rates of premature treatment termination are a well-reported issue in eating disorder treatment, and present a significant barrier for treatment effectiveness and longer term health outcomes of patients with eating disorders. Understanding patient perspectives on this phenomenon is essential in improving treatment completion rates and informing research and intervention development. The aim of this review is to synthesise qualitative literature on patient perspectives of premature termination of eating disorder treatment and to summarise the key issues leading to discontinuation of treatment.

METHODS

A systematic review of 1222 articles was conducted to identify studies using qualitative methods to investigate patient experiences of prematurely terminating eating disorder treatment. Ten articles were included in the review, with thematic synthesis used to analyse the primary research and develop overarching analytical themes.

RESULTS

Conflict around enmeshment of eating disorder with identity, and lack of support with reconstructing a sense of self without the eating disorder; challenges of managing pressures of social and clinical relationships while feeling unheard and misunderstood by both; expectations and disappointments around treatment; and dissatisfaction with progress were key themes behind premature termination of treatment.

CONCLUSIONS

The findings of this review demonstrate the key issues influencing the decision to end treatment early, highlighting the contribution of individual, environmental, and service-level factors. Implications of these factors are discussed and suggestions raised for future research and service development.

Clinicians' perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings

BACKGROUND

Admissions to intensive treatment (i.e., inpatient [IP] and/or day patient [DP]) for individuals with severe anorexia nervosa (AN) are common. Growing literature indicates potential risks and benefits of each intensive treatment approach; however, existing research has focused on patient and carer perspectives of these treatments. Also, there is scant empirical evidence available for guiding the parameters of intensive treatments for AN. We therefore explored clinicians' perspectives and experience of supporting adults with severe AN in intensive settings.

METHODS

We conducted twenty one semi-structured interviews with clinicians who deliver intensive treatments (i.e., IP and/or DP) for individuals with severe AN across four specialist Eating Disorder Services in the United Kingdom between May 2020 and June 2021. We asked clinicians about their views and experiences of supporting individuals with severe AN in intensive treatment settings and the challenges and opportunities associated with IP and DP treatment. Data were analysed using reflexive thematic analysis supported by NVivo software.

RESULTS

Five broad and interrelated themes were identified: (1) Intensive Support; (2) The Severity of Patients' Illnesses; (3) Hope and Recovery; (4) Which Treatment When; (5) Limited Resources; and (6) Carer Burden. We identified various similarities between the two intensive treatment approaches, including the value of intensive and multidisciplinary support and carer involvement, and the challenge of managing complex and unique needs in resource-limited intensive settings. We also found differences in the relationship of treatment to patients' home environments, the necessity of patient motivation, and the management of risk.

CONCLUSIONS

Both intensive treatment settings are valued by clinicians; however, there are unique challenges and opportunities for supporting individuals with severe AN within each. Our findings suggest DP treatment may be used as an alternative to IP treatment for individuals with severe AN. However, clear questions remain over which intensive treatment setting is best suited to which patient when and should be the focus of future research.

Percepção de familiares de pessoas com transtornos alimentares acerca do tratamento: uma metassíntese da literatura

Resumo Relações familiares parecem ter uma contribuição relevante na etiopatogenia dos transtornos alimentares (TAs), o que faz com que as diretrizes internacionais de tratamento recomendem a participação da família. Esta metassíntese teve como objetivo sintetizar e reinterpretar os resultados de estudos qualitativos primários sobre a percepção de familiares de pessoas com TAs acerca do tratamento. A estratégia de busca foi organizada utilizando-se a ferramenta SPIDER e as análises foram realizadas por dois revisores independentes. A partir de 1.115 estudos originariamente recuperados de 6 bases de dados (CINAHL, LILACS, PsycINFO, PubMed, Scopus e Web of Science), foram selecionados 19 artigos. Os resultados convergem para o reconhecimento de que a família é parte do processo saúde-doença e precisa ser considerada como destinatária de cuidados, não apenas como coadjuvante/acompanhante no cuidado à pessoa acometida. Como a dinâmica familiar tem contribuição relevante no desenvolvimento e na manutenção dos TAs, é necessário investir na transformação das relações familiares para que se possam obter ganhos mais efetivos e duradouros no tratamento.

