Setting the top 10 eating disorder research and translation priorities for Australia

OBJECTIVES

People with eating disorders, as well as their caregivers, experience high symptom burden, reduced quality of life and increased risk of early mortality. A lack of resources, disjointed vision and limited uptake of the evidence have limited the translation and implementation of research into practice. Little is known about what stakeholders (people with a lived experience, caregivers, health care professionals, researchers and policymakers) see as the most important research priorities. This study aimed to identify Australia's top 10 consensus-derived research and translation priorities for eating disorders.

METHODS

Participants (n = 606) included people with a lived experience, carers, health care professionals (clinicians) and researchers working in eating disorders. The methodology aligned with the James Lind Alliance priority setting process, which involved oversight by a co-design advisory committee and utilised a national online interim priority setting survey and co-design workshops to identify the top 10 research and translation priorities.

RESULTS

The initial national consultations elicited 1210 issues from 480 individuals. From this, 606 participants shortlisted 59 plain language questions in order of personal priority. In total, 16 questions were consistently ranked as important. As a final step, 24 individuals (with equal representation from all 4 stakeholder groups) attended the final prioritisation workshop to co-establish the top 10 research and translation priorities.

CONCLUSION

The findings highlight the need for people with a lived experience, carers, health professionals and researchers to work collaboratively to develop co-designed research and translation activities that address the key areas of early intervention, prevention, understanding the aetiology of eating disorders and effective treatment of people experiencing eating disorders.

Do People Want the 'New Normal'? A Mixed Method Investigation of Young Person, Parent, and Clinician Experience and Preferences for Eating Disorder Treatment Delivery in the Post-COVID-19 World

Eating disorder treatment was predominantly provided online during the COVID-19 pandemic, which has continued into the post-pandemic world. This mixed method study explored young person, parent/caregiver, and clinician experiences of child and adolescent eating disorder treatment. In total, 90 participants (25 young people, 49 parents/caregivers, and 16 clinicians) completed online surveys about the experience of online working. Data were compared to similar data collected by the same service earlier in the pandemic. The results show that preferences are largely unchanged since 2020; online treatment is considered helpful and acceptable by all groups. Nevertheless, face-to-face assessment sessions (young people: 52.2%; and parents/caregivers: 68.9%) and final sessions (young people: 82.6%; and parents/caregivers: 82.2%) were preferred compared to online. There was also a preference for early treatment sessions to either be always or mostly face-to-face (young people: 65.2%; and parents/caregivers: 73.3%). The middle and latter parts of treatment were a time when preferences shifted slightly to a more hybrid mode of delivery. Participants reported finding engagement with the therapist (young people: 70.6%; and parents/caregivers: 52.5%) easier during face-to-face treatment. Stepping away from the binary of online or face-to-face, the current data suggest that a hybrid and flexible model is a way forward with current findings providing insights into how to structure this.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

The efficacy of family treatments for adolescent anorexia nervosa in specialist versus non-specialist settings: protocol for a systematic review and meta-analysis

BACKGROUND

Anorexia nervosa (AN) is often diagnosed in adolescence, and most evidence-based treatments for AN in young people involve the family. Family therapies for AN are intensive, outpatient treatments that utilise the parents as the primary resource in the young person's recovery. Research regarding family treatment for AN is often conducted in specialist settings-with relatively little data reporting the translation of this specialised treatment into real-world, non-specialist settings. This systematic review and meta-analysis aims to determine the efficacy of family treatments for adolescents with AN in specialist settings versus non-specialist settings.

METHODS

This systematic review and meta-analysis will be conducted according to the preferred reporting items for systematic reviews and meta-analyses guidelines. Retrospective cohort studies, pilot studies, case series, randomised controlled trials and qualitative investigations that present original data and investigated the efficacy of family treatments for adolescents with AN in either a specialist or non-specialist setting will be included in the review. Data will be extracted by two reviewers and study quality will be assessed. The primary outcome, change in weight, will be used to determine via meta-analysis and, depending on study heterogeneity, subgroup analysis or meta-regression whether there is a statistically significant subgroup difference between specialist and non-specialist treatment settings. The review will also consider changes in eating disorder symptomology and related constructs.

DISCUSSION

Results from this review will help determine if there is a difference in the efficacy of family treatments for adolescent AN in specialist versus non-specialist treatment settings, primarily in relation to weight recovery. This, in turn, will inform the translation of evidence-based interventions that are generally studied and implemented within specialist centres into the non-specialist health care system.

