Eating Disorder Service Research Articles

Tertiary eating disorder services: is it time to integrate specialty care across the life span?

Australian tertiary eating disorder services (EDS) have a divided model of care, where child and adolescent mental health services (CAMHS) support patients until the age of 18 years, and thereafter, adult mental health services (AMHS) provide care. Consumers and carers have criticised this divided model because the age boundary occurs during the peak period of onset and acuity for eating disorders. Most CAMHS patients are lost to specialty follow-up around age 18, increasing the risks of relapse and premature mortality from eating disorders, since young women (aged 15-24) have the highest hospitalisation rates from anorexia nervosa. The current article is a commentary on the transition gap and possible service designs. Eating disorders require access to specialty treatment across the life span. The Australian Federal Government has expanded all-age care through the 2019 Medicare Benefit Schedule (MBS) eating disorder plans. Some new MBS patients require a rapid step-up in care intensity to a tertiary EDS, thereby increasing demand on the public sector. State/Territory Governments should strengthen EDS using the 'youth reach-down' model, where AMHS extend EDS to age 12. Vertical service integration from 12 to 64+ facilitates continuity of care for the duration of an eating disorder.

Therapists' Experiences of Working with Ethnic Minority Females with Eating Disorders: A Qualitative Study.

Ethnic minority females are less likely to receive a diagnosis or treatment for an eating disorder (ED). This study captured the experiences of therapists who have worked with ethnic minority females to improve outcomes for this group. Twelve therapists in the United Kingdom, London were recruited for semi-structured interviews and thematic analysis was used to analyse the data. Shame was cited as a barrier to accessing help. This influenced therapeutic work such as not challenging shame or linking this to a negative interpretation of parents. Emotional and interpersonal factors were thought to be more common risk factors for the ED. The minimising of weight and shape concern and non-fat-phobic anorexia was thought to lead to a complex and delayed route to accessing ED services. Therapists felt restricted by service management who they felt required them to deliver a narrow range of therapies that had not necessarily demonstrated therapeutic outcomes in ethnic minority females. Nevertheless, therapists reported using curiosity to guide their cultural adaptations when feeling uncertain. When working with ethnic minority females, therapists face challenges from the therapeutic and diagnostic framework that services are aligned to. Creative solutions to address this include adapting the patient care pathway, referral guides, cultural reflective practice, and the use of cultural genograms and scripts in therapeutic work to address unmet needs.

Assessing implementation fidelity in the First Episode Rapid Early Intervention for Eating Disorders service model

The First Episode Rapid Early Intervention for Eating Disorders (FREED) service model is associated with significant reductions in wait times and improved clinical outcomes for emerging adults with recent-onset eating disorders. An understanding of how FREED is implemented is a necessary precondition to enable an attribution of these findings to key components of the model, namely the wait-time targets and care package. This study evaluated fidelity to the FREED service model during the multicentre FREED-Up study. Participants were 259 emerging adults (aged 16-25 years) with an eating disorder of <3 years duration, offered treatment through the FREED care pathway. Patient journey records documented patient care from screening to end of treatment. Adherence to wait-time targets (engagement call within 48 h, assessment within 2 weeks, treatment within 4 weeks) and care package, and differences in adherence across diagnosis and treatment group were examined. There were significant increases (16-40%) in adherence to the wait-time targets following the introduction of FREED, irrespective of diagnosis. Receiving FREED under optimal conditions also increased adherence to the targets. Care package use differed by component and diagnosis. The most used care package activities were psychoeducation and dietary change. Attention to transitions was less well used. This study provides an indication of adherence levels to key components of the FREED model. These adherence rates can tentatively be considered as clinically meaningful thresholds. Results highlight aspects of the model and its implementation that warrant future examination.

