Clinical effectiveness of treatments for anorexia nervosa in adolescents: randomised controlled trial

Exploring biologically oriented precision mental health initiatives for the care of patients with eating disorders: A narrative review

OBJECTIVE

Eating disorders (EDs) represent a major public health burden. Increasingly, studies suggest mental health (MH) fields are failing to improve the effectiveness of treatments and that alternative models of care must be considered. Precision mental health (PMH) seeks to tailor treatment to individual needs and relies on a comprehensive understanding of the neurobiological and physiological underpinnings of mental illness.

METHODS

In this narrative review, published literature with focus on biological application of PMH strategies for EDs is reviewed and summarised.

RESULTS

A total of 39 articles were retained for the review covering a variety of themes with relevance to PMH. Many studies of biological markers with PMH applicability focused on anorexia nervosa. Although a variety of potential PMH research applications were identified, the review failed to identify any evidence of implementation into routine ED practice.

CONCLUSIONS

Despite the theoretical merit of biological application of PMH in ED treatment, clinical applications for standard practice are lacking. There is a need to invest further in studies that seek to identify biological markers and investigate neurobiological underpinnings of disease in hopes of targeting and developing treatments that can be better tailored to the individualised needs of patients.

Psychotropic medication prescribed for children and young people with eating disorders in mental health in-patient services: a quality improvement programme

The aims of this quality improvement programme were to enable providers of mental health in-patient services for children and young people in England to review their prescribing practice alongside the views and experiences of children, young people and their parent carers. Three online tools were developed. First was a medication census tool to be completed by provider clinicians to capture prescribing practices around psychotropic medication. The two other online tools were questionnaires that provided an opportunity for inpatient children and young people and their parent carers to express their views of the medication. 193 children and young people had a primary diagnosis of eating disorders. Antidepressants were the most widely prescribed (56%), followed by antipsychotics (41%), benzodiazepines, and antihistamines as sedatives (18%) and hypnotics (11%). Of those receiving regular psychotropic medications, 67% were prescribed two or more. Both the children and young people and their parent carers expressed concerns about the high level of psychotropic medication, the number of prn administrations, the number of psychotropic medications prescribed and the extent of side effects. Psychotropic medications are widely prescribed both on a regular and on a prn basis for children and young people with eating disorders in mental health in-patient services.

Differences in treatment trajectory following brief paediatric inpatient admissions for children and young people with eating disorders

OBJECTIVE

Little is known about factors associated with treatment trajectory following brief paediatric admissions for children and young people (CYP) admitted for medical complications of their eating disorder (ED). This project aimed to identify possible factors and ways to improve the usefulness of paediatric admissions.

METHOD

Retrospective NHS data was analysed to explore differences between paediatric admissions followed by community-based care or inpatient psychiatric care. Twelve parents were interviewed to seek feedback about paediatric admissions.

RESULTS

Patients who received subsequent inpatient psychiatric care were unwell for longer, had longer paediatric admissions and more crisis team input, were more likely to have had previous admissions, and had higher parent-reported anxiety and depression. However, the groups did not significantly differ in ED severity. The interviews identified recommendations for improving paediatric admissions, which included improving understanding of EDs, enhancing communication channels, and providing psychological support to parents.

CONCLUSIONS

Factors linked with illness severity (but not illness severity itself) appear to be associated with the difference between CYP either returning to community-based care or requiring more intensive psychiatric input. These factors may help clinicians understand who requires subsequent inpatient care, allowing clinicians to target more intensive support earlier and facilitate smoother transitions between services.

Inpatient Treatment Outcome in a Large Sample of Adolescents with Anorexia Nervosa

Anorexia nervosa is an illness affecting primarily adolescent girls and young women. Clinical guidelines recommend early intervention, with inpatient treatment for more severe cases. We present an evaluation of a multi-modal cognitive-behavioral inpatient treatment (CBT-E) involving carers in specialized units for adolescents. Routine data of 962 adolescent inpatients (26 boys) (mean age 15.48 [1.26]; range 12-17 years) were analyzed. Predictors of good body weight outcome (achieving a discharge BMI of at least 18.5 kg/m2) were identified by logistic regression analysis. Mean inpatient treatment lasted 96.69 (45.96) days. The BMI increased significantly from 14.93 (1.38) kg/m2 at admission to 17.53 (1.58) kg/m2 at discharge (z = 26.41; p < 0.001; d = 1.708). Drive for thinness decreased from 29.08 (9.87) to 22.63 (9.77; z = 18.41; p < 0.001; d = 0.787). All other subscores of the Eating Disorder Inventory also decreased significantly, with small to medium effect sizes. General psychopathology also showed significant decreases. The Beck Depression Inventory-II score decreased from 26.06 (11.74) to 16.35 (12.51; z = 18.41; p < 0.001; d = 0.883). A good body weight outcome was predicted by a higher BMI at admission (OR = 1.828), age at onset at 15 years or higher (OR = 1.722), and higher Somatization (OR = 1.436), Anxiety (OR = 1.320), and Bulimia (OR = 1.029) scores. CBT-E involving carers is an efficient intervention for adolescents with anorexia nervosa.

Advancing the Assessment and Treatment of Comorbid Pediatric Chronic Functional Abdominal Pain (CFAP) and Restrictive Eating Disorders

The aim of this review is to heighten awareness of the association between chronic functional abdominal pain (CFAP) and restrictive eating disorders (ED) in adolescents. We describe current diagnostic practices and propose future research efforts to improve the assessment and treatment of comorbid CFAP and restrictive EDs. A narrative review of the literature on CFAP and EDs was performed using PubMed, JSTOR, ScienceDirect, and PsycINFO and the following search terms: 'restrictive eating disorders', 'chronic functional abdominal pain', 'chronic pain' 'treatment' 'diagnosis' and 'adolescents'. Published studies on restrictive EDs and CFAP from May 2008 to March 2023 were included. Ascribable to the overlap in etiology and symptom presentation, adolescents with chronic pain are significantly less likely to have their ED pathology promptly identified by providers compared to adolescents without comorbid chronic pain. This highlights the importance of the time sensitive and accurate identification of EDs in adolescents with CFAP. Overall, assessment methods are limited and EDs take longer to be identified in adolescents with comorbid CFAP. Future efforts should address diagnostic practices in pediatric settings and improve the communication among medical and mental health providers in order to promote the rapid and effective diagnosis and treatment of comorbid CFAP and EDs.

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.

Caring for a child with an eating disorder: Understanding differences among mothers and fathers of adolescent and adult children

OBJECTIVE

This study investigated treatment-engagement fears, self-efficacy, and accommodating and enabling in mothers and fathers of adolescent and adult children with eating disorders.

METHODS

This study involved a secondary analysis of pre-treatment data from a subsample of 143 parents (95 mothers; 48 fathers) from a Canada-wide multi-site study. Parents completed the Caregiver Traps Scale, Parents Versus Anorexia Scale, and the Accommodation and Enabling Scale for Eating Disorders. Data were analysed using factorial Multivariate Analysis of Variance and mediation via multiple regression.

RESULTS

Mothers reported higher levels of treatment-engagement fears than fathers. Among mothers, higher fear predicted lower self-efficacy and more accommodating and enabling behaviours. Among fathers, neither fear nor self-efficacy predicted accommodating and enabling. No differences in treatment-engagement fear or self-efficacy between parents of adolescent child and adult children were found at pre-treatment.

