Acceptability and feasibility of SUCCEAT, an intervention for parents of adolescents with anorexia nervosa.

OBJECTIVE: "Supporting Carers of Children and Adolescents with Eating Disorders in Austria" (SUCCEAT), a skills training for parents, delivered via workshops (WS) or online modules (ONL), has been proven to be effective in terms of parental distress, caregiver skills, and adolescents' outcome. This study examined the adherence to and the acceptability and feasibility of SUCCEAT. METHOD: One-hundred parents (86% mothers) of adolescents with anorexia nervosa participated in the 8-week training. Parents were assigned to the WS (n = 50) or ONL (n = 50) format using a quasi-randomised design. Adherence, acceptability, and feasibility were assessed using self-report questionnaires. RESULTS: Adherence to the sessions was high (66%-98%) for both groups. The usage of the material was comparable between the groups. However, in the WS group, participants actively approached the coaches (71.8% vs. 48.9% often/very often) or other parents (63% vs. 4.4% often/very often) more often. Perceived helpfulness was high in both groups, overall satisfaction and practicability were higher in the WS group. CONCLUSIONS: Good adherence, acceptability, and feasibility were confirmed for both formats of SUCCEAT, with minimal advantages of the WS regarding satisfaction and contact with other parents and coaches. Thus, both formats can be recommended for implementation in clinical routine.

Psychological distress and caregiving experience during the first two years of the COVID-19 pandemic among parents of an offspring with anorexia nervosa.

OBJECTIVE: To compare different aspects of caregiving distress and experience in parents of patients with anorexia nervosa (AN) before and during the COVID-19 pandemic. METHODS: Three cohorts of parents of AN patients (cohort 1-pre-pandemic: N = 78, cohort 2-first pandemic year: N = 51, cohort 3-second pandemic year: N = 119) were recruited from child and adolescent psychiatry wards and cross-sectionally assessed as part of the clinical routine. Quantitative measures of psychological distress, psychopathology, eating disorder (ED)-related burden, expressed emotion and caregiver skills were obtained at the beginning of the child's inpatient or outpatient treatment. RESULTS: Cohort 2 showed lower levels of anxiety and a tendency of lower emotional overinvolvement and higher caregiving skills compared to the pre-pandemic cohort. In contrast, the levels of general psychological distress, depression, ED-related burden and criticism observed in cohort 3 significantly exceeded pre-pandemic levels. The prevalence of clinically relevant depression was higher in cohort 3 (41.5%) compared to cohorts 1 (24.4%) and 2 (21.6%). DISCUSSION: The pandemic effects on parents seem to be time-specific. Lower distress in the early phase of the pandemic may be associated with improvements in parent-child-relationships reported in previous studies. However, the pandemic may has negative consequences in the long-term emphasising the need of ongoing parental support.

Therapeutic drug monitoring in adolescents with anorexia nervosa for safe treatment with adjunct olanzapine.

OBJECTIVE: Medication is commonly used in anorexia nervosa (AN) despite largely missing high grade evidence. Olanzapine (OLZ) is the best-evidenced substance used off-label in this group, with conflicting outcome regarding BMI, clinical and safety parameters. Therefore, it is important to strictly assure quality of treatment with OLZ in AN by using 'Therapeutic Drug Monitoring' according to AGNP-guidelines, including serum levels and adverse drug reactions (ADRs) to support safety for adolescents with AN and attempt to generate an initial age- and disorder-specific therapeutic reference range. METHOD: Sixty-five adolescents with AN (aged 10-18) treated with OLZ (98% female; 97.5% AN-restricting-type) were prospectively observed, ADRs reported, and correlations between dosage and serum levels measured at trough level were calculated, a preliminary therapeutic range defined. RESULTS: Mean dosage of OLZ was 8.15 (SD: 2.91) mg and 0.19 (SD: 0.07) mg/kg respectively, average concentration was 26.57 (SD: 13.46) ng/mL. Correlation between daily dosage/dosage per kg and serum level was 0.72 (**p < 0.001)/0.65 (**p < 0.001), respectively. ADRs with impairment were rare (6.3%). 75% improved clinically (CGI). BMI increased significantly by 1.5 kg/m2 (t = 10.6, p < 0.001). A preliminary therapeutic reference range is 11.9 and 39.9 ng/mL. CONCLUSIONS: OLZ in the hands of specialists is a well-tolerated and safe treatment adjunct for adolescents with AN.

