Facets of shared decision-making on drug treatment for adults with an eating disorder

Analysis of Influencing Factors and Strategies of Implementing Shared Decision-Making Among Patients with Gastrointestinal Cancer: A Systematic Review and Meta-analysis of Qualitative Studies

BACKGROUND

Over the past 50 years, doctor-patient interactions have moved from paternalistic to patient-centered, emphasizing shared decision-making (SDM). SDM, which involves healthcare professionals and patients making clinical decisions together, is crucial for patient autonomy and is promoted worldwide, yet remains challenging to implement effectively. Our systematic review analyses the influencing factors of implementing shared decision-making in patients with colorectal cancer and summarizes coping strategies.

MATERIALS AND METHODS

A systematic search of the PubMed, Embase, Cochrane Library, Web of Science (Core library), Ovid, and EBSCO databases was performed from database inception to 1 September 2024 using a combination of subject words and free words. Qualitative studies on the factors affecting SDM for patients with gastrointestinal cancer were identified, the literature quality was evaluated using the Australian JBI Evidence-based Health Care Center quality evaluation standards for qualitative research, and the results were integrated by a pooled integration method.

RESULTS

A total of 37 results were extracted through meta-analysis, summarized into 9 themes, and summarized into 2 subthemes. The results were classified for nonmutually exclusive cases.

CONCLUSIONS

Medical staff should fully understand patients' needs and preferences for disease and treatment information, strengthen their communication skills regarding SDM, and actively provide effective treatment and care information for patients and their families to promote the implementation of SDM for patients with gastrointestinal tumors.

[Parental Distress of Patients Who Refuse to Eat: Toward a Deeper Understanding and Greater Support for Parents of Children Suffering from an Eating Disorder]

Parental Distress of Patients Who Refuse to Eat: Toward a Deeper Understanding and Greater Support for Parents of Children Suffering from an Eating Disorder Abstract: Many parents experience their role as parents of a daughter/son with anorexia nervosa as very troublesome and demanding. In several departments of child and adolescen psychiatry in Germany, the contact between parents and adolescent patients with anorexia nervosa is still restricted because parents are often judged responsible for the eating disorder of their child - or at least seen as troublemakers during their child's inpatient treatment. Parents blame themselves for the development of anorexia nervosa, and in comparison to other mental disorders of adolescence, they experience even more guilt and shame. Many of them suffer from psychiatric disorders themselves (not a few from eating disorders), which reinforce feelings of helplessness and shame. Several parents have partnership problems and must take off work to support their child, which often leads to financial losses for the whole family. They complain that they have insufficient support and feel misunderstood by health professionals whom they wish to have a profound knowledge of the disorder and who would trust and understand the carers. This article provides several recommendations to improve the relationship between parents and therapists: termination of contact restrictions, detailed information for the parents about possible biological and psychological causes of eating disorders, including psychoeducational groups and involvement in treatment, not only through therapeutic conversations but also through practical exercises such as meal support. An innovative approach is home treatment, which offers the chance to integrate parents into treatment and thus improve their skills in handling their daughter´s/son´s illness. We should be aware that parents are the most important resource to help young patients with debilitating eating disorders.

Treatment Targets and Strategies for Eating Disorders Recovery: A Delphi Consensus With Lived Experience, Carers, Researchers, and Clinicians

OBJECTIVE

Long-term recovery rates following eating disorders (EDs) treatment remain low. This might be partly due to a lack of agreement between key stakeholder groups, including people with lived experience, carers, clinicians, and researchers, regarding optimal therapeutic targets and strategies. We aimed to reach a consensus across these diverse groups on the most valued treatment targets and strategies for fostering ED recovery.

METHOD

We used the Delphi method with two phases: (i) Survey development and (ii) Expert rating. The survey development phase included the design of an initial set of items through scoping review and feedback from a committee of 14 experts. During the survey rating, we engaged a larger panel of 185 experts who comprised the stakeholder groups: Individuals with lived ED experience (n = 49), carers (n = 44), researchers (n = 46), and clinicians (n = 46).

