Health services use in eating disorders

Disparities in Medical Assessment Practices for Adolescents at Risk for Eating Disorders

PURPOSE

The United States Preventative Services Task Force found insufficient evidence to support universal screening for eating disorders (EDs) but did recommend assessing high-risk adolescents through laboratory tests, close follow-up, and referrals to other specialties. Yet, it is unclear whether youth at high risk for EDs receive such assessment and whether patient characteristics influence such practices.

METHODS

Using the Rochester Epidemiological Project, we identified adolescents (13-18 years) at risk for EDs (i.e., weight loss, underweight, or loss of appetite not explained by a medical condition) who presented for a medical appointment between January 1, 2005 to December 31, 2017 (n = 662; M age = 15.8 years; 66% female; 76% white). Patient and visit characteristics, assessment practices (i.e., tests, referrals, and follow-up), and ED diagnoses within 5 years following index visit were extracted.

RESULTS

Adolescents who received referrals to other providers were 4 times more likely to be diagnosed with a future ED (p < .001) and were diagnosed 137.8 days sooner (Est = -137.8, p = .04) compared to those who did not receive referrals. Compared to males, females were 2.2 times more likely to receive referrals (p < .001). Compared to those presenting at a lower body mass index, adolescents with a higher body mass index were more likely to receive medical tests (HR = 1.0, p < .01) and less likely to receive recommendations to improve eating/weight (HR = 0.99, p < .01) or follow up visits (HR = 0.99, p < .01).

DISCUSSION

Disparities in assessment practices for adolescents at high-risk for EDs underscore the need for improved tools to enhance early detection and treatment.

Evidence-Based Assessments for Transdiagnostic Eating Disorder Symptoms: Guidelines for Current Use and Future Directions

Eating disorders are severe and often chronic mental illnesses that are associated with high impairment and mortality rates. Recent estimates suggest that eating disorder prevalence rates are on the rise, indicating an increased need for accurate assessment and detection. The current review provides an overview of transdiagnostic eating disorder assessments, including interview, self-report, health and primary care screeners, and technology-based and objective assessments. We focused on assessments that are transdiagnostic in nature and exhibit high impact in the field. We provide recommendations for how these assessments should be used in research and clinical settings. We also discuss considerations that are crucial for assessment, including the use of a categorical versus dimensional diagnostic framework, assessment of eating disorders in related fields (i.e., anxiety and depression), and measurement-based care for eating disorders. Finally, we provide suggestions for future research, including the need for more research on short transdiagnostic screeners for use in health care settings, standardized assessments for ecological momentary assessment, development of state-based assessment of eating disorder symptoms, and consideration of assessment across multiple timescales.

Description of patients with eating disorders by general practitioners: a cohort study and focus on co-management with depression

BACKGROUND

International guidelines often state that general practitioners (GPs) provide early management for most patients with eating disorders (EDs). GP management of EDs has not been studied in France. Depressive disorders are often a comorbidity of EDs. The aims of this study were to describe in France the characteristics of people with all subcategories of EDs (Anorexia Nervosa, Bulimia Nervosa, ED Not Otherwise Specified) managed by their GPs and to study the management temporality between depression and all subcategories of EDs.

METHODS

Retrospective cohort study of patients with EDs visiting French GPs. Data collected from 1994 through 2009 were extracted from the French society of general electronic health record. A descriptive analysis of the population focused on depression, medication such as antidepressants and anxiolytics, and the management temporality between depression and EDs.

RESULTS

1310 patients aged 8 years or older were seen at least once for an ED by a GP participating in the database out of 355,848 patients, with a prevalence rate of 0.3%. They had a mean age of 35.19 years, 82.67% were women. 41.6% had anorexia nervosa, 26.4% bulimia nervosa, and 32% an ED not otherwise specified. Overall, 32.3% had been managed at least once for depression, and 18.4% had been prescribed an antidepressant of any type at least once. Benzodiazepines had been prescribed at least once for 73.9% of the patients treated for depression. Patients with an ED seen regularly by their GP ("during" profile) received care for depression more frequently than those with other profiles. 60.9% had a single visit with the participating GP for their ED Treatment and management for depression did not precede care for EDs.

CONCLUSIONS

Data extracted from the French society of general practice were the only one available in France in primary care about EDs and our study was the only one on this topic. The frequency of visits for EDs was very low in our general practice-based sample. Depressive disorders were a frequent comorbidity of EDs. GPs could manage common early signs of depression and EDs, especially if they improved their communication skills and developed collaborative professional management.

Use and misuse of the emergency room by patients with eating disorders in a matched-cohort analysis: What can we learn from it?

We examined the pattern of access to hospital emergency room (hER) in 2018-2021 among patients with eating disorders (ED) from Florence, Italy, diagnosed during 1994-2018, using a matched cohort design. We included 902 ED patients and an equal number of sex-, age-, and residence-matched individuals. We fitted conditional Poisson regression models with robust variance estimator to estimate incidence rate ratios (IRR) and 95% confidence intervals. ED patients accessed hER more than twice as often as matched individuals: the IRR was 2.11 (1.21-3.70), 2.02 (1.36-3.00), and 2.49 (1.71-3.61) among AN, BN, and BED patients. Factors associated with increased hER use were older age (≥40 years; for AN patients, also younger age, <20 years), BMI ≤ 16 kg/m2 (for AN), and psychopathological severity. The rise in access to hER was particularly marked during the early phases of the COVID-19 pandemic and declined only partially thereafter. Acute psychiatric symptoms and non-specific medical conditions represented the main causes of increased access to hER. Use of hER was more often inappropriate among ED patients than matched individuals. Integration of primary and mental health care may be necessary to counteract the high and often inappropriate use of hER by patients with ED.

A diagnostic subgroup comparison of health care utilization patterns in individuals with eating disorders diagnosed in childhood and/or adolescence

OBJECTIVE

This study examined a 2-year period after diagnosis of an eating disorder to compare health care utilization in diagnostic subgroups including: anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), and other specified eating disorders (Other).

METHOD

We conducted a retrospective study of children diagnosed with AN (n = 674), BN (n = 230), BED (n = 59), ARFID (n = 171), and Other (n = 315). We used a general population cohort for comparison, matched 5:1 to the diagnostic subgroups on sex and birth date. We then conducted a separate analysis using the ARFID subgroup as a reference group compared to the other subgroups. Outcomes were determined using data linkage with health administrative databases and included hospitalizations, emergency department, general practitioner, psychiatry, and pediatrician visits. Odds ratios (dichotomous outcomes) and rate ratios (continuous outcome) were calculated.

RESULTS

Mental health care utilization was higher for all subgroups compared to the general population. When the subgroups were compared to the ARFID subgroup, those with ARFID appeared to have similar health care utilization to the other subgroups, except when compared to those with AN. The AN subgroup had higher odds of a mental health related hospitalization (OR 1.62, 95% CI 1.04-2.5) higher rates of mental health related pediatrician visits (RR 1.76, 95% CI 1.26-2.46) and psychiatry visits (RR 1.69, 95% CI 1.07-2.68).

CONCLUSIONS

Those with ARFID have similar utilization as other subtypes of eating disorders, except when compared to those with AN who have higher health care utilization.

PUBLIC SIGNIFICANCE

Our study found that the health service needs of young people with all types of eating disorders are substantially higher than the general population, and it appears that Avoidant/Restrictive Food Intake Disorder (ARFID) has similar health care utilization to other eating disorders.

Economic evaluation of web-based guided self-help cognitive behavioral therapy-enhanced for binge-eating disorder compared to a waiting list: A randomized controlled trial

INTRODUCTION

The aim is to perform an economic evaluation alongside a randomized controlled trial comparing guided self-help cognitive behavioral therapy-enhanced (CBT-E) for binge-eating disorder (BED) to a waiting list control condition.

METHODS

BED patients (N = 212) were randomly assigned to guided self-help CBT-E or the 3-month waiting list. Measurements took place at baseline and the end-of-treatment. The cost-effectiveness analysis was performed using the number of binge-eating episodes during the last 28 days as an outcome indicator according to the eating disorder examination. A cost-utility analysis was performed using the EuroQol-5D.