Perception of family members of people with eating disorders about treatment: a metasynthesis of the literature,

Abstract Family relationships seem to have a relevant contribution to the etiopathogenesis of eating disorders (EDs), which makes the international treatment guidelines recommend family participation. This study aimed to synthesize and reinterpret the findings of primary qualitative studies about the perception of family of people with EDs about treatment. The search strategy was organized using the SPIDER tool, and the analyzes were carried out by two independent reviewers. From 1115 studies originally retrieved from six databases (CINAHL, LILACS, PsycINFO, PubMed, Scopus and Web of Science), 19 articles were selected. The results converge to the recognition that the family is part of the process and also needs to be considered as a care recipient, not just as a coadjuvant/companion for the patient. Since family dynamics have a relevant contribution in the development and maintenance of EDs, it is necessary to invest in the transformation of family relationships so that more effective and lasting gains in treatment can be obtained.

Exploring the experience of being viewed as "not sick enough": a qualitative study of women recovered from anorexia nervosa or atypical anorexia nervosa

BACKGROUND

Despite common misconceptions, an individual may be seriously ill with a restrictive eating disorder without an outwardly recognizable physical sign of the illness. The aim of this qualitative study was to investigate the perspectives of individuals who have previously battled a restrictive eating disorder who were considered "not sick enough" by others (e.g., peers, families, healthcare professionals) at some point during their illness, and to understand the perceived impact on the illness and recovery. Such misconceptions are potentially damaging, and have been previously linked with delayed help-seeking and poorer clinical outcomes.

METHODS

Seven women who had recovered from anorexia nervosa or atypical anorexia nervosa participated in semi-structured interviews. Interviews were transcribed and interpretive phenomenological analysis was used.

RESULTS

Three main themes emerged: (1) dealing with the focus upon one's physical appearance while battling a mental illness, (2) "project perfect": feeling pressure to prove oneself, and (3) the importance of being seen and understood. Participants reported that their symptoms were occasionally met with trivialization or disbelief, leading to shame, confusion, despair, and for some, deterioration in eating disorder symptoms which drove further weight loss. In contrast, social support and being understood were viewed as essential for recovery.

CONCLUSION

To facilitate treatment seeking and engagement, and to optimize chances of recovery, greater awareness of diverse, non-stereotypical presentations of restrictive eating disorders is needed which challenge the myth that weight is the sole indicator of the presence or severity of illness.

The experiential perspectives of parents caring for a loved one with a restrictive eating disorder in the UK

Background

Parents of a loved one with an eating disorder report high levels of unmet needs. Research is needed to understand whether clinical guidance designed to improve the experience of parents has been effective.

Aims

To establish parents’ experiential perspectives of eating disorder care in the UK, compared with guidance published by Beat, a UK eating disorders charity, and Academy for Eating Disorders, the leading international eating disorders professional association.

Method

A total of six focus groups (one online and five face-to-face) were held throughout the UK. A total of 32 parents attended. All participants were parents of a loved one with a diagnosis of anorexia nervosa or atypical anorexia nervosa (mean age 22 years; mean duration of illness 4.4 years). Focus groups were transcribed, and the text was analysed with an inductive approach, to identify emerging themes.

Results

Four key themes were identified: (a) impact of eating disorder on one's life, (b) current service provisions, (c) navigating the transition process and (d) suggestions for improvement.

Conclusions

Current experiences of parents in the UK do not align with the guidelines published by Beat and Academy of Eating Disorders. Parents identified a number of changes that healthcare providers could make, including improved information and support for parents, enhanced training of professionals, consistent care across all UK service providers, policy changes and greater involvement of families in their loved one's care. Findings from this project informed the design of a national web-survey on loved ones’ experience of care in eating disorders.

Effects of diet and fitness apps on eating disorder behaviours: qualitative study

Background

Diet and fitness apps are often promoted in university and college settings and touted as a means to improve health with little attention given to unanticipated negative effects, especially among those at risk for or with eating disorders.

Aims

Few researchers have studied how these apps affect women with eating disorders in university and college settings. This research investigates the unintended negative consequences of engaging with these tools.

Method

Data collection sessions comprised three components conducted with 24 participants: survey (demographic and eating disorder symptoms), think-aloud exercise and semi-structured interview. Thematic analysis was used to analyse data.