Fathers in the spotlight: parental burden and the effectiveness of a parental skills training for anorexia nervosa in mother-father dyads.

PURPOSE: Research on the engagement of fathers in the treatment of childhood psychiatric disorders is scarce. This study aims to investigate differences between mothers and fathers of adolescents with anorexia nervosa regarding parental burden and effectiveness of a parental skills training. METHODS: Ninety-one mother-father dyads caring for a child with anorexia nervosa participated in an 8-week parental skills training and completed a set of questionnaires assessing parental psychopathology, eating disorder related burden, caregiver skills and expressed emotion at baseline and post-intervention. RESULTS: Fathers showed lower levels of general psychological distress, depression, anxiety and eating disorder related burden as well as lower emotional overinvolvement compared to mothers. The skills training was effective in reducing parental psychopathology, eating disorder-related burden and emotional overinvolvement as well as in increasing caregiver skills with no differences between mothers and fathers. However, session adherence and the willingness to practice skills between the sessions were slightly lower in fathers. CONCLUSIONS: These findings show that fathers are a great resource for the child's eating disorder treatment as they may counterbalance maternal emotional overinvolvement and over-protection. Furthermore, this is the first study demonstrating that fathers can profit from a parental skills training for anorexia nervosa in a similar way as mothers. LEVEL III: Evidence obtained from well-designed cohort or case-control analytic studies.

Intranasal esketamine as therapeutic option: a case report of an adolescent with treatment resistant depression.

Depression is among the most common mental health disorders worldwide and treatment resistant depression (TRD) represents a major challenge for both patients and clinicians. In recent years ketamine has received attention as an antidepressant agent, demonstrating promising results in TRD in adults. To date, few attempts have been made in treating adolescent TRD with ketamine and none have used intranasal application. This paper discusses a case of a 17-year-old female adolescent suffering from TRD who underwent treatment with intranasal esketamine application (Spravato 28 mg). As symptoms showed clinically insignificant improvement despite modest gains in objective assessments (GAF, CGI, MADRS), treatment was prematurely discontinued. However, the treatment was tolerable and side effects were scarce and mild. Although this case report does not demonstrate clinical effectiveness, ketamine may nonetheless be a promising substance in treating TRD in other adolescents. Questions regarding the safety of ketamine use in the rapidly developing brains of adolescents still remain unanswered. To further explore the potential benefits of this treatment method a short term RCTs for adolescents with TRD is recommended.

Conspiracy beliefs and COVID-19 guideline adherence in adolescent psychiatric outpatients: the predictive role of adverse childhood experiences.

BACKGROUND: Conspiracy beliefs have become widespread throughout the COVID-19 pandemic. Previous studies have shown that endorsing conspiracy beliefs leads to lower protective guideline adherence (i.e., wearing face masks), posing a threat to public health measures. The current study expands this research across the lifespan, i.e., in a sample of adolescents with mental health problems. Here, we investigated the association between conspiracy beliefs and guideline adherence while also exploring the predictors of conspiracy beliefs. METHODS: N = 93 adolescent psychiatric outpatients (57% female, mean age: 15.8) were assessed using anonymous paper-pencil questionnaires. Endorsement of generic and COVID-19 conspiracy beliefs was assessed, in addition to items measuring adherence to protective guidelines and mental health (stress, depressive symptoms, emotional/behavioral problems, and adverse childhood experiences). Multiple regressions and supervised machine learning (conditional random forests) were used for analyses. RESULTS: Fourteen percent of our sample fully endorsed at least one COVID-19 conspiracy theory, while protective guidelines adherence was relatively high (M = 4.92, on a scale from 1 to 7). The endorsement of COVID-19 conspiracy beliefs-but not of generic conspiracy beliefs-was associated with lower guideline adherence (ß = - 0.32, 95% CI - 0.53 to - 0.11, p < .001). Conditional random forests suggested that adverse childhood experiences and peer and conduct problems were relevant predictors of both conspiracy belief categories. CONCLUSION: While a significant proportion of our sample of adolescents in psychiatric treatment endorsed conspiracy beliefs, the majority did not. Furthermore, and to some degree, contrary to public perception, we found that adolescents show relatively good adherence to public health measures-even while experiencing a high degree of mental distress. The predictive value of adverse childhood experiences and peer/conduct problems for conspiracy beliefs might be explained by compensatory mechanisms to ensure the safety, structure, and inclusion that conspiracies provide.