RESULTS

Thirty-one targets and 29 strategies reached consensus (> 70% agreement over three rounds). Psychological-emotional-social targets including quality of life, sense of purpose, and emotion regulation, along with ED behaviors, reached the highest agreement (> 90%). Strategies reflecting an individualized approach to treatment (i.e., considering diversity, assessing comorbidities, and enhancing rapport) achieved the highest agreement (> 90%). Responses across groups were similar, except researchers leaning more towards consideration of weight- and eating-related targets.

DISCUSSION

Holistic targets and individualized therapeutic strategies have consistent support from the different stakeholder groups involved in ED treatment. The agreed set of targets/strategies may be used, in triangulation with other sources of evidence, to design and evaluate coproduced and personalized interventions.

Treatment escalation for people with anorexia nervosa: setting, therapies and nutritional interventions

PURPOSE OF REVIEW

Adult patients with severe anorexia nervosa often receive the same unsuccessful treatment without changes regarding the setting, the therapies, or nutritional interventions.

RECENT FINDINGS

Settings where people with anorexia nervosa are treated include their general practitioner, an independent psychiatric practice, a community mental health team (CMHT), a specialized eating disorder outpatient service, eating disorder early intervention services, a highly intensive eating disorder outpatient or home treatment programme, eating disorder daycare, an inpatient eating disorder service, a general hospital or a general psychiatric hospital, or residential treatment. At a specialized eating disorder service, patients should be offered evidence-based psychotherapy for anorexia nervosa, dietary advice and physical health monitoring as a first step. Additionally, they may be allocated to a specific treatment pathway, family interventions and creative therapies. As a second step, clinicians may consider integrating interventions targeting psychiatric or physical comorbidities, medication for anorexia nervosa or noninvasive neurostimulation. After several years of futile treatment, deep brain stimulation (DBS) should be considered to prevent a chronic course of anorexia nervosa. Nutritional interventions can be escalated from nutritional counselling to nasogastric tube feeding. Patients who rely on nasogastric tube feeding might benefit from percutaneous endoscopic gastrostomy (PEG). Patients who vomit despite a nasogastric tube, might need nasojejunal tube feeding.

SUMMARY

Treatment for people with anorexia nervosa should be regularly reviewed and, if necessary, escalated to avoid a chronic and longstanding disease course.

Pharmacological Treatment of Binge Eating Disorder and Frequent Comorbid Diseases

Binge eating disorder (BED) is the most common specific eating disorder (ED). It is frequently associated with attention deficit hyperactivity disorder (ADHD), depression, bipolar disorder (BD), anxiety disorders, alcohol and nicotine use disorder, and obesity. The aim of this narrative review was to summarize the evidence for the pharmacological treatment of BED and its comorbid disorders. We recommend the ADHD medication lisdexamfetamine (LDX) and the antiepileptic and antimigraine drug topiramate for the pharmacological treatment of BED. However, only LDX is approved for the treatment of BED in some countries. Medications to treat diseases frequently comorbid with BED include atomoxetine and LDX for ADHD; citalopram, fluoxetine, sertraline, duloxetine, and venlafaxine for anxiety disorders and depression; aripiprazole for manic episodes of BD; lamotrigine, lirasidone and lumateperone for depressive episodes of BD; naltrexone for alcohol use disorder; bupropion for nicotine use disorder; and liraglutide, semaglutide, and the combination of bupropion and naltrexone for obesity. As obesity is a frequent health consequence of BED, weight gain-inducing medications, such as the atypical antipsychotics olanzapine or clozapine, the novel antidepressant mirtazapine and tricyclic antidepressants, and the mood stabilizer valproate should be avoided where possible. It is currently unclear whether the novel and promising glucagon, glucose-dependent insulinotropic polypeptide (GIP), and glucagon-like peptide 1 (GLP-1) receptor agonists like tirzepatide and retatrutide help with BED and its comorbidities. However, these compounds have been reported to reduce binge eating in individuals with obesity or overweight.

