Implementation and outcomes of home-based treatments for adolescents with anorexia nervosa: Study protocol for a pilot effectiveness-implementation trial

Cost-Effectiveness Analysis of Family-Based Treatment With Additional Home Treatment for Adolescent Anorexia Nervosa

OBJECTIVE

Family-based treatment (FBT) is promising for treating adolescents with anorexia nervosa, but long-term remission rates are modest. Home treatment (HT) as a supplement to FBT aims to enhance sustainability and effectiveness by supporting recovery within the family. This study compares the cost-effectiveness of FBT alone versus FBT with additional HT for adolescents with anorexia nervosa.

METHOD

This cost-effectiveness analysis is based on a non-randomized pilot study, which examined the effectiveness of HT for adolescents with anorexia nervosa, disregarding the financial aspects. HT involved therapeutic interventions delivered in the patient's home environment, while FBT involved structured therapy sessions at the psychiatric clinic. Data from 61 patients were analysed, with 40 receiving FBT + HT and 21 receiving FBT only. Costs included FBT sessions, HT sessions, and inpatient treatment. Effectiveness was measured by weight restoration at thresholds of expected body weight (EBW) > 85% and EBW > 95%.

RESULTS

FBT + HT promoted greater weight restoration within three months compared to FBT alone (70% vs. 52% at EBW > 85%; 38% vs. 29% at EBW > 95%). FBT + HT was more cost-effective, with lower average costs per patient meeting weight restoration criteria (8243 vs. 20,446 Swiss francs at EBW > 85%; 15,387 vs. 37,485 Swiss francs at EBW > 95%). Inpatient treatment accounted for most of the cost, with FBT + HT reducing hospitalisation needs.

CONCLUSIONS

FBT with additional HT is a more cost-effective treatment for adolescents with anorexia nervosa. Although the cost-effectiveness index was relatively high, effective treatment could reduce the long-term burdens of this disorder. Larger long-term studies are needed to validate these findings and assess sustained cost-effectiveness.

Child and adolescent mental health therapists' use of family-based treatment for adolescent restrictive eating disorders

In order to identify factors that may impede youth access to evidence-based treatment, the current study examined child and adolescent mental health therapists' use of Family-Based Treatment (FBT) and other psychotherapeutic approaches to treat adolescents with restrictive eating disorders. A sample of 91 therapists from a variety of backgrounds (e.g. social workers, doctoral-level psychologists, masters-level counselors, marriage and family therapists) completed a 74-item survey regarding their attitudes and beliefs about adolescent eating disorders and its treatment, as well as their use of FBT and other psychotherapeutic approaches. Only 5% of therapists indicated that they treat restrictive eating disorders and, of those who do provide care, few endorsed using FBT strategies. The majority of therapists reported using other psychotherapeutic approaches that may dilute the effect of FBT principles or may prove ineffective. Having more formal training in eating disorders was associated with FBT-consistent beliefs and the use of FBT strategies. Findings have implications for dissemination efforts that target common beliefs that can undermine the care of adolescent eating disorders. Finally, the field must consider disseminating treatments to general therapists in ways that are more accessible, such as a focus on basic over specialized competencies, and consider innovative approaches to engage other professionals in supporting families caring for young people with restrictive eating disorders.

Efficacy of Eating Disorder Focused Family Therapy for Adolescents With Anorexia Nervosa: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review and evaluate the efficacy of eating disorder focused family therapy (FT-ED) in comparison to all other forms of psychotherapy for children and adolescents with anorexia nervosa. A secondary aim is to assess the relative efficacy of different variations of FT-ED (e.g., shorter vs. longer dose, parent-focused).

METHODS

A search with relevant terms was systematically conducted on four databases. Twenty-three publications across 18 randomized controlled trials met inclusion criteria. Outcomes of interest included variables related to weight, eating psychopathology, and remission status. Study quality was assessed, and data were extracted by two independent researchers.