CONCLUSIONS

Mothers' and fathers' experience different levels of fear related to their involvement in their ill-child's treatment at pre-treatment, and that fear is uniquely related to variables that impact treatment outcomes. There is a need to support parents even when their child is an adult. This study can inform family-based treatments vis-a-vis tailoring interventions for mothers and fathers and providing support to parents of children with eating disorders across the lifespan.

Comparing randomized controlled trials of outpatient family-based or inpatient multimodal treatment followed by outpatient care in youth with anorexia nervosa: Differences in populations, metrics, and outcomes

OBJECTIVE

Various approaches exist to treat youth with anorexia nervosa (AN). Family-based treatment (FBT) has never been compared to long inpatient, multimodal treatment (IMT) in a randomized controlled trial (RCT). The aim of this study was to compare data on body weight trajectories, change in eating disorder psychopathology, hospital days and treatment costs in RCTs delivering FBT or IMT.

METHOD

Review of RCTs published between 2010 and 2020 in youth with AN, delivering FBT or IMT.

RESULTS

Four RCTs delivering FBT (United States, n = 2; Australia, n = 2), one RCT delivering Family Therapy for AN (United Kingdom) and two RCTs delivering IMT (France, n = 1; Germany, n = 1) were identified from previous meta-analyses. The comparison of studies was limited by (1) significant differences in patient baseline characteristics including pretreated versus non-pretreated patients, (2) use of different psychometric and weight measures and (3) different initial velocity of weight recovery. Minimal baseline and outcome reporting standards for body weight metrics and nature/dose of interventions allowing international comparison are needed and suggestions to developing these standards are presented.

DISCUSSION

An RCT should investigate, whether FBT is a viable alternative to IMT, leading to comparable weight and psychopathology improvement with less inpatient time and costs.

Implementing service transformation for children and adolescents with eating disorders across England: the theory, politics, and pragmatics of large-scale service reform

BACKGROUND

Eating disorders are among the most serious mental health problems affecting children and young people and without appropriate treatment often have a protracted course with high levels of morbidity and mortality. While considerable progress has been made in recent years in developing effective evidence-based outpatient treatments, these are not always readily available. In England, until recently, the usual care pathway for young people with an eating disorder was referral from primary care to local generic Child and Adolescent Mental Health Services with varying levels of expertise in eating disorders and a mix of outpatient treatments available. Poor treatment progress or physical deterioration would usually result in inpatient admission. Admission rates were high, with children and young people with an eating disorder accounting for nearly a quarter of all child and adolescent psychiatric hospital admissions. Inpatient treatment is costly and has high relapse rates with some evidence that it may contribute to poorer long-term outcomes in eating disorders. Accumulating clinical and research evidence that early expert outpatient treatment can significantly reduce the need for inpatient care indicates,+ that investing in dedicated community-based eating disorders services is likely to be both clinically and economically beneficial.

OVERVIEW OF PAPER

This paper describes a large-scale transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community-based eating disorders services for children and young people.

Weight gain and parental self-efficacy in a family-based partial hospitalization program

BACKGROUND

Family-based treatment (FBT) is an outpatient therapy, though FBT principles have been incorporated in higher levels of care (e.g., partial hospitalization programs, PHPs). It is unknown how participation in a family-based PHP impacts weight restoration and parental self-efficacy.

METHODS

Weight gain and parental self-efficacy were examined in 98 participants with anorexia nervosa or atypical anorexia nervosa during the first five weeks of participation in a family-based PHP. Maternal self-efficacy was assessed using the Parent versus Anorexia Scale.

RESULTS

Significant increases in weight, percent expected body weight (EBW), and maternal self-efficacy were observed, with large effect sizes. During the first five weeks of treatment, patients in the PHP gained an average of 4.5 kg, or 8.3% EBW. Maternal self-efficacy improved within two weeks of treatment.

CONCLUSIONS

Findings suggest that family-based PHPs may facilitate rapid weight restoration without decreasing parental self-efficacy. Randomized trials are needed to directly compare family-based PHPs to outpatient FBT and PHPs with alternate treatment approaches, including longer-term follow-up and cost-effectiveness modeling.

From efficacy to effectiveness: child and adolescent eating disorder treatments in the real world (Part 2): 7-year follow-up

BACKGROUND

Eating disorders are often characterised as disabling, chronic or relapsing conditions with high mortality rates. This study reports follow-up outcomes for patients seen at the Maudsley Centre for Child and Adolescent Eating Disorders (MCCAED), whose end of treatment outcomes are reported in a separate paper.

METHODS

Three-hundred-and-fifty-seven former patients, who received evidence-based treatment for an eating disorder as a child or adolescent in MCCAED between 2009 and 2014 were eligible to participate. Current contact information was available for 290, of whom 149 (51.4%) consented to follow-up. Participants were sent links to online questionnaires, with additional demographic information extracted from medical records. Descriptive analyses of key socioeconomic and health outcomes were performed on data collected.

RESULTS

Mean length of follow-up was 6 years 11 months. Ten (6.7%) participants reported a current diagnosis of an eating disorder at follow-up. The great majority reported no (63.8%) or minimal (26.8%) interference from eating disorder difficulties. More than half (53.6%) reported other mental health diagnoses with most reporting no (33.8%) or minimal (50.7%) interference from those difficulties. One third (33.3%) had sought help for an eating disorder and around 20% received prolonged/intensive treatment during the follow-up period. Approximately 70% had sought treatment for other mental health difficulties (mostly anxiety or depression) and 35.4% had substantial treatment. At follow-up more than half (55.5%) reported doing generally well, and around two-thirds reported general satisfaction with their social well-being (65%). The majority (62.7%) had a good outcome on the Morgan Russell criteria, which was consistent with low self-reported ratings on EDE-Q, and low impact of eating disorder or mental health symptoms on work and social engagement. Most of the former patients who had day and/or inpatient treatment as a part of their comprehensive integrated care at MCCAED did well at follow-up.

CONCLUSIONS

Young people seen in specialist eating disorder services do relatively well after discharge at longer-term follow-up especially regarding eating disorders but less favourably regarding other mental health difficulties. Few reported a diagnosable eating disorder, and the great majority went on to perform similarly to their peers in educational and vocational achievements.

[Diversity of hospital care for anorexia nervosa in psychiatry in France]

BACKGROUND

Hospitalization is rare in anorexia nervosa (AN) and local application of indications is heterogeneous. However, no study has evaluated the effect of these different treatment modalities on the mean length of stay. Our objective was to describe the context and modalities of a wide range of hospital care programs offered to patients with anorexia nervosa in eleven specialized French psychiatric centers for patients from childhood to adulthood. This work was carried out within the framework of the EVHAN (Evaluation of Hospitalization for AN, Eudract number: 2007-A01110-53, registered in Clinical trials) research program. The EVHAN program comprises five main lines: weight objectives at discharge, the practice or not of a separation period, the use of clear nutritional dietary objectives (cognitive/behavioral), the intensity of family involvement in treatment, and the existence or absence of a stabilization phase before ending inpatient treatment. These main lines will make it possible to study the impact of treatment modalities on the future of patients in the short and medium term (at discharge and at 1-year follow-up).

METHODS

The eleven centers are located in France (Bordeaux, Nantes, Paris and Ile-de-France, Rouen and Saint-Étienne). Various staff members (psychiatrists, somatic doctors, nurses, dieticians, psychologists) from each center were interviewed using a semi-structured questionnaire. Data on operating modalities and context of care were collected and analyzed.