Anorexia nervosa: diagnostic, therapeutic, and risk biomarkers in clinical practice

In anorexia nervosa (AN), measurable biological parameters can inform the process of treating patients. Such biomarkers include established laboratory parameters as well as a range of potential future biomarkers, including genetic, metabolomic, microbiomic, endocrine, immunological, hematological, electrophysiological, and neuroimaging parameters. In this opinion article we discuss how these biomarkers can support diagnosic and therapeutic processes at specific steps during the AN treatment cycle, that is, the diagnosis, diagnostic specification, risk management, choice of therapy, therapy monitoring, and treatment review. History-taking, physical and neuropsychological examination, clinical observation, and judgment about treatment success by the patient, their carers, and members of the multidisciplinary team are essential to interpret laboratory and imaging data appropriately and to assess the full clinical picture.

Shifting Perspectives on the Challenges of Shared Decision Making in Mental Health Care

Although shared decision making (SDM) has become the most preferable way in doctor-patient communication, it is not fully implemented in mental health care likely due to the complex nature of psychiatric syndromes and treatments. In this review we provide a systematic overview of all perceived and reported barriers to SDM in the literature, acknowledging field-specific challenges, and offering perspectives to promote its wider use. We conducted a systematic search of the wider literature in different databases and included all publications mentioning specified barriers to SDM in psychiatric care. Relevant data and opinions were categorised into micro-, meso- and macro-level themes and put into clinical perspective. We derived 20 barriers to SDM from 100 studies and reports. Eight were on micro-level care delivery, seven involved meso-level issues, five concerned macro-level themes. The multitude of perceived and actual barriers to SDM underline the challenges its implementation poses in mental health care, some of which can be resolved while others are inherent to the nature of the care, with its long-term relationships, complex dynamics, and social consequences, all requiring a flexible approach. We present four perspectives to help change views on the potential of SDM in mental health care.

Metabolic Adverse Effects of Psychotropic Drug Therapy: A Systematic Review

This review aimed to investigate the metabolic alterations associated with psychopharmacological treatment of neuropsychiatric disorders, which can significantly impact patients' physical health and overall quality of life. The study utilized the PRISMA methodology and included cross-sectional, retrospective studies, and randomized clinical trials from reputable databases like SCOPUS, CLARIVATE, SCIENCE DIRECT, and PUBMED. Out of the 64 selected studies, various psychotropic drug classes were analyzed, including antidepressants, anticonvulsants, and antipsychotics. Among the antidepressants, such as amitriptyline, Imipramine, and clomipramine, weight gain, constipation, and cardiovascular effects were the most commonly reported metabolic adverse effects. SSRI antidepressants like Fluoxetine, Sertraline, Citalopram, Escitalopram, and Paroxetine exhibited a high prevalence of gastrointestinal and cardiac alterations. Regarding anticonvulsants, valproic acid and Fosphenytoin were associated with adverse reactions such as weight gain and disturbances in appetite and sleep patterns. As for antipsychotics, drugs like Clozapine, Olanzapine, and Risperidone were linked to weight gain, diabetes, and deterioration of the lipid profile. The findings of this review emphasize the importance of continuous monitoring for adverse effects, particularly considering that the metabolic changes caused by psychopharmacological medications may vary depending on the age of the patients. Future research should focus on conducting field studies to further expand knowledge on the metabolic effects of other commonly prescribed psychotropic drugs. Overall, the study highlights the significance of understanding and managing metabolic alterations induced by psychopharmacological treatment to enhance patient care and well-being.

