Does embedding pediatric eating disorder treatment in primary care bridge the access gap?

Given the numerous barriers to accessing child and adolescent eating disorder treatment, there is a need for innovation in how this care is delivered. Primary care-based eating disorder treatment has established proof-of-concept, yet it is unclear whether this model can bridge the treatment-access gap. This retrospective chart review study compared demographic and illness characteristics of 106 adolescents (M age = 15.1 years) SD = 1.8 consecutively evaluated in a primary care-based eating disorder clinic with 103 adolescent patients (M age = 15.2 years) SD = 2.2 seen consecutively in a specialty eating disorder clinic at the same medical center. Relative to adolescents in specialty care, those in the primary care group presented at a significantly higher BMI percentile, had less weight suppression, a shorter illness duration, lower rates of amenorrhea and lower scores on the EDE-Q Dietary Restraint subscale. In addition, more patients in the primary care group identified as non-white and had government/public assistance insurance compared to those in the specialty group. The results suggest that, compared to traditional specialty care clinics, embedded eating disorder treatment in primary care may reach a more racially and socioeconomically diverse group of adolescents when they are earlier in the course of their illness. Future research determining the relative effectiveness of this model as compared to interventions delivered in specialty care is needed.

Adapting Behavioral Treatments for Primary Care Using a Theory-Based Framework: The Case of Adolescent Eating Disorders.

Evidence-based treatments have been developed for a range of pediatric mental health conditions. These interventions have proven efficacy but require trained pediatric behavioral health specialists for their administration. Unfortunately, the widespread shortage of behavioral health specialists leaves few referral options for primary care providers. As a result, primary care providers are frequently required to support young patients during their lengthy and often fruitless search for specialty treatment. One solution to this treatment-access gap is to draw from the example of integrated behavioral health and adapt brief evidence-based treatments for intra-disciplinary delivery by primary care providers in consultation with mental health providers. This solution has potential to expand access to evidence-based interventions and improve patient outcomes. We outline how an 8-step theory-based process for adapting evidence-based interventions, developed from a scoping review of the wide range of implementation science frameworks, can guide treatment development and implementation for pediatric behavioral health care delivery in the primary care setting, using an example of our innovative treatment adaptation for child and adolescent eating disorders. After reviewing the literature, obtaining input from leaders in eating disorder treatment research, and engaging community stakeholders, we adapted Family-Based Treatment for delivery in primary care. Pilot data suggest that the intervention is feasible to implement in primary care and preliminary findings suggest a large effect on adolescent weight gain. Our experience using this implementation framework provides a model for primary care providers looking to develop intra-disciplinary solutions for other areas where specialty services are insufficient to meet patient needs.

The Role of Primary Care in Bridging Adolescents Awaiting Eating Disorder Treatment.

The striking rise in adolescent eating disorders since the severe acute respiratory coronavirus syndrome 2 pandemic has amplified demands for specialty eating disorders services and contributed to protracted delays in care. In the context of these delays, patients are at risk for increased weight loss, medical instability, escalating disease progression and poor prognosis. Primary care providers (PCPs) are frequently the first point of contact for young patients with eating disorders and are often left to bridge the gap while families struggle to establish specialty care. Yet, beyond case detection and medical comanagement, there are no evidence-based guidelines that can assist PCPs to prepare families for treatment, halt disease progression, and begin the lengthy process of weight and nutritional restoration in efforts to reduce medical complications and support a favorable prognosis. We present the case of a 13-year-old girl with a restrictive eating disorder to illustrate how PCPs can use intervention principles and strategies derived from evidence-based eating disorder treatment to successfully manage adolescent patients until they can access specialty treatment. We offer concrete guidelines for decision-making, as well as suggested behavioral and medical interventions for the PCP. With evidence-based tools, PCPs are well-positioned to support young patients with restrictive eating disorders and their family members as they begin the process of recovery from an eating disorder.