The COVID-19 pandemic and eating disorders in children, adolescents, and emerging adults: virtual care recommendations from the Canadian consensus panel during COVID-19 and beyond

ObjectiveThe COVID-19 pandemic has had detrimental effects on mental health. Literature on the impact on individuals with eating disorders is slowly emerging. While outpatient eating disorder services in Canada have attempted to transition to virtual care, guidelines related to optimal virtual care in this field are lacking. As such, the objective of our Canadian Consensus Panel was to develop clinical practice guidelines related to the provision of virtual care for children, adolescents, and emerging adults living with an eating disorder, as well as their caregivers, during the COVID-19 pandemic and beyond.MethodsUsing scoping review methodology (with literature in databases from 2000 to 2020 and grey literature from 2010 to 2020), the Grading of Recommendations, Assessment, Development, and Evaluation system, the Appraisal of Guidelines, Research and Evaluation tool, and a panel of diverse stakeholders from across Canada, we developed high quality treatment guidelines that are focused on virtual interventions for children, adolescents, and emerging adults with eating disorders, and their caregivers.ResultsStrong recommendations were supported specifically in favour of in-person medical evaluation when necessary for children, adolescents, and emerging adults, and that equity-seeking groups and marginalized youth should be provided equal access to treatment. For children and adolescents, weak recommendations were supported for telehealth family-based treatment (FBT) and online guided parental self-help FBT. For emerging adults, internet cognitive-behavioural therapy (CBT)-based guided self-help was strongly recommended. Weak recommendations for emerging adults included CBT-based group internet interventions as treatment adjuncts, internet-based relapse prevention Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) guided self-help, telehealth relapse prevention using MANTRA, and guided CBT-based smartphone apps as treatment adjuncts. For caregivers of children and adolescents, weak recommendations were supported for virtual parent meal support training, and moderated online caregiver forums and support groups. For caregivers of emerging adults, guided parental self-help CBT was strongly recommended, and unguided caregiver psychoeducation self-help was weakly recommended.ConclusionsSeveral gaps for future work were identified including the impact of sex, gender, race, and socioeconomic status on virtual care among children, adolescents, and emerging adults with eating disorders, as well as research on more intensive services, such as virtual day hospitals.

COVID-19 and eating disorders in young people

Over the past year, child and adolescent eating disorder services of the UK National Health Service have seen almost a doubling in the number of both urgent and routine referrals.1 Although these services managed to meet recommended waiting times initially, waiting lists are now starting to grow.

The First Episode Rapid Early Intervention for Eating Disorders - Upscaled study: Clinical outcomes.

BackgroundFirst Episode Rapid Early Intervention for Eating Disorders (FREED) is a service model and care pathway for emerging adults aged 16 to 25‐years with a recent onset eating disorder (ED) of <3 years. A previous single‐site study suggests that FREED significantly improves clinical outcomes compared to treatment‐as‐usual (TAU). The present study (FREED‐Up) assessed the scalability of FREED. A multi‐centre quasi‐experimental pre‐post design was used, comparing patient outcomes before and after implementation of FREED in participating services.MethodsFREED patients (n = 278) were consecutive, prospectively ascertained referrals to four specialist ED services in England, assessed at four time points over 12 months on ED symptoms, mood, service utilization and cost. FREED patients were compared to a TAU cohort (n = 224) of similar patients, identified retrospectively from electronic patient records in participating services. All were emerging adults aged 16–25 experiencing a first episode ED of <3 years duration.ResultsOverall, FREED patients made significant and rapid clinical improvements over time. 53.2% of FREED patients with anorexia nervosa reached a healthy weight at the 12‐month timepoint, compared to only 17.9% of TAU patients (X 2 [1, N = 107] = 10.46, p < .001). Significantly fewer FREED patients required intensive (i.e., in‐patient or day‐patient) treatment (6.6%) compared to TAU patients (12.4%) across the follow‐up period (X 2 [1, N = 40] = 4.36, p = .037). This contributed to a trend in cost savings in FREED compared to TAU (−£4472, p = .06, CI −£9168, £233).DiscussionFREED is robust and scalable and is associated with substantial improvements in clinical outcomes, reduction in inpatient or day‐patient admissions, and cost‐savings.

