Treatment Protocols for Eating Disorders: Clinicians' Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions

Premature termination of eating disorder treatment - a qualitative study of therapist perspectives

BACKGROUND

High dropout rates are a problem in eating disorder treatment and the knowledge about how therapists who work in this field understand and intervene to reduce drop out is scarce. The aim of this study was to explore how therapists understand and work to prevent dropout during eating disorder treatment.

METHODS

Five focus group interviews with a total number of 17 therapists were conducted. The therapists all worked in specialized mental health care and had different occupational backgrounds, including psychologists, specialist nurses, and doctors. All of them reported receiving training in CBT-E. Transcripts were analysed using a reflexive thematic analysis.

RESULTS

Our analysis resulted in the development of three main themes: (1) Accepting dropout; (2) Balancing resources; and (3) Recognizing the demands of treatment.

CONCLUSIONS

Our findings suggest that preparation for treatment is conceptualized by therapists as something quite separate from treatment itself and as crucial for preventing dropout and providing good treatment results. Interestingly, interventions and processes during treatment received much less focus in the discussions among therapists during the interviews.

TRIAL REGISTRATION

This project has been approved by Regional Committees for Medical and Health Research Ethics in Norway (REK), REK-number 55,304.

Intervention research in anorexia nervosa - a plea for single case experimental designs

Anorexia nervosa (AN) is a severe eating disorder and among the mental disorders with the highest mortality rate. To date, not much is known about its development and maintenance, and treatment outcomes are improvable. At the same time, research on psychological interventions for AN is a complicated endeavor, often characterized by small sample sizes and methodological heterogeneity, which impedes the comparison and evaluation of treatment outcomes. In this paper, several population-related, therapist-related and methodological challenges that may be encountered during research on psychological interventions for AN are discussed. The use of single case experimental designs (SCEDs), which could account for several of these challenges, is suggested as a complementary approach to current methods of assessing treatment efficacy. The use of SCEDs could be beneficial to the field, by contributing to the knowledge about AN and to the development and evaluation of better treatments, which are sorely needed.

Quality of cognitive-behavioural therapy in routine psychiatric care: therapist adherence and competence, and patient outcomes for depression and anxiety disorders

BACKGROUND

Quality of care is essential for the dissemination of evidence-based practices, yet therapist adherence and competence are seldom assessed. We examined the quality of delivery of cognitive-behavioural therapy (CBT) in routine psychiatric care for depression and anxiety disorders, considering therapist adherence and competence, and therapy effectiveness, as well as their associations.

METHODS

Twenty-nine therapists recruited 85 patients with a principal diagnosis of depression or anxiety disorder from two routine psychiatric outpatient clinics in Stockholm, Sweden. Therapist adherence was assessed mid-CBT by observers and post-CBT by patients and therapists, respectively, using an instrument developed as part of the present study. Therapist competence was assessed using role-plays with a standardised patient. Patients rated symptoms, functional impairment, and global health pre- and post-CBT. Linear mixed models were used to analyse associations.

RESULTS

Therapist adherence was high according to patients, moderate to high according to therapists, and moderate according to observers. Most therapists demonstrated competence in CBT, as assessed using the Cognitive Therapy Scale-Revised (M = 40.5, SD = 6.5; 76% passed the ≥ 36 points competence threshold). Patients improved significantly from pre- to post-CBT across outcome measures (Cohen's ds = 0.80 - 1.36). Neither therapist adherence nor competence was associated with patient outcomes.

CONCLUSIONS

In routine psychiatric care, therapists delivered CBT with adherence, competence, and improvements for patients with depression and anxiety disorders, on par with previous research results in controlled settings. The implications for quality assessment and improvement are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03625024 10/08/2018.

Clinical Experiences Using Cognitive-Behavioral Therapy for Eating Disorders

Data suggests that despite the availability of evidence-based psychological treatments for eating disorders (EDs), techniques from these therapies may be less frequently used within real-life clinical practice. The aim of this study was to provide the opportunity for clinicians to give feedback on their experiences treating EDs using cognitive-behavioral therapy (CBT) through reporting on use of CBT techniques and barriers to treatment implementation in naturalistic settings. Clinicians (N = 126) who self-identified as using CBT for EDs reported demographic information, frequency/usefulness of empirically supported treatment techniques, problems/limitations of CBT, and barriers faced while implementing CBT. The most frequently used technique reported by clinicians was psychoeducation, and the least frequently used technique was use of surveys to address mind reading. Patients' unwillingness to follow a meal plan/nutritional guide was rated as the most impactful barrier, alongside ED severity. Of the problems/limitations of CBT, too little guidance on treating co-occurring symptoms was rated as the most impactful. This study provided a mechanism for clinicians to share their experiences using CBT for EDs in real-world settings. Overall, results regarding frequency of use and usefulness of techniques indicate a high level of endorsement. Moreover, the most frequently endorsed barriers to/limitations of CBT related to lack of guidance on treating complex ED presentations. Future research should explore ways to treat cases that go beyond the prototypical ED case and explore ways to adapt CBT to meet the needs of naturalistic treatment settings.

Development and usability testing of an online platform for provider training and implementation of cognitive-behavioral therapy guided self-help for eating disorders

Background

Most individuals with eating disorders (EDs) do not receive treatment, and those who do receive care typically do not receive evidence-based treatment, partly due to lack of accessible provider training. This study developed a novel "all-in-one" online platform for disseminating training for mental health providers in cognitive-behavioral therapy guided self-help (CBTgsh) for EDs and supporting its implementation. The aim of the study was to obtain usability data from the online platform prior to evaluating its effects on provider training outcomes and patient ED symptom outcomes in an open pilot trial.

Methods

Nine mental health provider participants (n = 4 in Cycle 1; n = 5 in Cycle 2) and 9 patient participants (n = 4 in Cycle 1; n = 5 in Cycle 2) were enrolled over two cycles of usability testing. In Cycle 1, we recruited providers and patients separately to complete brief platform testing sessions. In Cycle 2, we recruited provider-patient dyads; providers completed training using the platform and subsequently delivered CBTgsh to a patient for three weeks. Usability was assessed using the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), and semi-structured interviews.

Results

Interview feedback converged on two themes for providers (applicability of program for real-world use, platform structure and function) and two themes for patients (barriers and facilitators to engagement, perceived treatment effects). SUS and USE scores were in the "average" to "good" ranges across cycles.

Conclusions

Findings from this study demonstrate preliminary feasibility and acceptability of the online platform. Data collected in this study will inform further refinements to the online platform. The platform's effects on provider training outcomes and patient ED symptom outcomes will be evaluated in an open pilot trial. Given the wide treatment gap for EDs and barriers to dissemination and implementation of evidence-based treatments, the online platform represents a scalable solution that could improve access to evidence-based care for EDs.

Does embedding pediatric eating disorder treatment in primary care bridge the access gap?