Results

Participants reported that diet and fitness apps trigger and exacerbate symptoms by focusing heavily on quantification, promoting overuse and providing certain types of feedback. Eight themes of negative consequences emerged: fixation on numbers, rigid diet, obsession, app dependency, high sense of achievement, extreme negative emotions, motivation from ‘negative’ messages, and excess competition. Although these themes were common when users’ focus was to lose weight or eat less, they were also prevalent when users wanted to focus explicitly on eating disorder recovery.

Conclusions

Unintended negative consequences are linked to the quantified self movement, conception of appropriate usage, and visual cues and feedback. This paper critically examines diet and fitness app design and discusses implications for designers, educators and clinicians. Ultimately, this research emphasises the need for a fundamental shift in how diet and fitness apps promote health, with mental health at the forefront.

Parental experiences with their child's eating disorder treatment journey

BACKGROUND

Parents are integral in the treatment of pediatric eating disorders. The current study was conducted to further understand the barriers and facilitators that parents experience in accessing specialized, tertiary level eating disorder treatment for children and adolescents. The goals of the study were to understand the processes leading to diagnosis and treatment, perceived barriers and facilitators to accessing care, and parents' experiences over the course of their child's eating disorder treatment.

METHODS

Ten parents whose children were admitted to a Canadian tertiary level specialized pediatric eating disorders program took part in an exit interview upon their child's completion of treatment in the program. In-depth semi-structured interviews were combined with a visual timeline. Interpretive induction was performed to generate high-level concepts that emerged from the interviews.

RESULTS

Five high-level concepts were identified: (1) delays in identifying eating disorder symptoms, (2) challenges in accessing eating disorder services, (3) the right treatment at the right time, (4) emotional impact on parents, and (5) parental expertise and involvement.

CONCLUSIONS

Several barriers were identified by parents that interfered with treatment, including system-related challenges when accessing specialized eating disorder treatment, concerns about a lack of appropriate mental health support for their child, and difficulties with transitioning between community and tertiary level care. Negative emotions, including guilt and self-blame, were common early in the treatment journey. Themes of parental involvement throughout treatment, and parents taking charge of their child's recovery, emerged across interviews. The results of this study suggest the importance of early identification of eating disorder symptoms, facilitating smoother transitions between levels of care (e.g., community services and hospital-based eating disorder care), and improving clinical decision-making to ensure children and adolescents with eating disorders receive the most appropriate treatment based on their clinical presentation.

Cost-effectiveness of specialist eating disorders services for children and adolescents with anorexia nervosa: a national surveillance study

BACKGROUND

Evidence suggests specialist eating disorders services for children and adolescents with anorexia nervosa have the potential to improve outcomes and reduce costs through reduced hospital admissions. This study aimed to evaluate the cost-effectiveness of assessment and diagnosis in community-based specialist child and adolescent mental health services (CAMHS) compared to generic CAMHS for children and adolescents with anorexia nervosa.

METHOD

Observational, surveillance study of children and adolescents aged 8 to 17, in contact with community-based CAMHS in the UK or Republic of Ireland for a first episode of anorexia nervosa. Data were reported by clinicians at baseline, 6 and 12-months follow-up. Outcomes included the Children's Global Assessment Scale (CGAS) and percentage of median expected body mass for age and sex (%mBMI). Service use data included paediatric and psychiatric inpatient admissions, outpatient and day-patient attendances. A joint distribution of incremental mean costs and effects for each group was generated using bootstrapping to explore the probability that each service is the optimal choice, subject to a range of values a decision-maker might be willing to pay for outcome improvements. Uncertainty was explored using cost-effectiveness acceptability curves.

RESULTS

Two hundred ninety-eight children and adolescents met inclusion criteria. At 12-month follow-up, there were no significant differences in total costs or outcomes between specialist eating disorders services and generic CAMHS. However, adjustment for pre-specified baseline covariates resulted in observed differences favouring specialist services, due to significantly poorer clinical status of the specialist group at baseline. Cost-effectiveness analysis using CGAS suggests that the probability of assessment in a specialist service being cost-effective compared to generic CAMHS ranges from 90 to 50%, dependent on willingness to pay for improvements in outcome.

