Patient responsiveness as a safewards fidelity indicator: a qualitative interview study on an acute psychiatric in-patient ward.

BACKGROUND: The Safewards model aims to reduce conflict and use of containment on psychiatric wards. To evaluate the implementation of Safewards and understand why it is effective in some settings but not in others, it is important to assess the level of implementation fidelity. To do this, the Safewards Fidelity Checklist (SFC) is often used, which focuses on objective visual observations of interventions but does not include patient responsiveness. The latter is a key indicator of implementation fidelity and includes engagement, relevance, acceptability and usefulness. The aim of the present study was to investigate the fidelity of Safewards implementation on an acute psychiatric ward from the perspective of patient responsiveness. METHOD: The study was conducted on a ward for patients with mainly affective disorders. To assess the general level of fidelity the SFC was used together with a detailed ward walkthrough. Ten patients were interviewed with a focus on patient responsiveness to each of the seven interventions implemented on the ward. Data were analysed using qualitative descriptive analysis. RESULTS: The findings indicate high implementation fidelity, which was reflected in the SFC assessment, walkthrough and patient responsiveness. Patients gave examples of improvements that had happened over time or of the ward being better than other wards. They felt respected, less alone, hopeful and safe. They also described supporting fellow patients and taking responsibility for the ward climate. However, some patients were unfamiliar with a ward where so much communication was expected. Several suggestions were made about improving Safewards. CONCLUSIONS: This study confirms previous research that patient responsiveness is an important factor for achieving fidelity in a prevention programme. The patients' descriptions of the acceptability, relevance and usefulness of the specific interventions reflected to a high degree the objective visual observations made by means of the SFC and ward walkthrough. Patient engagement was demonstrated by several suggestions about how to adapt the interventions. There is potential to obtain valuable input from patients when adapting Safewards in practice. This study also presents many examples of practical work with these interventions and the effects it can have on patients' experiences of care.

Social inclusion and violence prevention in psychiatric inpatient care. A qualitative interview study with service users, staff members and ward managers.

BACKGROUND: Many psychiatric services include social inclusion as a policy with the aim to offer users the opportunity to participate in care and to form reciprocal relationships. The aim of this study was to explore opportunities and problems with regard to participation, reciprocity and social justice that different stakeholders experience when it comes to social inclusion for service users and minimizing violence in psychiatric inpatient care. METHODS: Qualitative interviews were performed with 12 service users, 15 staff members, and six ward managers in three different kinds of psychiatric wards in Sweden. The data were analyzed using the framework method and qualitative content analysis, which was based on the three following social inclusion values: participation, reciprocity, and social justice. RESULTS: Themes and subthemes were inductively constructed within the three social inclusion values. For participation, staff and ward managers reported difficulties in involving service users in their care, while service users did not feel that they participated and worried about what would happen after discharge. Staff gave more positive descriptions of their relationships with service users and the possibility for reciprocity. Service users described a lack of social justice, such as disruptive care, a lack of support from services, not having access to care, or negative experiences of coercive measures. Despite this, service users often saw the ward as being safer than outside the hospital. Staff and managers reported worries about staffing, staff competence, minimizing coercion and violence, and a lack of support from the management. CONCLUSIONS: By applying the tentative model on empirical data we identified factors that can support or disrupt the process to create a safe ward where service users can feel socially included. Our results indicate that that staff and service users may have different views on the reciprocity of their relationships, and that users may experience a lack of social justice. The users may, due to harsh living conditions, be more concerned about the risk of violence in the community than as inpatients. Staff and ward managers need support from the management to foster a sense of community in the ward and to implement evidence-based prevention programs.

Violence and aggression in psychiatric inpatient care in Sweden: a critical incident technique analysis of staff descriptions.