RESULTS

Adolescents receiving FT-ED gained significantly more weight by the end of treatment in comparison to those receiving individual psychotherapy. FT-ED that was delivered just to parents or to parents and child separately offered preferable weight outcomes and rates of recovery at the end of treatment in comparison to conjoint FT-ED. No other outcomes tested in the meta-analysis were statistically significant at the end of treatment or follow-up.

DISCUSSION

Currently available data suggest the use of FT-ED in its conjoint or separated/parent focused format is the best outpatient treatment option for adolescents with anorexia nervosa when immediate weight gain is paramount. The variability of outcome measurement, including the tools used and timepoints chosen, limit comparison among no more than a handful of studies. The field would benefit from the standardization of measurement and reporting guidelines for future clinical trials.

TRIAL REGISTRATION

PROSPERO number: CRD42023396263.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adolescent utilization of eating disorder higher level of care: roles of family-based treatment adherence and demographic factors

BACKGROUND

Outpatient family-based treatment (FBT) is effective in treating restrictive eating disorders among adolescents. However, little is known about whether FBT reduces higher level of care (HLOC) utilization or if utilization of HLOC is associated with patient characteristics. This study examined associations between utilization of eating disorder related care (HLOC and outpatient treatment) and reported adherence to FBT and patient characteristics in a large integrated health system.

METHODS

This retrospective cohort study examined 4101 adolescents who received care for restrictive eating disorders at Kaiser Permanente Northern California. A survey was sent to each medical center to identify treatment teams as high FBT adherence (hFBT) and low FBT adherence (lFBT). Outpatient medical and psychiatry encounters and HLOC, including medical hospitalizations and higher-level psychiatric care as well as patient characteristics were extracted from the EHR and examined over 12 months post-index.

RESULTS

2111 and 1990 adolescents were treated in the hFBT and lFBT, respectively. After adjusting for age, sex, race/ethnicity, initial percent median BMI, and comorbid mental health diagnoses, there were no differences in HLOC or outpatient utilization between hFBT and lFBT. Females had higher odds of any utilization compared with males. Compared to White adolescents, Latinos/Hispanics had lower odds of HLOC utilization. Asian, Black, and Latino/Hispanic adolescents had lower odds of psychiatric outpatient care than Whites.

CONCLUSIONS

Reported FBT adherence was not associated with HLOC utilization in this sample. However, significant disparities across patient characteristics were found in the utilization of psychiatric care for eating disorders. More efforts are needed to understand treatment pathways that are accessible and effective for all populations with eating disorders.

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

BACKGROUND

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

METHODS

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

RESULTS

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

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

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness associated with high rates of morbidity and mortality. Family-based treatment (FBT) is a well-established treatment for adolescent AN, yet it is underutilized in community settings and is unavailable to many families, particularly those from lower income and racial and ethnic minority backgrounds. Furthermore, some families do not respond optimally to FBT, possibly because of challenges translating skills acquired in office-based treatment settings to naturalistic settings. Home-based treatment could reduce barriers to access and enhance generalization of newly learned treatment skills. Home-based models demonstrate initial feasibility, acceptability, and efficacy for adolescent AN, however, FBT principles have yet to be applied as a stand-alone intervention in a home-based level of care. This paper describes the rationale for and process of adapting FBT principles/interventions to improve fit within a home-based model delivered in the context of community mental health, and discusses potential strengths and opportunities associated with this approach.

RESULTS

Adaptations were made through consultation with collaborating community agencies and were guided by the complex interventions framework. The primary modifications included: (1) altered dose; (2) multiple family meals; (3) additional support for meal preparation and supervision; (4) clinician attendance at medical appointments; (5) cultural adaptation; and (6) introduction of distress tolerance and emotion regulation skills.

CONCLUSIONS

Implementing FBT in the home may present one promising and novel approach to enhance engagement and treatment outcomes for adolescents with restrictive eating disorders, particularly those who are underserved, but evaluation of efficacy/effectiveness is needed.