RESULTS

Four of the eleven centers were exclusively child/adolescent centers, and seven of 11 were adolescent (from 11, 13 or 16 years) and young adult centers. All centers offered a graduated approach from outpatient to full hospitalization. The majority had a number of beds allocated for patients with eating disorders. The criteria for hospitalization were homogeneous with respect to somatic and/or psychic severity prefiguring the consensus criteria defined by the French Health Authority (HAS) in 2010. Child/adolescent units used the weight curve to set weight objectives at discharge (between the 10th and 50th percentiles). Most adult units used weight objectives at discharge corresponding to a body mass index between 17 and 20kg/m². Nine centers used a written or oral care contract. One unit did not separate the patient from her/his usual environment, the others had a practice gradient of partial separation and total separation times. These were either short, lasting a maximum of 3 weeks, or long, lasting more than 3 weeks. Conversely, patients were not isolated within the unit, and benefited from a rich social life, depending on her/his physical condition. The patient's family was in contact with the team and fully supported. The longest periods of separation involved adolescents and adults. Nutritional support varied from a group approach (meals in the dining room, standardized meals of the care center) to very individualized approaches within a specific framework. All the units reported meeting with families at least once during the hospitalization; with the patient's parents for child/adolescent patients and/or unmarried patients and with the husband/wife for married patients. The majority of the centers requested a phase of weight stabilization, whatever the age before hospital discharge.

CONCLUSION

There is international and national consensus regarding the indications for hospitalization, and the main lines of multidisciplinary care to be developed within this framework. However, local application of these indications was heterogeneous resulting in diverse modalities of hospital care for anorexia nervosa in France. Specialized teams have developed management strategies arising from their "team culture". The complexity of the anorexic pathology, due to the psyche-soma intrication and the diversity of age groups, highlights the complexity of care available. The impact of this diversity of hospital care on patient outcomes will be studied as a result of this work.

A systematic review of cognitive behavior therapy and dialectical behavior therapy for adolescent eating disorders

BACKGROUND

Eating disorders have serious psychological and physical consequences. Current evidence-based treatments for adolescents with eating disorders have modest effects, underscoring the need to improve current treatment approaches. Cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) have been proposed as alternative treatment options, with burgeoning research in this area. This review aims to summarize and critically analyze the current literature on the feasibility, acceptability, effectiveness, and efficacy of CBT and DBT for adolescent eating disorders, and then proposes areas of future research.

METHODS

PsycINFO and PubMed were searched using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify studies examining the feasibility, acceptability, effectiveness and/or efficacy of CBT or DBT for adolescent eating disorders.

RESULTS

Eligible studies (N = 50; CBT: n = 40, DBT: n = 10) indicated that both treatments are reasonably feasible, acceptable, and possibly effective for adolescent eating disorders across diagnoses and levels of care, though efficacy trials are lacking.

CONCLUSIONS

CBT and DBT demonstrate promise as alternatives to family-based approaches for adolescent eating disorders. Adequately powered trials to establish the effectiveness and efficacy of CBT and DBT are needed, particularly ones that compare these treatments against other leading approaches. Despite high rates of relapse and likelihood for severe and enduring illness, there is a dearth of evidence-based treatment options for adolescents with eating disorders. Potentially viable but less well-studied treatments for adolescents with eating disorders include cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT). This systematic review of CBT and DBT for adolescent eating disorders focuses on feasibility (i.e., how easy it was to implement the treatment), acceptability (i.e., how well the intervention was received by patients and therapists), effectiveness (i.e., how well the intervention performed under routine, real-world circumstances), and efficacy (i.e., how well the intervention performed in highly-controlled research settings). This review concludes that research supports the feasibility and acceptability of these approaches, as well as preliminary evidence of their effectiveness. However, the field is lacking studies that systematically compare CBT and DBT to other evidence-based approaches. Recommendations to advance research on CBT and DBT for adolescent eating disorders are provided, including a call for efficacy studies that clarify their performance compared to other leading approaches.

Rescripting-A grounded theory study of the contribution that fathers make to Family-Based Treatment when a young person has anorexia nervosa

AIM

To present a grounded theory of the contribution that fathers make to family-based treatment when a young person has anorexia nervosa.

BACKGROUND

Research indicates a potential to improve outcomes by involving both parents in the treatment of anorexia nervosa. However, fathers are underrepresented both within treatment and research. Family-based treatment requiring the involvement of both parents presents an opportunity to better understand the role of the father in treatment.

DESIGN

Classic grounded theory.

METHODS

Individual interviews conducted with fifteen fathers involved in family-based treatment. The COREQ checklist was followed.

RESULTS

Fathers valued being involved in family-based treatment and felt they had an important contribution to make. The analysis captures the overall contribution that fathers make and the impact of their involvement. Four categories; Being on the Outside, Finding a Way In, Finding a Way to Be and Finding a Way to Let Go and one core category Repositioning were generated from the data. A substantive theory of Rescripting, generated from categories and the core category, describes the way that participating in family-based treatment changes fathers and their role.

CONCLUSIONS

Fathers make an important and significant contribution to family-based treatment when a young person has anorexia nervosa. The findings inform clinicians about the importance of including fathers in the treatment of young people with anorexia nervosa. They highlight the importance of incorporating support mechanisms into family-based treatment to harness and maximise the paternal contribution.

RELEVANCE TO CLINICAL PRACTICE

Paternal contribution to family-based treatment can be maximised to improve outcomes for young people with anorexia nervosa.

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.

Can you find the right support for children, adolescents and young adults with anorexia nervosa: Access to age-appropriate care systems in various healthcare systems

OBJECTIVE

Anorexia nervosa (AN) often has its onset in childhood or adolescence. However, there is insufficient knowledge regarding access to and utilisation of age-specific clinical diagnostics and treatment.

METHODS

A literature review covering the last 10 years was conducted to provide a narrative review of the current state of research on the detection and treatment of young patients with AN in primary and secondary care.

RESULTS

Most articles were of Western European or US origin. Timely diagnosis of the eating disorder (ED) and treatment options more often depend on the structure and quality of the national health care system than on scientific evidence. Regular paediatric health check-ups and age-appropriate eating disorder services appear to facilitate early diagnosis. Age-specific treatment that also involves the carers is often associated with a higher continuity of care and a better outcome. Although many adolescents require an extension of treatment into young adulthood, individual and health care system-related obstacles in many countries prevent a smooth transition.

CONCLUSION

To improve outcomes in childhood and adolescent AN, age-specific and timely diagnostic and therapeutic procedures are urgently needed.

Post-hospitalization Daycare Treatment for Adolescents With Eating Disorders

Background: There are several possible facilities for the treatment of eating disorders (EDs). Specifically, there is the issue of the use of specialized daycare and ambulatory services over inpatient settings and the place of daycare programs following inpatient treatment. Aim: We sought to examine the contribution of post-hospitalization daycare program to the treatment of adolescents hospitalized with an ED. Methods: We assessed 61 female adolescents hospitalized with an ED. All but three were diagnosed with clinical or subthreshold anorexia nervosa (AN). Three were diagnosed with bulimia nervosa. Thirty-seven patients continued with a post-hospitalization daycare program for at least 5 months, whereas 24 did not enter or were enrolled in the program for <5 months. Patients completed on admission to, and discharge from, inpatient treatment self-rating questionnaires assessing ED-related symptoms, body-related attitudes and behaviors, and depression and anxiety. Social functioning was assessed 1 year from discharge using open-ended questions. One-year ED outcome was evaluated according to the patients' body mass index (BMI) and according to composite remission criteria, assessed with a standardized semistructured interview. To be remitted from an ED, patients were required to maintain a stable weight, to have regular menstrual cycles, and not to engage in binging, purging, and restricting behaviors for at least eight consecutive weeks before their assessment. Results: BMI was within normal range at follow-up, whether completing or not completing daycare treatment, and around 75% of the patients had menstrual cycles. By contrast, when using comprehensive composite remission criteria, less than a quarter of former inpatients not entering/not completing daycare program achieved remission vs. almost a half of the completers. In addition, a greater percentage of completers continued with psychotherapy following discharge. Fifty percent of both groups showed good post-discharge social functioning. No between-group differences were found in the BMI and the scores of the self-rating questionnaires at admission to, and discharge from, inpatient treatment. Conclusion: Adolescent females with EDs can maintain a normal-range BMI from discharge to 1-year follow-up, even if not completing daycare treatment. By contrast, completion of a post-hospitalization daycare program may improve the 1-year follow-up ED-related outcome of former ED inpatients.