A Framework for Outpatient Infusion of Antispike Monoclonal Antibodies to High-Risk Patients with Mild-to-Moderate Coronavirus Disease-19: The Mayo Clinic Model.

The administration of spike monoclonal antibody treatment to patients with mild to moderate COVID-19 is very challenging. This article summarizes essential components and processes in establishing an effective spike monoclonal antibody infusion program. Rapid identification of a dedicated physical infrastructure was essential to circumvent the logistical challenges of caring for infectious patients while maintaining compliance with regulations and ensuring the safety of our personnel and other patients. Our partnerships and collaborations among multiple different specialties and disciplines enabled contributions from personnel with specific expertise in medicine, nursing, pharmacy, infection prevention and control, electronic health record (EHR) informatics, compliance, legal, medical ethics, engineering, administration, and other critical areas. Clear communication and a culture in which all roles are welcomed at the planning and operational tables are critical to the rapid development and refinement needed to adapt and thrive in providing this time-sensitive beneficial therapy. Our partnerships with leaders and providers outside our institutions, including those who care for underserved populations, have promoted equity in the access of monoclonal antibodies in our regions. Strong support from institutional leadership facilitated expedited action when needed, from a physical, personnel, and system infrastructure standpoint. Our ongoing real-time assessment and monitoring of our clinical program allowed us to improve and optimize our processes to ensure that the needs of our patients with COVID-19 in the outpatient setting are met.

Can adolescents with eating disorders be treated in primary care? A retrospective clinical cohort study.

BACKGROUND: Family-Based Treatment (FBT) is considered the first-line intervention for adolescent anorexia nervosa. However, access to this treatment is limited. Treatment programs for other pediatric mental health conditions have successfully overcome barriers to accessing evidence-based intervention by integrating mental health services into primary care. This study evaluated the proof-of-concept of a novel modification of FBT, Family-Based Treatment for Primary Care (FBT-PC) for adolescent restrictive eating disorders designed for delivery by primary care providers in their practices. METHODS: This retrospective clinical cohort study evaluated 15 adolescents with restrictive eating disorders receiving FBT-PC and 15 adolescents receiving standard FBT. We examined improvement in BMI percentile, reduction in weight suppression, and clinical benchmarks of eating disorder recovery including weight restoration to > 95% of expected body weight (EBW) and resolution of DSM-5 criteria for eating disorders. RESULTS: In both groups, effect sizes for increased BMI percentile exceeded Cohen's convention for a large effect (FBT-PC: d = .94; standard FBT: d = 1.15) as did effect sizes for reduction in weight suppression (FBT-PC: d = 1.83; standard FBT: d = 1.21). At the end of treatment, 80% of the FBT-PC cohort and 87% in the standard FBT group achieved > 95%EBW and 67% in the FBT-PC group and 60% in the standard FBT group no longer met DSM-5 criteria for an eating disorder. There were no cohort differences in the number of treatment drop-outs or referrals to a more intensive level of eating disorder treatment. CONCLUSIONS: Findings suggest that primary care providers have potential to improve weight and clinical status in adolescents with restrictive eating disorders. Based on these results, more rigorous testing of the FBT-PC model is warranted.

Family-Based Treatment (FBT) is considered the first-choice intervention for adolescent anorexia nervosa. However, finding a qualified provider in this modality is difficult. Treatment programs for other pediatric mental health conditions have successfully overcome barriers to accessing quality treatment by integrating mental health services into primary care. This study evaluated the proof-of-concept of a novel modification of FBT, Family-Based Treatment for Primary Care (FBT-PC) for adolescent restrictive eating disorders designed for delivery by primary care providers in their practices. This study examined weight gain in 15 adolescents with restrictive eating disorders receiving FBT-PC and 15 adolescents receiving standard FBT. At the end of treatment, both groups showed large improvements in BMI percentile and large decreases in weight suppression. Each group had the same number of drop-outs and referrals to more intensive eating disorder treatment. Findings suggest that primary care providers have potential to improve weight and clinical status in adolescents with restrictive eating disorders. Based on these preliminary results, more rigorous testing of the FBT-PC model is indicated.