BACKGROUND: Violence towards staff working in psychiatric inpatient care is a serious problem. The aim of the present study was to explore staff perspectives of serious violent incidents involving psychiatric inpatients through the following research questions: Which factors contributed to violent incidents, according to staff? How do staff describe their actions and experiences during and after violent incidents? METHODS: We collected data via a questionnaire with open-ended questions, and captured 283 incidents reported by 181 staff members from 10 inpatient psychiatric wards in four different regions. We used the Critical Incident Technique to analyse the material. Our structural analysis started by structuring extracts from the critical incidents into descriptions, which were grouped into three chronological units of analyses: before the incident, during the incident and after the incident. Thereafter, we categorised all descriptions into subcategories, categories and main areas. RESULTS: Staff members often attributed aggression and violence to internal patient factors rather than situational/relational or organisational factors. The descriptions of violent acts included verbal threats, serious assault and death threats. In addition to coercive measures and removal of patients from the ward, staff often dealt with these incidents using other active measures rather than passive defence or de-escalation. The main effects of violent incidents on staff were psychological and emotional. After violent incidents, staff had to continue caring for patients, and colleagues provided support. Support from managers was reported more rarely and staff expressed some dissatisfaction with the management. CONCLUSIONS: As a primary prevention effort, it is important to raise awareness that external factors (organisational, situational and relational) are important causes of violence and may be easier to modify than internal patient factors. A secondary prevention approach could be to improve staff competence in the use of de-escalation techniques. An important tertiary prevention measure would be for management to follow up with staff regularly after violent incidents and to increase psychological support in such situations.

Justifications for coercive care in child and adolescent psychiatry, a content analysis of medical documentation in Sweden.

BACKGROUND: There has been considerable interest in normative ethics regarding how and when coercive care can be justified. However, only a few empirical studies consider how professionals reason about ethical aspects when assessing the need for coercive care for adults, and even less concerning children and adolescents. The aim of this study was to examine and describe how professionals document their value arguments when considering the need for coercive psychiatric care of young people. METHODS: All 16 clinics that admitted children or adolescents to coercive care during one year in Sweden were included in the study. These clinics had a total of 155 admissions of 142 patients over one year. Qualitative content analysis with a deductive approach was used to find different forms of justification for coercive care that was documented in the medical records, including Care Certificates. RESULTS: The analysis of medical records revealed two main arguments used to justify coercive care in child and adolescent psychiatry: 1) the protection argument - the patients needed protection, mainly from themselves, and 2) the treatment requirement argument - coercive care was a necessary measure for administering treatment to the patient. Other arguments, namely the caregiver support argument, the clarification argument and the solidarity argument, were used primarily to support the two main arguments. These supportive arguments were mostly used when describing the current situation, not in the explicit argumentation for coercive care. The need for treatment was often only implicitly clarified and the type of care the patient needed was not specified. Few value arguments were used in the decision for coercive care; instead physicians often used their authority to convince others that treatment was necessary. CONCLUSIONS: One clinical implication of the study is that decisions about the use of coercive care should have a much stronger emphasis on ethical aspects. There is a need for an ethical legitimacy founded upon explicit ethical reasoning and after communication with the patient and family, which should be documented together with the decision to use coercive care.

Development and pilot validation of a sensory reactivity scale for adults with high functioning autism spectrum conditions: Sensory Reactivity in Autism Spectrum (SR-AS).

BACKGROUND: Unusual reactions to sensory stimuli are experienced by 90-95% of people with an autism spectrum condition (ASC). Self-reported sensory reactivity in ASC has mainly been measured with generic questionnaires developed and validated on data from the general population. Interest in sensory reactivity in ASC increased after the inclusion of hyper- and hypo-reactivity together with unusual sensory interest as diagnostic markers of ASC in the DSM-5. AIMS: To develop and pilot validate a self-report questionnaire designed from first-hand descriptions of the target group of adults diagnosed with high functioning ASC. Psychometric properties of the questionnaire were evaluated on a sample of participants with ASC diagnoses (N = 71) and a random sample from the general population (N = 162). RESULTS: The Sensory Reactivity in Autism Spectrum (SR-AS is intended to be used as a screening tool in diagnostic processes with adults and for support in adapting compensating strategies and environmental adjustments. The internal consistency was high for both the SR-AS and its subscales. The total scale Cronbach's alpha was 0.96 and the subscales alphas were ≥ 0.80. Confirmatory factor analysis (CFA) showed best fit for a four-factor model of inter-correlated factors: hyper and hypo-reactivity, strong sensory interest and a sensory/motor factor. The questionnaire discriminated well between ASC-diagnosed participants and participants from the general population. CONCLUSIONS: The SR-AS displayed good internal consistency and discriminatory power and promising factorial validity.