Screening, assessment and diagnosis in the eating disorders: findings from a rapid review

BACKGROUND

Limited screening practices, minimal eating disorder training in the healthcare professions, and barriers related to help-seeking contribute to persistent low rates of eating disorder detection, significant unmet treatment need, and appreciable associated disease burden. The current review sought to broadly summarise the literature and identify gaps relating to the screening, assessment, and diagnosis of eating disorders within Western healthcare systems.

METHODS

This paper forms part of a Rapid Review series scoping the evidence base for the field of eating disorders, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for studies published between 2009 and mid 2021 in English. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised through purposive sampling. Data from selected studies relating to Screening, Assessment and Diagnosis of eating disorders were synthesised and are disseminated in the current review.

RESULTS

Eighty seven studies were identified, 38% relating to screening and 62% to assessment and diagnosis. The majority of screening studies were conducted in university student samples, showing high prevalence but only modest improvements in help-seeking in those studies that followed up post-screen. In healthcare settings, clinicians continue to have difficulty identifying eating disorder presentations, particularly Binge Eating Disorder, Other Specified Feeding or Eating Disorders, and sub-threshold eating disorders. This is preceded by inadequate and frequently homogenous screening mechanisms and exacerbated by considerable personal and health-system barriers, including self-stigma and lack of resourcing. While all groups are at risk of delayed or no diagnosis, those at particular risk include LGBTQ+ and gender diverse individuals, individuals living in larger bodies, and males.

CONCLUSIONS

A majority of individuals with eating disorders remain undiagnosed and untreated despite a high prevalence of these conditions and increased advocacy in recent years. Research into improving detection and clinician diagnostic skill is extremely limited. Innovative empirical research is strongly recommended to address significant individual and health-system barriers currently preventing appropriate and timely intervention for many. Limited screening in healthcare settings and low rates of eating disorder training in the healthcare professions are just some of the barriers to help-seeking which may contribute to delayed intervention and diagnosis in the eating disorders. This has significant impacts, prolonging treatment when it is finally received, and increasing healthcare costs for both the individual and the healthcare system. The current review is part of a larger Rapid Review series conducted to inform the development of Australia's National Eating Disorders Research and Translation Strategy 2021-2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policy-making and address urgent health concerns. The Rapid Review synthesises the current evidence-base and identifies gaps in eating disorder research and care, in order to guide decision making and address urgent health concerns. This paper gives a critical overview of the scientific literature relating to the current state of screening, assessment, and diagnosis of eating disorders within Western healthcare systems that may inform health policy and research in an Australian context. It covers screening initiatives in both general and high-risk populations; personal, clinician and healthcare system challenges relating to help-seeking; and obstacles to accurate and timely clinical diagnosis across the eating disorders.

'In an otherwise limitless world, I was sure of my limit.'† Experiencing Anorexia Nervosa: A phenomenological metasynthesis

Anorexia Nervosa (AN) has the highest mortality rate of the mental disorders, with still less than 50% of affected individuals achieving recovery. Recent calls to bring innovative, empirical research strategies to the understanding of illness and its core psychopathological features highlight the need to address significant paucity of efficacious treatment. The current study brings a phenomenological approach to this challenge, synthesizing lived experience phenomena as described by qualitative literature. Fifty-three studies published between the years 1998 and 2021 comprising a total of 1557 participants aged 12-66 suffering from AN or sub-threshold AN are included. Reciprocal and refutational analysis generated six key third-order constructs: "emotion experienced as overwhelming," "identity," "AN as a tool," "internal conflict relating to Anorexia," "interpersonal communication difficulties" and "corporeality." Twenty-six sub-themes were identified, the most common being fear, avoidance, AN as guardian/protector, and AN as intertwined with identity. Some themes associated with current treatment models such as low self-esteem, need for social approval and feelings of fatness were less common. We highlight the significant role of intense and confusing emotion in AN, which is both rooted in and engenders amplified fear and anxiety. Restrictive eating functions to numb these feelings and withdraw an individual from a chaotic and threatening world whilst providing a sense of self around which to build an illness identity. Results have implications for therapeutic practice and overly protective weight and shape focused medical treatment models, which may serve to reinforce the disease.