Engaging primary care providers in managing pediatric eating disorders: a mixed methods study.

BACKGROUND: The primary care setting offers an attractive opportunity for, not only the identification of pediatric eating disorders, but also the delivery of evidence-based treatment. However, constraints of this setting pose barriers for implementing treatment. For interventions to be successful, they need to take into consideration the perspectives of stakeholders. As such, the purpose of this study was to examine in-depth primary care providers' perspective of challenges to identifying and managing eating disorders in the primary care setting. METHODS: This mixed methods study surveyed 60 Pediatric and Family Medicine providers across 6 primary care practices. Sixteen of these providers were further interviewed using a qualitative, semi-structured interview. RESULTS: Providers (n = 60, response rate of 45%) acknowledged the potential of primary care as a point of contact for early identification and treatment of pediatric eating disorders. They also expressed that this was an area of need in their practices. They identified numerous barriers to successful implementation of evidence-based treatment in this setting including scarcity of time, knowledge, and resources. CONCLUSIONS: Investigations seeking to build capacities in primary care settings to address eating disorders must address these barriers.

Addressing Disparities in Adolescent Eating Disorders: A Case Report of Family-Based Treatment in Primary Care.

Eating disorders typically have a protracted course, marked by significant morbidity. Male adolescents and adolescents of color are at risk of delayed care. Primary care providers are well-positioned to identify eating disorders early and initiate treatment. This case report describes an adaptation of Family-Based Treatment delivered by a primary care provider to an Asian-American male adolescent from an immigrant family with restrictive anorexia nervosa. The adolescent achieved full-weight restoration and remission of his anorexia through treatment in primary care. Embedding eating disorder treatment within primary care could improve detection, engagement, and retention in treatment among young people from diverse backgrounds.

A primary care modification of family-based treatment for adolescent restrictive eating disorders.

Although eating disorders pose a significant threat to the health and well-being of children and adolescents, due to a profound scarcity of specialty providers, only a small percentage of patients receives evidence-based treatment. To improve access to care for restrictive eating disorders, we developed a modified version of Family-Based Treatment to be delivered by primary care providers (PCPs) and conducted a pilot study to evaluate the feasibility and preliminary outcomes of this intervention. Fifteen adolescents (mean age = 15.5 years) with restrictive eating disorders and their caregiver(s) were enrolled in Family-Based Treatment for Primary Care (FBT-PC), delivered by three trained PCPs. Retention for the intervention was high (n = 13, 86.7%). Over the course of 3 months, participants attended an average of 9.2 (SD = 2.8) sessions and experienced a significant increase in BMI percentile from 39.1 to 54.8 (t (13) = -6.71, p < .001; d = .61). FBT-PC appears to be feasible for implementation in the primary care setting and has the potential to improve access to treatment and yield positive outcomes for young patients with restrictive eating disorders.

Oral erosions associated with surreptitious marijuana vaping in an adolescent boy.

A 15-year-old boy presented with painful ulcerations affecting the oral mucosa that were eventually attributed to marijuana vaping. In this case report, we highlight cannabis vaping as a potential cause of oral erosions due to injury and chronic inflammation of the oral mucosa.

An Examination of Screening Tools for Collaborative Care of Adolescent Depression.