CONCLUSIONS

Assessment in a specialist eating disorders service for children and adolescents with anorexia nervosa may have a higher probability of being cost-effective than assessment in generic CAMHS.

TRIAL REGISTRATION

ISRCTN12676087 . Date of registration 07/01/2014.

Exploring alternatives for adolescent anorexia nervosa: adolescent and parent treatment (APT) as a novel intervention prospect

Recovery and remission rates of adolescent anorexia nervosa (AN) following Family Based Treatment (FBT) have seen a relative decline over recent years. While reasonably successful in achieving physical recovery (i.e. weight restoration), both empirical and anecdotal accounts highlight a lack of attention to the psychological recovery of the adolescent within manualised FBT. As such, there is a need for innovation to explore treatment variations and alternatives for the proportion of adolescents with AN who do not respond favourably to this first-line treatment. This paper introduces a new treatment framework to the field for clinical consideration and empirical assessment. Adolescent and Parent Treatment (APT) for adolescent AN draws from both family-based and individual treatment models, applying a developmental lens. APT attends to physical and psychological recovery simultaneously and from the start of treatment, with capacity to tailor individual psychological modules to the adolescent formulation. While clearly in its infancy, APT provides an exciting new avenue for exploration within the field, as we seek new avenues to support young people and their families to effectively combat this deadly illness.

The value of including families in the treatment of anorexia nervosa

The aim of this paper is to consider family and wider carer involvement in the treatment of anorexia nervosa, and how this can be used to add value to services. We discuss widely adopted interventions involving the family that have been manualised and studied in trials that have outcome measures that are of relevance to illness costs. The therapeutic targets of these interventions range from a focus on feeding to the wellbeing of the whole family. The theoretical models that underpin interventions involving the family/wider carers include both intra and interpersonal processes, with the exception of family-based therapy, which in its original form holds an agnostic stance towards aetiology. Although formal evaluation of the cost effectiveness of these interventions is minimal, there is evidence that involving the family can reduce bed use and improve the wellbeing of both patients and family members. Moreover, for the most part, these interventions are acceptable to patients and carers. Finally, we consider how these approaches can be disseminated and scaled up more widely into services.

Intensive Treatments in Adolescent Anorexia Nervosa

Approximately one-fifth to one-third of patients with adolescent anorexia nervosa (AN) need intensive care in the course of their illness. This article provides an update and discussion on different levels of intensive care (inpatient treatment (IP), day patient treatment (DP) and home treatment (HoT)) in different health care systems based on recently published literature. Important issues discussed in this article are new recommendations for the refeeding process and the definition of target weight as well as principles of medical stabilization and psychotherapeutic approaches. The pros and cons of longer or shorter hospitalization times are discussed, and the advantages of stepped care and day patient treatment are described. A new promising intensive treatment method involving the patient, their caregivers and the direct home environment is introduced. Parents and caregivers should be included in treatment research to foster collaborative work with the attending clinicians. There is an urgent need to evaluate the mid- to long-term outcomes of various intensive treatment programs to compare their effectiveness and costs across different health care systems. This could help policy makers and other stakeholders, such as public and private insurances, to enhance the quality of eating disorder care.

"I'm truly free from my eating disorder": Emerging adults' experiences of FREED, an early intervention service model and care pathway for eating disorders

BACKGROUND

Eating disorders (EDs) typically start during adolescence or emerging adulthood, periods of intense biopsychosocial development. FREED (First Episode Rapid Early Intervention for EDs) is a service model and care pathway providing rapid access to developmentally-informed care for emerging adults with EDs. FREED is associated with reduced duration of untreated eating disorder and improved clinical outcomes, but patients' experiences of treatment have yet to be assessed.

OBJECTIVE

This study aimed to assess emerging adults' experiences of receiving treatment through FREED.

METHOD

This study triangulated qualitative data on participants' experiences of FREED treatment from questionnaires and semi-structured interviews. Participants were 106 emerging adults (aged 16-25; illness duration < 3 yrs) (questionnaire only = 92; interview only = 6; both = 8). Data were analysed thematically.