Body Image Distress and Its Associations From an International Sample of Men and Women Across the Adult Life Span: Web-Based Survey Study

BACKGROUND

Previous research on body image distress mainly relied on samples that were small, generally homogeneous in age or sex, often limited to one geographical region, and were characterized by a lack of comprehensive analysis of multiple psychosocial domains. The research presented in this paper extends the international literature using the results of the web-based Global Health and Wellbeing Survey 2015. The survey included a large sample of both men and women aged ≥16 years from Australia, Canada, New Zealand, the United Kingdom, or the United States.

OBJECTIVE

The main objectives of this study are to examine body image distress across the adult life span (≥16 years) and sex and assess the association between body image distress and various psychosocial risk and protective factors.

METHODS

Data were extracted from the Global Health and Wellbeing Survey 2015, a web-based international self-report survey with 10,765 respondents, and compared with previous web-based surveys conducted in 2009 and 2012.

RESULTS

The body image distress of young Australians (aged 16-25 years) significantly rose by 33% from 2009 to 2015. In 2015, 75.19% (961/1278) of 16- to 25-year-old adults reported body image distress worldwide, and a decline in body image distress was noted with increasing age. More women reported higher levels of body image distress than men (1953/3338, 58.51% vs 853/2175, 39.22%). Sex, age, current dieting status, perception of weight, psychological distress, alcohol and other substance misuse, and well-being significantly explained 24% of the variance in body image distress in a linear regression (F_15,4966=105.8; P<.001).

CONCLUSIONS

This study demonstrates the significant interplay between body image distress and psychosocial factors across age and sex.

Technology-Enabled Reform in a Nontraditional Mental Health Service for Eating Disorders: Participatory Design Study

BACKGROUND

The recent Australian National Agenda for Eating Disorders highlights the role technology can play in improving accessibility and service development through web-based prevention, early access pathways, self-help, and recovery assistance. However, engagement with the eating disorders community to co-design, build, and evaluate these much-needed technology solutions through participatory design processes has been lacking and, until recently, underresourced.

OBJECTIVE

This study aims to customize and configure a technology solution for a nontraditional (web-based, phone, email) mental health service that provides support for eating disorders and body image issues through the use of participatory design processes.

METHODS

Participants were recruited chiefly through the Butterfly National Helpline 1800 ED HOPE (Butterfly's National Helpline), an Australian-wide helpline supporting anyone concerned by an eating disorder or body image issue. Participants included individuals with lived experience of eating disorders and body image issues, their supportive others (such as family, health professionals, support workers), and staff of the Butterfly Foundation. Participants took part in participatory design workshops, running up to four hours, which were held nationally in urban and regional locations. The workshop agenda followed an established process of discovery, evaluation, and prototyping. Workshop activities included open and prompted discussion, reviewing working prototypes, creating descriptive artifacts, and developing user journeys. Workshop artifacts were used in a knowledge translation process, which identified key learnings to inform user journeys, user personas, and the customization and configuration of the InnoWell Platform for Butterfly's National Helpline. Further, key themes were identified using thematic techniques and coded in NVivo 12 software.

RESULTS

Six participatory design workshops were held, of which 45 participants took part. Participants highlighted that there is a critical need to address some of the barriers to care, particularly in regional and rural areas. The workshops highlighted seven overarching qualitative themes: identified barriers to care within the current system; need for people to be able to access the right care anywhere, anytime; recommendations for the technological solution (ie, InnoWell Platform features and functionality); need for communication, coordination, and integration of a technological solution embedded in Butterfly's National Helpline; need to consider engagement and tone within the technological solution; identified challenges and areas to consider when implementing a technological solution in the Helpline; and potential outcomes of the technological solution embedded in the Helpline relating to system and service reform. Ultimately, this technology solution should ensure that the right care is provided to individuals the first time.

CONCLUSIONS

Our findings highlight the value of actively engaging stakeholders in participatory design processes for the customization and configuration of new technologies. End users can highlight the critical areas of need, which can be used as a catalyst for reform through the implementation of these technologies in nontraditional services.

Technology-Enabled Solutions for Australian Mental Health Services Reform: Impact Evaluation

Background

Health information technologies (HITs) are becoming increasingly recognized for their potential to provide innovative solutions to improve the delivery of mental health services and drive system reforms for better outcomes.