Towards an evidence-based out-patient care pathway for children and young people with avoidant restrictive food intake disorder

Despite growing research and clinical interest in avoidant restrictive food intake disorder (ARFID), robust, evidence-based guidance on optimal treatment interventions, appropriate clinic structures, and modes of service delivery remain absent. Current consensus recommendations include a multi-disciplinary, multi-modal approach to assessment and treatment, with out-patient care being appropriate for the majority of patients, yet to date there is no clear guidance on how this might best be organised or implemented. This lack of guidance is due to a number of factors, that include the time required to conduct the necessary controlled trials and other well-designed investigations and for the subsequent body of research evidence to build. Lack of specific treatment guidance may also be related to the heterogeneous nature of ARFID clinical presentations potentially limiting the likelihood of uniform recommendations. This situation presents a challenge for clinicians required to engage in evidence-based practice, and for health care planners, providers, and policy makers. We describe here a proposed evidence-informed framework for care, subjected to preliminary testing and currently in use in an out-patient eating disorders service for children and young people aged 2–17 years. The use of the simplified care pathway diagram is illustrated with three case examples, and intended to serve as a possible model for further testing in a range of settings. In the face of ongoing uncertainty and inconsistency in the clinical management of ARFID, our intention is to share our experience in the form of an evidence-informed, trialled approach to structuring and providing intervention for this patient population.

Face-to-face imagery rescripting as a treatment adjunct for day patients with an eating disorder: A randomised controlled pilot study

Imagery rescripting (IR) has been widely used to treat various mental health problems, however, little is known about its usefulness in eating disorders. The primary aim of this pilot study was to evaluate the feasibility of using a face-to-face imagery rescripting as a treatment adjunct among day patients with an eating disorder. Our secondary aim was to investigate within-group effect size changes between groups in order to ensure the suitability of IR in this population. Twelve participants were recruited from the Statewide Eating Disorders Services and were randomly assigned to either treatment as usual (TAU) or treatment as usual plus imagery rescripting (TAU + IR). Participants in the TAU + IR group received a one-hour face-to-face imagery rescripting session with a postgraduate trainee therapist within their first week of treatment. Outcome measures, including psychological distress, eating disorder symptoms, self-compassion and dysfunctional attitudes, were measured at baseline and 4 weeks. Overall, feasibility was promising with all participants completing the protocol and assessment once randomised, but no one completed seven days of home practice. Recruitment was slow with less than 50% agreeing to be randomised. TAU demonstrated a quicker reduction in symptoms than the TAU + IR group. Possible explanations include the timing of the imagery rescripting session was not appropriate for this group of patients, IR has a longer term effect that cannot be observed in merely four weeks, or the current form of imagery rescripting is not appropriate to use with this group of patients. Future research is needed to clarify whether imagery rescripting is indeed appropriate to use for eating disorder patients, and if so, how it can best be delivered (e.g., time point, content, targeted population).

Can you find the right support for children, adolescents and young adults with anorexia nervosa: Access to age-appropriate care systems in various healthcare systems.

Anorexia nervosa (AN) often has its onset in childhood or adolescence. However, there is insufficient knowledge regarding access to and utilisation of age-specific clinical diagnostics and treatment. A literature review covering the last 10 years was conducted to provide a narrative review of the current state of research on the detection and treatment of young patients with AN in primary and secondary care. Most articles were of Western European or US origin. Timely diagnosis of the eating disorder (ED) and treatment options more often depend on the structure and quality of the national health care system than on scientific evidence. Regular paediatric health check-ups and age-appropriate eating disorder services appear to facilitate early diagnosis. Age-specific treatment that also involves the carers is often associated with a higher continuity of care and a better outcome. Although many adolescents require an extension of treatment into young adulthood, individual and health care system-related obstacles in many countries prevent a smooth transition. To improve outcomes in childhood and adolescent AN, age-specific and timely diagnostic and therapeutic procedures are urgently needed.

'It's not that they don't want to access the support . . . it's the impact of the autism': The experience of eating disorder services from the perspective of autistic women, parents and healthcare professionals.