Do patient and ward-related characteristics influence the use of coercive measures? Results from the EUNOMIA international study.

PURPOSE: This study aims to identify whether selected patient and ward-related factors are associated with the use of coercive measures. Data were collected as part of the EUNOMIA international collaborative study on the use of coercive measures in ten European countries. METHODS: Involuntarily admitted patients (N = 2,027) were divided into two groups. The first group (N = 770) included patients that had been subject to at least one of these coercive measures during hospitalization: restraint, and/or seclusion, and/or forced medication; the other group (N = 1,257) included patients who had not received any coercive measure during hospitalization. To identify predictors of use of coercive measures, both patients' sociodemographic and clinical characteristics and centre-related characteristics were tested in a multivariate logistic regression model, controlled for countries' effect. RESULTS: The frequency of the use of coercive measures varied significantly across countries, being higher in Poland, Italy and Greece. Patients who received coercive measures were more frequently male and with a diagnosis of psychotic disorder (F20-F29). According to the regression model, patients with higher levels of psychotic and hostility symptoms, and of perceived coercion had a higher risk to be coerced at admission. Controlling for countries' effect, the risk of being coerced was higher in Poland. Patients' sociodemographic characteristics and ward-related factors were not identifying as possible predictors because they did not enter the model. CONCLUSIONS: The use of coercive measures varied significantly in the participating countries. Clinical factors, such as high levels of psychotic symptoms and high levels of perceived coercion at admission were associated with the use of coercive measures, when controlling for countries' effect. These factors should be taken into consideration by programs aimed at reducing the use of coercive measures in psychiatric wards.

Barriers and enablers to the implementation of Safewards and the alignment to the i-PARIHS framework - A qualitative systematic review.

Inpatient mental healthcare settings should offer safe environments for patients to heal and recover and for staff to provide high-quality treatment and care. However, aggressive patient behaviour, unengaged staff approaches, and the use of restrictive practices are frequently reported. The Safewards model includes ten interventions that aim to prevent conflict and containment. The model has shown promising results but at the same time often presents challenges to successful implementation strategies. The aim of this study was to review qualitative knowledge on staff experiences of barriers and enablers to the implementation of Safewards, from the perspective of implementation science and the i-PARIHS framework. A search of the Web of Science, ASSIA, Cochrane Library, SCOPUS, Medline, Embase, PsycINFO, and CINAHL databases resulted in 10 articles. A deductive framework analysis approach was used to identify barriers and enablers and the alignment to the i-PARIHS. Data most represented by the i-PARIHS were related to the following: local-level formal and informal leadership support, innovation degree of fit with existing practice and values, and recipients' values and beliefs. This indicates that if a ward or organization wants to implement Safewards and direct limited resources to only a few implementation determinants, these three may be worth considering. Data representing levels of external health system and organizational contexts were rare. In contrast, data relating to local (ward)-level contexts was highly represented which may reflect Safewards's focus on quality improvement strategies on a local rather than organizational level.

Gender differences in coerced patients with schizophrenia.