RESULTS

The difference in societal costs over the 3 months of the intervention between both conditions was €679 (confidence interval [CI] 50-1330). The incremental costs associated with one incremental binge eating episode prevented in the guided self-help condition was approximately €18 (CI 1-41). From a societal perspective there was a 96% likelihood that guided self-help CBT-E led to a greater number of binge-eating episodes prevented, but at higher costs. Each additional quality-adjusted life year (QALY) gained was associated with incremental costs of €34,000 (CI 2494-154,530). With a 95% likelihood guided self-help CBT-E led to greater QALY gain at higher costs compared to waiting for treatment. Based on the National Institute for Health and Clinical Excellence willingness-to-pay threshold of €35,000 per QALY, guided self-help CBT-E can be considered cost-effective with a likelihood of 95% from a societal perspective.

DISCUSSION

Guided self-help CBT-E is likely a cost-effective treatment for BED in the short-term (3-month course of treatment). Comparison to treatment-as-usual is recommended for future research, as it enables an economic evaluation with a longer time horizon.

PUBLIC SIGNIFICANCE

Offering treatment remotely has several benefits for patients suffering from binge-eating disorders. Guided self-help CBT-E is an efficacious and likely cost-effective treatment, reducing binge eating and improving quality-of-life, albeit at higher societal costs.

Health service utilization among women veterans who report eating disorder symptoms

OBJECTIVE

Describe health service utilization in women veterans with eating disorder symptoms and characterize the nature of mental health services received.

METHOD

Women veterans (N = 191) in a northeastern Veterans Health Administration region completed the Eating Disorders Examination Questionnaire. Health service utilization was then observed for 5 years across multiple domains (i.e., mental health, primary care, telephone consultations, emergency services); negative binomial or zero-inflated negative binomial regression models (mental health) estimated the relative impact of reported eating disorder symptoms on health service utilization.

RESULTS

After adjusting for the effects of age and body mass index, higher eating disorder symptoms were associated with higher primary care, mental health services, and telephone consultations. Eating disorder diagnoses were infrequent across the sample.

DISCUSSION

Women veterans with higher self-reported eating disorder symptoms evidence higher health service utilization across common healthcare domains. Encounter data suggest that eating disorder symptoms are rarely identified or clinically addressed by providers. Existing mental health visits may represent an opportunity for selective screening for eating disorder symptoms, particularly among women who evidence known risk factors.

PUBLIC SIGNIFICANCE

This study reveals that women veterans with higher levels of eating disorder symptoms (e.g., dietary restriction, poor body image) use more primary care, mental health, and telephone consultations than others, but may not receive services that target disordered eating. Opportunities may exist to better identify eating disorder symptoms in the context of existing mental health visits, or potentially to combine treatment for eating disorder symptoms into their mental health care.

Crossed clinical features between eating disorders and types of bipolar disorder: Results from the FondaMental Advanced Centers of Expertise - Bipolar Disorder cohort

BACKGROUND

Eating disorders (EDs) are liable to alter the disease course of bipolar disorder (BD). We explored the crossed clinical features between EDs and BD, particularly as a function of BD type (BD1 vs. BD2).

METHODS

2929 outpatients attending FondaMental Advanced Centers of Expertise were assessed for BD and lifetime EDs with a semi-structured interview, and their sociodemographic, dimensional and clinical data were collected according to a standardized procedure. For each ED type, bivariate analyses were used to investigate associations between these variables and the type of BD type followed by multinomial regressions with the variables associated with EDs and BDs after Bonferroni correction.

RESULTS

Comorbid EDs were diagnosed in 478 (16.4 %) cases, and were more prevalent in patients with BD2 than in those with BD1 (20.6 % vs. 12.4 %, p < 0.001). Regression models showed no difference according to the subtype of bipolar disorder on the characteristics of patients with anorexia nervosa (AN), bulimia nervosa (BN) or binge eating disorder (BED). After multiple adjustments, the factors differentiating BD patients with versus without ED were primarily age, gender, body mass index, more affective lability and comorbidity with anxiety disorders. BD patients with BED also scored higher regarding childhood trauma. BD patients with AN also showed higher risk of past suicide attempts than those with BED.

CONCLUSIONS

In a large sample of patients with BD, we found a high prevalence of lifetime EDs, especially for the BD2 type. EDs were associated with several severity indicators, but not with BD type-specific characteristics. This should prompt clinicians to carefully screen patients with BD for EDs, regardless of BD and ED types.

"What will people say?": Mental Health Stigmatization as a Barrier to Eating Disorder Treatment-Seeking for South Asian American Women

This study used focus group methodology to identify culturally-specific barriers to, and facilitators of, eating disorder (ED) treatment-seeking for South Asian (SA) American women. Seven focus groups were conducted with 54 participants (Mage=20.11 years, SD=2.52), all of whom had lived in the United States (US) for at least three years (63.0% of the sample was born in the US). Transcripts were independently coded by a team of researchers (n=4) and the final codebook included codes present in at least half of the transcripts. Thematic analysis identified salient themes (barriers, n=6; facilitators, n=3) for SA American women. Barriers to ED-treatment seeking were inextricable from barriers to mental health treatment, more broadly. In addition to generalized mental health stigma, participants cited social stigma (i.e., a pervasive fear of social ostracization), as a significant treatment-seeking barrier. Additional barriers were: cultural influences on the etiology and treatment of mental illness, parents' unresolved mental health concerns (usually tied to immigration), healthcare providers' biases, general lack of knowledge about EDs, and minimal SA representation within ED research/clinical care. To address these obstacles, participants recommended that clinicians facilitate intergenerational conversations about mental health and EDs, partner with SA communities to create targeted ED psychoeducational health campaigns, and train providers in culturally-sensitive practices for detecting and treating EDs. SA American women face multiple family, community, and institutional barriers to accessing mental health treatment generally, which limits their ability to access ED-specific care. Recommendations to improve ED treatment access include: (a) campaigns to destigmatize mental health more systematically, (b) collaboration with SA communities and, (c) and training providers in culturally-sensitive care.

Pathways to improve early intervention for eating disorders: Findings from a systematic review and meta-analysis

OBJECTIVE

Treatment-seeking rates among eating disorder (ED) populations are relatively low, with only one in four individuals seeking help. Previous research has identified many factors that might be associated with help-seeking in EDs, but to date no review has investigated the quantitative association between these factors and actual help-seeking behavior. The aim of the current review was to synthesize the relevant quantitative literature on factors (i.e., perceived barriers, characteristics associated with treatment seeking, demographic variables) associated with help-seeking using meta-analytic strategies, as well as provide recommendations on future early intervention research strategies to promote early help-seeking.

METHOD

Overall, 19 studies were included, identifying 141 perceived barriers (e.g., stigma) or individual characteristics (e.g., BMI, duration of illness) and 56 demographic variables (e.g., ethnicity), which were synthesized into 24 unique variables.

RESULTS

Less help-seeking was predicted by higher levels of denial and less perceived ability of others to provide help.

DISCUSSION

Given the small number of studies these results should be considered preliminary. Future studies should consider barriers to help-seeking when creating early intervention approaches. To improve help-seeking rates we suggest the use of targeted psychoeducational materials and co-design with people with lived experience when developing new strategies.

PUBLIC SIGNIFICANCE

The present study addresses a significant gap in the literature by synthesizing factors associated with help-seeking, with the aim of informing early intervention strategies to promote early help-seeking in eating disorder populations. Denial of illness and perceived inability of others to provide help were associated with lower help-seeking. Future studies should consider barriers to help-seeking and co-design with people with lived experience when creating new early intervention strategies.

Cost-Effectiveness of 5 Public Health Approaches to Prevent Eating Disorders

INTRODUCTION

Eating disorders cause suffering and a high risk of death. Accelerating the translation of research into implementation will require intervention cost-effectiveness estimates. The objective of this study was to estimate the cost-effectiveness of 5 public health approaches to preventing eating disorders among adolescents and young adults.