Given the numerous barriers to accessing child and adolescent eating disorder treatment, there is a need for innovation in how this care is delivered. Primary care-based eating disorder treatment has established proof-of-concept, yet it is unclear whether this model can bridge the treatment-access gap. This retrospective chart review study compared demographic and illness characteristics of 106 adolescents (M age = 15.1 years)  SD = 1.8 consecutively evaluated in a primary care-based eating disorder clinic with 103 adolescent patients (M age = 15.2 years)  SD = 2.2 seen consecutively in a specialty eating disorder clinic at the same medical center. Relative to adolescents in specialty care, those in the primary care group presented at a significantly higher BMI percentile, had less weight suppression, a shorter illness duration, lower rates of amenorrhea and lower scores on the EDE-Q Dietary Restraint subscale. In addition, more patients in the primary care group identified as non-white and had government/public assistance insurance compared to those in the specialty group. The results suggest that, compared to traditional specialty care clinics, embedded eating disorder treatment in primary care may reach a more racially and socioeconomically diverse group of adolescents when they are earlier in the course of their illness. Future research determining the relative effectiveness of this model as compared to interventions delivered in specialty care is needed.

Staging models in eating disorders: A systematic scoping review of the literature

Eating Disorders (ED) are characterized by low remission rates, treatment drop-out, and residual symptoms. To improve assessment and treatment of ED, the staging approach has been proposed. This systematic scoping review is aimed at mapping the existing staging models that explicitly propose stages of the progression of ED. A systematic search of PubMed, PsycINFO, Scopus was conducted with the terms staging, anorexia nervosa, bulimia nervosa, binge-eating disorders, eating disorders. Eleven studies met inclusion criteria presenting nine ED staging models, mostly for anorexia nervosa. Three were empirically tested, one of which was through an objective measure specifically developed to differentiate between stages. Most staging models featured early stages in which the exacerbation of EDs unfolds and acute phases are followed by chronic stages. Intermediate stages were not limited to acute stages, but also residual phases, remission, relapse, and recovery. The criteria for stage differentiation encompassed behavioral, psychological, cognitive, and physical features including body mass index and illness duration. One study recommended stage-oriented interventions. The current review underscores the need to empirically test the available staging models and to develop and test new proposals of staging models for other ED populations. The inclusion of criteria based on medical features and biomarkers is recommended. Staging models can potentially guide assessment and interventions in daily clinical settings.

Understanding drift in the treatment of eating disorders using a mixed-methods approach

Despite strong empirical support for treatments of eating disorders, research has demonstrated a trend of clinicians deviating from protocols outlined in empirically supported manuals. The present study used a convergent mixed-methods design to understand clinicians' use of and drift from empirically supported treatments in a sample of 114 licensed clinicians in the US who had substantial experience (i.e. one-third of caseload) working with patients with eating disorders and training in cognitive-behavioral therapy (CBT), family-based therapy (FBT), and/or interpersonal therapy (IPT) for eating disorders. Results revealed that 63.7-76.3% of clinicians drift from empirically supported treatments and 71.8% were aware they deviated from empirically supported treatments. Qualitative analyses identified client differences (57.2%) to be the primary reason why clinicians drift, with less participants describing therapist factors (20.4%), treatment shortcomings (12.6%), treatment setting (11.7%), logistic constraints (4.9%) and family factors (4.9%) as reasons why they drift. These findings suggest that drift for most clinicians may be better explained under the umbrella of evidence-based practice. Clinicians also identified a number of ways in which treatment and access to treatment can be improved. This broadened understanding of the use of empirically supported treatments within evidence-based practice may serve to help bridge the gap between research and practice.

The Role of Primary Care in Bridging Adolescents Awaiting Eating Disorder Treatment

The striking rise in adolescent eating disorders since the severe acute respiratory coronavirus syndrome 2 pandemic has amplified demands for specialty eating disorders services and contributed to protracted delays in care. In the context of these delays, patients are at risk for increased weight loss, medical instability, escalating disease progression and poor prognosis. Primary care providers (PCPs) are frequently the first point of contact for young patients with eating disorders and are often left to bridge the gap while families struggle to establish specialty care. Yet, beyond case detection and medical comanagement, there are no evidence-based guidelines that can assist PCPs to prepare families for treatment, halt disease progression, and begin the lengthy process of weight and nutritional restoration in efforts to reduce medical complications and support a favorable prognosis. We present the case of a 13-year-old girl with a restrictive eating disorder to illustrate how PCPs can use intervention principles and strategies derived from evidence-based eating disorder treatment to successfully manage adolescent patients until they can access specialty treatment. We offer concrete guidelines for decision-making, as well as suggested behavioral and medical interventions for the PCP. With evidence-based tools, PCPs are well-positioned to support young patients with restrictive eating disorders and their family members as they begin the process of recovery from an eating disorder.

Adapting a mobile app to support patients with anorexia nervosa following post-acute care: perspectives from eating disorder treatment center stakeholders

Introduction

Anorexia nervosa (AN) is a harmful, life-threatening illness. Patients with severe AN often receive acute treatment but, upon discharge, experience high relapse rates. Evidence-based, outpatient treatment following acute care is critical to preventing relapse; however, numerous barriers (e.g., location, financial limitations, low availability of providers) preclude individuals from accessing treatment. mHealth technologies may help to address these barriers, but research on such digital approaches for those with AN is limited. Further, such technologies should be developed with all relevant stakeholder input considered from the outset. As such, the present study aimed to garner feedback from eating disorder (ED) treatment center providers on (1) the process of discharging patients to outpatient services, (2) their experiences with technology as a treatment tool, and (3) how future mHealth technologies may be harnessed to offer the most benefit to patients in the post-acute period.

Methods

Participants (N = 11, from 7 ED treatment centers across the United States) were interviewed. To analyze the data for this study, each interview was manually transcribed and analyzed using components of Braun and Clarke's six-phase thematic analysis framework (Braun & Clarke, 2006).

Results

Participants indicated proactively securing outpatient care for their patients, but mentioned several barriers their patients face in accessing evidence-based ED treatment. All participants had some experience using various technologies for treatment (e.g., teletherapy, self-monitoring apps), and mentioned a high level of interest in the development of a new app to be used by patients recently discharged from acute treatment for AN. Participants also offered suggestions of effective and relevant content for a potential app and adjunctive social networking component for post-acute care of AN.

Discussion

Overall, participants expressed positive attitudes toward the integration of an app into the care flow, suggesting the high potential benefit of harnessing technology to support individuals recovering from AN.

Eating Disorder Screening and Treatment in a Medically Underserved Southern State: Data Collected by a Legislative Eating Disorder Council and Implications for Statewide Assessment

Healthcare providers play a key role in early identification of eating disorders (EDs), especially in underserved states where ED treatment resources are lacking. Currently, there is little known about ED screening and treatment practices in underserved states. The current study assessed current ED screening and treatment practices among healthcare providers in an underserved state using data collected by a government-formed state ED council. Healthcare providers (N = 242; n = 209 behavioral health providers; n = 33 medical providers) practicing in Kentucky completed a brief, anonymous survey on ED screening and treatment practices, comfort with screening for EDs, and interest in continued education. Over half of healthcare providers indicated screening for EDs, with the majority using a clinical interview. After identification of ED symptoms, providers reported a combination of treating in-house, referring out, or seeking consultation. In bivariate analyses, medical providers were significantly more likely than behavioral health providers to use a screening tool specifically designed for EDs. The majority of medical providers indicated that they received education about EDs and feel knowledgeable about ED screening tools, though most reported infrequent use of these screening tools in their practice. Nearly all behavioral health and medical providers expressed interest in continuing education on ED screening and treatment. These findings indicate a need for, and interest in, education on evidence-based ED screening and treatment resources in underserved states and demonstrate the utility of a state ED council to collect these data to inform future education and treatment strategies.

Predictors of family-based treatment for adolescent eating disorders: Do family or diagnostic factors matter?