BACKGROUND: Despite the recent increase of research interest in involuntary treatment and the use of coercive measures, gender differences among coerced schizophrenia patients still remain understudied. It is well recognized that there are gender differences both in biological correlates and clinical presentations in schizophrenia, which is one of the most common diagnoses among patients who are treated against their will. The extent to which these differences may result in a difference in the use of coercive measures for men and women during the acute phase of the disease has not been studied. METHODS: 291 male and 231 female coerced patients with schizophrenia were included in this study, which utilized data gathered by the EUNOMIA project (European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice) and was carried out as a multi-centre prospective cohort study at 13 centers in 12 European countries. Sociodemographic and clinical characteristics, social functioning and aggressive behavior in patients who received any form of coercive measure (seclusion and/or forced medication and/or physical restraint) during their hospital stay were assessed. RESULTS: When compared to the non-coerced inpatient population, there was no difference in sociodemographic or clinical characteristics across either gender. However coerced female patients did show a worse social functioning than their coerced male counterparts, a finding which contrasts with the non-coerced inpatient population. Moreover, patterns of aggressive behavior were different between men and women, such that women exhibited aggressive behavior more frequently, but men committed severe aggressive acts more frequently. Staff used forced medication in women more frequently and physical restraint and seclusion more frequently with men. CONCLUSIONS: Results of this study point towards a higher threshold of aggressive behavior the treatment of women with coercive measures. This may be because less serious aggressive actions trigger the application of coercive measures in men. Moreover coerced women showed diminished social functioning, and more importantly more severe symptoms from the "excitement/hostile" cluster in contrast to coerced men. National and international recommendation on coercive treatment practices should include appropriate consideration of the evidence of gender differences in clinical presentation and aggressive behaviors found in inpatient populations.

Too much or too little: hyper- and hypo-reactivity in high-functioning autism spectrum conditions.

BACKGROUND: Sensory reactivity in people with autism spectrum conditions (ASC) has been found to differ in comparison to reactivity in people without ASC. In this study sensory experiences of high-functioning individuals with ASC were explored and described. METHOD: Interview data from 15 participants with a diagnosis of ASC were analysed by content analysis. RESULTS: Seven aspects of sensory experiences were identified: Being hyper- and hypo-reactive, reacting to general overload, having strong stimuli preferences, managing attentiveness to stimuli, managing sensory/motor stimuli, and dealing with consequences of sensory reactions in daily life. CONCLUSIONS: The categorisation of sensory reactivity in this study can guide clinicians on how to pose questions about sensory issues to individuals with ASC. The assessment of spectrum-specific sensory experiences in high-functioning ASC and their association with other social and nonsocial features of ASC are goals for further research.

Caregivers' appraisals of patients' involuntary hospital treatment: European multicentre study.

BACKGROUND: Mental health policies emphasise that caregivers' views of involuntary psychiatric treatment should be taken into account. However, there is little evidence on how caregivers view such treatment. AIMS: To explore caregivers' satisfaction with the involuntary hospital treatment of patients and what factors are associated with caregivers' appraisals of treatment. METHOD: A multicentre prospective study was carried out in eight European countries. Involuntarily admitted patients and their caregivers rated their appraisal of treatment using the Client Assessment of Treatment Scale 1 month after admission. RESULTS: A total of 336 patients and their caregivers participated. Caregivers' appraisals of treatment were positive (mean of 8.5 on a scale from 0 to 10) and moderately correlated with patients' views. More positive caregivers' views were associated with greater patients' symptom improvement. CONCLUSIONS: Caregivers' appraisals of involuntary in-patient treatment are rather favourable. Their correlation with patients' symptom improvement may underline their relevance in clinical practice.

Criminal recidivism and mortality among patients discharged from a forensic medium secure hospital.