Implementing family based treatment in a child and youth eating disorder program: impact on admissions

OBJECTIVES

Anorexia Nervosa (AN) treatment is frequently associated with high costs often due to the use of hospitalization. In Family Based Treatment (FBT) a main goal is to manage recovery of AN in the home environment rather than relying on lengthy hospital admissions. This study examined whether the use of hospitalization altered following the introduction of FBT to a youth eating disorders program in 2009.

METHOD

This study compared retrospective data of 71 female adolescent patients diagnosed with AN: 10 who received treatment as usual prior to the implementation of FBT; 10 who were treated immediately after FBT implementation; and a further 51 adolescents who received FBT since 2009.

RESULTS

Results indicate that since the implementation of FBT there was a significant reduction in admissions to the medical ward and a significant reduction in cumulative length of stay on both the psychiatric and medical wards in adolescents presenting with AN.

Self-determination theory in acute child and adolescent mental health inpatient care. A qualitative exploratory study

Introduction

There is a dearth of research to guide acute adolescent mental health inpatient care. Self-determination Theory provides evidence that meeting needs for relatedness, autonomy and competence is likely to increase wellbeing and intrinsic motivation. These needs may be able to be met in the inpatient environment.

Method

This qualitative study aimed to explore young people’s experience of acute mental health inpatient care with particular attention to meeting of these three needs. Fifteen young people were interviewed. The importance of relatedness with staff, other young people and families was identified.

Results

Relatedness with staff and peers were valued parts of admission. Some young people describe enhanced relatedness with family. They described loss of autonomy as a negative experience but appreciated opportunities to be involved in choices around their care and having more freedom. Coming into hospital was associated with loss of competence but they described building competence during the admission. Engaging in activities was experienced positively and appeared to enhance meeting of all three needs. Meeting of the three needs was associated with an experience of increased safety.

Conclusions

Engaging young people in activities with a focus on relatedness, autonomy and competence may have specific therapeutic potential. Autonomy, experience of competence and connection with staff may enhance safety more effectively than physical containment. Peer contact may have untapped therapeutic value we understand little of. This study supports the value of Self-determination Theory as a guide day to day inpatient care to meet the needs of adolescents for relatedness, autonomy and competence.

'Therapists in action'-Home treatment in adolescent anorexia nervosa: A stepped care approach to shorten inpatient treatment

OBJECTIVE

It was the aim of this pilot study to apply a novel eating disorder (ED)-specific home treatment (HoT) to adolescents with anorexia nervosa (AN) and to investigate its feasibility, effects and safety.

METHOD

Twenty-two patients consecutively admitted to the hospital and fulfilling DSM-5 criteria for typical or atypical AN received HoT after 4-8 weeks of inpatient treatment. During the first two months of HoT, the patient and her family were visited on average three to four times per week, during the third and fourth months of HoT once or twice a week by a multi-professional team. Body mass index, ED and general psychopathology, quality of life and treatment satisfaction were assessed in the patients at admission, start and end of HoT and the 1-year follow-up as well as carers' skills and burden.

RESULTS

The majority of patients successfully achieved target weight within HoT and maintained it successfully at the 1-year follow-up. ED and general psychopathology in the patients and carers' skills improved significantly associated with a high treatment satisfaction.

CONCLUSIONS

HoT seems to be a promising new tool to improve outcome in adolescent AN and to reduce time of hospitalisation. Larger randomised controlled trials are needed to generalise these results.

Anorexia nervosa in adolescents

Anorexia nervosa is an eating disorder with peak onset in adolescence, which carries the highest mortality rate of all psychiatric illnesses. It is commonly comorbid with other physical and mental health problems, yet training on management of people with eating disorders and working knowledge of clinicians working with underweight adolescents is inconsistent. This review of anorexia nervosa in adolescents provides an overview of the presentation, aetiology and treatment of this disorder, with a particular focus on the assessment and management of physical health risks, including refeeding syndrome.

Pragmatic Sensory Screening in Anorexia Nervosa and Associations with Autistic Traits

BACKGROUND

Research suggests that people with anorexia nervosa (AN) experience subjective hypersensitivity to external sensations that may require consideration in treatment. These difficulties may be particularly pronounced in people with AN and high autistic traits. The purpose of this pilot study was to explore the use of a brief screening tool to assess sensory sensitivity in individuals receiving treatment for AN, and to assess if self-rated sensitivity in AN is related to autistic traits.

METHODS

47 individuals receiving treatment for AN completed a brief sensory screening tool and self-rated their autistic traits. Individuals were also asked to give qualitative feedback on the screening tool.

RESULTS

People with AN and high autistic traits rated themselves as more hypersensitive compared to people with AN and low autistic traits. Feedback surrounding the use of the screener was positive.

CONCLUSIONS

The results of this study suggest that the use of this screener may be beneficial in eating disorder settings to help adjust and calibrate treatment to personal needs, although further research and psychometric evaluation around the clinical use of the screener is required. The finding that people with AN and high autistic traits may experience elevated hypersensitivity also warrants further exploration in future research.

Exploring Differences in the Role of Hospitalization on Weight Gain Based on Treatment Type From Randomized Clinical Trials for Adolescent Anorexia Nervosa

Background: This study explores the impact of weight gain during medical stabilization hospitalization on weight outcomes between three outpatient treatments for adolescent anorexia nervosa (AN): Adolescent Focused Therapy (AFT), Systemic Family Therapy (SyFT), and Family Based Treatment (FBT). Methods: A secondary analysis of weight gain data (N = 215) of adolescents (12-18 years) meeting DSM-IV criteria for AN (exclusive of amenorrhea criteria) who participated in two randomized clinical trials (RCTs) was conducted. Main outcomes examined were changes in weight restoration (≥95% expected body weight or EBW) and differences in weight change attributable to hospital weight gain. Results: Weight gain resulting from hospitalizations did not substantially change weight recovery rates. Hospital weight gain contributed most to overall treatment weight gain in AFT compared to FBT and SyFT. Conclusion: Brief medical stabilization weight gain does not contribute substantially to weight recovery in adolescents with AN who participated in RCTs.

Feeding and eating disorders

Eating disorders (EDs) are a group of prevalent psychiatric illnesses with an onset in early to late adolescence-a time of significant neural development, physical and psychologic growth, and self-exploration. The etiology and neurobiology of EDs are not well understood, but EDs are recognized as brain-based illnesses with serious acute and long-term consequences if undertreated or ignored. Two EDs, anorexia nervosa (AN) and bulimia nervosa (BN), have historically been the primary EDs of focus. The DSM-5 updated diagnostic criteria for these disorders added two more: binge-eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID). EDs severely impact males as well as females across the weight spectrum. Comorbidity is high; mortality rates for AN and BN are the highest in psychiatric conditions and higher than many medical conditions. Several treatment options are available to treat an ED ranging from inpatient hospitalization to outpatient services and different psychotherapy options. This chapter reviews the diagnostic criteria, clinical presentation, and treatment for these disorders. Where available, sex differences and developmental considerations will be noted. For all EDs, early recognition and swift treatment are necessary to avoid a chronic course.