OBJECTIVE

Misconceptions around which patients will and will not benefit from family-based treatment (FBT) for adolescent eating disorders (EDs) limit referrals and access to this treatment modality. The present study explored whether common demographic and clinical factors that may prevent referral to FBT predict treatment outcomes in adolescent anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

The following predictors of treatment outcomes were assessed: baseline family and diagnostic factors (socioeconomic status, comorbidity, illness duration, parent feelings of self-efficacy, family status, prior treatment, sex and prior hospitalizations) in a combined sample of adolescents receiving FBT compared to those randomized to other treatment conditions, across six clinical trials in the United States and Canada (total n = 724, ages 12-18, 90% female across both diagnoses). AN and BN samples were examined separately.

RESULTS

Any prior ED treatment emerged as the only predictor of outcome in AN and BN, such that having no prior treatment predicted better outcomes in FBT for AN, and in both FBT and other treatment modalities for BN. No other sociodemographic or clinical variables predicted outcomes for AN or BN in FBT or in other evidence-based treatment modalities.

CONCLUSIONS

The findings of this exploratory analysis suggest that commonly assumed factors do not predict outcome in FBT. Specifically socioeconomic and demographic factors or clinical variability in families seeking treatment do not predict treatment outcomes in FBT, or other evidence-based treatment modalities, with the exception of prior treatment. Providers should consider referring to FBT even when these factors are present.

PUBLIC SIGNIFICANCE

This manuscript reports that commonly assumed family, sociodemographic and diagnostic factors do not predict outcome in FBT or other evidence-based treatment modalities, with the exception of prior treatment. This data may be helpful for providers when considering referrals to FBT in the context of variability in these variables.

Effectiveness of delivering evidence-based eating disorder treatment via telemedicine for children, adolescents, and youth

Barriers limit access to eating disorder treatment. Evidence-based treatment delivered using telemedicine could expand access. This study determined the effectiveness of enhanced Family-Based Treatment (FBT+) delivered using telemedicine for children and adolescents with eating disorders. Participants had a confirmed eating disorder diagnosis, lived in states where treatment was available, and lived with a family member willing to participate. Virtual FBT+ was administered by a five-person team including a therapist, dietitian, medical provider, peer mentor, and family mentor for up to 12 months. Measures were recorded at baseline and varying frequencies throughout treatment. Weight was self-reported. Eating disorder symptoms were assessed with the Eating Disorder Examination-Questionnaire Short Form (EDE-QS) and depression and anxiety were measured using the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7). Caregiver burden and self-efficacy were measured using the Burden Assessment Scale, and Parent Versus Eating Disorder scale. The majority of patients (N = 210; 6 to 24 years old [mean 16 · 1 years]) were cisgender female (83%) White, (71%), required weight restoration (78%), and had anorexia nervosa, restricting type (63%). After 16 weeks, patients on weight restoration gained on average 11 · 3 [9 · 86, 12 · 8] pounds and the average change in EDE-QS score was -6 · 31 [-8 · 67, -4 · 10] points. Similar reductions were seen for depression (-2 · 62 [-4 · 24, -1 · 04]), anxiety (-1 · 44 [-1 · 12, 0 · 78]), and caregiver burden (-4 · 41 [2 · 45, 6 · 31]). Caregiver self-efficacy increased by 4 · 56 [3 · 53, 5 · 61] points. Patients and caregivers reported satisfaction with treatment. Virtual FBT+ for eating disorders can transcend geographical and psychosocial treatment barriers, expanding access to evidence-based eating disorder treatment.

Accessibility of Psychological Treatments for Bulimia Nervosa: A Review of Efficacy and Engagement in Online Self-Help Treatments

Bulimia nervosa is an eating disorder characterised by marked impairment to one's physical health and social functioning, as well as high rates of chronicity and comorbidity. This literature review aims to summarise existing academic research related to the symptom profile of BN, the costs and burden imposed by the illness, barriers to the receipt of care, and the evidence base for available psychological treatments. As a consequence of well-documented difficulties in accessing evidence-based treatments for eating disorders, efforts have been made towards developing innovative, diverse channels to deliver treatment, with several of these attempting to harness the potential of digital platforms. In response to the increasing number of trials investigating the utility of online treatments, this paper provides a critical review of previous attempts to examine digital interventions in the treatment of eating disorders. The results of a focused literature review are presented, including a detailed synthesis of a knowledgeable selection of high-quality articles with the aim of providing an update on the current state of research in the field. The results of the review highlight the potential for online self-help treatments to produce moderately sized reductions in core behavioural and cognitive symptoms of eating disorders. However, concern is raised regarding the methodological limitations of previous research in the field, as well as the high rates of dropout and poor adherence reported across most studies. The review suggests directions for future research, including the need to replicate previous findings using rigorous study design and methodology, as well as further investigation regarding the utility of clinician support and interactive digital features as potential mechanisms for offsetting low rates of engagement with online treatments.

Integrating clinician and patient case conceptualization with momentary assessment data to construct idiographic networks: Moving toward personalized treatment for eating disorders

Eating disorders are serious psychiatric illnesses with treatments ineffective for about 50% of individuals due to high heterogeneity of symptom presentation even within the same diagnoses, a lack of personalized treatments to address this heterogeneity, and the fact that clinicians are left to rely upon their own judgment to decide how to personalize treatment. Idiographic (personalized) networks can be estimated from ecological momentary assessment data, and have been used to investigate central symptoms, which are theorized to be fruitful treatment targets. However, both efficacy of treatment target selection and implementation with 'real world' clinicians could be maximized if clinician input is integrated into such networks. An emerging line of research is therefore proposing to integrate case conceptualizations and statistical routines, tying together the benefits from clinical expertise as well as patient experience and idiographic networks. The current pilot compares personalized treatment implications from different approaches to constructing idiographic networks. For two patients with a diagnosis of anorexia nervosa, we compared idiographic networks 1) based on the case conceptualization from clinician and patient, 2) estimated from patient EMA data (the current default in the literature), and 3) based on a combination of case conceptualization and patient EMA data networks, drawing on informative priors in Bayesian inference. Centrality-based treatment recommendations differed to varying extent between these approaches for patients. We discuss implications from these findings, as well as how these models may inform clinical practice by pairing evidence-based treatments with identified treatment targets.

Parent and clinician perspectives on virtual guided self-help family-based treatment (GSH-FBT) for adolescents with anorexia nervosa

PURPOSE

Guided self-help (GSH) treatments have the capacity to expand access to care, decrease costs, and increase dissemination compared to traditional therapist-directed treatment approaches. However, little is known about parent and clinician perspectives about the acceptability of GSH for adolescents with eating disorders.

METHODS

This study utilized a mixed methods approach to obtain qualitative and quantitative data regarding clinician and participants' experiences with GSH. Parent participants were enrolled in a randomized trial comparing GSH family-based treatment (GSH-FBT) to family-based treatment delivered via videoconferencing (FBT-V) for adolescents (12-18 years old) with a DSM-5 diagnosis of anorexia nervosa (AN). Parent participants provided qualitative feedback using the Helping Alliances Questionnaire about their experience of treatment. Clinician participants were six master's or PhD-level therapists. These clinicians were trained in and provided both treatments (GSH-FBT and FBT-V). They provided responses to questionnaires and participated in a 1-h focus group about their experience as treatment providers.