Descriptions of Disordered Eating in German Psychiatric Textbooks, 1803-2017

The most common eating disorders (EDs) according to DSM-5 are anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED). These disorders have received increasing attention in psychiatry due to rising prevalence and high morbidity and mortality. The diagnostic category "anorexia nervosa," introduced by Ernest-Charles Lasègue and William Gull in 1873, first appears a century later in a German textbook of psychiatry, authored by Gerd Huber in 1974. However, disordered eating behavior has been described and discussed in German psychiatric textbooks throughout the past 200 years. We reviewed content regarding eating disorder diagnoses but also descriptions of disordered eating behavior in general. As material, we carefully selected eighteen German-language textbooks of psychiatry across the period 1803-2017. Previously, in German psychiatry, disordered eating behaviors were seen as symptoms of depressive disorders, bipolar disorder or schizophrenia, or as manifestations of historical diagnoses no longer used by the majority of psychiatrists such as neurasthenia, hypochondria and hysteria. Interestingly, 19th and early 20th century psychiatrists like Kraepelin, Bumke, Hoff, Bleuler, and Jaspers reported symptom clusters such as food refusal and vomiting under these outdated diagnostic categories, whereas nowadays they are listed as core criteria for specific eating disorder subtypes. A wide range of medical conditions such as endocrinopathies, intestinal or brain lesions were also cited as causes of abnormal food intake and body weight. An additional consideration in the delayed adoption of eating disorder diagnoses in German psychiatry is that people with EDs are commonly treated in the specialty discipline of psychosomatic medicine, introduced in Germany after World War II, rather than in psychiatry. Viewed from today's perspective, the classification of disorders associated with disordered eating is continuously evolving. Major depressive disorder, schizophrenia and physical diseases have been enduringly associated with abnormal eating behavior and are listed as important differential diagnoses of EDs in DSM-5. Moreover, there are overlaps regarding the neurobiological basis and psychological and psychopharmacological therapies applied to all of these disorders.

Developments in the psychological treatment of anorexia nervosa and their implications for daily practice

PURPOSE OF REVIEW

Our aim is to give an overview of the recent literature on psychological treatment for young adults and adults with anorexia nervosa and to discuss the implications of the findings for clinical practice.

RECENT FINDINGS

Three systematic reviews and meta-analyses have recently been published on psychological treatments for anorexia nervosa. Treatment outcomes are still modest and mainly focus on weight outcome, although outcomes for eating disorder disease and quality of life have also been reported. Adhering to a treatment protocol might lead to faster and better results.

SUMMARY

For children and adolescents with anorexia nervosa, the major guidelines recommend a family-based treatment. The treatments of choice for young adults and adults with anorexia nervosa are the Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), Cognitive Behaviour Therapy-Enhanced (CBT-E) and Specialist Supportive Clinical Management (SSCM), but none of these treatments seem to be superior. In search of other ways to improve outcome, shared decision making may be a way to help patients become more involved in their treatment, enhance their motivation and consequently improve the outcome.

Pharmacological treatment of eating disorders, comorbid mental health problems, malnutrition and physical health consequences

The pharmacological treatment of patients with an eating disorder (ED) often includes medications to treat their ED, comorbid mental health problems, malnutrition and the physical health problems resulting from it. The currently approved pharmacological treatment options for EDs are limited to fluoxetine for bulimia nervosa (BN) and - in some countries - lisdexamfetamine for binge eating disorder (BED). Thus, there are no approved pharmacological options for anorexia nervosa (AN), even though study results for olanzapine and dronabinol are promising. Topiramate might be an additional future option for the treatment of BN and BED. Selective serotonin reuptake inhibitors (SSRI), mirtazapine and bupropion could be considered for the treatment of comorbid unipolar depression. However, AN and BN are contraindications for bupropion. For ED patients with a manic episode, we recommend olanzapine in AN and risperidone in BN and BED; whereas for bipolar depression, olanzapine (plus fluoxetine) seems appropriate in AN and lamotrigine in BN and BED. Acute anxiety or suicidality may warrant benzodiazepine treatment with lorazepam. Proton-pump inhibitors, gastroprokinetic drugs, laxatives and hormones can alleviate certain physical health problems caused by EDs. Therapeutic drug monitoring, pharmacogenomic testing, a more restrictive use of "pro re nata" (PRN) medication, an interdisciplinary treatment approach, shared decision making (SDM) and the formulation of common treatment goals by the patients, their family or carers and clinicians could improve treatment success and safety. Novel genetic, immunological, microbiome and brain imaging research as well as new pharmacological developments like the use of psychedelics, stimulants, novel monoaminergic drugs, hormone analogues and drugs which enhance the effects of psychotherapy may extend our therapeutic options in the near future.