RESULTS

Most participants reported psychological and behavioural changes over the course of treatment (e.g. reduction in symptoms; increased acceptance and understanding of difficulties). Participants identified five beneficial characteristics of FREED treatment: i) rapid access to treatment; ii) knowledgeable and concerned clinicians; iii) focusing on life beyond the eating disorder; iv) building a support network; v) becoming your own therapist.

CONCLUSION

This study provides further supports for the implementation of early intervention and developmentally-informed care for EDs. Future service model development should include efforts to increase early help-seeking.

"If she had broken her leg she would not have waited in agony for 9 months": Caregiver's experiences of eating disorder treatment

This study aims to explore caregivers' experiences of eating disorder services and subsequent impacts on the caregiving burden and patient outcomes. Thematic analysis was employed to investigate qualitative data from a caregiver-targeted online survey run by BEAT, the UK's largest eating disorder charity. Six hundred and 16 caregivers completed the survey. Participants' experiences of eating disorder treatment were predominantly negative, characterised by three main themes: (a) Barriers to care: enduring obstacles caregivers face in accessing support for their loved ones, (b) Experiences of services: high levels of unmet needs for caregivers and patients alike, (c) Affected domains: the pervasive impact of caregiving, influenced by experiences of services. This study is the largest of its kind to explore caregivers' experiences of eating disorder treatment services and aims to give voice to this overlooked group within research. Notably, little has been done to address broader systemic challenges faced by caregivers in accessing support for loved ones. Results indicate these challenges may play a substantial role in shaping the caregiving burden, carer coping styles, and subsequent patient outcomes. Findings denote wider systemic issues and a lack of specificities of information and practical skills that could help prevent caregivers from experiencing the caregiving burden and subsequent consequences on eating disorder patient outcomes.

Eating Disorders among College Students in France: Characteristics, Help-and Care-Seeking

The aim of this paper was to identify the characteristics of broader categories of eating disorders (ED) and help- and care-seeking among college students. An online cross-sectional study was conducted among students of the University of Rouen-Normandy, France. The Expali-validated algorithmic tool, combining SCOFF test (Sick, Control, One stone, Fat, Food) and body mass index, was used to screen eating disorders into three diagnostic categories: restrictive eating disorders, bulimic eating disorders, and hyperphagic eating disorders. A total of 1493 college students were included; mean age was 20.1 years (SD = 1.9). The prevalence of likely cases of eating disorder was 24.8% (95% CI, 22.6-27.0). Percentage distributions of bulimic eating disorders, hyperphagic eating disorders, and restrictive eating disorders were 13.3%, 8.6%, and 2.9%, respectively. The two main resources for help-seeking in emotional stress situations were friends and family, whatever the ED. Students with eating disorders consulted their general practitioner more often for stress or anxiety than students without eating disorders: hyperphagic eating disorders (44.9%), restrictive eating disorders (35.1%), bulimic eating disorders (30.2%), and no eating disorder (20.4%) (p < 0.0001). The prevalence of healthcare renunciation was 21.9%, with a higher risk among students with bulimic eating disorders (AOR CI 95% 1.91 (1.34-2.72). The findings show one quarter of students screened positive for an eating disorder. Stress management was not necessarily different between students with eating disorders and students without eating disorders, but the former had a greater risk of renouncing treatment, especially related to a fear of seeing a general practitioner.

How do you define recovery? A qualitative study of patients with eating disorders, their parents, and clinicians

OBJECTIVE

Recovery from an eating disorder (ED) may be defined differently by different stakeholders. We set out to understand the definition of ED recovery from the perspective of patients, their parents, and clinicians.

METHOD

We recruited patients with EDs (n = 24, ages 12-23 years) representing different diagnoses (anorexia nervosa n = 17, bulimia nervosa n = 4, binge-ED n = 2, avoidant/restrictive food intake disorder n = 1), along with their parents (n = 20), dietitians (n = 11), therapists (n = 14), and primary care providers (n = 9) from three sites: Boston Children's Hospital, University of Michigan C. S. Mott Children's Hospital, and Penn State Hershey Children's Hospital. In-depth, semi-structured, qualitative interviews explored participants' definitions of recovery. Interviews were analyzed using inductive data-driven thematic analysis. Statistical analyses followed to examine the distribution within each theme by respondent type.