OBJECTIVE: Collaborative care models for treatment of adolescent depression are rapidly evolving. However, a dearth of information exists regarding patient characteristics associated with positive outcomes. We explored the association between baseline scores on routine screening tools for substance abuse, mood disorders, and anxiety with depression remission and graduation from a collaborative care program in an outpatient pediatric practice. METHODS: Adolescents (aged 12-17 years) with Patient Health Questionnaire-9 Modified for Adolescents (PHQ-9A) score ≥ 10 and a diagnosis of depressive disorder based on DSM-IV criteria between July 2011 and August 2015 were eligible for enrollment in a collaborative care model and inclusion in this study. Remission was defined as a single PHQ-9A score < 5; the criterion for graduation was 3 consecutive months with PHQ-9A score < 5. Analyses compared baseline assessment scores with those at remission and graduation. RESULTS: Of the 182 patients included in the analysis, the overall remission rate was 55%; program graduation rate was 27%. There was no association between scores on baseline screening tools and remission. Graduation was associated with lower scores on a screening tool for substance abuse (unit odds ratio [OR] = 1.62; P = .01) and anxiety (unit OR = 1.03; P = .02). When the scores were examined as categorical variables, graduation was associated with negative assessments on screening tools for substance abuse (OR = 3.21; P = .003) and anxiety (OR = 2.35; P = .02). CONCLUSIONS: Baseline substance abuse and anxiety assessments may have utility in identifying depressed adolescents who are less likely to maintain remission and graduate from a collaborative care program, suggesting that these patients may need additional intervention to achieve sustained remission.

Effectiveness in Regular Practice of Collaborative Care for Depression Among Adolescents: A Retrospective Cohort Study.

OBJECTIVE: Depression is common among adolescents, but many lack ready access to mental health services. Integrated models of care for depression are needed, along with evidence to support their use in regular practice. The authors examined the effectiveness of an ongoing collaborative care program for depressed adolescents embedded in a busy primary care practice. METHODS: This retrospective cohort study assessed EMERALD (Early Management and Evidence-based Recognition of Adolescents Living with Depression), a collaborative care program. All patients ages 12-17 and age 18 and still in high school with a score of ≥10 on the nine-item Patient Health Questionnaire for Adolescents (PHQ-9A) and without a diagnosis of bipolar disorder were eligible. The sample included 162 EMERALD participants and 499 similarly eligible non-EMERALD patients. Outcomes were six-month remission of depression (score <5) and six-month treatment response (>50% reduction from baseline) as measured by the PHQ-9A. Analyses included logistic regression and propensity score matching to adjust for differences in demographic factors and number of contacts-observations. RESULTS: After propensity score matching, EMERALD patients had better adjusted rates of depression remission (11 percentage points higher, p=.035) and treatment response (14 percentage points higher, p<.001) than comparison patients. Results from primary analyses were as conservative as or more conservative than results from all sensitivity analyses tested. CONCLUSIONS: Collaborative care for adolescents in regular practice led to better remission and treatment response than usual care. Future studies could examine which groups might benefit most and flexible payment models to support these services.

Eating disorders in adolescents with a history of obesity.

Adolescent patients with obesity are at significant risk of developing an eating disorder (ED), yet due to their higher weight status their symptoms often go unrecognized and untreated. Although not widely known, individuals with a weight history in the overweight (BMI-for-age ≥85th percentile but <95th percentile, as defined by Centers for Disease Control and Prevention growth charts) or obese (BMI-for-age ≥95th percentile, as defined by the Centers for Disease Control and Prevention growth charts) range, represent a substantial portion of adolescents presenting for ED treatment. Given research that suggests that early intervention promotes the best chance of recovery, it is imperative that these children's and adolescents' ED symptoms are identified and that intervention is offered before the disease progresses. This report presents 2 examples of EDs that developed in the context of obese adolescents' efforts to reduce their weight. Each case shows specific challenges in the identification of ED behaviors in adolescents with this weight history and the corresponding delay such teenagers experience accessing appropriate treatment.

The power of collaboration: integrating a preventive medicine-public health curriculum into a pediatric residency.

This is one of six short papers that describe additional innovations to help integrate public health into medical education; these were featured in the "Patients and Populations: Public Health in Medical Education" conference. They represent relatively new endeavors or curricular components that had not been explored in prior publications. Although evaluation data are lacking, it was considered to be of value to medical educators to share a brief description of the collaboration between the Division of Preventive, Occupational, and Aerospace Medicine and the Department of Pediatrics at Mayo Clinic to integrate a preventive medicine-public health curriculum into the pediatric residency.