Adverse childhood experiences as risk factors for recurrent admissions in young psychiatric inpatients.

Background: Patients who require psychiatric inpatient treatment early in life are a particularly at-risk population. Factors such as adverse childhood experiences (ACEs) are, however, not well studied in those requiring psychiatric inpatient treatment during both childhood or adolescence and adulthood. Thus, the aim of the current study was to investigate, in young adult inpatients, the risk factors for prior admissions in Child and Adolescent Psychiatry, with a focus on ACEs. Materials and methods: An explorative population-based systematic chart investigation of psychiatric inpatients aged 18-25 was conducted at the University Hospital Tulln, Austria. Data analysis was done with descriptive methods and Pearson's chi- squared-, Fisher's exact-, Mann-Whitney-U-tests and predictive logistic regression models. Results: The sample comprised 390 inpatients (51.8% female), with an average age of 20 years at first psychiatric hospital admission. Those with a former child and adolescent psychiatry inpatient treatment (10.3%) were predominantly female (77.5%). Their number of documented ACEs was increased compared to those without former child and adolescent psychiatry admissions (2 vs 1.1), with up to twice as many experiences of family dysfunction, neglect or abuse. Sexual abuse (OR: 3.0), having been an adopted or fostered child (OR: 4.5), and female sex (OR: 3.0) were identified as main risk factors. Furthermore, former child and adolescent psychiatry inpatients suffered from higher rates of psychosomatic or personality disorders, comorbidities and functional impairment, and were readmitted twice as often in young adulthood. Conclusion: Young adult inpatients with reoccurring psychiatric inpatient treatments have increased rates of severe ACEs. Thus, special attention should be given to identifying ACEs, evaluating needs for psychosocial support and therapy, and meeting these needs after discharge.

Short-Term Outcome of Inpatient Treatment for Adolescents with Anorexia Nervosa Using DSM-5 Remission Criteria.

This study evaluated the short-term outcome of a multimodal inpatient treatment concept for adolescents with anorexia nervosa (AN). In this prospective observational study, a cohort of 126 female adolescents with AN (age range: 11-17, mean age: 14.83) was longitudinally followed from admission to discharge (average duration of stay: 77 days). We used gold-standard clinical interviews and self-report data, as well as DSM-5 remission criteria, to evaluate the treatment outcome. From admission to discharge, body-mass-index (BMI) significantly improved by 2.6 kg/m2. Data from clinical interviews and self-reports yielded similar improvements in restraint eating and eating concerns (large effects). Lower effects were observed for variables assessing weight/shape concerns and drive for thinness. At discharge, 23.2% of patients showed full remission of AN, 31.3% partial remission, and 45.5% no remission according to DSM-5 criteria. Differences in remission groups were found regarding AN severity, age at admission, and use of antidepressant medication. Living with both parents, longer duration of inpatient treatment and the use of antipsychotic medication were significantly associated with higher BMI change. The findings provide evidence for the short-term effectiveness of our inpatient treatment concept. We recommend using DSM-5 based remission criteria to evaluate the treatment outcome to improve the comparability of studies.