METHODS

Using data from 2001 to 2017, the authors developed a microsimulation model of a closed cohort starting at the age of 10 years and ending at 40 years. In 2021, an analysis was conducted of 5 primary and secondary prevention strategies for eating disorders: school-based screening, primary care‒based screening, school-based universal prevention, excise tax on over-the-counter diet pills, and restriction on youth purchase of over-the-counter diet pills. The authors estimated the reduction in years lived with eating disorders and the increase in quality-adjusted life-years. Intervention costs and net monetary benefit were estimated using a threshold of $100,000/quality-adjusted life year.

RESULTS

All the 5 interventions were estimated to be cost-saving compared with the current practice. Discounted per person cost savings (over the 30-year analytic time horizon) ranged from $63 (clinic screening) to $1,102 (school-based universal prevention). Excluding caregiver costs for binge eating disorder and otherwise specified feeding and eating disorders substantially reduced cost savings (e.g., from $1,102 to $149 for the school-based intervention).

CONCLUSIONS

A range of public health strategies to reduce the societal burden of eating disorders are likely cost saving. Universal prevention interventions that promote healthy nutrition, physical activity, and media use behaviors without introducing weight stigma may prevent additional negative health outcomes, such as excess weight gain.

A retrospective cohort study examining health care utilization patterns in individuals diagnosed with an eating disorder in childhood and/or adolescence

OBJECTIVE

This study examined a 2-year period following an eating disorder (ED) diagnosis in order to determine patterns of health care utilization.

METHOD

We conducted a retrospective cohort study of children (n = 1560) diagnosed with an ED between 2000 and 2017. The ED diagnosis was made at a tertiary level hospital for children and adolescents presenting for outpatient assessment by specialist adolescent medicine physicians and recorded in a program database over this period of time. We then created three sex- and age-matched comparison cohorts using provincial health administrative databases including: a general population cohort, a diabetes cohort (to compare nonmental health care utilization) and a mood disorder cohort (to compare mental health care utilization). Outcomes included hospitalizations, emergency department visits, as well as general practitioner, psychiatrist, and pediatrician visits. Odds ratios (dichotomous outcomes) and rate ratios (continuous outcomes) were calculated.

RESULTS

Compared to the general population cohort, the ED cohort had higher odds and rates of all types of health care utilization. Compared to the diabetes cohort, the ED cohort had higher odds of nonmental health-related admissions (OR 1.45, 95% CI 1.09-1.95) and higher rates of nonmental health-related emergency department visits (RR 1.59, 95% CI 1.18-2.13). Compared to the mood disorder cohort, the ED cohort had higher rates of pediatrician visits, which were mental health-related (RR 14.88, 95% CI 10.64-20.82), however most other types of mental health service utilization were lower.

DISCUSSION

These patterns indicate that the service needs of young people diagnosed with EDs are higher than those with diabetes with respect to nonmental health admissions and emergency department visits, while in terms of mental health service utilization, there appears to be a lack of use of mental health services compared to youth with mood disorders with the exception of pediatrician mental health visits. These findings must be interpreted in the context of under-detection and under-treatment of EDs.

PUBLIC SIGNIFICANCE STATEMENT

Our study found that the health service needs of young people with EDs are higher than those with diabetes with respect to admissions and emergency department visits, while there appears to be a lack of use of mental health services compared to youth with mood disorders with the exception of pediatrician mental health visits.

Considering a risk profile based on emergency department utilization in young people with eating disorders: Implications for early detection

OBJECTIVE

While screening tools are available for the early identification of eating disorders, it may not be feasible to employ them in an emergency department (ED). Establishing a risk profile may improve the screening process. The purpose of this study was to investigate ED service utilization among patients with eating disorders and create a risk profile to help detect eating disorders at an earlier and more treatable stage.

METHOD

We applied a concurrent mixed methods research design, however, only the quantitative findings will be presented. Our study involved a retrospective cohort analysis of administrative ED health data for patients (n = 243) aged 12-24 years in an eating disorders program. Two control groups: (1) all-cause (n = 716), (2) and mental health (n = 679) were included.

RESULTS

68.7% of eating disorder patients were discharged from the ED without follow-up being arranged. Comorbidities were recorded as the primary or secondary diagnosis, and patients presented with suicidality more frequently than controls (χ = 31.2, p < .001). Patients accessed ED services five times more often than controls.

DISCUSSION

Despite eating disorder patients accessing the ED more frequently than controls, eating disorder diagnoses were not always assigned or documented. Our findings highlight the importance of enhanced eating disorder training for ED health care staff to better understand the risk profile, and the consideration of comorbidities and suicide risk when assessing patients to ensure early detection.

CONCLUSION

As eating disorders are often undetected, more comprehensive training and access to screening tools may help improve detection, mitigate symptom progression, and enhance patient safety.

Study protocol for training providers in private practice in family-based treatment for adolescents with anorexia nervosa: A randomized controlled feasibility trial

BACKGROUND

Private practice clinicians make up approximately 50% of US mental health outpatient providers and treat a high number of eating disorder patients. While family-based treatment (FBT) is a first-line treatment for adolescent anorexia nervosa (AN), private practice clinicians experience difficulties receiving training in evidence-based treatments such as FBT. This report outlines the study protocol for a randomized control trial (RCT) training private practice clinicians in FBT for adolescent AN (NCT04428580).

METHODS

In this study, we intend to recruit 140 private practice mental health practitioners and randomize them to complete either a standard webinar-based online training or an enhanced online training that incorporates additional modules related to the putative mechanisms of treatment effect in FBT (i.e., use of externalization and agnosticism). Following the training, participants will begin expert case consultation for an adolescent with AN using FBT from their private practice.

CONCLUSION

Based on preliminary studies suggesting the importance of enhanced skills related to agnosticism and externalization, we hypothesize that feasibility data will support a larger randomized clinical trial (RCT) and that the enhanced training arm will significantly improve FBT knowledge and skills compared to the standard webinar training arm. We also expect that patient weight gain early in treatment will be associated with clinician fidelity to the inventions used in FBT regardless of training type.

First onset of treatment of patients with eating disorders and treatment course: Results of data from a German health insurance company

OBJECTIVE

This study examines, inpatient treatment costs, and typical treatment courses of patients with an eating disorder using secondary data.

METHOD

The data were provided by a German health insurance company (data from 4.2 million members from 2004 to 2010; corresponds to a market share of 6% of all statutorily insured persons in Germany). An age and gender matched control group without an eating disorder diagnosis was assessed for comparisons from the same dataset.

RESULTS

Two thousand seven hundred and thirty four cases with an eating disorder diagnosis (anorexia nervosa [AN], bulimia nervosa [BN] or combination [ANBN]) were identified. The inpatient costs of treatment were €5471.15 for BN, €9080.26 for AN, €10,809.16 for ANBN and €339.37 for the control group. Interestingly, there are numerous mild episodes of eating disorders that could be successfully treated solely on an outpatient basis with a short treatment duration.

CONCLUSION

Our findings suggest that course and severity of eating disorders can vary from mild to very severe. Data from health insurance companies depict rather different disease and treatment courses than studies on primary data derived from treatment institutions.

Cost-of-illness for non-underweight binge-eating disorders

PURPOSE

This study examined economic costs associated with untreated eating disorders (EDs) characterised by regular binge eating in the absence of low weight. Both direct and indirect costs were assessed, reporting a limited societal perspective of economic impact as some costs were not included.

METHODS

One hundred and twenty six adults seeking treatment for recurrent binge eating were asked to report impairment associated with an ED. Costs were calculated using 2017 prices, including an examination of variables associated with costs.

RESULTS

Estimated societal costs for the year preceding assessment were £3268.47 (€3758.54) per person. In multivariate analyses, no reliable baseline associates of cost were identified.

CONCLUSION

The economic burden of EDs characterised by regular binge eating is significant, and underscores the need for efficacious and cost-effective treatments. Individuals with binge-eating disorders report work impairment and healthcare use that may cost the United Kingdom economy upwards of £3.5 billion (€4bn) per annum. Further studies should consider academic impairment and the economic impact of EDs on families.