This study explores autistic women’s experiences of eating disorder services. Estimates suggest that 20%–30% of women in treatment for anorexia nervosa display diagnostic features characteristic of autism. Research suggests that autistic individuals’ needs are not being met by standard anorexia nervosa treatments. In the current study, in-depth interviews were conducted with 15 autistic women with experience of anorexia nervosa, 12 parents of autistic women with anorexia nervosa, and 11 eating disorder healthcare professionals. Using thematic analysis, three overarching themes were identified: misunderstanding autism and autistic traits, one treatment does not fit all, and improving accessibility and engagement within services. We found that there were diverse barriers facing autistic women when in treatment for anorexia nervosa, and these were accentuated by a lack of autism understanding within eating disorder services. Future research should focus on developing interventions that are tailored to the specific needs of autistic individuals with anorexia nervosa.Lay This study explores autistic women’s experiences of eating disorder services. About 20%–30% of people with anorexia nervosa are also autistic, and current treatments seem not to work as well for them. We interviewed 15 autistic women with experience of anorexia nervosa, 12 parents of autistic women with anorexia nervosa, and 11 healthcare professionals working in eating disorder services. We asked autistic women and parents about their experiences of eating disorder services, and we asked healthcare professionals about their experiences treating autistic women with anorexia nervosa. Participants’ views were represented by three overall themes: misunderstanding autism and autistic traits, one treatment does not fit all, and improving accessibility and engagement within services. We found that autistic women face many barriers when in treatment for anorexia nervosa, often because of a lack of autism understanding within eating disorder services. Future research should look at developing anorexia nervosa treatments that can specifically help autistic individuals.

Experience of transition between a child and adolescent service and adult service for the treatment of eating disorders

PurposeThere is a dearth of research on what constitutes effective transfer of care from children’s and young people services to adult services for patients with eating disorders (EDs) in the UK. Transition has implications for continuity of care and particularly for early intervention which has the best prognosis. The purpose of this paper is to understand the experience of transition and identify facilitators and barriers to this.Design/methodology/approachQualitative methodology was used. Focus groups (n = 4) were held with clinicians (n = 22) working in Child and Adolescent Mental Health Services or adult ED services. Individual interviews were conducted with patients (n = 5) who had commenced/completed transition to adult services and with parents/carers (n = 6) of patients invited for interview.FindingsA number of factors may facilitate or impede transition and can be grouped into the broad themes of communication, managing the differences between services and timing of transition. Improvements in communication, clear explanation of service differences and flexibility around the timing of transitions may enhance the experience for patients and parents/carers.Research limitations/implicationsThe service evaluation was limited to transition between two specialist ED services in one geographical location. The findings provide the basis for a wider research study to examine which factors are most important when planning transition from the perspectives of patients, parents/carers and clinicians.Originality/valueThis is the first study examining ED transitions in the UK. It provides valuable insight of the experience of service users and carers and highlights potential improvements when planning transitions for this patient group.

Association between anorexia nervosa and other specified eating or feeding disorders and paranoia in adolescents: what factors are involved?

In eating disorders, the association with other psychiatric symptoms is of particular interest. The association between anorexia nervosa and psychotic symptoms is less studied than that with affective disorders (anxiety/depression). The aim of this study is to describe a psychotic symptom (paranoia) in adolescents with anorexia nervosa looking at several potential explicative associated factors: eating disorder symptoms, body image concerns, depression and social anxiety. Our hypothesis is that paranoia in anorexia nervosa patients is better explained by the concomitant depression and social anxiety symptoms than the core symptoms of the disease (eating disorder symptoms or body image concerns). This is a retrospective study. Consecutive, help-seeking adolescents, admitted to the Eating Disorder Service of the Integrated Pediatric Care Department, Luigi Vanvitelli University Hospital, constituted the sample. Data was obtained through retrospective collection of clinical interviews and self-report questionnaires, used for the routine assessment of these patients, administered by trained and expert child and adolescent psychiatrists, they were the Eating Attitude Test-26 (EAT-26), the Body Uneasiness Test-A (BUT-A), the Children Depression Inventory (CDI), the Liebowitz Social Anxiety Scale-Children and Adolescents (LSAS-CA) and the paranoia subscale of the Specific Psychotic Experiences Questionnaire (SPEQ). We obtained data from 92 adolescents with anorexia nervosa and other specified feeding or eating disorder (OSFED). Our regression model explained that paranoia (SPEQ-paranoia subscale) in this population was better explained by depression (CDI) (coefficient= 0.415 SD: 0.210, p=0.052) and social anxiety symptoms (LSAS-CA) (coefficient= 0.253 SD: 0.060; p<0.001) than eating disorder symptoms (EAT-26) (coefficient= 0.092 SD: 0.107; p=0.398) and body image concerns (BUT-A) (coefficient= 1.916 SD: 2.079; p=0.359). This study has some theoretical, clinical and treatment implications. It is important to carrying out screening for the presence of psychotic symptoms in patients with eating or feeding disorders. These symptoms and associated factors (depression and social anxiety) may complicate the clinical picture of the disease with the need, in certain cases, of psychopharmacological drugs and, among these, anti-psychotics. Finally in the psychotherapy context, paranoid ideas may be subject of treatment for patient with anorexia nervosa.