RESULTS

Regardless of treatment condition, parents listed more improvement than worsening of symptoms in their child with AN. Clinicians reported lower scores on competency and comfort metrics with GSH-FBT compared to FBT-V. Qualitatively, clinicians reported both advantages and disadvantages of delivering GSH-FBT.

CONCLUSION

Further studies are needed to better understand how GSH interventions can be disseminated to patients and families, particularly those with limited access to specialized eating disorder treatment centers. Level of evidence Level I, data collected as part of a randomized controlled trial.

Barriers and Facilitators to the Implementation of an Eating Disorders Knowledge Exchange Program for Non-specialist Professionals

Despite availability of evidence-based treatments for eating disorders (EDs), individuals with EDs often do not receive informed treatment. Training of non-specialized clinicians by experienced professionals through knowledge exchange (KE) programs is an effective way to enhance accessibility to evidence-based treatments for EDs. The authors conducted a qualitative analysis of factors that facilitated or impeded the uptake of an ED-focused KE program. Semi-structured interviews were conducted with mental health professionals (n = 43) and managers (n = 11) at 13 community mental-health sites at which the KE program was offered. Data were analyzed using a qualitative content analysis. Key facilitators identified were management support for the program and building competence through ongoing supervision of clinicians. Main barriers were limited access to ED patients to treat and having insufficient time to apply ED interventions in front-line settings. The results provide insights into the practical imperatives involved in implementing a KE initiative for ED treatment.

Developing, Deploying, and Evaluating Digital Mental Health Interventions in Spaces of Online Help- and Information-Seeking

The internet is frequently the first point of contact for people seeking support for their mental health symptoms. Digital interventions designed to be deployed through the internet have significant promise to reach diverse populations who may not have access to, or are not yet engaged in, treatment and deliver evidence-based resources to address symptoms. The liminal nature of online interactions requires designing to prioritize needs detection, intervention potency, and efficiency. Real-world implementation, data privacy and safety are equally important and can involve transparent partnerships with stakeholders in industry and non-profit organizations. This commentary highlights challenges and opportunities for research in this space, grounded in learnings from multiple research projects and teams aligned with this effort.

Feasibility of guided internet-based cognitive behavioral therapy for patients with anorexia nervosa

OBJECTIVE

The objective of the present study was to investigate the feasibility of guided internet cognitive behavioral therapy (ICBT) for anorexia nervosa.

METHODS

We conducted a prospective single-arm study between January 2020 and March 2021. The intervention was built using videos, web programs, and chat tools. The intervention program was largely based on metacognitive training. Participants performed the self-help program once a week for 12 consecutive weeks. The primary outcome was the global Eating Disorder Examination Questionnaire (EDE-Q) score. Secondary outcomes included clinical symptoms of eating disorders, metacognitive function, body mass index, depression, and generalized anxiety. The main statistical analysis examined whether the EDE-Q score and other outcomes at the end of the intervention differed from the baseline.

RESULTS

Fourteen participants underwent the trial treatment, and 13 completed the intervention. There was a significant reduction in the global EDE-Q score from 3.48 (SD = 1.4) to 2.54 (SD = 1.5, p = 0.02, Cohen's d = 0.75) from baseline to post-intervention. Some EDE-Q subscales and body checking questionnaire scale demonstrated statistically significant improvements, with moderate to large effect sizes. Although there was no significant improvement in body mass index, metacognitive function, or depressive symptoms, there was a significant improvement in the severity of generalized anxiety (M = -4.0, p = 0.01, Cohen's d = 0.95). No adverse events were observed.

DISCUSSION

Our findings suggest that guided ICBT for anorexia nervosa is well accepted by female patients and practical as a telemedicine approach that improves symptoms. In the future, tightly controlled randomized controlled trials should be conducted for efficacy verification.

Experiences when implementing enhanced cognitive behavioral therapy as a standard treatment for anorexia nervosa in outpatients at a public specialized eating-disorder treatment unit

BACKGROUND

Enhanced cognitive behavioral therapy (CBT-E) is a promising treatment option for outpatients with anorexia nervosa (AN). We aimed to determine the effectiveness of CBT-E as a standard treatment for adult outpatients with AN from the specialized eating-disorder unit of a public hospital with responsibilities to their catchment area.

METHODS

This study had an open, longitudinal design. Thirty three (of planned 100) outpatients aged > 16 years suffering from AN were included to receive 40 sessions of CBT-E. Eating-disorder psychopathology and body mass index (BMI) were assessed before and after treatment, while comorbid psychiatric symptoms and trauma experiences were evaluated at the baseline, and therapeutic alliance was assessed after 4 weeks of treatment.

RESULTS

A high proportion (69%) of patients dropped out of the treatment. Patient recovery was considered when they reached BMI > 18.5 and Eating Disorder Examination Questionnaire (EDE-Q) score < 2.5, and 27% of all patients recovered.

CONCLUSIONS

Patients who completed the treatment had mostly satisfactory outcomes. Considering the high dropout rate, it is necessary to improve the strategies for engaging patients in therapy. Several aspects of CBT-E as a standard treatment are discussed regarding the high dropout rate. Trial registration ClinicalTrials.gov. Identifier: NCT02745067. Registered: April 20, 2016. https://clinicaltrials.gov/ct2/showNCT02745067.

Experiences of eating disorders from the perspectives of patients, family members and health care professionals: a meta-review of qualitative evidence syntheses

BACKGROUND

Eating disorders are serious conditions that cause major suffering for patients and their families. Better knowledge about perceptions of eating disorders and their treatment, and which factors that facilitate or hinder recovery, is desired in order to develop the clinical work. We aimed to explore and synthesise experiences of eating disorders from the perspectives of those suffering from an eating disorder, their family members and health care professionals through an overarching meta-review of systematic reviews in the field.

METHODS

A systematic literature search was conducted in the databases PubMed, PsycInfo, Scopus, and CINAHL. Inclusion criteria were systematic reviews of qualitative research on experiences, perceptions, needs, or desires related to eating disorders from the perspective of patients, family members or health care professionals. Systematic reviews that fulfilled the inclusion criteria were assessed for relevance and methodological limitations by at least two researchers independently. The key findings were analysed and synthesised into themes.

RESULTS

We identified 17 systematic reviews that met our inclusion criteria. Of these, 13 reviews reported on the patients' perspective, five on the family members' perspective, and three on the health care professionals' perspective. The study population in the reviews was predominantly girls and young women with anorexia nervosa, whilst systematic reviews focusing on other eating disorders were scarce. The findings regarding each of the three perspectives resulted in themes that could be synthesised into three overarching themes: 1) being in control or being controlled, 2) balancing physical recovery and psychological needs, and 3) trusting relationships.

CONCLUSIONS

There were several similarities between the views of patients, family members and health care professionals, especially regarding the significance of building trustful therapeutic alliances that also included family members. However, the informants sometimes differed in their views, particularly on the use of the biomedical model, which was seen as helpful by health care professionals, while patients and family members felt that it failed to address their psychological distress. Acknowledging these differences is important for the understanding of anorexia nervosa and other eating disorders, and may help clinicians to broaden treatment approaches to meet the expectations of patients and family members.

From research to practice: a model for clinical implementation of evidence-based outpatient interventions for eating disorders

BACKGROUND

A question frequently raised in the field is whether evidence-based interventions have adequate translational capacity for delivery in real-world settings where patients are presumed to be more complex, clinicians less specialized, and multidisciplinary teams less coordinated. The dual purpose of this article is to (a) outline a model for implementing evidence-driven, outpatient treatments for eating disorders in a non-academic clinical setting, and (b) report indicators of feasibility and quality of care.