Measuring Clinical Efficacy Through the Lens of Audit Data in Different Adult Eating Disorder Treatment Programmes

Background: Audit data is important in creating a clear picture of clinical reality in clinical services, and evaluating treatment outcomes. This paper explored the data from an audit of a large national eating disorder (ED) service and evaluated the outcome of inpatient and day treatment programmes for patients with anorexia nervosa (AN) with and without autistic traits. Methods: Four hundred and seventy-six patients receiving treatment for AN at inpatient (IP), day-care (DC) and step-up (SU) programmes were assessed at admission and at discharge on the following measures: autistic traits, body-mass-index (BMI), ED symptoms, depression and anxiety symptoms, work and social functioning, and motivation for change. Outcomes were analyzed first at a within-group level based on change in mean scores and then at an individual level based on the clinical significance of improvement in eating disorder symptoms. Outcomes were compared between patients with high autistic traits (HAT) and low autistic traits (LAT) in each programme. Results: The findings suggest that 45.5% of DC and 35.1% of IP patients showed clinically significant changes in ED symptoms following treatment. Co-occurring high autistic traits positively predicted improvement in ED symptoms in IP setting, but was a negative predictor in DC. In IP, more HAT inpatients no longer met the BMI cut-off for AN compared to LAT peers. In terms of general psychopathology, patients with AN and HAT exhibited more severe depression symptoms, anxiety symptoms and social functioning impairment than their LAT peers, and these symptoms stayed clinically severe after treatment. Conclusions: Patients with AN and hight autistic traits are more likely than their peers with low autistic traits to show weight restoration and improvement in ED systems after inpatient treatment. This reverses in DC, with high autistic trait patients less likely to improve after treatment compared to low autistic trait patients. Our results suggest that inpatient treatment with individualized and structured routine care may be an effective model of treatment for patients with AN and high autistic traits.

Incidence of anorexia nervosa in young people in the UK and Ireland: a national surveillance study

OBJECTIVES

This study aimed to estimate the incidence of DSM5 anorexia nervosa in young people in contact with child and adolescent mental health services in the UK and Ireland.

DESIGN

Observational, surveillance study, using the Child and Adolescent Psychiatry Surveillance System, involving monthly reporting by child and adolescent psychiatrists between 1st February 2015 and 30th September 2015.

SETTING

The study was based in the UK and Ireland.

PARTICIPANTS

Clinician-reported data on young people aged 8-17 in contact with child and adolescent mental health services for a first episode of anorexia nervosa.

MAIN OUTCOME MEASURES

Annual incidence rates (IRs) estimated as confirmed new cases per 100 000 population at risk.

RESULTS

305 incident cases of anorexia nervosa were reported over the 8-month surveillance period and assessed as eligible for inclusion. The majority were young women (91%), from England (70%) and of white ethnicity (92%). Mean age was 14.6 years (±1.66) and mean percentage of median expected body mass index for age and sex was 83.23% (±10.99%). The overall IR, adjusted for missing data, was estimated to be 13.68 per 100 000 population (95% CI 12.88 to 14.52), with rates of 25.66 (95% CI 24.09 to 27.30) for young women and 2.28 (95% CI 1.84 to 2.79) for young men. Incidence increased steadily with age, peaking at 15 (57.77, 95% CI 50.41 to 65.90) for young women and 16 (5.14, 95% CI 3.20 to 7.83) for young men. Comparison with earlier estimates suggests IRs for children aged 12 and under have increased over the last 10 years.

CONCLUSION

These results provide new estimates of the incidence of anorexia nervosa in young people. Service providers and commissioners should consider evidence to suggest an increase in incidence in younger children.

TRIAL REGISTRATION NUMBER

ISRCTN12676087.

Updates on Treatments for Adolescent Anorexia Nervosa

This article provides background information, descriptions, and evidential support for the more recent treatments for adolescents with anorexia nervosa, including family-based treatment, adolescent focused therapy, cognitive behavioral therapy, systemic family therapy, and psychopharmacologic treatments. At this time, family-based treatment has the best evidence of efficacy and cost-effectiveness. Future directions in treatment research for adolescent anorexia nervosa are discussed.

The Role of Higher Levels of Care for Eating Disorders in Youth

Many eating disorder patients are successfully treated in outpatient settings. Family-based treatment allows youth to recover at home. Higher levels of care may be necessary for medical or psychiatric stabilization, or to provide added structure. Historically, hospital lengths of stay were long. Currently, insurance limitations encourage intermediate care levels to support patients not requiring inpatient treatment but not ready for outpatient care. Options include inpatient medical stabilization, locked units for individuals with suicidal ideation, and outpatient programs offering daily meal support and group therapy. Outpatient teams and families collaborate to determine the appropriate level of care.

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.

Family therapy approaches for anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is characterised by a failure to maintain a normal body weight due to a paucity of nutrition, an intense fear of gaining weight or behaviour that prevents the individual from gaining weight, or both. The long-term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality. 'Family therapy approaches' indicate a range of approaches, derived from different theories, that involve the family in treatment. We have included therapies developed on the basis of dominant family systems theories, approaches that are based on or broadly similar to the family-based therapy derived from the Maudsley model, approaches that incorporate a focus on cognitive restructuring, as well as approaches that involve the family without articulation of a theoretical approach.This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To evaluate the efficacy of family therapy approaches compared with standard treatment and other treatments for AN.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and PsycINFO (OVID) (all years to April 2016). We ran additional searches directly on Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Ovid Embase, and PsycINFO (to 2008 and 2016 to 2018). We searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov, together with four theses databases (all years to 2018). We checked the reference lists of all included studies and relevant systematic reviews. We have included in the analyses only studies from searches conducted to April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of family therapy approaches compared to any other intervention or other types of family therapy approaches were eligible for inclusion. We included participants of any age or gender with a primary clinical diagnosis of anorexia nervosa.

DATA COLLECTION AND ANALYSIS

Four review authors selected the studies, assessed quality and extracted data. We used a random-effects meta-analysis. We used the risk ratio (with a 95% confidence interval) to summarise dichotomous outcomes and both the standardised mean difference and the mean difference to summarise continuous measures.