LEVEL OF EVIDENCE

III: evidence obtained from well-designed cohort or case-control analytic studies.

Perspectives on barriers to treatment engagement of people with eating disorder symptoms who have not undergone treatment: a qualitative study

BACKGROUND

Many people with an eating disorder (ED) never engage with an evidence-based ED treatment. Of the few studies that have qualitatively explored barriers to receiving treatment, some do so in relation to mental health conditions in general, and others focus on participants who have already undergone treatment. This study aims to address this gap in the literature by exploring the barriers to ED treatment engagement from the perspectives of individuals in the community with an ED (either self-identified or professionally diagnosed) and had not received ED treatment/s.

METHOD

Fifty-six of 772 participants in an online Eating Disorders Treatment Experience survey had self-identified as having symptoms consistent with an ED, or had received a diagnosis of an ED and indicated that they had never undergone treatment for an ED. They were asked to share the reasons for which they did not receive treatment with an open-ended question. Qualitative analysis of survey responses was completed using the Framework Method to generate overarching themes that encapsulated the diverse participant accounts.

RESULTS

The thematic analysis generated two main themes, each with two subthemes. The first theme was the negotiation of the need for treatment within oneself (intrapersonal factors; theme 1). The second theme explored interpersonal contexts that shaped the participant's decision not to seek treatment (interpersonal/external factors; theme 2). Two cross-cutting subthemes of fear and health literacy were also generated that demonstrated a high degree of overlap with the aforementioned main themes.

CONCLUSIONS

The process by which individuals decide whether or not to engage with ED treatment services is complex and involves intra- and interpersonal negotiations intertwined with health literacy and fear. A factor not prominent in previous research was negative self-perceptions and the belief of being undeserving of treatment. These factors have implications for ongoing community and clinical interventions to further address barriers to ED treatment engagement.

A retrospective investigation of the prodromal stages of eating disorders and use of health services in young patients the year prior to the diagnosis

AIM

The aim of this study was to analyse the characteristics and the frequency of medical consultations in the year prior to the diagnosis and the intervention onset of the Eating Disorder, as well as the different prodromal symptoms. The final aim was to understand the origin of all referrals and their possible influence on the duration of untreated illness.

METHODS

We selected 99 young patients (15-25 years) and 61 healthy controls. Their primary and specialized care medical records were both studied retrospectively.

RESULTS

87.6% of patients attended different consultations (primary care, specialized care and emergency department) the year prior compared to 67.2% of the controls (p = .002). The average number of consultations was 3.59 in the case group and 1.57 in the control group (p < .001). These consultations were related to prodromal symptoms in 57.4% compared to 16.4% for the controls (p < .001). They ranged from 29.8% of unspecific digestive symptoms, 22.8% of psychological symptoms, 19.3% of gynaecologic symptoms, 11.9% of weight variation, 8.8% of analytical changes, to 5.3% of malnutrition symptoms. Patients were mainly referred by Primary Care (42.7%). Overall, the mean of the Duration of Untreated Illness was of 7.45 months.

CONCLUSIONS

The majority of reasons for consultation were related to symptoms that could be prodromal symptoms, but the patients were not diagnosed with an eating disorder. These findings highlight the importance of professionals understanding how to identify the warning signs of an eating disorder, so they can refer patients to a specialized unit to establish an early treatment.

Repetitive Transcranial Magnetic Stimulation (rTMS) as a Promising Treatment for Craving in Stimulant Drugs and Behavioral Addiction: A Meta-Analysis

Addiction is a mental disorder with limited available treatment options. The therapeutic potential of repetitive transcranial magnetic stimulation (rTMS) on it, by targeting craving in particular, has been explored with heterogenous results. This meta-analysis uses updated evidence to assess overall rTMS efficacy on craving, differential effects between addiction types clustered into three groups (depressant (alcohol, cannabis, opiate), stimulant (nicotine, cocaine, methamphetamine), and behavioral addiction (gambling, eating disorder)), and stimulation settings. Studies on substance use, gambling, and eating disorders are included, with unrestricted stimulation settings, by searching the PubMed, Embase, PsycINFO, and Cochrane databases up to 30 April 2020. A total of 34 eligible studies (42 units of analysis) were identified. Because of highly significant heterogeneity in primary results, a sensitivity analysis was performed on a remaining sample of 26 studies (30 units of analysis). Analyses performed using random effects model revealed a small effect size favoring active rTMS over shamTMS stimulation in the reduction in craving. We found a significant difference between addiction types, with a persistent small effect only for stimulant and behavioral groups. In these groups we found no difference between the different combinations of target and frequency of stimulation, but a significant correlation between number of sessions and craving reduction. In conclusion, efficacy of rTMS on craving in stimulant and behavioral addiction was highlighted, but recommendations on optimal stimulation settings and its clinical application await further research.

Prevalence and management of people with eating disorders presenting to primary care: A national study

OBJECTIVE

Primary care practitioners are well placed to support diagnosis and appropriate treatment of eating disorders as they are often the first point of contact with the health care system. However, little is known about management of eating disorders in primary care. We aimed to estimate the prevalence of management of eating disorders in primary care and identify how these disorders are managed.

METHODS

This study used data from the Bettering the Evaluation of Care of Health programme, which annually surveys 1000 randomly sampled general practitioners in Australia who each record details of 100 successive patient encounters. In total, data were utilised from 1,568,100 primary care encounters between 2000/2001 and 2015/2016.

RESULTS

Eating disorders were managed in less than 1% of primary care encounters between 2000/2001 and 2015/2016. When extrapolated to the Australian population, up to 0.32% of the population were managed in primary care for a primary or probable eating disorder. In the majority of encounters where an eating disorder was managed (58.5%), the encounter was initiated for reasons other than the eating disorder itself. Of a group of patients identified with a clinically significant low body mass index (N = 5917), a small number (n = 118) had either no other diagnosis or a related condition that may be indicative of an eating disorder. In encounters where an eating disorder was managed, referrals to a mental health specialist/service, medical specialist and nutritionist/dietician were provided in 20%, 8% and 6% of encounters, respectively. Mental health treatment plans, which provide subsidised access to mental health services, were ascribed in approximately 7.7% of encounters where an eating disorder was managed.

CONCLUSION

Primary care provides an opportunity to improve detection and management of eating disorders, particularly when patients present for 'other' issues or with unexplained low body mass index and one or more symptoms related to an eating disorder.

Prevention of eating disorders-Efficacy and cost-benefit of a school-based program ("MaiStep") in a randomized controlled trial (RCT)

OBJECTIVE

Given the severity of eating disorders, effective and easily implementable prevention programs which reduce incidence rates and in addition have health-economic benefits are essential. The majority of research on prevention programs focuses on questionnaire-based efficacy or the reduction of eating disorder symptoms while neglecting the health-economic perspective. By contrast, the present study focuses on both an efficacy analysis considering diagnostic criteria (DSM-5) and on evaluating the cost-benefit of a universal prevention program for eating disorders ("MaiStep").

METHOD

A three-arm randomized controlled trial with baseline, posttreatment and 12-month follow-up was conducted with 1,654 adolescents (M = 13.35, SD = 0.76), comprising two intervention groups (MaiStep delivered by psychologists or teachers, IG-T) and an active control group (ACG). The primary outcome was DSM-5 eating disorder diagnosis measured with the SIAB-S. Furthermore, the costs of the prevention program and the savings in health care costs were calculated.

RESULTS

A significant difference in eating disorder diagnosis was found between the IG-T and the ACG for posttreatment (χ² (1= 7.352, p = .007), Relative Risk (RR) = .53 and 12-month follow-up (χ² (1= 5.203, p = .023), RR = .61. MaiStep proved to be cost-effective (t_cbr  = 6.75), saving about 560,000 € (standardized per 1,000 students = 601,388.19 €).

DISCUSSION

Universal prevention can both reduce incidence rates of eating disorders and be cost-beneficial for health care systems. Future research should analyze prevention programs regarding efficacy and cost-benefit to enable comparability and derive guidelines for political decision-makers.