MAIN BODY

Since our inception (2015), we have completed nearly 1000 phone intakes, with first-quarter 2021 data suggesting an increase in the context of COVID-19. Our caseload for the practice currently consists of approximately 200 active patients ranging from 6 to 66 years of age. While the center serves a transdiagnostic and trans-developmental eating disorder population, modal concerns for which we receive inquiries are Anorexia Nervosa and Avoidant Restrictive Food Intake Disorder, with the most common age range for prospective patients spanning childhood through late adolescence/emerging adulthood; correspondingly, the modal intervention employed is Family-based treatment. Our team for each case consists, at a minimum, of a primary internal therapist and a physician external to the center.

SHORT CONCLUSION

We will describe our processes of recruiting, training and coordinating team members, of ensuring ongoing fidelity to evidence-based interventions, and of training the next generation of clinicians. Future research will focus on a formal assessment of patient outcomes, with comparison to benchmark outcomes from randomized controlled trials.

Challenging rigidity in Anorexia (treatment, training and supervision): questioning manual adherence in the face of complexity

BACKGROUND

Anorexia Nervosa is a debilitating illness. While there have been many advancements to treatment protocols and outcomes for people with eating disorders, the field acknowledges there remains considerable room for improvement. This timely Special Edition of the Journal of Eating Disorders has invited those of us in the field to consider a range of topics in aid of this task, including potential modifications and implementation of evidence-based practice, specific and common psychotherapy factors, treatment manuals, adherence and individualising treatment approaches for individuals and families. BODY: In this paper, we briefly outline the key manualised treatments currently available to treat children, adolescents and adults with Anorexia Nervosa, considering the benefits, potential reasons for adaptations and limitations. We then review the current evidence for training strict adherence to treatment manuals which is often a key focus in training and supervision, questioning the association of increased treatment adherence with improved therapeutic outcome. We then summarise some key evidence behind other therapeutic factors which have been demonstrated to affect outcome regardless of which manual is implemented, such as readiness to change and therapeutic alliance.

CONCLUSION

The paper concludes with implications and considerations for future research, clinical guidelines, training and supervision, highlighting the need to consider the therapeutic relationship and processes alongside manual content to conduct best evidence-informed practice.

Formulation in eating disorder focused family therapy: why, when and how?

In the broadest sense, formulation, or case conceptualisation, is the process of collaborative sense-making. It is something all clinicians are doing constantly, whether formally and consciously or not. Most clinicians are familiar with the general principals and need to formulate as it is a core part of clinical training across most disciplines. Treatment manuals often discuss formulation, but the practical steps involved and the process of developing, building upon and revising formulations are not always provided. In clinical practice, the active use and continued development of formulation during treatment is not always prioritised, especially beyond the initial assessment. This could be due to a number of reasons, such as a potential lack of clarity, understanding or confidence in the use of formulation across treatment, a lack of dedicated time and reflective space for formulation in the context of increasingly busy clinical settings, or a perception that it may be less necessary in the context of treatment approaches that are more structured and prescriptive. This article outlines the use of formulation in family therapy for child and adolescent eating disorders, provides guidance on how to actively include formulation more throughout treatment and discusses why this might be useful.

Virtually delivered family-based eating disorder treatment using an enhanced multidisciplinary care team: A case study

Both patients experienced meaningful clinical improvements with this virtual approach and the augmented treatment team in regards to weight gain, acceptability, and clinical assessment scores. These findings offer preliminary support for this model.

How precisely can psychotherapists predict the long-term outcome of anorexia nervosa and bulimia nervosa at the end of inpatient treatment?

OBJECTIVE

To assess the ability of psychotherapists to predict the future outcome for inpatients with anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

Psychotherapists rated the prognosis of the patient's eating disorder on a five point Likert scale on several dimensions at the end of inpatient treatment. Actual outcome was assessed about 10 years after treatment. The sample comprised 1,065 patients treated for AN, and 1,192 patients treated for BN.

RESULTS

Psychotherapists' rating of their patient's prognosis was not better than chance for good outcome in AN and BN and for poor outcome in BN. Prediction of poor outcome in AN was somewhat better with approximately two thirds of correct predictions. In logistic regression analysis, psychotherapists' rating of the patients' prognosis for AN contributed to the explained variance of long-term outcome, increasing the variance explained from 7% (by conventional predictors) to 8% after including psychotherapists' prognosis. In BN, there was no significant contribution of psychotherapists' prognosis to overall prediction.

DISCUSSION

Our current knowledge of risk and protective factors for the course of eating disorders is unsatisfying. More specialized research is urgently needed.

ANZAED practice and training standards for mental health professionals providing eating disorder treatment

INTRODUCTION

The Australia & New Zealand Academy for Eating Disorders (ANZAED) recently developed general principles and clinical practice standards recommended for mental health clinicians and dietitians providing treatment for people with eating disorders. Separate mental health practice and training standards were then devised as a foundation for strengthening the workforce and providing guidance to professional training programs and service providers on the minimal standards required for practice in the eating disorder field.

RECOMMENDATIONS

The present recommendations for mental health professionals providing eating disorder treatment describe the following practice and training standards: eating disorder treatment foundations (including co-ordination of services, establishing a positive therapeutic alliance, professional responsibility and knowledge of levels of care), assessment, diagnosis, intervention (including evidence-based intervention, managing psychiatric risk and managing co-morbid mental health problems), and monitoring and evaluation.

CONCLUSIONS

Further work is required to disseminate these standards to clinicians providing services across Australia to people with eating disorders, and to support adherence in the clinic room where they can translate to improved outcomes for clients. Pathways to supporting adherence include expert supervision of practice, incorporation in training and supervised practice in university settings, and support with checklists that can be used by consumers and referring professionals.

Effectiveness of a Digital Cognitive Behavior Therapy-Guided Self-Help Intervention for Eating Disorders in College Women: A Cluster Randomized Clinical Trial

Importance

Eating disorders (EDs) are common, serious psychiatric disorders on college campuses, yet most affected individuals do not receive treatment. Digital interventions have the potential to bridge this gap.

Objective

To determine whether a coached, digital, cognitive behavior therapy (CBT) intervention improves outcomes for college women with EDs compared with referral to usual care.

Design, Setting, and Participants

This cluster randomized trial was conducted from 2014 to 2018 at 27 US universities. Women with binge-purge EDs (with both threshold and subthreshold presentations) were recruited from enrolled universities. The 690 participants were followed up for up to 2 years after the intervention. Data analysis was performed from February to September 2019.

Interventions

Universities were randomized to the intervention, Student Bodies-Eating Disorders, a digital CBT-guided self-help program, or to referral to usual care.

Main Outcomes and Measures

The main outcome was change in overall ED psychopathology. Secondary outcomes were abstinence from binge eating and compensatory behaviors, as well as ED behavior frequencies, depression, anxiety, clinical impairment, academic impairment, and realized treatment access.