BACKGROUND: One of the goals in forensic psychiatric care is to reduce the risk of recidivism, but current knowledge about the general outcome of forensic psychiatric treatment is limited. AIMS: To analyse the rate of criminal recidivism and mortality after discharge in a sample of patients sentenced to forensic psychiatric treatment in a Swedish county. METHODS: All offenders in Örebro County, Sweden, sentenced to forensic psychiatric treatment and discharged during 1992-2007 were included: 80 males and eight females. Follow-up data was retrieved from the Swedish National Council for Crime Prevention, the National Cause-of-Death register and clinical files. Mean follow-up time was 9.4 years. RESULTS: The mean age at discharge was 40 years. Schizophrenia, other psychoses and personality disorders were the most prevalent diagnoses. Thirty-eight percent of those still alive and still living in the country re-offended and were sentenced to a new period of forensic psychiatric treatment or incarceration during follow-up. Four male re-offenders committed serious violent crimes. Substance-related diagnosis was significantly associated with risk of recidivism and after adjustment for diagnoses, age and history of serious violent crime, the Hazard Ratio was 4.04 (95% CI 1.51-10.86, P = 0.006). Of all included patients, 23% had died at the end of follow-up (standardized mortality rate 10.4). CONCLUSIONS: Since repetition of serious violent crimes was unusual, results indicate a positive development subsequent to treatment for those alive at follow-up. CLINICAL IMPLICATIONS: The high mortality rate suggests that more attention should be paid in evaluation of the patients' somatic and psychiatric health during and after care in order to prevent premature death.

Autobiographical accounts of sensing in Asperger syndrome and high-functioning autism.

Sensory experiences in Asperger syndrome (AS) or high-functioning autism (HFA) were explored by qualitative content analysis of autobiographical texts by persons with AS/HFA. Predetermined categories of hyper- and hyposensitivity were applied to texts. Hypersensitivity consists of strong reactions and heightened apprehension in reaction to external stimuli, sometimes together with overfocused or unselective attention. It was common in vision, hearing, and touch. In contrast, hyposensitivity was frequent in reaction to internal and body stimuli such as interoception, proprioception, and pain. It consists of less registration, discrimination, and recognition of stimuli as well as cravings for specific stimuli. Awareness of the strong impact of sensitivity is essential for creating good environments and encounters in the context of psychiatric and other health care.

Strategies for the Prevention of Violence in Institutional Care: A Qualitative Interview Study With Ward Managers.

Background: The presence of violence within psychiatric and residential settings remains a challenge. Research on this problem has often focused on describing violence prevention strategies from either staffs' or service users' perspectives, and the views of ward managers has been largely overlooked. The aim of the present study was therefore to identify ward managers' strategies to prevent violence in institutional care, focusing on safety and values. Methods: Data were collected using semi-structured interviews with 12 ward managers who headed four different types of psychiatric wards and two special residential homes for adolescents. Qualitative content analysis was applied, first using a deductive approach, in which quotes were selected within a frame of primary, secondary, and tertiary prevention, then by coding using an inductive approach to create themes and subthemes. Results: Ward managers' strategies were divided into the four following themes: (1) Balancing being an active manager with relying on staff's abilities to carry out their work properly while staying mostly in the background; (2) Promoting value awareness and non-coercive practices in encounters with service users by promoting key values and adopting de-escalation techniques, as well as focusing on staff-service user relationships; (3) Acknowledging and strengthening staff's abilities and competence by viewing and treating staff as a critical resource for good care; and (4) Providing information and support to staff by exchanging information and debriefing them after violent incidents. Conclusions: Ward managers described ethical challenges surrounding violence and coercive measures. These were often described as practical problems, so there seems to be a need for a development of higher ethical awareness based on a common understanding regarding central ethical values to be respected in coercive care. The ward managers seem to have a high awareness of de-escalation and the work with secondary prevention, however, there is a need to develop the work with primary and tertiary prevention. The service user group or user organizations were not considered as resources in violence prevention, so there is a need to ensure that all stakeholders are active in the process of creating violence prevention strategies.

Predictors of outcome following a body image treatment based on acceptance and commitment therapy for patients with an eating disorder.