TRIAL REGISTRATION NUMBER

MaiStep is registered at the German Clinical Trials Register (DRKS00005050).

A mixed-method systematic review of text-based telehealth interventions in eating disorder management

Purpose

Eating disorders (EDs) is a major health condition affecting 9% of the global population and 10% of those with EDs lost their lives as a result. Text-based telehealth interventions (TTIs) seem to provide a low-cost and convenient treatment option; however, the evidence is scarce. This study aimed to synthesize evidence relating to the use of TTIs for the management of EDs.

Design/methodology/approach

Five databases were searched published between January 2020 and May 2019. The authors used keywords relating to telehealth and EDs. The authors used Joanna Briggs Institute's (JBI's) critical appraisal instrument to assess the methodology quality of included studies.

Findings

Fifteen studies were included in this mix-method systematic review and assessed for methodology quality. Email, web-based texting, text-messaging and online chat room were used as mode for deliver healthcare for patients with EDs. In the treatment phase, all studies (nine studies; n = 860 participants) showed effectiveness (for RCTs) and usefulness (for non-RCT studies). In the aftercare phase (six studies; n = 364 participants), the results regarding the effectiveness of TTIs were mixed. Two studies showed effectiveness whilst four studies did not find statistically significant change of ED outcomes.

Research limitations/implications

The qualities of these studies varied; firstly, 66% (n = 10) of the studies were non-randomized studies (e.g. single-arm trial, case report) with small samples. Moreover, one-fourth (n = 4) of the studies did not use validated instruments or indicate the instrument. Also, half (n = 7) of the studies used TTIs as adjunct to face-to-face treatment or bigger online treatment, it is hard to make conclusion that the changes were due to TTIs' effect. In addition, follow-up rate is not satisfactory, thus results should be interpreted cautiously.

Practical implications

TTIs seem to be promising for management of EDs, particularly in the treatment phase. This provides an important treatment option for health practitioners and people with EDs as an alternative or in adjunct with face-to-face services.

Originality/value

This is the first review to synthesis the use of TTIs for ED management.

[Feasibility of a psychoeducation group for patients with anorexia nervosa: An open study]

INTRODUCTION

Management of anorexia nervosa is difficult and few treatments have shown their effectiveness, justifying the exploration of new therapeutic approaches. Available evidence suggests an interest of psychoeducational groups in a significant number of psychiatric disorders. In patients suffering from anorexia, to date there are few groups or interventions available. We aimed to assess the feasibility and acceptability of a psycho-educational program promoting information about the disease and presenting techniques that can help to cope with anorexia and the functional impact it causes. The exploratory secondary objectives were to evaluate if such a group is associated with clinical improvement.

METHOD

Twenty-seven patients suffering from anorexia nervosa, in three groups, received eight weekly interventions in addition to their usual care. The study was open-label and non-randomized. Patients were assessed three times (baseline, at the end of the group and three months later). The assessments were both qualitative (Eating Disorder Examination questionnaire, The Anorexia Nervosa Stage of Change Questionnaire, the Eating Disorders Quality of Life questionnaire, Work and Social Adjustment Scale) and qualitative.

RESULTS

Seventy-eight percent of participants attended more than 75 % of the sessions. Seventy percent of participants found the group useful, and 95 % said it helped them improve their knowledge of the disease and its consequences. The average BMI of participants changed significantly with an average increase of 2.5kg between baseline and the three month assessment. There was an improvement of the eating disorders features in EDE-Q for the total score and for all subscores. The improvement in the total score was significant at the end of the group sessions, while the improvement in the sub scores became significant at three months. There was also a significant mood improvement at the end of the group. Finally, there was a significant improvement in daily functioning with a decrease in Work and Social Adjustment Scale scores and an improvement in quality of life. On qualitative assessment, patients were satisfied with the care proposal. They were able to appreciate the support and sharing of experience provided by the group formula. Most of them reported changes in their daily lives, either in their relationship to care and illness, or in their relationships with their loved ones, their leisure/work, their mood or their eating behavior.

CONCLUSION

Both qualitative and quantitative results suggest that this group psychoeducation program is feasible and well accepted by patients in addition to usual management. Although the methodology does not allow any conclusions, the clinical improvements observed during the group are encouraging with regard to the safety of this type of intervention and its possible effectiveness and argue for a controlled study.

Social and economic cost of eating disorders in the United States: Evidence to inform policy action

OBJECTIVE

To estimate one-year costs of eating disorders in the United States (U.S.) from a societal perspective, including the costs to the U.S. health system, individual and family productivity costs, lost wellbeing, and other societal economic costs, by setting and payer. Findings will inform needed policy action to mitigate the impact of eating disorders in the U.S.

METHOD

Costs of eating disorders were estimated using a bottom-up cost-of-illness methodology, based on the estimated one-year prevalence of eating disorders. Intangible costs of reduced wellbeing were also estimated using disability-adjusted life years.

RESULTS

Total economic costs associated with eating disorders were estimated to be $64.7 billion (95% CI: $63.5-$66.0 billion) in fiscal year 2018-2019, equivalent to $11,808 per affected person (95% CI: $11,754-$11,863 per affected person). Otherwise Specified Feeding or Eating Disorder accounted for 35% of total economic costs, followed by Binge Eating Disorder (30%), Bulimia Nervosa (18%) and Anorexia Nervosa (17%). The substantial reduction in wellbeing associated with eating disorders was further valued at $326.5 billion (95% CI: $316.8-$336.2 billion).

DISCUSSION

The impact of eating disorders in the U.S. is substantial when considering both economic costs and reduced wellbeing (nearly $400 billion in fiscal year 2018-2019). Study findings underscore the urgency of identifying effective policy actions to reduce the impact of eating disorders, such as through primary prevention and screening to identify people with emerging or early eating disorders in primary care, schools, and workplaces and ensuring access to early evidence-based treatment.

Paths to the first-time diagnoses of anorexia nervosa and bulimia nervosa in Taiwan

OBJECTIVE

This study aimed to examine the characteristics of psychiatrists and the hospital settings in relation to the first-time diagnoses of anorexia nervosa (AN) and bulimia nervosa (BN) and depict medical utilization and the detection rate before diagnosis of patients with AN and BN.

METHOD

We extracted data of individuals with AN or BN, as defined by the International Classification of Diseases, Ninth Revision, Clinical Modification, from a national health insurance database. Individuals with AN (n = 1,893) or BN (n = 10,542) who were first-time diagnosed by psychiatrists from 2002 to 2013 were included. Individuals with schizophrenia were selected as control groups that were matched with the incident AN and BN cases for sex, age stratum, and year of diagnosis.

RESULTS

AN was more likely to be diagnosed by female psychiatrists. Patients with AN were more frequently diagnosed in medical centers while patients with BN were mostly diagnosed in primary care clinics. Nearly all patients with AN and BN had sought treatment for physical problems but less than half had sought help for mental health problems in the year preceding the diagnosis. Individuals with AN, BN, and schizophrenia were all under-detected by nonpsychiatric medical professionals. Notably, BN was least likely to be recognized by both psychiatrists and other medical professionals.

DISCUSSION

Our findings underscore the importance of educational programs that are designed to improve the detection and management of eating disorders by medical professionals in Taiwan. Advanced educational programs that target differential diagnosis and the tailored management of different eating disorders should be highlighted among psychiatrists.

Healthcare use and costs of adults with anorexia nervosa and bulimia nervosa in Taiwan

OBJECTIVE

This study aimed to examine the health service use and healthcare costs of adults with anorexia nervosa (AN) and bulimia nervosa (BN) in Taiwan.

METHOD

AN and BN cases between 2002-2013 were extracted from a national health insurance database. For each AN and BN case, we randomly selected 10 controls with no eating disorder, matched for sex, age, urbanization of residence, and year of medical visit. The percentage and frequency of health services use and costs in the year preceding and after the diagnosis of AN/BN were compared between groups. We used generalized linear models with gamma distribution and log link function to determine the effects of age, sex, and psychiatric comorbidities on the total cost adjusting for physical comorbidities and to calculate the mean cost difference between groups by using marginal and incremental effects.