MAIN RESULTS

We included 25 trials in this version of the review (13 from the original 2010 review and 12 newly-included studies). Sixteen trials were of adolescents, eight trials of adults (seven of these in young adults aged up to 26 years) and one trial included three age groups: one adolescent, one young adult and one adult. Most investigated family-based therapy or variants. Reporting of trial conduct was generally inadequate, so that in a large number of studies we rated the risk of bias as unclear for many of the domains. Selective reporting bias was particularly problematic, with 68% of studies rated at high risk of bias in this area, followed by incomplete outcome data, with 44% of studies rated at high risk of bias in this area. For the main outcome measure of remission there was some low-quality evidence (from only two studies, 81 participants) suggesting that family therapy approaches might offer some advantage over treatment as usual on rates of remission, post intervention (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.49 to 8.23; I2 = 0%). However, at follow-up, low-quality evidence from only one study suggested this effect was not maintained. There was very low-quality evidence from only one trial, which means it is difficult to determine whether family therapy approaches offer any advantage over educational interventions for remission (RR 9.00, 95% CI 0.53 to 153.79; 1 study, N = 30). Similarly, there was very low-quality evidence from only five trials for remission post-intervention, again meaning that it is difficult to determine whether there is any advantage of family therapy approaches over psychological interventions (RR 1.22, 95% CI 0.89 to 1.67; participants = 252; studies = 5; I2 = 37%) and at long-term follow-up (RR 1.08, 95% CI 0.91 to 1.28; participants = 200; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 0%). There was no indication that the age group had any impact on the overall treatment effect; however, it should be noted that there were very few trials undertaken in adults, with the age range of adult studies included in this analysis from 20 to 27. There was some evidence of a small effect favouring family based therapy compared with other psychological interventions in terms of weight gain post-intervention (standardised mean difference (SMD) 0.32, 95% CI 0.01 to 0.63; participants = 210; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 11%) . Overall, there was insufficient evidence to determine whether there were any differences between groups across all comparisons for most of the secondary outcomes (weight, eating disorder psychopathology, dropouts, relapse, or family functioning measures), either at post-intervention or at follow-up.

AUTHORS' CONCLUSIONS

There is a limited amount of low-quality evidence to suggest that family therapy approaches may be effective compared to treatment as usual in the short term. This finding is based on two trials that included only a small number of participants, and both had issues about potential bias. There is insufficient evidence to determine whether there is an advantage of family therapy approaches in people of any age compared to educational interventions (one study, very low quality) or other psychological therapies (five studies, very low quality). Most studies contributing to this finding were undertaken in adolescents and youth. There are clear potential impacts on how family therapy approaches might be delivered to different age groups and further work is required to understand what the resulting effects on treatment efficacy might be. There is insufficient evidence to determine whether one type of family therapy approach is more effective than another. The field would benefit from further large, well-conducted trials.

Stopping the "revolving door": "Zeida Laderech," a unique rehabilitation house for young adults with severe and enduring eating disorders

A failure to maintain improvement achieved during acute treatment, followed by a "revolving door syndrome," is a common phenomenon in eating disorders (EDs). As a result, many patients develop a chronic course that is difficult to treat. To target these difficulties, we established a novel rehabilitation treatment model in Israel for patients with severe and enduring EDs, based on the "recovery theory" in mental health treatment. This paper describes the process of conceiving this model and specifies the components of this rehabilitation house, "Zeida Laderech" (Provisions for the Journey), that aims to provide a home-like environment, while assisting in developing a healthy and balanced lifestyle. Finally, the model is discussed in light of other residential programs established in the world. With the hope to improve the overall prognosis of individuals with EDs, it is suggested that the similar programs and ongoing innovation will continue to emerge internationally.

Treatment outcomes for anorexia nervosa: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

To determine the impact of specialized treatments, relative to comparator treatments, upon the weight and psychological symptoms of anorexia nervosa (AN) at end-of-treatment (EOT) and follow-up.

METHODS

Randomized controlled trials (RCTs) between January 1980 and December 2017 that reported the effects of at least two treatments on AN were screened. Weight and psychological symptoms were analyzed separately for each study. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed, and studies were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) criteria and Cochrane risk of bias tool.

RESULTS

We identified 35 eligible RCTs, comprising data from 2524 patients. Meta-analyses revealed a significant treatment effect on weight outcomes at EOT [g = 0.16, 95% CI (0.05-0.28), p = 0.006], but not at follow-up [g = 0.11, 95% CI (-0.04 to 0.27), p = 0.15]. There was no significant treatment effect on psychological outcomes at either EOT [g = -0.03, 95% CI (-0.14 to 0.08), p = 0.63], or follow-up [g = -0.001, 95% CI (-0.11 to 0.11), p = 0.98]. There was no strong evidence of publication bias or significant moderator effects for illness duration, mean age, year of publication, comparator group category, or risk of bias (all p values &gt; 0.05).

CONCLUSIONS

Current specialized treatments are more adept than comparator interventions at imparting change in weight-based AN symptoms at EOT, but not at follow-up. Specialized treatments confer no advantage over comparator interventions in terms of psychological symptoms. Future precision treatment efforts require a specific focus on the psychological symptoms of AN.

Inpatient versus outpatient care, partial hospitalisation and waiting list for people with eating disorders

BACKGROUND

Clinical guidelines recommend outpatient care for the majority of people with an eating disorder. The optimal use of inpatient treatment or combination of inpatient and partial hospital care is disputed and practice varies widely.

OBJECTIVES

To assess the effects of treatment setting (inpatient, partial hospitalisation, or outpatient) on the reduction of symptoms and increase in remission rates in people with:1. Anorexia nervosa and atypical anorexia nervosa;2. Bulimia nervosa and other eating disorders.

SEARCH METHODS

We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 2 July 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 20 November 2015). We also searched the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (6 July 2018). We ran a forward citation search on the Web of Science to identify additional reports citing any of the included studies, and screened reference lists of included studies and relevant reviews identified during our searches.

SELECTION CRITERIA

We included randomised controlled trials that tested the efficacy of inpatient, outpatient, or partial hospital settings for treatment of eating disorder in adults, adolescents, and children, whose diagnoses were determined according to the DSM-5, or other internationally accepted diagnostic criteria. We excluded trials of treatment setting for medical or psychiatric complications or comorbidities (e.g. hypokalaemia, depression) of an eating disorder.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane procedures to select studies, extract and analyse data, and interpret and present results. We extracted data according to the DSM-5 criteria. We used the Cochrane tool to assess risk of bias. We used the mean (MD) or standardised mean difference (SMD) for continuous data outcomes, and the risk ratio (RR) for binary outcomes. We included the 95% confidence interval (CI) with each result. We presented the quality of the evidence and estimate of effect for weight or body mass index (BMI) and acceptability (number who completed treatment), in a 'Summary of findings' table for the comparison for which we had sufficient data to conduct a meta-analysis.

MAIN RESULTS

We included five trials in our review. Four trials included a total of 511 participants with anorexia nervosa, and one trial had 55 participants with bulimia nervosa. Three trials are awaiting classification, and may be included in future versions of this review. We assessed a risk of bias from lack of blinding of participants and therapists in all trials, and unclear risk for allocation concealment and randomisation in one study.We had planned four comparisons, and had data for meta-analyses for one. For anorexia nervosa, there may be little or no difference between specialist inpatient care and active outpatient or combined brief hospital and outpatient care in weight gain at 12 months after the start of treatment (standardised mean difference (SMD) -0.22, 95% CI -0.49 to 0.05; 2 trials, 232 participants; low-quality evidence). People may be more likely to complete treatment when randomised to outpatient care settings, but this finding is very uncertain (risk ratio (RR) 0.75, 95% CI 0.64 to 0.88; 3 trials, 319 participants; very low-quality evidence). We downgraded the quality of the evidence for these outcomes because of risks of bias, small numbers of participants and events, and variable level of specialist expertise and intensity of treatment.We had no data, or data from only one trial for the primary outcomes for each of the other three comparisons.No trials measured weight or acceptance of treatment for anorexia nervosa, when comparing inpatient care provided by a specialist eating disorder service and health professionals and a waiting list, no active treatment, or treatment as usual.There was no clear difference in weight gain between settings, and only slightly more acceptance for the partial hospital setting over specialist inpatient care for weight restoration in anorexia nervosa.There was no clear difference in weight gain or acceptability of treatment between specialist inpatient care and partial hospital care for bulimia nervosa, and other binge eating disorders.