RESULTS

Qualitative analysis resulted in the emergence of four overarching themes of ED recovery: (a) psychological well-being, (b) eating-related behaviors/attitudes, (c) physical markers, and (d) self-acceptance of body image. Endorsement of themes two and four did not significantly differ between patients, parents, and clinicians. Clinicians were significantly more likely to endorse theme one (χ² = 9.90, df = 2, p = .007, φ_c = 0.356) and theme three (χ² = 6.42, df = 2, p = .04, φ_c = 0.287) than patients and parents.

DISCUSSION

Our study demonstrates overwhelming support for psychological markers as indicators of ED recovery by all three groups. Clinicians should remain open to additional markers of recovery such as body acceptance and eating-related behaviors/emotions that may be of critical importance to patients and their caregivers.

Personal recovery of young adults with severe anorexia nervosa during adolescence: a case series

PURPOSE

Despite the emergence of a growing qualitative literature about the personal recovery process in mental disorders, this topic remains little understood in anorexia nervosa (AN), especially severe AN during adolescence. This cases series is a first step that aims to understand recovery after severe AN among adolescents in France, from a first-person perspective.

METHODS

This cases series applied the interpretative phenomenological analysis (IPA) method to data collected in semi-structured face-to-face interviews about the recovery process of five young women who had been hospitalized with severe AN 10 years earlier during adolescence.

RESULTS

A model of recovery in four stages (corseted, vulnerable, plastic, and playful) crossing seven dimensions (struggle and path of initiation; work on oneself; self-determination and help; body; family; connectedness; and timeline) emerged from the analysis. New features of the AN personal recovery process were characterized: bodily well-being and pleasure of body; stigmatization; the role of the group; relation to time; and importance of narratives. We suggest a new shape to model the AN recovery process, one that suggests several tipping points. Recruitment must now be widened to different AN contexts.

CONCLUSIONS

The personal recovery paradigm may provide a new approach to care, complementary to medical paradigm.

REGISTRATION OF CLINICAL TRIAL

No. NCT03712384. Our study was purely observational, without assignment of medical intervention. As a consequence, this clinical trial was registered retrospectively.

LEVEL OF EVIDENCE

Level V, descriptive study.

First episode rapid early intervention for eating disorders: A two-year follow-up

AIM

We describe 2-year outcomes of a novel first episode early intervention service for young adults with a recent onset eating disorder (FREED). Outcomes in FREED patients with anorexia nervosa (AN) were compared with those from patients previously seen in our service [treatment as usual (TAU) cohort], matched for age, illness duration and diagnosis.

METHODS

Electronic case records of FREED-AN (n = 22) and TAU-AN patients (n = 35) were examined to identify service utilisation and clinical outcomes over 24 months.

RESULTS

Outpatient service utilisation was similar in both groups, but FREED-AN patients needed intensive (in- or day-patient) treatment less frequently than TAU-AN (23% vs 32%). FREED-AN patients had a higher estimated mean body mass index [19.2 kg/m² ; 95% CI (18.21, 20.16)] than TAU patients [18.0 kg/m² ; 95% CI (16.90, 19.15)] at last contact.

CONCLUSION

Introduction of FREED led to a more complete recovery in patients with AN at 24 months.

Eating Disorders During Emerging Adulthood: A Systematic Scoping Review

Background: Eating disorders (EDs) during the transition to adulthood can derail social, psychological, and vocational development. Effective treatment is of paramount importance, yet young adults' treatment needs are typically less well met than those of adolescents. In recent years, there has been a considerable shift in how developmental psychologists understand the transition to adulthood, with this life-phase reconceptualized as “emerging adulthood” (EA) (~18–25 years). Engagement with burgeoning developmental research is likely key to providing more effective care for young people experiencing EDs.

Aims: To review ED research which has utilized the concept of EA, and to assess the usefulness of this concept for ED research and practice.

Methods: A systematic scoping review was conducted in accordance with the Joanna Briggs Institute guidelines for scoping reviews. Three databases (Psychinfo, PubMed, Embase) were searched for papers which explicitly focused on EDs during EA. No restrictions as to publication type, language, study design, or participants were applied. Included studies were assessed for developmental “informedness,” and findings were qualitatively synthesized.