RESULTS

Both individuals with AN and BN had significantly elevated healthcare utilization and costs compared to controls during the baseline and one-year period after diagnosis. Patients with AN had more than three times higher total costs (US $792) and patients with BN had two times higher total costs (US $320) than individuals without eating disorders. Comorbidity of depressive disorder and older age significantly increased healthcare costs among both individuals with AN and BN.

DISCUSSION

There are high medical and economic burdens of care for individuals with AN and BN. Early diagnosis and integrated care for eating disorders are important tasks to reduce disease burden in Taiwan.

Development of consensus-based guidelines for outpatient dietetic treatment of eating disorders: A Delphi study

OBJECTIVE

To generate consensus-based guidelines for outpatient dietetic treatment of patients with an eating disorder (ED) using Delphi methodology.

METHOD

A modified Delphi method was used to develop consensus-based guidelines in several categories: referral to a dietitian; essential components of outpatient dietetic treatment; strategies to promote collaboration between dietitians and other healthcare professionals; and skills dietitians should possess if treating patients with an ED. Participants (n = 162) were coded into three panels: ED specialists (n = 79), non-ED specialists (n = 28), and consumers and carers with lived experience of an ED (n = 55). A total of 122 statements were rated across three rounds.

RESULTS

Eighty-one statements reached consensus level (66.4%). A high proportion of endorsed statements were consistent with current guidelines for ED treatment, though some statements for which evidence exists were not endorsed as essential components of dietetic treatment. Compared to consumers and carers, ED specialists were less likely to endorse assessment or involvement by a dietitian as a standard component of treatment, and a number of discrepancies between ED specialists and consumers and carers were observed regarding essential components of dietetic treatment.

DISCUSSION

This study provides consensus-based guidelines in the current absence of clinical practice guidelines for dietetic treatment of EDs. It also highlights the importance of further research into: (a) the effectiveness of different components of dietetic intervention in this population and (b) how dietetic assessment and intervention is best incorporated into outpatient treatment.

Effects associated with the use of healthcare for eating disorders by women in the community: a longitudinal cohort study

OBJECTIVES

This study examined formal and informal healthcare use (HCU) in community women with disordered eating, and associations of HCU with mental health-related quality of life (MHRQoL), psychological distress, mental health literacy (MHL) and eating disorder (ED) symptoms over time.

HYPOTHESIS

We hypothesised that HCU would lead to improvement in ED symptom severity, MHRQoL, MHL and psychological distress.

DESIGN, SETTING, PARTICIPANTS

Data were from years 2, 4 and 9 of a longitudinal cohort of 443 community women (mean age 30.6, SE 0.4 years) with a range of ED symptoms, randomly recruited from the Australian Capital Territory electoral role or via convenience sampling from tertiary education centres. Data were collected using posted/emailed self-report questionnaires; inclusion criteria were completion of the HCU questionnaire at time point of 2 years (baseline for this study). HCU was measured using a multiple-choice question on help seeking for an eating problem. To test the effect of HCU over time on MHRQoL (Short Form-12 score), psychological distress (Kessler Psychological Distress Scale score), ED symptom severity (Eating Disorder Examination Questionnaire score) and ED-MHL, linear or logistic mixed-effects regression analyses were used.

RESULTS

20% of participants sought ED-specific help at baseline; more than half of participants sought help that was not evidence based. HCU at baseline was significantly associated with improved MHRQoL and ED symptom severity and decreased psychological distress over time (Cohen's d all >0.3, ie, small). HCU was not significantly associated with MHL over time. The predictive ability of the fitted models ranged from 32.18% to 42.42% for psychological distress and MHL treatment, respectively.

CONCLUSIONS

Formal and informal HCU were associated with small improvements in ED symptoms, MHRQoL and psychological distress but not with improved MHL. Informal services in ED management should be investigated further along with efforts to improve ED-MHL.

Brain Stimulation in Eating Disorders: State of the Art and Future Perspectives

The management of eating disorders (EDs) is still difficult and few treatments are effective. Recently, several studies have described the important contribution of non-invasive brain stimulation (repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and electroconvulsive therapy) and invasive brain stimulation (deep brain stimulation and vagal nerve stimulation) for ED management. This review summarizes the available evidence supporting the use of brain stimulation in ED. All published studies on brain stimulation in ED as well as ongoing trials registered at clinicaltrials.gov were examined. Articles on neuromodulation research and perspective articles were also included. This analysis indicates that brain stimulation in EDs is still in its infancy. Literature data consist mainly of case reports, cases series, open studies, and only a few randomized controlled trials. Consequently, the evidence supporting the use of brain stimulation in EDs remains weak. Finally, this review discusses future directions in this research domain (e.g., sites of modulation, how to enhance neuromodulation efficacy, personalized protocols).

Identifying research priorities in eating disorders: A Delphi study building consensus across clinicians, researchers, consumers, and carers in Australia

OBJECTIVE

Eating disorders are underrepresented among successful applications for medical research funding. Developing agreement on the top research priorities may assist in fostering collaborations, innovation, and meaningful consumer and carer involvement. This study aimed to develop consensus among Australian clinicians, researchers, consumers, carers, and interested members of affiliated industries, on the priorities for eating disorders research.

METHOD

The Delphi expert consensus method was used. Participants were 291 members of the Australia New Zealand Academy for Eating Disorders (ANZAED) or the National Eating Disorders Collaboration (NEDC). Three panels were formed based on participant expertise: "ED Specialists," Consumers/Carers, and Affiliates. A total of 32 potential research areas (29 in Survey 1, 3 in Survey 2) were rated on a 5-point scale of importance, with 80% agreement across all three panels required for endorsement as a priority. Participants also ranked 7 broad research domains in order of priority.

RESULTS

Research areas describing early intervention and evidence-based treatments were the most highly rated, with more than 90% endorsement from each of the three panels. The research domains of accessible evidence-based treatments, early intervention and detection, and origins of eating disorders, were the most highly ranked. The ED specialists and Consumers/Carers panels had very similar patterns of responding, while the Affiliates panel showed small differences.

DISCUSSION

Using the Delphi expert consensus method resulted in a collaborative consensus driven eating disorders research agenda for the Australian context and forms a model upon which other countries may also develop their funding priorities.

Healthcare utilisation for eating disorders among patients with depression: a cross-sectional study in Taiwan

OBJECTIVES

Although depressed patients may have a comorbid eating disorder (ED), to date, no study has focused on healthcare utilisation among this population. This study was designed to investigate the characteristics of healthcare service utilisation among depressed patients with ED.

DESIGN

A cross-sectional study.

SETTING

This population-based study used claims data from Taiwan's National Health Insurance Research database between 2001 and 2012.

PARTICIPANTS

The study involved 1270 participants. These included 254 depressed individuals with ED and 1016 propensity score-matched depressed individuals without ED.

OUTCOME MEASURES

We tracked each patient for a 1 year period to evaluate their healthcare service utilisation, including outpatient visits, inpatient days, and costs for psychiatry and non-psychiatry services. We performed a Mann-Whitney U test to compare outcome variables in healthcare service utilisation between the two groups.

RESULTS

Patients with both depression and ED had significantly more outpatient visits (32.2 vs 28.9, p=0.023), outpatient costs (US$1089 vs US$877, p<0.001) and total costs (US$1356 vs US$1296, p<0.001) than comparison patients. For psychiatric services, patients with depression and ED had more outpatient visits (11.0 vs 6.8, p<0.001), outpatient costs (US$584 vs US$320, p<0.001) and total costs (US$657 vs US$568, p<0.001) than those without ED. For non-psychiatric services, there was no significant difference for all utilisation. This indicates that the total costs were about 1.0-fold greater for depression patient with ED than those without ED.

CONCLUSION

Depression patients with ED had more outpatient visits, outpatient costs and total costs of healthcare services than those without ED.

