Clinician perspectives of the implementation of an early intervention service for eating disorders in England: a mixed method study.

BACKGROUND: The First Episode Rapid Early Intervention for Eating Disorders (FREED) service has been shown to reduce the wait for care and improve clinical outcomes in initial evaluations. These findings led to the national scaling of FREED in England. To support this scaling, we conducted a mixed method evaluation of the perceptions and experiences of clinicians in the early phases of scaling. The Normalisation Process Theory (NPT) was used as a conceptual lens to understand if and how FREED becomes embedded in routine practice. METHODS: The convergent mixed method evaluation included 21 semi-structured interviews with clinicians from early adopter sites and 211 surveys administered to clinicians before, immediately after and 3 months after the FREED training. The interview guide and survey included questions evaluating attitudes towards early intervention for eating disorders (EDs) and NPT mechanisms. Interview data were analysed using an inductive thematic analysis. The NPT was applied to the inductively derived themes to evaluate if and how NPT domains impacted the implementation. Survey data were analysed using multilevel growth models. RESULTS: Six themes and 15 subthemes captured barriers and facilitators to implementation at the patient, clinician, service, intervention, implementation and wider system levels. These interacted with the NPT mechanisms to facilitate or hinder the embedding of FREED. Overall, clinicians were enthusiastic and positive towards early intervention for EDs and FREED, largely because of the expectation of improved patient outcomes. This was a considerable driver in the uptake and implementation of FREED. Clinicians also had reservations about capacity and the potential impact on other patients, which, at times, was a barrier for its use. The FREED training led to significant improvements in positive attitudes and NPT mechanisms that were largely maintained at the 3-month follow-up. However, negative attitudes did not significantly improve following training. CONCLUSIONS: Positive attitudes towards early intervention for EDs increased enthusiasm and engagement with the model. Features of the model and its implementation were effective at developing adopter commitment and capabilities. However, there were aspects of the model and its implementation which require attention in the future (e.g., capacity and the potential impact on the wider service).

Participant Experiences of Transcranial Direct Current Stimulation (tDCS) as a Treatment for Antipsychotic Medication Induced Weight Gain.

Background: Despite the growing number of studies on the use of non-invasive brain stimulation in people with schizophrenia, there is limited research on participant views of such treatment methods. Aim: Explore participant experiences and perceptions of transcranial direct current stimulation (tDCS). Methods: Twelve people with schizophrenia took part in semi-structured interviews after having completed 5 sessions of tDCS. Thematic analysis was used to identify codes and themes. Results: Five themes were identified: (1) motivation for study enrolment; (2) concerns about tDCS; (3) factors reducing the fear of tDCS; (4) experience of tDCS; (5) perceived effects of tDCS. Conclusions: The study provides insight into the perceptions and experiences of each individual. Participants were concerned about the safety of tDCS and associated it with invasive procedures such as electroconvulsive therapy and lobotomy. Educational materials and a good relationship with the researcher played an important role in reducing the fear of brain stimulation. All participants described tDCS as uncomfortable, however, agreed that unpleasant sensations only lasted for a short while (20 s-5 min). After the first session, participants no longer felt anxious about the remaining ones. Strategies to improve treatment experience and study recruitment have been identified.

The effect of repetitive transcranial magnetic stimulation on food choice-related self-control in patients with severe, enduring anorexia nervosa.

OBJECTIVE: Individuals with anorexia nervosa (AN) pursue low-fat, low-calorie diets even when in a state of emaciation. These maladaptive food choices may involve fronto-limbic circuitry associated with cognitive control, habit, and reward. We assessed whether high-frequency repetitive transcranial magnetic stimulation (rTMS) to the left dorsolateral prefrontal cortex (DLPFC) influenced food-related choice behavior in patients with severe, enduring (SE)-AN. METHOD: Thirty-four females with SE-AN completed a Food Choice Task before and after 20 sessions of real or sham rTMS treatment and at a 4-month follow-up. During the task, participants rated high- and low-fat food items for healthiness and tastiness and then made a series of choices between a neutral-rated food and high- and low-fat foods. Outcomes included the proportion of high-fat and self-controlled choices made. A comparison group of 30 healthy women completed the task at baseline only. RESULTS: Baseline data were consistent with previous findings: relative to healthy controls, SE-AN participants showed a preference for low-fat foods and exercised self-control on a greater proportion of trials. There was no significant effect of rTMS treatment nor time on food choices related to fat content. However, among SE-AN participants who received real rTMS, there was a decrease in self-controlled food choices at post-treatment, relative to baseline. Specifically, there was an increase in the selection of tasty-unhealthy foods. DISCUSSION: In SE-AN, rTMS may promote more flexibility in relation to food choice. This may result from neuroplastic changes in the DLPFC and/or in associated brain areas.

Effects of Transcranial Direct Current Stimulation (tDCS) and Approach Bias Modification (ABM) training on food cravings in people taking antipsychotic medication.

BACKGROUND: Antipsychotic drug-induced weight gain puts individuals with schizophrenia at increased cardiometabolic risk. As a potential intervention for this problem, we describe the theoretical background and a protocol for a feasibility randomised controlled trial (RCT) of approach bias modification (ABM) training combined with real versus sham (placebo) transcranial direct current stimulation (tDCS). The primary aim of this trial is to obtain information that will guide decision making and protocol development in relation to a future large-scale RCT of ABM and tDCS in this group of participants. Second, the study will assess the preliminary efficacy of ABM + tDCS in reducing food cravings in people who take antipsychotic medication. METHODS: Thirty adults with a DSM-V diagnosis of schizophrenia or schizoaffective disorder treated with anti-psychotic medication will be randomly allocated to receive five sessions that will combine ABM and real or sham tDCS, in a parallel group design. In this feasibility study, a broad range of outcome variables will be examined. Measures will include food craving, psychopathology (e.g. symptoms of schizophrenia and depression), neuropsychological processes (such as attentional bias and impulsiveness), and the tolerability and acceptability of tDCS. The feasibility of conducting a large-scale RCT of ABM + tDCS and appropriateness of tDCS as a treatment for antipsychotic drug-induced weight gain will be evaluated by assessment of recruitment and retention rates, acceptability of random allocation, blinding success (allocation concealment), completion of treatment sessions and research assessments (baseline, post-treatment and follow-up). DISCUSSION: The effect sizes generated and other findings from this trial will inform a future large-scale RCT with respect to decisions on primary outcome measures and other aspects of protocol development. In addition, results from this study will provide a preliminary indication of the efficacy of ABM + tDCS treatment for antipsychotic drug-induced weight gain. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN13280178. Registered on 16 October 2018.