Does a Skills Intervention for Parents Have a Positive Impact on Adolescents' Anorexia Nervosa Outcome? Answers from a Quasi-Randomised Feasibility Trial of SUCCEAT.

Skills trainings for caregivers of patients with anorexia nervosa (AN) have been proven to be effective in improving caregiver skills and reducing caregivers' psychopathology. The effects on patients, especially adolescents, are largely unknown. The aim of this study was to evaluate the effectiveness of a caregivers' skills training program (Supporting Carers of Children and Adolescents with Eating Disorders in Austria, SUCCEAT, workshop or online version) on adolescents with AN delivered as workshops (WS) or online (ONL). Outcomes are Body-Mass-Index (BMI) percentile, eating psychopathology (Eating Disorder Examination, EDE), attitudinal and behavioural dimensions of eating disorders (Eating Disorder Inventory-2), motivation to change (AN Stages of Change Questionnaire), emotional and behavioural problems (Youth Self-Report) and quality of life (KINDL). All outcome variables significantly improved across both SUCCEAT groups (WS and ONL) and were sustained at 12-month follow-up. The online and workshop delivery of SUCCEAT were equally effective. Most effect sizes were in the medium-to-high range. Full or partial remission was observed in 72% (WS) and 87% (ONL) of patients. Caregiver skills trainings, either delivered as workshops or online modules, are highly recommended to complement treatment as usual.

The Maudsley model of anorexia nervosa treatment for adolescents and young adults (MANTRa): a study protocol for a multi-center cohort study.

BACKGROUND: The treatment of anorexia nervosa (AN) is often challenging due to medical complications as well as high relapse and mortality rates. Studies about effective treatment options for people with AN are particularly scarce in the adolescent population. This paper is a study protocol for a multi-center cohort study assessing the feasibility, acceptability and efficacy of a new, manualized treatment program, the "Maudsley Model of Anorexia Nervosa Treatment for Adolescents and Young Adults" (MANTRa) compared to psychotherapeutic treatment as usual (TAU). METHODS/DESIGN: One hundred patients between 13 and 21 years who meet the inclusion criteria will receive 24 to 34 individual weekly MANTRa therapy sessions or weekly TAU sessions. Primary outcome variables will be BMI and eating disorder psychopathology 12 months after baseline. Further changes in central coherence, cognitive flexibility, emotion recognition, comorbid psychopathology (e.g. depression, obsessive-compulsive and anxiety disorders, non-suicidal self-injury), personality factors and therapeutic alliance will be assessed. DISCUSSION: This multi-center study will examine the utility of the treatment program MANTRa for adolescents with AN and, therefore enhances the current knowledge about potential treatments for this patient group. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03535714 . Registered: 24/05/2018 (retrospectively registered, still recruiting).

Reduction of High Expressed Emotion and Treatment Outcomes in Anorexia Nervosa-Caregivers' and Adolescents' Perspective.

High expressed emotion (EE) is common in caregivers of patients with anorexia nervosa (AN) and associated with poorer outcome for patients. In this study, we examined the prevalence of high EE in caregivers of adolescents with AN and analyzed predictors for EE using multivariate linear regression models. We further analyzed whether EE is reduced by the "Supporting Carers of Children and Adolescents with Eating Disorders in Austria" (SUCCEAT) intervention using general linear mixed models and whether a reduction of EE predicts patients' outcomes. Caregivers were randomly allocated to the SUCCEAT workshop (N = 50) or online intervention (N = 50) and compared to a comparison group (N = 49). EE and patients' outcomes were assessed at the baseline, post-intervention, and at the 12-month follow-up. Up to 47% of caregivers showed high EE. Lower caregiver skills, higher AN symptom impact, higher levels of depression and motivation to change in caregivers were significant predictors for high EE. EE significantly decreased in the SUCCEAT groups and the comparison group according to the caregivers', but not the patients' perspective. The level of reduction could partially predict subjective improvement and improvement in clinically assessed AN symptoms and body mass index of patients. Implementing interventions for caregivers addressing EE in the treatment of adolescents with AN is strongly recommended.