What was the impact of a global pandemic (COVID-19) lockdown period on experiences within an eating disorder service? A service evaluation of the views of patients, parents/carers and staff

BackgroundThe World Health Organization declared the outbreak of COVID-19 as a global pandemic on the 11th March 2020. As a result, the UK Government imposed severe restrictions on working and social contact as part of “lockdown.” Whilst the full extent of the pandemic’s impact on eating disorder patients is unknown, the literature suggests that patients with pre-existing mental illness may be more vulnerable to the mental health impacts. In addition, the restrictions greatly reduced the access to mental health services and presented new challenges to service delivery. A service evaluation was carried out to explore how the COVID-19 global pandemic changed service provision in a young person’s eating disorder service and how this affected patient, family and staff experiences.MethodsAn audit was carried out to explore how the lockdown period had impacted referrals and service delivery. Quantitative data was collected in an online survey and qualitative data was collected in two formats: open ended answers as part of the online survey and open-ended focus groups, structured using narrative enquiry. The 43 participants consisted of 12 patients, 19 parents/carers, and 12 staff members. Patients were under the age of 18 and had a diagnosis of an eating disorder.ResultsCOVID-19 and lockdown increased the pressure on the service and changed service provision significantly. This has impacted the relational experiences for patients and their carers and staff have been faced with new challenges. Patients, parents/carers and staff all preferred face-to-face appointments over virtual options. There was no difference in service satisfaction before and during COVID-19.ConclusionsIt is possible to provide an eating disorder service in lockdown restrictions that patients and parents report high satisfaction with. Providing face-to-face appointments at the beginning of treatment and including families in the planning should be prioritised. Staff support is crucial to be able to continue delivering high quality services. The key themes are identified, and clinical recommendations are made to guide service delivery.

Effectiveness of a brief form of group dialectical behavior therapy for binge‐eating disorder: Case series in a routine clinical setting

While there is evidence to support the use of group dialectical behavior therapy (DBT) in the treatment of binge-eating disorder (BED), treatment is relatively long compared with other evidence-based treatments. This study explored the effectiveness of brief DBT groups for BED, delivered in a routine community setting. Eighty-four adults with BED entered 10-week DBT group treatment in a community eating disorders service. In total, 12 groups were conducted. Patients completed measures of eating disorder pathology, anxiety, depression, and emotional eating at the start and end of treatment, and at 1-month follow-up. Frequency of weekly binges was recorded. Outcomes were similar to those of longer versions of DBT, with an attrition rate of 26%, and significant reductions in eating disorder psychopathology and emotional eating by the end of treatment and at follow-up. Over 50% of patients were abstinent from binge eating by Session 4. Group DBT delivered in a 10-session format is clinically equivalent to longer versions of the same treatment. Future research is required to explore patterns of change and to demonstrate replicability under controlled conditions, but these findings are promising for the efficient delivery of effective treatment and reducing waiting times.

Risk and resilience factors for specific and general psychopathology worsening in people with Eating Disorders during COVID-19 pandemic: a retrospective Italian multicentre study.