Results

A total of 690 women with EDs (mean [SD] age, 22.12 [4.85] years; 414 [60.0%] White; 120 [17.4%] Hispanic; 512 [74.2%] undergraduates) were included in the analyses. For ED psychopathology, there was a significantly greater reduction in the intervention group compared with the control group at the postintervention assessment (β [SE], -0.44 [0.10]; d = -0.40; t1387 = -4.23; P < .001), as well as over the follow-up period (β [SE], -0.39 [0.12]; d = -0.35; t1387 = -3.30; P < .001). There was not a significant difference in abstinence from any ED behaviors at the postintervention assessment (odds ratio, 1.48; 95% CI, 0.48-4.62; P = .50) or at follow-up (odds ratio, 1.51; 95% CI, 0.63-3.58; P = .36). Compared with the control group, the intervention group had significantly greater reductions in binge eating (rate ratio, 0.82; 95% CI, 0.70-0.96; P = .02), compensatory behaviors (rate ratio, 0.68; 95% CI, 0.54-0.86; P < .001), depression (β [SE], -1.34 [0.53]; d = -0.22; t1387 = -2.52; P = .01), and clinical impairment (β [SE], -2.33 [0.94]; d = -0.21; t1387 = -2.49; P = .01) at the postintervention assessment, with these gains sustained through follow-up for all outcomes except binge eating. Groups did not differ in terms of academic impairment. The majority of intervention participants (318 of 385 participants [83%]) began the intervention, whereas only 28% of control participants (76 of 271 participants with follow-up data available) sought treatment for their ED (odds ratio, 12.36; 95% CI, 8.73-17.51; P < .001).

Conclusions and Relevance

In this cluster randomized clinical trial comparing a coached, digital CBT intervention with referral to usual care, the intervention was effective in reducing ED psychopathology, compensatory behaviors, depression, and clinical impairment through long-term follow-up, as well as realizing treatment access. No difference was found between the intervention and control groups for abstinence for all ED behaviors or academic impairment. Given its scalability, a coached, digital, CBT intervention for college women with EDs has the potential to address the wide treatment gap for these disorders.

Trial Registration

ClinicalTrials.gov Identifier: NCT02076464.

Treating Eating: A Dynamical Systems Model of Eating Disorders

Mainstream forms of psychiatric talk therapy and cognitive behavioral therapy (CBT) do not reliably generate lasting recovery for eating disorders. We discuss widespread assumptions regarding the nature of eating disorders as fundamentally psychological disorders and highlight the problems that underlie these notions, as well as related practical problems in the implementation of mainstream treatments. We then offer a theoretical and practical alternative: a dynamical systems model of eating disorders in which behavioral interventions are foregrounded as powerful mediators between psychological and physical states. We go on to present empirical evidence for behavioral modification specifically of eating speed in the treatment of eating disorders, and a hypothesis accounting for the etiology and progression, as well as the effective treatment, of the full spectrum of eating problems. A dynamical systems approach mandates that in any dietary and lifestyle change as profound as recovery from an eating disorder, acknowledgment must be made of the full range of pragmatic (psychological, cultural, social, etc.) factors involved. However, normalizing eating speed may be necessary if not sufficient for the development of a reliable treatment for the full spectrum of eating disorders, in its role as a mediator in the complex feedback loops that connect the biology and the psychology with the behaviors of eating.

Implementing cognitive behavioral therapy-enhanced in a routine inpatient and outpatient setting: Comparing effectiveness and treatment costs in two consecutive cohorts

BACKGROUND

Even though evidence-based interventions can enhance clinical outcomes and cost effectiveness, in the field of eating disorders, implementation of empirically supported treatments (ESTs) in routine inpatient and outpatient settings is slow.

OBJECTIVE

This study examined differential (cost-) effectiveness, after implementing evidence-based cognitive behavioral therapy-enhanced (CBT-E) throughout a Dutch treatment center.

METHOD

Two consecutive cohorts of adult patients, BMI between 17.5 and 40, were compared, with one cohort (N = 239) receiving treatment-as-usual (TAU) between 2012 and 2014 and the other (N = 320) receiving CBT-E between 2015 and 2017.

RESULTS

Eating disorder pathology, measured with self-reports, decreased significantly in both cohorts; overall, no differences in clinical outcomes between both cohorts were found. Treatment costs and treatment duration were considerably lower in 2015-2017. When limiting the cost analysis to direct costs, there is a 71% likelihood that CBT-E is more cost-effective and a 29% likelihood that CBT-E leads to fewer remissions at lower costs, based on the distribution of the cost-effectiveness plane. The likelihood that TAU leads to lower costs is 0%.

DISCUSSION

Findings show that implementing an EST throughout inpatient and outpatient settings leads to lower costs with similar treatment effect and has the advantage of shorter treatment duration and a shorter inpatient stay.

Outpatient treatment for adults with complex eating disorders and co-morbid conditions: a decision making model and case example

Although Cognitive Behavioral Therapy (CBT-E) for eating disorders has the most empirical support for the outpatient treatment of adult eating disorders (EDs), this model does not include a focus on intense emotion dysregulation, suicidality, and non-suicidal self-injury (NSSI). Furthermore, a subset of patients do not achieve sustained remission with CBT-E. Given that Dialectical Behavior Therapy (DBT) was designed for treatment refractory, complex patients, clinicians must be able to use assessment information to determine which type of treatment to use. The aims of this manuscript are to 1) describe a DBT-based and research-informed conceptual model for treatment decision making for an outpatient non-academic setting, 2) present a case example of a client with significant ED symptoms and complex medical and psychiatric comorbidities, using this decision making model and 3) present descriptive data from a private practice setting in which patients are referred to DBT vs. CBT-E according to this decision making model.

Therapist adherence to family-based treatment for adolescents with anorexia nervosa: A multi-site exploratory study

OBJECTIVE

This exploratory study is the first to examine family-based treatment (FBT) adherence and association to treatment outcome in the context of a large-scale, multi-centre study for the treatment of adolescents with anorexia nervosa.

METHOD

One hundred and ninety recorded FBT sessions from 68 adolescents with anorexia nervosa and their families were recruited across multiple sites (N = 6). Each site provided 1-4 tapes per family over four treatment time points, and each was independently rated for therapist adherence.

RESULTS

There were differences in adherence scores within and between sites. ANOVA produced a main effect for site, F(5, 46) = 8.6, p < .001, and phase, F(3, 42) = 12.7, p < .001, with adherence decreasing in later phases. Adherence was not associated to end of treatment percent ideal body weight after controlling for baseline percent ideal body weight (r = .088, p = .48).

CONCLUSIONS

Results suggest that FBT can be delivered with adherence in phase one of treatment. Adherence was not associated with treatment outcome as determined using percent ideal body weight.

Developing more efficient, effective, and disseminable treatments for eating disorders: an overview of the multiphase optimization strategy

The present manuscript describes the multiphase optimization strategy (MOST) and its potential applications to treatments for eating disorders (EDs). The manuscript describes the three phases of MOST, discusses a hypothetical case example of how MOST could be applied to developing a disseminable ED treatment, and reviews the pros and cons of the MOST approach. Outcomes from treatments for EDs leave room for improvement. However, traditional methods of treatment development and evaluation (i.e., the treatment package approach) make it challenging to determine how best to improve ED treatments. For example, testing full treatment packages in open trials and RCTs without systematic testing of each component is inefficient (as it is unknown which components are effective), and often does not provide concrete future directions for optimization of the treatment. Much stands to be gained by optimizing treatments in the early stages before testing them in open trials or RCTs. MOST is an alternative, engineering-inspired research framework that is well-suited to address the issues of inefficiency associated with the treatment package approach. MOST entails identifying the most promising treatment components for inclusion in interventions, then eliminating or deemphasizing less efficacious/inert components. This strategy results in a treatment comprised of only effective components that can then be tested via RCT. Though the MOST approach has limitations, it has the potential to greatly benefit ED treatment research and is worthy of application in the field.