Results: Thirty-six studies (N = 25,475) were included in the review. Most studies used quantitative methodologies, were cross-sectional in design and focused on identifying psychological and social factors which contribute to etiology of EDs. Many studies (N = 22) used well-defined samples of emerging adults (EAs); few studies (N = 8) included developmental measures relevant to EAs. Findings indicate that whilst factors implicated in EDs in adolescence and adulthood are relevant to EAs, EA-specific factors (e.g., identity exploration) may also contribute. Conventional ED services and treatments present difficulties for EAs, whilst those adapted to EAs' needs are feasible, acceptable, and more effective than treatment-as-usual. Directions for future research and clinical implications are discussed.

Conclusion: Existing research indicates that the EA concept is relevant for understanding EDs during the transition to adulthood, and ED services should implement adaptations which exploit the opportunities and overcome the challenges of this developmental stage. EA is currently an underused concept in ED research, and future engagement with the developmental literature by both researchers and clinicians may be key to understanding and treating EDs during transition to adulthood.

Alternative community-based models of care for young people with anorexia nervosa: the CostED national surveillance study

Background

Evidence suggests that investing in specialist eating disorders services for young people with anorexia nervosa could have important implications for the NHS, with the potential to improve health outcomes and reduce costs through reductions in the number and length of hospital admissions.

Objectives

The primary objectives were to evaluate the costs and cost-effectiveness of alternative community-based models of service provision for young people with anorexia nervosa and to model the impact of potential changes to the provision of specialist services.

Design

Observational surveillance study using the Child and Adolescent Psychiatry Surveillance System.

Setting

Community-based secondary or tertiary child and adolescent mental health services (CAMHS) in the UK and the Republic of Ireland.

Participants

A total of 298 young people aged 8–17 years in contact with CAMHS for a first episode of anorexia nervosa in accordance with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnostic criteria.

Interventions

Community-based specialist eating disorders services and generic CAMHS.

Main outcome measures

Children’s Global Assessment Scale (CGAS) score (primary outcome) and percentage of median expected body mass index (BMI) for age and sex (%mBMI) (secondary outcome) were assessed at baseline and at 6 and 12 months.

Data sources

Data were collected by clinicians from clinical records.

Results

Total costs incurred by young people initially assessed in specialist eating disorders services were not significantly different from those incurred by young people initially assessed in generic CAMHS. However, adjustment for baseline covariates resulted in observed differences favouring specialist services (costs were lower, on average) because of the significantly poorer clinical status of the specialist group at baseline. At the 6-month follow-up, mean %mBMI was significantly higher in the specialist group, but no other significant differences in outcomes were evident. Cost-effectiveness analyses suggest that initial assessment in a specialist service has a higher probability of being cost-effective than initial assessment in generic CAMHS, as determined by CGAS score and %mBMI. However, no firm conclusion can be drawn without knowledge of society’s willingness to pay for improvements in these outcomes. Decision modelling did not support the hypothesis that changes to the provision of specialist services would generate savings for the NHS, with results suggesting that cost per 10-point improvement in CGAS score (improvement from one CGAS category to the next) varies little as the percentage of participants taking the specialist or generic pathway is varied.

Limitations

Follow-up rates were lower than expected, but the sample was still larger than has been achieved to date in RCTs carried out in this population in the UK, and an exploration of the impact of missing cost and outcome data produced very similar results to those of the main analyses.

Conclusions

The results of this study suggest that initial assessment in a specialist eating disorders service for young people with anorexia nervosa may have a higher probability of being cost-effective than initial assessment in generic CAMHS, although the associated uncertainty makes it hard to draw firm conclusions. Although costs and outcomes were similar, young people in specialist services were more severely ill at baseline, suggesting that specialist services were achieving larger clinical effectiveness gains without the need for additional expenditure. The results did not suggest that providing more specialist services would save money for the NHS, given similar costs and outcomes, so decisions about which service type to fund could be made with reference to other factors, such as the preferences of patients and carers.

Future work

Data on measures of quality of life capable of generating quality-adjusted life-years are needed to confirm the cost-effectiveness of specialist services.

Trial registration

Current Controlled Trials ISRCTN12676087.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 37. See the NIHR Journals Library website for further project information.