BACKGROUND: It is important to target body image in individuals with an eating disorder (ED). Acceptance and commitment therapy (ACT) has been trialed in a few studies for individuals with an ED. Although ACT outcomes in ED patients hold promise, studies of predictors are scarce. The aim of the present study was to explore differences in ED symptom outcome at two-year follow-up in subgroups of participants attending either treatment as usual (TAU), or a group intervention based on ACT targeting body image. Additionally, we aimed to compare subjective recovery experiences between groups. METHODS: The study took place at a specialized ED outpatient clinic, and included patients diagnosed with an ED that had received prior treatment and achieved a somewhat regular eating pattern. Study participants were randomly assigned to continue TAU or to participate in a group intervention based on ACT for body image issues. Only participants that completed the assigned intervention and had completed follow up assessment by two-years were included. The total sample consisted of 77 women. RESULTS: In general, ACT participants showed more favorable outcomes compared to TAU, and results were more pronounced in younger participants with shorter prior treatment duration and lower baseline depression ratings. Participants with restrictive ED psychopathology had three times higher ED symptom score change if participating in ACT in comparison to TAU. CONCLUSIONS: An ACT group intervention targeting body image after initial ED treatment may further enhance treatment effects. There is a need for further investigation of patient characteristics that might predict response to body image treatment, particularly regarding ED subtypes and depression ratings.

Patient participation in forensic psychiatric care: Mental health professionals' perspective.

Patient participation is a central concept in modern health care and an important factor in theories/models such as person-centred care, shared decision-making, human rights approaches, and recovery-oriented practice. Forensic psychiatric care involves the treatment of patients with serious mental illnesses who also have committed a crime, and there are known challenges for mental health staff to create a health-promoting climate. The aim of the present study was to describe mental health professionals' perceptions of the concept of patient participation in forensic psychiatric care. Interviews were conducted with 19 professionals and were analysed with a phenomenographic approach. The findings are presented as three descriptive categories comprising five conceptions in an hierarchic order: 1. create prerequisites - to have good communication and to involve the patient, 2. adapt to forensic psychiatric care conditions - to take professional responsibility and to assess the patient's current ability, and 3. progress - to encourage the patient to become more independent. The findings highlight the need for professionals to create prerequisites for patient participation through good communication and involving the patient, whilst adapting to forensic psychiatric care conditions by taking professional responsibility, assessing the patient's ability, and encouraging the patient to become more independent without adding any risks to the care process. By creating such prerequisites adapted to the forensic psychiatric care, it is more likely that the patients will participate in their care and take more own responsibility for it, which also may be helpful in the patient recovery process.

Patients' views of involuntary hospital admission after 1 and 3 months: prospective study in 11 European countries.

BACKGROUND: Legislation and practice of involuntary hospital admission vary substantially among European countries, but differences in outcomes have not been studied. AIMS: To explore patients' views following involuntary hospitalisation in different European countries. METHOD: In a prospective study in 11 countries, 2326 consecutive involuntary patients admitted to psychiatric hospital departments were interviewed within 1 week of admission; 1809 were followed up 1 month and 1613 3 months later. Patients' views as to whether the admission was right were the outcome criterion. RESULTS: In the different countries, between 39 and 71% felt the admission was right after 1 month, and between 46 and 86% after 3 months. Females, those living alone and those with a diagnosis of schizophrenia had more negative views. Adjusting for confounding factors, differences between countries were significant. CONCLUSIONS: International differences in legislation and practice may be relevant to outcomes and inform improvements in policies, particularly in countries with poorer outcomes.

Accumulated coercion and short-term outcome of inpatient psychiatric care.