Differential Item Functioning in Brief Instruments of Disordered Eating

Abstract. Most instruments for the assessment of disordered eating were developed and validated in young female samples. However, they are often used in heterogeneous general population samples. Therefore, brief instruments of disordered eating should assess the severity of disordered eating equally well between individuals with different gender, age, body mass index (BMI), and socioeconomic status (SES). Differential item functioning (DIF) of two brief instruments of disordered eating (SCOFF, Eating Attitudes Test [EAT-8]) was modeled in a representative sample of the German population ( N = 2,527) using a multigroup item response theory (IRT) and a multiple-indicator multiple-cause (MIMIC) structural equation model (SEM) approach. No DIF by age was found in both questionnaires. Three items of the EAT-8 showed DIF across gender, indicating that females are more likely to agree than males, given the same severity of disordered eating. One item of the EAT-8 revealed slight DIF by BMI. DIF with respect to the SCOFF seemed to be negligible. Both questionnaires are equally fair across people with different age and SES. The DIF by gender that we found with respect to the EAT-8 as screening instrument may be also reflected in the use of different cutoff values for men and women. In general, both brief instruments assessing disordered eating revealed their strengths and limitations concerning test fairness for different groups.

Drunkorexia: A new term and diagnostic criteria

Individuals who restrict their caloric intake and/or exercise excessively to mitigate the calories from alcohol consumption may suffer from an eating disorder, substance abuse disorder, or both. While the term "drunkorexia" has been used in both academic articles and popular culture, issues persist with respect to diagnosing and treating this condition. Classifying the behavior as a subcategory of Other Specified Feeding and Eating Disorders (OSFED) would provide patients with an increased likelihood of receiving insurance coverage for this condition. A consistent definition of this behavior and a more medically accurate/appropriate term-such as "alcoholimia"-are both needed to advance treatment and prevention efforts.

Associations between disordered eating and intimate partner violence mediated by depression and posttraumatic stress disorder symptoms in a female veteran sample

OBJECTIVE

This study established a link between intimate partner violence (IPV) and eating disorders (EDs) via mediators of depression and posttraumatic stress disorder (PTSD) symptoms in female veterans.

METHOD

A nationally representative sample of female veterans (N = 190, Mean age = 48.41 years) completed online surveys assessing IPV and symptoms of depression, PTSD, and EDs, at three time points from 2014 to 2017.

RESULTS

Approximately 14.11% of participants met criteria for any ED (7.83% Bulimia Nervosa; 6.28% Binge Eating Disorder), and 49.42% reported lifetime histories of IPV. Eating disorder symptoms were significantly associated with lifetime IPV, PTSD and depression symptoms at the bivariate level. Mediation model results revealed that lifetime IPV was indirectly associated with EDDS scores, via PTSD symptoms and depression symptoms.

CONCLUSION

Findings confirmed elevated rates of probable EDs and lifetime IPV among female veterans; significant associations between EDs, lifetime IPV, depression, and PTSD; and mediation of the association between IPV and EDs by PTSD and depression symptoms. Implications for screening, treatment and research are discussed.

A randomized comparison of long acting methylphenidate and cognitive behavioral therapy in the treatment of binge eating disorder

Cognitive behavioral therapy (CBT) is a well-established treatment for binge eating disorder (BED); however, this treatment is underutilized, highlighting the need for additional treatment alternatives. Dopamine neurotransmission has been associated with dysregulated eating, and pharmaceutical agents targeting the dopamine system are associated with decreased binge eating and weight. The primary objective of the current investigation was to evaluate the efficacy of psychostimulant medication versus current best practices in the treatment of BED symptoms, in a randomized trial of methylphenidate versus CBT for BED. The secondary objective was to evaluate the ability of impulsivity to predict treatment outcomes. Female outpatients with BED were randomized to receive methylphenidate (n = 22) or CBT (n = 27) for 12 weeks. The primary outcome was objective binge episode frequency; secondary outcomes included subjective binge episode frequency, body mass index (BMI), BED symptoms, and quality of life. Results showed that both treatments had a significant impact on primary and secondary outcomes. Methylphenidate and CBT were associated with decreases in subjective and objective binge episodes; methylphenidate was associated with greater decreases in BMI. Two impulsivity traits predicted clinical outcomes. Results provide preliminary support for the therapeutic benefit of methylphenidate in BED treatment, and prognostic utility of impulsivity in this context.

Associations between healthcare use and disordered eating among female veterans

OBJECTIVE

Individuals with eating disorders (EDs) have considerable medical and psychiatric comorbidity as well as increased healthcare use and associated costs. However, EDs remain largely undetected and understudied among veteran populations, and EDs are not routinely screened for or treated in Veterans Affairs (VA) medical settings. Research elucidating the links between disordered eating and VA and non-VA healthcare use is needed to inform policy and practice for ED screening and treatment.

METHOD

Data regarding probable EDs and VA and non-VA healthcare use was obtained through a mail survey of 198 female veterans receiving care from VA.

RESULTS

A total of 21 participants (10.6%) met probable criteria for subthreshold anorexia nervosa, bulimia nervosa, or binge-eating disorder. Negative binomial regression models revealed that female veterans with EDs reported higher frequency of VA mental healthcare use and substance use disorder treatment, above and beyond the association of comorbid PTSD and depression symptoms.

DISCUSSION

These findings confirm the high probability that female veterans with EDs are utilizing significant VA mental health resources. Screening for EDs may be particularly important in VA medical and mental health settings.

An Aristotelian view of therapists' practice in multifamily therapy for young adults with severe eating disorders

Background:

Eating disorders are serious conditions which also impact the families of adult patients. There are few qualitative studies of multifamily therapy with adults with severe eating disorders and none concerning the practice of therapists in multifamily therapy.

Objectives:

The aim of the study is to explore therapists’ practice in multifamily therapy.

Research design and participants:

A grounded theory approach was chosen. Data were collected through participant observation in two multifamily therapy groups and qualitative interviews with the therapists in those groups.

Ethical considerations:

The study conforms to the principles outlined in the Declaration of Helsinki. All participants in the multifamily therapy groups received information about the research project and signed consent forms. The data are treated confidentially and anonymised.

Findings:

The core category was identified as ‘having many strings to one’s bow’, consisting of three subcategories: ‘planning and readjusting’, ‘developing as therapist and team’ and ‘regulating the temperature of the group’. This article discusses the empirical findings in the frame of Aristotelian virtue ethics.

Patterns of medical utilization before the first hospitalization for women with anorexia nervosa in Taiwan

OBJECTIVE

The aim of this paper was to analyze medical utilization patterns of female patients with anorexia nervosa before their first inpatient care visit for anorexia nervosa using the National Health Insurance Research Database (NHIRD) of Taiwan.

METHOD

We selected female anorexia nervosa patients (n=239) and control participants hospitalized for peptic ulcers (n=478) or appendectomy (n=478) who were matched by age and incident year from two subsets of the NHIRD. The number of visits, specialists, diagnosis distribution, and selected procedures used in ambulatory services during the 2-year period before the index admission were identified and compared. Healthcare service expenditures were also analyzed.

RESULTS

Compared to the control groups, the female anorexia nervosa patients used more outpatient services (anorexia nervosa, 58.6±45.0 visits; peptic ulcers, 45.3±37.3 visits; appendectomy, 32.5±26.0 visits), mainly due to psychiatric visits. Anorexia nervosa patients were more likely to have received a diagnosis of digestive, endocrine/metabolic, and mental disorders than patients in the control groups. Although nearly equal percentages of patients in the three groups had obtained a diagnosis of a digestive disease, anorexia nervosa patients received digestive disease diagnoses with greater frequency.

CONCLUSIONS

We posit that the various physical symptoms of anorexia nervosa patients and physicians' low level of suspicion of anorexia nervosa led to delayed diagnoses and greater medical utilization than that of the controls groups. Education to raise awareness of anorexia nervosa and other eating disorders among physicians is warranted.