PurposeThe COVID-19 pandemic restrictions had negative impact on the psychopathology of people with Eating Disorders (EDs). Factors involved in the vulnerability to stressful events have been under-investigated in this population. We aimed to assess which factors contributed to COVID-19-induced worsening in both general and specific psychopathology.MethodsThree-hundred and twelve people with a clinically defined diagnosis of an ED and undergoing a specialist ED treatment in different Italian ED services before the spreading of COVID-19 pandemic filled in an online survey. ED specific and general psychopathology changes after COVID-19 quarantine were retrospectively evaluated. Factors related to COVID-19 concerns (financial condition, fear of contagion, perceived social isolation/support, satisfaction in peer, family or sentimental relationships), illness duration and treatment-related variables (type of treatment provided, type of access to care, satisfaction with therapeutic relationships) were included as predicting factors in a structural equational model, which included latent variables consisting of general and ED psychopathology items as outcomes.ResultsA perceived low quality of therapeutic relationships, fear of contagion and increased isolation were positively associated with psychopathology worsening. Reduced satisfaction with family and with friends’ relationships and reduced perceived social support were associated with ED and general symptoms deterioration, respectively. No significant effect emerged for intimate relationships, illness duration, economic condition and type of treatment.ConclusionsThis study provides a comprehensive evaluation of clinical variables associated with psychopathological changes during the COVID-19 lockdown period highlighting potential risk and resilience factors and, possibly, informing treatment as well as prevention strategies for EDs.Level of evidence IVEvidence obtained from multiple time series analysis such as case studies

Measuring Clinical Efficacy Through the Lens of Audit Data in Different Adult Eating Disorder Treatment Programmes.

Background: Audit data is important in creating a clear picture of clinical reality in clinical services, and evaluating treatment outcomes. This paper explored the data from an audit of a large national eating disorder (ED) service and evaluated the outcome of inpatient and day treatment programmes for patients with anorexia nervosa (AN) with and without autistic traits.Methods: Four hundred and seventy-six patients receiving treatment for AN at inpatient (IP), day-care (DC) and step-up (SU) programmes were assessed at admission and at discharge on the following measures: autistic traits, body-mass-index (BMI), ED symptoms, depression and anxiety symptoms, work and social functioning, and motivation for change. Outcomes were analyzed first at a within-group level based on change in mean scores and then at an individual level based on the clinical significance of improvement in eating disorder symptoms. Outcomes were compared between patients with high autistic traits (HAT) and low autistic traits (LAT) in each programme.Results: The findings suggest that 45.5% of DC and 35.1% of IP patients showed clinically significant changes in ED symptoms following treatment. Co-occurring high autistic traits positively predicted improvement in ED symptoms in IP setting, but was a negative predictor in DC. In IP, more HAT inpatients no longer met the BMI cut-off for AN compared to LAT peers. In terms of general psychopathology, patients with AN and HAT exhibited more severe depression symptoms, anxiety symptoms and social functioning impairment than their LAT peers, and these symptoms stayed clinically severe after treatment.Conclusions: Patients with AN and hight autistic traits are more likely than their peers with low autistic traits to show weight restoration and improvement in ED systems after inpatient treatment. This reverses in DC, with high autistic trait patients less likely to improve after treatment compared to low autistic trait patients. Our results suggest that inpatient treatment with individualized and structured routine care may be an effective model of treatment for patients with AN and high autistic traits.

Enhanced cognitive behavior therapy for severe and extreme anorexia nervosa: An outpatient case series.

The study aimed to assess outcomes in patients with severe and extreme anorexia nervosa managed with enhanced cognitive behavior therapy (CBT-E) in a real-world outpatient setting. Thirty patients with anorexia nervosa and body mass index (BMI) <16 aged ≥17 years were recruited from consecutive referrals to an eating disorder service clinic offering outpatient CBT-E. BMI and Eating Disorder Examination Questionnaire (EDE-Q), Brief Symptom Inventory (BSI), and Clinical Impairment Assessment (CIA) scores were recorded at admission, end of treatment, and 20- and 60-week follow-ups for treatment completers. Twenty patients (66.7%) completed the treatment and showed both considerable weight gain (Cohen's f = 1.43), and significantly reduced scores for clinical impairment (f = 1.26) and eating-disorder (f = 1.03) and general psychopathology (f = 0.99). Changes remained stable at both follow-ups. About half of the patients who completed treatment had a BMI ≥18.5 at the end of treatment and follow-ups. CBT-E seems suitable and promising for patients with severe and extreme anorexia nervosa seeking treatment in a real-world clinical setting, provided that their medical conditions are stable, and they have no current major depressive episodes or substance abuse; it may represent a valid alternative to inpatient treatment for those who are able to sustain engagement in a full course of outpatient treatment.