Behavioral Interventions in the Treatment of Eating Disorders

Behavioral methods are inherent in many evidence-based treatments of eating disorders and have also been used separately. This review demonstrates that behavioral methods are necessary in the effective treatment of eating disorders-in particular, the improvement of nutrition and exposure-based methods. It is also possible that these methods are sufficient to treat anorexia nervosa, although other elements are needed on the treatment of bulimia nervosa. The impacts and mechanisms of behavioral and nutritional change merit serious attention in clinical work and research. Clinicians are often reluctant, however, to use these methods, and that needs to be the focus of supervision.

Chinese Therapists' Beliefs About Exposure Therapy for Anxiety and Obsessive-Compulsive Disorders

OBJECTIVES

The goal of this study was to assess Chinese therapists' beliefs about exposure therapy and to examine the psychometric properties of the Chinese version of the Therapist Beliefs about Exposure Scale (TBES). Modification of therapists' beliefs about exposure therapy was also assessed following attendance at an exposure and response prevention therapy (ERP) training workshop.

METHODS

A total of 203 therapists participated in the study. The TBES and a measure of anxiety sensitivity were administered in Chinese. After a half-day ERP training workshop, the Chinese version of the TBES was administered to the participants again.

RESULTS

The Chinese version of the TBES demonstrated adequate internal consistency, moderate item-level psychometric properties, and a normal distribution in the sample in this study. The TBES scores of the participants decreased significantly after they attended an ERP training course. The reduction in TBES scores was significantly correlated with therapists' caseload of clients with obsessive-compulsive disorder.

CONCLUSIONS

The results of this study support the reliability of the Chinese version of the TBES. Chinese therapists had more negative beliefs about exposure than did American therapists who were evaluated in a different study; however, therapists' negative beliefs were significantly reduced after they attended an ERP training workshop. Future studies are encouraged to explore effective strategies to improve the disseminiation and delivery of exposure therapy in China.

Identifying and responding to child maltreatment when delivering family-based treatment-A qualitative study

INTRODUCTION

This study describes practitioner strategies, perceptions, experiences with identifying and responding to child emotional abuse (CEA) and child exposure to intimate partner violence (CEIPV) when providing Family-Based Treatment (FBT) to children and adolescents with eating disorders.

METHOD

Using qualitative interpretive description, this study recruited a purposeful sample of practitioners (N = 30, 90% female) implementing FBT for adolescent eating disorders. Semi-structured interviews focused on eliciting their perspectives regarding identifying and responding to CEA and CEIPV in practice. Interviews were conducted over the phone, were audio recorded, transcribed verbatim, and coded using conventional content analysis. Interim member checking, the thoughtful clinician test, and coding memos were used to ensure the integrity of the analysis.

RESULTS

Participants were 31-57 years old and practicing FBT in five countries. Three data patterns emerged: (a) perceptions of child maltreatment prevalence and identification; (b) complicating factors; and finally (c) strategies to support family-based work. Practitioners described important considerations for CEA and CEIPV identification, as well as possible FBT adaptations that can support the safety of children and adolescents while simultaneously ensuring the treatment of the eating disorder.

CONCLUSIONS

Practitioners describe a need for additional training to identify and respond to CEA and CEIPV within FBT and within practice more broadly. There is a need for trials that detail the appropriateness and efficacy of FBT for patients experiencing CEA and/or CEIPV.

Binge-Eating Disorder

Binge-eating disorder (BED), first included as a diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, is characterized by recurrent episodes of binge eating without regular compensatory behaviors to prevent weight gain. With a complex multifactorial etiology, BED is the most frequent eating disorder co-occuring with significant psychopathology, mental and physical comorbidity, obesity, and life impairment. Despite its significance, BED is not sufficiently diagnosed or treated. Evidence-based treatments for BED include psychotherapy and structured self-help treatment, with cognitive-behavioral therapy as most well-established approach, and pharmacotherapy with lisdexamfetamine as FDA approved medication with a limitation of use.

Therapist adherence and therapeutic alliance in individual cognitive-behavioural therapy for adolescent binge-eating disorder

To evaluate psychological treatments for adolescent binge-eating disorder (BED), reliable information on therapeutic process factors is needed. This study examines therapist adherence and therapeutic alliance and their associations in cognitive-behavioural therapy (CBT) for adolescents with BED. In a randomised-controlled efficacy trial, adherence and alliance were objectively determined based on 247 audio-taped CBT sessions from a sample of N = 64 adolescents with BED. Variability of adherence and alliance, explained by treatment module, patient, and therapist were examined using multilevel modeling. Although adherence and alliance were excellent and unaffected by treatment module and therapist, there was significant between-patient variability for both concepts. Adherence was negatively associated with patient's treatment expectation. Alliance was negatively associated with the number of loss of control eating episodes and positively associated with adherence. Excellent adherence supported the internal validity of CBT for adolescent BED. Associations between process factors and patient characteristics demand adequate supervision in CBT.

Increasing the Availability of Psychological Treatments: A Multinational Study of a Scalable Method for Training Therapists

BACKGROUND

One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. A highly scalable form of Web-centered therapist training, undertaken without external support, has recently been shown to have promise in promoting therapist competence.

OBJECTIVE

The aim of this study was to conduct an evaluation of the acceptability and effectiveness of a scalable independent form of Web-centered training in a multinational sample of therapists and investigate the characteristics of those most likely to benefit.

METHODS

A cohort of eligible therapists was recruited internationally and offered access to Web-centered training in enhanced cognitive behavioral therapy, a multicomponent, evidence-based, psychological treatment for any form of eating disorder. No external support was provided during training. Therapist competence was assessed using a validated competence measure before training and after 20 weeks.

RESULTS

A total of 806 therapists from 33 different countries expressed interest in the study, and 765 (94.9%) completed a pretraining assessment. The median number of training modules completed was 15 out of a possible 18 (interquartile range, IQR: 4-18), and 87.9% (531/604) reported that they treated at least one patient during training as recommended. Median pretraining competence score was 7 (IQR: 5-10, range: 0-19; N=765), and following training, it was 12 (IQR: 9-15, range: 0-20; N=577). The expected change in competence scores from pretraining to posttraining was 3.5 (95% CI 3.1-3.8; P<.001). After training, 52% (300/574) of therapists with complete competence data met or exceeded the competence threshold, and 45% (95% CI 41-50) of those who had not met this threshold before training did so after training. Compliance with training predicted both an increase in competence scores and meeting or exceeding the competence threshold. Expected change in competence score increased for each extra training module completed (0.19, 95% CI 0.13-0.25), and those who treated a suitable patient during training had an expected change in competence score 1.2 (95% CI 0.4-2.1) points higher than those who did not. Similarly, there was an association between meeting the competence threshold after training and the number of modules completed (odds ratio, OR=1.11, 95% CI 1.07-1.15), and treating at least one patient during training was associated with competence after training (OR=2.2, 95% CI 1.2-4.1).

CONCLUSIONS

Independent Web-centered training can successfully train large numbers of therapists dispersed across a wide geographical area. This finding is of importance because the availability of a highly scalable method of training potentially increases the number of people who might receive effective psychological treatments.