Reducing the burden of suffering from eating disorders: Unmet treatment needs, cost of illness, and the quest for cost-effectiveness

Eating disorders are serious mental disorders as reflected in significant impairments in health and psychosocial functioning and excess mortality. Despite the clear evidence of clinical significance and despite availability of evidence-based, effective treatments, research has shown a paradox of elevated health services use and, yet, infrequent treatment specifically targeting the eating disorder (i.e., high unmet treatment need). This review paper summarizes key studies conducted in collaboration with G. Terence Wilson and offers an update of the research literature published since 2011 in three research areas that undergirded our collaborative research project: unmet treatment needs, cost of illness, and cost-effectiveness of treatments. In regards to unmet treatment needs, epidemiological studies find that the number of individuals with an eating disorder who do not receive disorder-specific treatment continues to remain high. Cost-of-illness show that eating disorders are associated with substantial financial burdens for individuals, their family, and society, yet comprehensive examination of costs across public sectors is lacking. Cost measures vary widely, making it difficult to draw firm conclusions. Hospitalization is a major driver of medical costs incurred by individuals with an eating disorder. Only a handful of cost-effectiveness studies have been conducted, leaving policy makers with little information on which to base decisions about allocation of resources to help reduce the burden of suffering attributable to eating disorders.

Effect of Hospitalization on Percent Median Body Mass Index at One Year, in Underweight Youth With Restrictive Eating Disorders

PURPOSE

Data from low-weight patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED treatment programs were analyzed to determine whether there was an association between hospitalization and gain to at least 90% median body mass index (mBMI) at 1-year follow-up.

METHODS

Data were retrospectively collected for 322 low-weight (<85% mBMI at intake) patients aged 9-21 years, who presented with restrictive EDs to 14 adolescent medicine-based ED programs in 2010. Positive outcome was defined as being at least 90% mBMI (%mBMI = patient's body mass index/mBMI for age × 100) at 1-year follow-up. Association between treatment at a higher level of care and gain to at least 90% mBMI was analyzed for 140 patients who were <85% mBMI at the time of presentation, had not been previously hospitalized, and had 1-year follow-up data available.

RESULTS

For patients presenting at <85% mBMI, those who were hospitalized in the year following intake had 4.0 (95% confidence interval: 1.6-10.1) times the odds of gain to at least 90% mBMI, compared with patients who were not hospitalized, when controlling for baseline %mBMI.

CONCLUSION

In this national cohort of patients with restrictive EDs presenting to adolescent medicine-based ED programs at <85% mBMI, those who were hospitalized had greater odds of being at least 90% mBMI at 1-year follow-up.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Trial registration

Current Controlled Trials ISRCTN42594993, ISRCTN67720902, ISRCTN06149665 and ISRCTN18274621.

Funding

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

Characteristics of seeking treatment among U.S. adolescents with eating disorders

OBJECTIVE

The majority of persons with eating disorders (EDs) do not seek ED treatment, yet little is known about treatment-seeking barriers or facilitators. The aim of the study is to describe the characteristics associated with seeking ED treatment among U.S. adolescents with EDs.

METHOD

Data from a nationally representative cross-sectional study of U.S. adolescents ages 13-18 years were used for these analyses. Specifically, adolescents who met criteria for lifetime EDs (N = 281) were included. Sociodemographic information, characteristics of EDs, psychiatric comorbidities, and other mental health service use were assessed via interview.

RESULTS

Only 20% of adolescents sought ED treatment. Females were 2.2 (95% CI 0.8, 6.4) times more likely to seek treatment than males (19.9% vs. 8.9%). Adolescents who met criteria for anorexia nervosa or bulimia nervosa were 2.4 (95% CI 0.9, 6.3) and 1.9 (95% CI 1.0, 3.8) times more likely to seek treatment than adolescents who met criteria for binge-eating disorder (27.5% and 22.3% vs. 11.6%). Specific ED behaviors (restriction and purging), ED-related impairment, and any mental health service use were also associated with adolescent treatment seeking.

DISCUSSION

Adolescent treatment seeking was infrequent overall, with individuals with counter-stereotypic ED presentations least likely to have sought treatment. Adolescent treatment seeking could be promoted through increasing awareness among the public and healthcare professionals that EDs affect a heterogeneous group of people. More generally, research involving both treatment-seeking and non-treatment-seeking individuals holds great potential to refine the field's knowledge of ED etiology, prevalence, treatment, and prevention.

Direct and indirect costs among patients with binge-eating disorder in the United States

OBJECTIVE

To quantify the economic burden of binge-eating disorder (BED) in terms of work productivity loss, healthcare resource utilization, and healthcare costs.

METHODS

Respondents of the US National Health and Wellness Survey 2013 were invited to participate in a follow-up internet survey to identify adults with BED using DSM-5 criteria. Work productivity loss, healthcare resource utilization, and direct and indirect costs were assessed for BED respondents and matched non-BED respondents using generalized linear models or two-part models as appropriate.

RESULTS

A total of 1,720 people were included in our analysis (N = 344 with BED; N= 1,376 without BED). BED respondents had higher levels of activity impairment than non-BED respondents (41.29% vs. 23.18%, p < .001). Employed BED respondents (N = 178) had a greater level of work impairment than employed non-BED respondents (N = 686) (36.83% vs. 14.41%, p = .009). Higher healthcare resource utilization in the past 6 months among BED respondents was reported than matched non-BED respondents: numbers of surgeries (0.23 vs. 0.13, p = .021), ER visits (0.26 vs. 0.15, p = .016), and physician visits (6.09 vs. 4.56, p = .002). BED respondents reported higher total direct costs than matched non-BED respondents ($20,194 vs. $14,465, p = .005). The indirect costs among employed BED respondents were also higher than those without BED ($19,327 vs. $9,032, p < .001).

DISCUSSION

Individuals with BED reported significantly greater economic burden with respect to work productivity loss, level of healthcare resource utilization, and costs compared to non-BED respondents. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:523-532).

Screening disordered eating in a representative sample of the German population: Usefulness and psychometric properties of the German SCOFF questionnaire

The prevention of eating disorders and the identification of high-risk individuals are essential for the public health sector. There is need for sensitive and specific screening instruments of disordered eating that can be applied in universal samples as an initial step into disease prevention. The SCOFF is a screening instrument for disordered eating, frequently used in international and cross-cultural contexts to detect individuals at risk. The objective of this research is to evaluate whether the SCOFF can be used as a screening tool for disordered eating in universal samples. This is the first study which examined the psychometric properties of the German version of the SCOFF in a general population sample. A representative sample (N=2527) of the German population, aged 14-95years, was recruited. Psychometric properties were determined including reliability, concurrent and construct validity, and factor structure. The prevalence of disordered eating was assessed. The prevalence of disordered eating in the general population was 10%. Using the established cutoff point of ≥2, values for diagnostic accuracy were 26% (sensitivity), 97% (specificity), 80% (positive predictive value), and 74% (negative predictive value). Factorial analyses revealed an excellent model fit of a unidimensional model. Due to its low sensitivity and a high percentage of false negatives, there are limitations in using the German version of the SCOFF in general population samples with wide age ranges.

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.

Medical comorbidity of binge eating disorder

PURPOSE

To gain further understanding of the general medical comorbidity of binge eating disorder (BED) beyond its association with obesity.

METHOD

We reviewed studies of general medical comorbidity in people with BED or clinically significant binge eating behavior beyond obesity. We also reviewed studies of BED in specific medical conditions.

RESULTS

Three broad study categories of medical comorbidity in BED were found: cross-sectional studies of medical conditions in BED; prospective studies of medical conditions in BED; and studies of BED in specific medical conditions. Cross-sectional epidemiologic data suggest that BED is associated with medical conditions related to obesity, including diabetes, hypertension, dyslipidemias, sleep problems/disorders, and pain conditions, and that BED may be related to these conditions independent of obesity and co-occurring psychiatric disorders. Prospective data suggest that BED may be associated with type 2 diabetes and metabolic syndrome. BED or binge eating behavior is also associated with asthma and gastrointestinal symptoms and disorders, and among women, menstrual dysfunction, pregnancy complications, intracranial hypertension, and polycystic ovary syndrome.

CONCLUSIONS

BED is associated with substantial medical comorbidity beyond obesity. Further study of the general medical comorbidity of BED and its relationship to obesity and co-occurring psychiatric disorders is greatly needed.