Clinicians' views on neuromodulation as atreatment for eating disorders: Aqualitative study.

Neuromodulation techniques, such as repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS) and deep brain stimulation (DBS), are emerging as promising treatment options in eating disorders (EDs). To date, the views of ED clinicians regarding these interventions have not been explored. Eighteen clinicians were recruited from aspecialist ED Service in London, UK. Following ashort educational presentation on rTMS, tDCS and DBS, they completed asemi-structured interview to explore their views on the use of these treatment options in EDs. Clinician knowledge of neuromodulation techniques was low. They raised safety and ethical (particularly capacity to consent) concerns mainly with regard to DBS. Neuromodulation treatments were considered most appropriate as an adjunct to psychotherapy and for patients with severe, enduring illness (who had completed previous psychological treatments). Improving clinicians' knowledge and understanding of neuromodulation is fundamental for bridging the gap between research and clinical work. This is especially so given the predominance of psychological theory and practice in the treatment of EDs.

Factors related to length of stay, referral on discharge and hospital readmission for children and adolescents with anorexia nervosa.

This study examined factors related to hospital length of stay (LOS), reported referral on discharge, and hospital readmission, for children and adolescents (C&A) admitted to public hospitals for anorexia nervosa (AN), in a large health jurisdiction in Australia. Sociodemographic, illness, treatment, and hospital factors associated with LOS, reported referral to post-hospital treatment, and readmission within 28 days were analyzed for C&A with AN admitted to all New South Wales public hospitals in 2017, using median, multinomial logit and logit models. The sample comprised 289 admissions by 200 C&A aged 9-18 years with a primary or secondary diagnosis of AN. AN as a primary diagnosis and the presence of some physical and mental co-occurring conditions (e.g., malnutrition and obsessive-compulsive disorders) conferred a longer LOS. The majority of admissions were recorded being referred to primary care physicians (59.86%) and relatively small numbers to outpatient mental health services (5.54%) or outpatient eating disorder services (8.30%), with age, area socioeconomic status, and illness factors related to referral type. Male, low socioeconomic status, the presence of some co-occurring illnesses (e.g., adjustment disorder and viral infection), and rural or remote locations increased the likelihood of readmission. The findings have implications for service design, in particular the pathway to care from hospital into community for AN. Targeted interventions should consider recognizing and treating physical co-occurring illnesses at presentation to the health system, ensuring appropriate referral to community services, and providing services in socioeconomically disadvantaged and rural or remote areas.

A comparison of eating disorder symptomatology, psychological distress and psychosocial function between early, typical and later onset anorexia nervosa

ObjectiveEpidemiological studies suggest that the incidence of anorexia nervosa (AN) is increasing in younger populations, with some evidence that clinical differences occur according to age of onset (AOO), which may impact prognostic outcomes. The current study sought to compare eating disorder (ED) symptomatology, psychological distress and psychosocial function between early onset (EO), typical onset (TO) and later onset (LO) AN in a large sample of treatment-seeking patients with a diagnosis of AN.MethodsParticipants included 249 individuals with a diagnosis of AN who were assessed at an outpatient ED service. The sample was divided into three groups based on AOO; those with an AOO ≤14 years (N = 58) were termed ‘EO-AN’, those with an AOO between 15 and 18 years (N = 113) were termed ‘TO-AN’ and those with an AOO of > 18 years (N = 78) were termed ‘LO-AN’. Comparisons were made between AOO groups on assessments of ED symptomatology, psychological distress and psychosocial function.ResultsEO-AN patients reported a significantly longer illness duration than both TO-AN and LO-AN groups. After controlling for effect of illness duration, the EO-AN group demonstrated significantly higher ED symptomatology and dysmorphic concern compared to the LO-AN group. The EO-AN group demonstrated significantly decreased cognitive flexibility compared to both the TO-AN and LO-AN groups.DiscussionThese findings suggest that clinical differences do occur according to AOO in AN whereby EO-AN may represent a more severe form of illness that is not attributable to increased illness duration. Treatment strategies which specifically address patients with EO-AN may improve long term health outcomes and recovery.