Implementation of enhanced cognitive behaviour therapy (CBT-E) for adults with anorexia nervosa in an outpatient eating-disorder unit at a public hospital

BACKGROUND

Anorexia nervosa (AN) in adults is difficult to treat, and no current treatment is supported by robust evidence. A few studies, most of which were performed by highly specialized research units, have indicated that enhanced cognitive behaviour therapy (CBT-E) for eating disorders can be effective. However, the dropout rate is high and the evidence from non-research clinical units is sparse.

METHODS

This quality assessment project implemented CBT-E in an outpatient setting at a public hospital. Forty-four patients with AN started therapy. Each patient received at least 40 sessions of CBT-E over a 12-month period. Their body mass index (BMI) was recorded at baseline and after 3, 6 and 12 months. Reasons for not starting therapy or for leaving therapy prematurely were recorded.

RESULTS

Half (n = 22) of the 44 patients who started outpatient CBT-E did not complete the treatment. In the remaining sample there was a large (and statistically significant) weight gain after 12 months. The percentage of patients achieving the target BMI of > 18.5 kg/m² was 36.4, 50.0 and 77.3% after 3, 6 and 12 months, respectively.

CONCLUSIONS

This quality assessment project shows that it is possible to establish effective CBT-E in an outpatient eating-disorder unit at a public hospital. Although half of the patients did not complete CBT-E, the remaining patients achieved a significant increase in BMI at 1 year after the start of therapy.

Exploring the perceived usefulness of practical food groups in day treatment for individuals with eating disorders

BACKGROUND/AIM

Recovery from eating disorders is a challenging process. Emerging literature suggests that occupational therapists may provide a useful contribution in delivering purposeful eating-related interventions as a potential treatment to support sustained cognitive and behavioural changes for individuals with eating disorders. This study aimed to evaluate participants' perceptions of the contribution of occupational therapy practical food groups (food based outings and cooking groups) in supporting their functional recovery.

METHODS

Individuals attended practical food groups as part of standard treatment at an outpatient eating disorders day program. Ninety-nine participants completed questionnaires at discharge and up to three follow-up points (6, 12 and 24 months). Questions related to practical food groups were analysed, exploring participants' experiences and perceived usefulness of groups using rating-scale and open-ended questions. Open-ended responses were analysed using thematic analysis. Descriptive statistics were calculated for responses to rating-scale questions.

RESULTS

At discharge, participants rated the importance and usefulness of practical food groups as high (4.73 and 4.43 on 5-point scales, respectively), but tended to rate their enjoyment of the groups lower (3.50 on a 5-point scale). Some skill transfer was typically reported by participants at discharge (3.92 on a 5-point scale). One core theme, 'success through participation', emerged from qualitative comments. Six subthemes were also identified: helpful components of practical food groups; perceived benefit of exposure; impact of applying cognitive and behavioural skills; challenges affecting participation; facilitating adaptation; and influence of eating disorders on challenging feared foods.

CONCLUSION

This study highlights that participation in practical food groups was perceived as useful in assisting individuals to improve eating behaviours and, in some circumstances, transfer these skills into their lives outside of day program. Results suggest that occupational therapists may have an important contribution in delivering these interventions to support recovery and facilitate application of adaptive coping strategies.

Maximizing the public health impact of eating disorder services: A simulation study

OBJECTIVE

Although effective interventions for eating disorders (ED) are available, the impact of health care services on a population level is far from satisfactory. A mathematical model of how health care for ED affects the population's disease burden can stimulate discussions and provide guidance about promising strategies to reduce ED-related suffering on the population level.

METHOD

The current health care situation for ED is modeled taking into account the reach and effectiveness of prevention, treatment, and aftercare, as well as incidence rates, relapse rates, and rates for spontaneous remissions. A first-order Markov model is applied and the effect of changes in single service parameters on the populations overall disease burden are simulated.

RESULTS

Improvements of treatment utilization and the reach of prevention programs would have the largest effects on the population's disease burden. Improving the efficacy of treatment, prevention, and aftercare show only limited effects.

DISCUSSION

In order to maximize the public health impact of health care for ED new models of treatment delivery as well as public health approaches to the prevention of ED are critical.

Evidence-based clinical guidelines for eating disorders: international comparison

PURPOSE OF REVIEW

The current systematic review sought to compare available evidence-based clinical treatment guidelines for all specific eating disorders.

RECENT FINDINGS

Nine evidence-based clinical treatment guidelines for eating disorders were located through a systematic search. The international comparison demonstrated notable commonalities and differences among these current clinical guidelines.

SUMMARY

Evidence-based clinical guidelines represent an important step toward the dissemination and implementation of evidence-based treatments into clinical practice. Despite advances in clinical research on eating disorders, a growing body of literature demonstrates that individuals with eating disorders often do not receive an evidence-based treatment for their disorder. Regarding the dissemination and implementation of evidence-based treatments, current guidelines do endorse the main empirically validated treatment approaches with considerable agreement, but additional recommendations are largely inconsistent. An increased evidence base is critical in offering clinically useful and reliable guidance for the treatment of eating disorders. Because developing and updating clinical guidelines is time-consuming and complex, an international coordination of guideline development, for example, across the European Union, would be desirable.

Using the Internet to Train Therapists: Randomized Comparison of Two Scalable Methods

Background

One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. The currently accepted method of training is not scalable. Recently, a scalable form of training, Web-centered training, has been shown to have promise.

Objective

The goal of our research was to conduct a randomized comparison of the relative effects of independent and supported Web-centered training on therapist competence and investigate the persistence of the effects.

Methods

Eligible therapists were recruited from across the United States and Canada. They were randomly assigned to 1 of 2 forms of training in enhanced cognitive behavior therapy (CBT-E), a multicomponent evidence-based psychological treatment for any form of eating disorder. Independent training was undertaken autonomously, while supported training was accompanied by support from a nonspecialist worker. Therapist competence was assessed using a validated competence measure before training, after 20 weeks of training, and 6 months after the completion of training.

Results

A total of 160 therapists expressed interest in the study, and 156 (97.5%) were randomized to the 2 forms of training (81 to supported training and 75 to independent training). Mixed effects analysis showed an increase in competence scores in both groups. There was no difference between the 2 forms of training, with mean difference for the supported versus independent group being –0.06 (95% Cl –1.29 to 1.16, P=.92). A total of 58 participants (58/114, 50.9%) scored above the competence threshold; three-quarters (43/58, 74%) had not met this threshold before training. There was no difference between the 2 groups in the odds of scoring over the competence threshold (odds ratio [OR] 1.02, 95% CI 0.52 to 1.99; P=.96). At follow-up, there was no significant difference between the 2 training groups (mean difference 0.19, 95% Cl –1.27 to 1.66, P=.80). Overall, change in competence score from end of training to follow-up was not significant (mean difference –0.70, 95% CI –1.52 to 0.11, P=.09). There was also no difference at follow-up between the training groups in the odds of scoring over the competence threshold (OR 0.95, 95% Cl 0.34 to 2.62; P=.92).

Conclusions

Web-centered training was equally effective whether undertaken independently or accompanied by support, and its effects were sustained. The independent form of Web-centered training is particularly attractive as it provides a means of training large numbers of geographically dispersed therapists at low cost, thereby overcoming several obstacles to the widespread dissemination of psychological treatments.

Addressing critical gaps in the treatment of eating disorders

Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.