Objective

This paper describes the baseline results of a study designed to systematically monitor and evaluate the impact of implementing an HIT, namely the InnoWell Platform, into Australian mental health services to facilitate the iterative refinement of the HIT and the service model in which it is embedded to meet the needs of consumers and their supportive others as well as health professionals and service providers.

Methods

Data were collected via web-based surveys, semistructured interviews, and a workshop with staff from the mental health services implementing the InnoWell Platform to systematically monitor and evaluate its impact. Descriptive statistics, Fisher exact tests, and a reliability analysis were used to characterize the findings from the web-based surveys, including variability in the results between the services. Semistructured interviews were coded using a thematic analysis, and workshop data were coded using a basic content analysis.

Results

Baseline data were collected from the staff of 3 primary youth mental health services (n=18), a counseling service for veterans and their families (n=23), and a helpline for consumers affected by eating disorders and negative body image issues (n=6). As reported via web-based surveys, staff members across the services consistently agreed or strongly agreed that there was benefit associated with using technology as part of their work (38/47, 81%) and that the InnoWell Platform had the potential to improve outcomes for consumers (27/45, 60%); however, there was less certainty as to whether their consumers’ capability to use technology aligned with how the InnoWell Platform would be used as part of their mental health care (11/45, 24% of the participants strongly disagreed or disagreed; 15/45, 33% were neutral; and 19/45, 42% strongly agreed or agreed). During the semistructured interviews (n=3) and workshop, participants consistently indicated that the InnoWell Platform was appropriate for their respective services; however, they questioned whether the services’ respective consumers had the digital literacy required to use the technology. Additional potential barriers to implementation included health professionals’ digital literacy and service readiness for change.

Conclusions

Despite agreement among participants that HITs have the potential to result in improved outcomes for consumers and services, service readiness for change (eg, existing technology infrastructure and the digital literacy of staff and consumers) was noted to potentially impact the success of implementation, with less than half (20/45, 44%) of the participants indicating that their service was ready to implement new technologies to enhance mental health care. Furthermore, participants reported mixed opinions as to whether it was their responsibility to recommend technology as part of standard care.

Translating evidence-based treatment for digital health delivery: a protocol for family-based treatment for anorexia nervosa using telemedicine

BACKGROUND

Family-based treatment (FBT) is an efficacious outpatient intervention for young people diagnosed with Anorexia Nervosa (AN). To date, treatment to protocol has relied on standard face-to-face delivery. Face-to-face therapy is subject to geographic, temporal and human factors, rendering it particularly susceptible to inequities and disruption. This has resulted in poorer service provision for rural and regional families, and recently a significant challenge to providing face-to-face services during the COVID-19 global pandemic. The present study examines whether FBT for AN can be successfully translated to a digital delivery platform to address these access issues.

METHOD

Forty young people aged 12 to 18 years who meet DSM-5 diagnostic criteria for AN, and live in a rural or regional setting, will along with their family be recruited to the study. Trained therapists will provide 18 sessions of FBT over 9 months via telemedicine to the home of the young person and their family. The analysis will examine treatment effectiveness, feasibility, acceptability, and cost-effectiveness.

DISCUSSION

The study addresses the treatment needs of families not able to attend face-to-face clinical services for evidence-based treatment for eating disorders. This might be due to several barriers, including a lack of local services or long travel distances to services. There has been a recent and unprecedented demand for telemedicine to facilitate the continuity of care during COVID-19 despite geographical circumstances. If delivering treatment in this modality is clinically and economically effective and feasible, it will facilitate access to potentially lifesaving, evidence-based treatments for families formerly unable to access such care and provide evidence for the continuity of services when and where face-to-face treatment is not feasible.

Actions of the novel bronchodilator, trimetaquinol, on bovine pulmonary vein

The actions of the beta-sympathomimetic bronchodilator trimetaquinol (TMQ) were examined on bovine pulmonary vein smooth muscle in vitro. TMQ partially and reversibly inhibited 5-hydroxytryptamine (5HT) induced contractions of the vein strips. The relaxant activity was neither blocked by propranolol (10(-7) M) nor enhanced by phentolamine (10(-7) M). Isoproterenol, alone or in the presence of phentolamine (10(-7) M), was much less effective than TMQ in relaxing 5HT-induced contractions. From these results it is suggested that TMQ functions via a "non-beta-adrenergic" mechanism to relax bovine pulmonary vein smooth muscle.