BACKGROUND: The knowledge of the impact of coercion on psychiatric treatment outcome is limited. Multiple measures of coercion have been recommended. The aim of the study was to examine the impact of accumulated coercive incidents on short-term outcome of inpatient psychiatric care METHODS: 233 involuntarily and voluntarily admitted patients were interviewed within five days of admission and at discharge or after maximum three weeks of care. Coercion was measured as number of coercive incidents, i.e. subjectively reported and in the medical files recorded coercive incidents, including legal status and perceived coercion at admission, and recorded and reported coercive measures during treatment. Outcome was measured both as subjective improvement of mental health and as improvement in professionally assessed functioning according to GAF. Logistic regression analyses were performed with patient characteristics and coercive incidents as independent and the two outcome measures as dependent variables RESULTS: Number of coercive incidents did not predict subjective or assessed improvement. Patients having other diagnoses than psychoses or mood disorders were less likely to be subjectively improved, while a low GAF at admission predicted an improvement in GAF scores CONCLUSION: The results indicate that subjectively and professionally assessed mental health short-term outcome of acute psychiatric hospitalisation are not predicted by the amount of subjectively and recorded coercive incidents. Further studies are needed to examine the short- and long-term effects of coercive interventions in psychiatric care.

Perceived expectations in daily life among adolescent girls suffering from an eating disorder: a phenomenographic study.

The aim of this study was to describe the variation of perceived expectations in daily life of adolescent girls suffering from eating disorders. Eighteen interviews with girls between the age of 15 and 19 years were analyzed according to the phenomenographic approach. The results could be summarized into three categories: expectations from others, self-imposed expectations, and conflicting expectations. Each of these could be further subdivided into two conceptions. Conflicting and unattainable expectations were severe stressors in the participants' lives. Many participants had problems identifying expectations that were not explicit. The participants internalized these expectations and interpreted them to be self-imposed. Clinical implications are suggested.

Acceptance and commitment therapy to reduce eating disorder symptoms and body image problems in patients with residual eating disorder symptoms: A randomized controlled trial.

Body image problems are central aspects of eating disorders (ED), and risk factors both for the development of and relapse into an ED. Acceptance and commitment therapy (ACT) aims at helping patients accept uncomfortable internal experiences while committing to behaviors in accordance with life values. The aim of the present study was to compare the effectiveness of a group intervention, consisting of 12 sessions, based on ACT to treatment as usual (TAU) for patients with residual ED symptoms and body image problems. The study was a randomized controlled superiority trial. Patients with residual ED symptoms and body image problems were recruited from a specialized ED clinic in Sweden. The final sample consisted of 99 women, randomized to ACT or TAU. At the two-year follow-up, patients who received ACT showed a significant greater reduction in ED symptoms and body image problems and received less specialized ED care than patients in TAU. In conclusion, ACT was superior in reducing ED symptoms and body image problems.

Adolescents with full or subthreshold anorexia nervosa in a naturalistic sample: treatment interventions and patient satisfaction.

BACKGROUND: Despite major research efforts, current recommendations of treatment interventions for adolescents with anorexia nervosa are scarce, and the importance of patient satisfaction for treatment outcome is yet to be established. The overall aim of the present study was to examine treatment interventions and patient satisfaction in a naturalistic sample of adolescents with anorexia nervosa or subthreshold anorexia nervosa and possible associations to outcome defined as being in remission or not at treatment follow-up. METHODS: Participants were identified through the Swedish national quality register for eating disorder treatment (SwEat). The samples consisted of 1899 patients who were follow-up registered 1 year after entering treatment and 474 patients who had completed a 1-year patient satisfaction questionnaire. A two-step cluster analysis was used for identifying subgroups of patients who received certain combinations and various amounts of treatment forms. RESULTS: Patients who received mainly family-based treatment and/or inpatient care were most likely to achieve remission at 1-year follow-up, compared to patients in the other clusters. They were also younger, in general. Individual therapy was the most common treatment form, and was most appreciated among the adolescents. At 1-year follow-up, many patients reported improvements in eating habits, but far fewer reported improvements regarding cognitive symptoms. Overall, the patients rated the therapist relationship in a rather positive way, but they gave quite low ratings to statements associated with their own participation in treatment. CONCLUSIONS: The results indicate that young adolescents who receive mainly family-based treatment and/or inpatient care respond more rapidly to treatment compared to older adolescents who receive mainly individual therapy or mixed treatment interventions. At 1-year follow-up, the adolescents reported improvements in behavioral symptoms and seemed quite satisfied with the therapist relationship.