AUTHORS' CONCLUSIONS

There was insufficient evidence to conclude whether any treatment setting was superior for treating people with moderately severe (or less) anorexia nervosa, or other eating disorders.More research is needed for all comparisons of inpatient care versus alternate care.

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

BACKGROUND

Perspectives of young people with eating disorders and their parents on helpful aspects of care should be incorporated into evidence-based practice and service design, but data are limited.AimsTo explore patient and parent perspectives on positive and negative aspects of care for young people with eating disorders.

METHOD

Six online focus groups with 19 young people aged 16-25 years with existing or past eating disorders and 11 parents.

RESULTS

Thematic analysis identified three key themes: the need to (a) shift from a weight-focused to a more holistic, individualised and consistent care approach, with a better balance in targeting psychological and physical problems from an early stage; (b) improve professionals' knowledge and attitude towards patients and their families at all levels of care from primary to 'truly specialist'; (c) enhance peer and family support.

CONCLUSIONS

Young people and parents identified an array of limitations in approaches to care for young people with eating disorders and raised the need for change, particularly a move away from a primarily weight-focused treatment and a stronger emphasis on psychological needs and individualised care.Declaration of interestNone.

Family therapy approaches for anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is characterised by a failure to maintain a normal body weight due to a paucity of nutrition, an intense fear of gaining weight or behaviour that prevents the individual from gaining weight, or both. The long-term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality. 'Family therapy approaches' indicate a range of approaches, derived from different theories, that involve the family in treatment. We have included therapies developed on the basis of dominant family systems theories, approaches that are based on or broadly similar to the family-based therapy derived from the Maudsley model, approaches that incorporate a focus on cognitive restructuring, as well as approaches that involve the family without articulation of a theoretical approach.This is an update of a Cochrane Review first published in 2010.

OBJECTIVES

To evaluate the efficacy of family therapy approaches compared with standard treatment and other treatments for AN.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and PsycINFO (OVID) (all years to April 2016). We ran additional searches directly on Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Ovid Embase, and PsycINFO (to 2008 and 2016 to 2018). We searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov, together with four theses databases (all years to 2018). We checked the reference lists of all included studies and relevant systematic reviews. We have included in the analyses only studies from searches conducted to April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of family therapy approaches compared to any other intervention or other types of family therapy approaches were eligible for inclusion. We included participants of any age or gender with a primary clinical diagnosis of anorexia nervosa.

DATA COLLECTION AND ANALYSIS

Four review authors selected the studies, assessed quality and extracted data. We used a random-effects meta-analysis. We used the risk ratio (with a 95% confidence interval) to summarise dichotomous outcomes and both the standardised mean difference and the mean difference to summarise continuous measures.

MAIN RESULTS

We included 25 trials in this version of the review (13 from the original 2010 review and 12 newly-included studies). Sixteen trials were of adolescents, eight trials of adults (seven of these in young adults aged up to 26 years) and one trial included three age groups: one adolescent, one young adult and one adult. Most investigated family-based therapy or variants. Reporting of trial conduct was generally inadequate, so that in a large number of studies we rated the risk of bias as unclear for many of the domains. Selective reporting bias was particularly problematic, with 68% of studies rated at high risk of bias in this area, followed by incomplete outcome data, with 44% of studies rated at high risk of bias in this area. For the main outcome measure of remission there was some low-quality evidence (from only two studies, 81 participants) suggesting that family therapy approaches might offer some advantage over treatment as usual on rates of remission, post intervention (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.49 to 8.23; I2 = 0%). However, at follow-up, low-quality evidence from only one study suggested this effect was not maintained. There was very low-quality evidence from only one trial, which means it is difficult to determine whether family therapy approaches offer any advantage over educational interventions for remission (RR 9.00, 95% CI 0.53 to 153.79; 1 study, N = 30). Similarly, there was very low-quality evidence from only five trials for remission post-intervention, again meaning that it is difficult to determine whether there is any advantage of family therapy approaches over psychological interventions (RR 1.22, 95% CI 0.89 to 1.67; participants = 252; studies = 5; I2 = 37%) and at long-term follow-up (RR 1.08, 95% CI 0.91 to 1.28; participants = 200; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 0%). There was no indication that the age group had any impact on the overall treatment effect; however, it should be noted that there were very few trials undertaken in adults, with the age range of adult studies included in this analysis from 20 to 27. There was some evidence of a small effect favouring family based therapy compared with other psychological interventions in terms of weight gain post-intervention (standardised mean difference (SMD) 0.32, 95% CI 0.01 to 0.63; participants = 210; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 11%) . Overall, there was insufficient evidence to determine whether there were any differences between groups across all comparisons for most of the secondary outcomes (weight, eating disorder psychopathology, dropouts, relapse, or family functioning measures), either at post-intervention or at follow-up.

AUTHORS' CONCLUSIONS

There is a limited amount of low-quality evidence to suggest that family therapy approaches may be effective compared to treatment as usual in the short term. This finding is based on two trials that included only a small number of participants, and both had issues about potential bias. There is insufficient evidence to determine whether there is an advantage of family therapy approaches in people of any age compared to educational interventions (one study, very low quality) or psychological therapies (five studies, very low quality). Most studies contributing to this finding were undertaken in adolescents and youth. There are clear potential impacts on how family therapy approaches might be delivered to different age groups and further work is required to understand what the resulting effects on treatment efficacy might be. There is insufficient evidence to determine whether one type of family therapy approach is more effective than another. The field would benefit from further large, well-conducted trials.

Eating disorders in children and adolescents

This article provides an overview of classification and outcome of eating disorders, before focusing on current evidence-based treatment for the two main disorders of anorexia nervosa and bulimia nervosa.

René Girard and the Mimetic Nature of Eating Disorders

French historian and literary critic René Girard (1923-2015), most widely known for the concepts of mimetic desire and scapegoating, also engaged in the discussion of the surge of eating disorders in his 1996 essay Eating Disorders and Mimetic Desire. This article explores Girard's ideas on the mimetic nature and origin of eating disorders from a clinical psychiatric perspective and contextualizes them within the field of eating disorders research as well as in relation to broader psychological, sociological and anthropological models of social comparison and non-consumption. Three main themes in Girard's thinking on the topic of eating disorders are identified and explored: the 'end of prohibitions' as a driving force in the emergence of eating disorders, eating disorders as a phenomenon specific to modernity, and the significance of 'conspicuous non-consumption' in the emergence of eating disorders.

Psychotherapeutic Treatment for Anorexia Nervosa: A Systematic Review and Network Meta-Analysis

Background: The aim of the study was a systematic review of studies evaluating psychotherapeutic treatment approaches in anorexia nervosa and to compare their efficacy. Weight gain was chosen as the primary outcome criterion. We also aimed to compare treatment effects according to service level (inpatient vs. outpatient) and age group (adolescents vs. adults). Methods:The data bases PubMed, Cochrane Library, Web of Science, Cinahl, and PsychInfo were used for a systematic literature search (until Feb 2017). Search terms were adapted for data base, combining versions of the search terms anorexia, treat^*/therap^* and controlled trial. Studies were selected using pre-defined in- and exclusion criteria. Data were extracted by two independent coders using piloted forms. Network-meta-analyses were conducted on all RCTs. For a comparison of service levels and age groups, standard mean change (SMC) statistics were used and naturalistic, non-randomized studies included. Results: Eighteen RCTs (trials on adults: 622 participants; trials on adolescents: 625 participants) were included in the network meta-analysis. SMC analyses were conducted with 38 studies (1,164 participants). While family-based approaches dominate interventions for adolescents, individual psychotherapy dominates in adults. There was no superiority of a specific approach. Weight gains were more rapid in adolescents and inpatient treatment. Conclusions: Several specialized psychotherapeutic interventions have been developed and can be recommended for AN. However, adult and adolescent patients should be distinguished, as groups differ in terms of treatment approaches considered suitable as well as treatment response. Future trials should replicate previous findings and be multi-center trials with large sample sizes to allow for subgroup analyses. Patient assessment should include variables that can be considered relevant moderators of treatment outcome. It is desirable to explore adaptive treatment strategies for subgroups of patients with AN. Identifying and addressing maintaining factors in AN remains a major challenge.

Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis

Background

Self-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems.

Objectives

To determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people.

Design

Systematic review with meta-analysis.

Population

Children and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression).

Intervention

Self-care support in health, social care, educational or community settings.

Comparator

Usual care.

Outcomes

Generic/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs.

Design

Randomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs.

Data sources

MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015.

Methods

We conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity).

Results

Ninety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings.

Limitations

Identification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded.

Conclusions

Self-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs.

Future work

Research is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs.

Study registration

This study is registered as PROSPERO CRD42014015452.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

First Sociodemographic, Pretreatment and Clinical Data from a German Web-Based Registry for Child and Adolescent Anorexia Nervosa

Abstract. Objective: The first web-based registry for childhood and adolescent anorexia nervosa (AN) in Germany was established to systematically collect demographic and clinical data. These data as well as information on how young individuals with AN can find access to healthcare services are presented. Method: Patients´ data from child and adolescent psychiatry departments of 12 university hospitals and two major nonuniversity hospitals in Germany were collected between January 2015 and December 2016. All patients met the ICD-10 diagnostic criteria for (atypical) AN. Sociodemographic data, type and amount of healthcare utilization before admission, and clinical data at admission and discharge were compiled. Results: 258 patients with a mean age of 14.7 years and a mean BMI at admission of 15.3 kg/m2 were included. The parents and patients had a higher educational level than the general German population. More than 80 % of the patients reported having utilized healthcare before hospitalization. The mean duration of outpatient treatment before hospitalization was 7 months. Conclusions: There seem to be major barriers to specialist treatment for young patients with AN in Germany, which should be analyzed in future studies.

Treating Eating Disorders at Higher Levels of Care: Overview and Challenges

Higher levels of care (HLC)-including inpatient hospitalization, residential treatment, partial hospitalization, and intensive outpatient treatment-are frequently utilized within routine care for eating disorders. Despite widespread use, there is limited research evaluating the efficacy of HLC, as well as clinical issues related to care in these settings. This review describes the different levels of care for eating disorders and briefly reviews the most up-to-date guidelines and research regarding how to choose a level of care. In addition, as HLC approaches for ED continue to be developed and refined, pragmatic and conceptual challenges have emerged that provide barriers to clinical efficacy and the execution of high-quality treatment research. This review includes a discussion of various issues specific to HLC, as well as a summary of recent literature addressing them.

Are lifetime affective disorders predictive of long-term outcome in severe adolescent anorexia nervosa?

Depression and anxiety are commonly associated with anorexia nervosa (AN) and contribute to difficulties in social integration, a negative factor for outcome in AN. The link between those disorders and AN has been poorly studied. Thus, our objective was to investigate (1) the link between outcome nine years after hospitalisation for AN and the occurrence of lifetime anxious or depressive comorbidities; (2) the prognostic value of these comorbidities on patient outcome; 181 female patients were hospitalised for AN (between 13 and 22 years old), and were re-evaluated for their psychological, dietary, physical and social outcomes, from 6 to 12 years after their hospitalisation. The link between anxious and depressive disorders (premorbid to AN and lifetime) and the outcome assessment criteria were tested through multivariate analyses; 63% of the participants had good or intermediate outcome, 83% had presented at least one anxiety or depression disorder in the course of their lives, half of them before the onset of AN. Premorbid obsessive compulsive disorders (OCD), BMI at admission, and premenarchal AN all contribute to poor prognosis. Social phobia and agoraphobia affect the subjects' quality of life and increase eating disorder symptoms. These results encourage a systematic assessment of, and care for, anxiety and depression comorbidities among female adolescent patients with a particular focus on premorbid OCD.

Treatment of anorexia nervosa: a multimethod investigation translating experimental neuroscience into clinical practice

Background

Anorexia nervosa (AN) is a severe psychiatric condition and evidence on how to best treat it is limited.

Objectives

This programme consists of seven integrated work packages (WPs) and aims to develop and test disseminable and cost-effective treatments to optimise management for people with AN across all stages of illness.

Methods

WP1a used surveys, focus groups and a pre–post trial to develop and evaluate a training programme for school staff on eating disorders (EDs). WP1b used a randomised controlled trial (RCT) [International Standard Randomised Controlled Trial Number (ISRCTN) 42594993] to evaluate a prevention programme for EDs in schools. WP2a evaluated an inpatient treatment for AN using case reports, interviews and a quasi-experimental trial. WP2b used a RCT (ISRCTN67720902) to evaluate two outpatient psychological therapies for AN. WP3 used a RCT (ISRCTN06149665) to evaluate an intervention for carers of inpatients with AN. WP4 used actimetry, self-report and endocrine assessment to examine physical activity (PA) in AN. WP5 conducted a RCT (ISRCTN18274621) of an e-mail-guided relapse prevention programme for inpatients with AN. WP6 analysed cohort data to examine the effects of maternal EDs on fertility and their children’s diet and growth. WP7a examined clinical case notes to explore how access to specialist ED services affects care pathways and user experiences. Finally, WP7b used data from this programme and the British Cohort Study (1970) to identify the costs of services used by people with AN and to estimate annual costs of AN for England.

Results

WP1a: a brief training programme improved knowledge, attitudes and confidence of school staff in managing EDs in school. WP1b: a teacher-delivered intervention was feasible and improved risk factors for EDs in adolescent girls. WP2a: both psychological therapies improved outcomes in outpatients with AN similarly, but patients preferred one of the treatments. WP2b: the inpatient treatment (Cognitive Remediation and Emotional Skills Training) was acceptable with perceived benefits by patients, but showed no benefits compared with treatment as usual (TAU). WP3: compared with TAU, the carer intervention improved a range of patient and carer outcomes, including carer burden and patient ED symptomatology. WP4: drive to exercise is tied to ED pathology and a desire to improve mood in AN patients. PA was not increased in these patients. WP5: compared with TAU, the e-mail-guided relapse prevention programme resulted in higher body mass index and lower distress in patients at 12 months after discharge. WP6: women with an ED had impaired fertility and their children had altered dietary and growth patterns compared with the children of women without an ED. WP7a: direct access to specialist ED services was associated with higher referral rates, lower admission rates, greater consistency of care and user satisfaction. WP7b: the annual costs of AN in England are estimated at between £45M and £230M for 2011.

Conclusions

This programme has produced evidence to inform future intervention development and has developed interventions that can be disseminated to improve outcomes for individuals with AN. Directions for future research include RCTs with longer-term outcomes and sufficient power to examine mediators and moderators of change.

Trial registration

Current Controlled Trials ISRCTN42594993, ISRCTN67720902, ISRCTN06149665 and ISRCTN18274621.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 16. See the NIHR Journals Library website for further project information.