Assessing clinician competence in the delivery of cognitive-behavioural therapy for eating disorders: development of the Cognitive-Behavioural Therapy Scale for Eating Disorders (CBTS-ED).

Evidence-based cognitive-behaviour therapy for eating disorders (CBT-ED) differs from other forms of CBT for psychological disorders, making existing generic CBT measures of therapist competence inadequate for evaluating CBT-ED. This study developed and piloted the reliability of a novel measure of therapist competence in this domain-the Cognitive Behaviour Therapy Scale for Eating Disorders (CBTS-ED). Initially, a team of CBT-ED experts developed a 26-item measure, with general (i.e. present in every session) and specific (context- or case-dependent) items. To determine statistical properties of the measure, nine CBT-ED experts and eight non-experts independently observed six role-played mock CBT-ED therapy sessions, rating the therapists' performance using the CBTS-ED. The inter-item consistency (Cronbach's alpha and McDonald's omega) and inter-rater reliability (ICC) were assessed, as appropriate to the clustering of the items. The CBTS-ED demonstrated good internal consistency and moderate/good inter-rater reliability for the general items, at least comparable to existing generic CBT scales in other domains. An updated version is proposed, where five of the 16 "specific" items are reallocated to the general group. These preliminary results suggest that the CBTS-ED can be used effectively across both expert and non-expert raters, though less experienced raters might benefit from additional training in its use.

A framework for conceptualising early intervention for eating disorders.

OBJECTIVE: This paper outlines the evidence base for early intervention for eating disorders; provides a global overview of how early intervention for eating disorders is provided in different regions and settings; and proposes policy, service, clinician and research recommendations to progress early intervention for eating disorders. METHOD AND RESULTS: Currently, access to eating disorder treatment often takes many years or does not occur at all. This is despite neurobiological, clinical and socioeconomic evidence showing that early intervention may improve outcomes and facilitate full sustained recovery from an eating disorder. There is also considerable variation worldwide in how eating disorder care is provided, with marked inequalities in treatment provision. Despite these barriers, there are existing evidence-based approaches to early intervention for eating disorders and progress is being made in scaling these. CONCLUSIONS: We propose action steps for the field that will transform eating disorder service provision and facilitate early detection, treatment and recovery for everyone affected by eating disorders, regardless of age, socioeconomic status and personal characteristics.

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

BACKGROUND: First 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. METHODS: FREED 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. RESULTS: Overall, 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 (X2 [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 (X2 [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). DISCUSSION: FREED is robust and scalable and is associated with substantial improvements in clinical outcomes, reduction in inpatient or day-patient admissions, and cost-savings.

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

BACKGROUND: 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. AIMS: This study evaluated fidelity to the FREED service model during the multicentre FREED-Up study. METHOD: 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. RESULTS: 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. CONCLUSIONS: 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.

Implementing evidence-based individual psychotherapies for adults with eating disorders in a real world clinical setting.

OBJECTIVE: This study aimed to evaluate the effectiveness of evidenced-based psychological treatments (specifically, Cognitive-Behaviour Therapy for Eating Disorders [CBT-ED] and Maudsley Anorexia Nervosa Treatment for Adults [MANTRA]) for a transdiagnostic eating disorder population in a routine clinical setting. In particular, it aimed to determine the extent to which treatment was provided in line with current clinical guidelines (NICE, 2017) and how effective treatment was in improving eating disorder and general psychopathology. METHOD: Three hundred and seventy-nine participants meeting criteria for DSM-5 anorexia nervosa, bulimia nervosa, binge-eating disorder or other specified feeding or eating disorder completed pre- and posttreatment measures of eating disorder pathology and general distress. Clinicians recorded weight and episodes of bingeing and purging. RESULTS: Ninety seven percent of participants received treatment in line with evidence-based psychotherapies. Treatment was completed by 59.9% of the whole sample. Using stringent criteria and ITT analysis 21.4% met criteria for remission at end of treatment. In the underweight sample, there was a significant increase in BMI, averaging 1.38 kg/m2 over treatment, with similar outcomes for MANTRA and CBT-ED. DISCUSSION: These findings, in a large transdiagnostic population, add to emerging literature on the translation of evidence-based psychotherapies to real-world clinical settings. Our results converge well with prior similar studies. Findings highlight the need for routine data collection in services and for the ongoing improvement of treatments for the eating disorders.

"I'm truly free from my eating disorder": Emerging adults' experiences of FREED, an early intervention service model and care pathway for eating disorders.

BACKGROUND: Eating disorders (EDs) typically start during adolescence or emerging adulthood, periods of intense biopsychosocial development. FREED (First Episode Rapid Early Intervention for EDs) is a service model and care pathway providing rapid access to developmentally-informed care for emerging adults with EDs. FREED is associated with reduced duration of untreated eating disorder and improved clinical outcomes, but patients' experiences of treatment have yet to be assessed. OBJECTIVE: This study aimed to assess emerging adults' experiences of receiving treatment through FREED. METHOD: This study triangulated qualitative data on participants' experiences of FREED treatment from questionnaires and semi-structured interviews. Participants were 106 emerging adults (aged 16-25; illness duration < 3 yrs) (questionnaire only = 92; interview only = 6; both = 8). Data were analysed thematically. RESULTS: Most participants reported psychological and behavioural changes over the course of treatment (e.g. reduction in symptoms; increased acceptance and understanding of difficulties). Participants identified five beneficial characteristics of FREED treatment: i) rapid access to treatment; ii) knowledgeable and concerned clinicians; iii) focusing on life beyond the eating disorder; iv) building a support network; v) becoming your own therapist. CONCLUSION: This study provides further supports for the implementation of early intervention and developmentally-informed care for EDs. Future service model development should include efforts to increase early help-seeking.

Exploring the use of individualised patient-reported outcome measures in eating disorders: Validation of the Psychological Outcome Profiles.

RATIONALE: Psychotherapies for eating disorders (EDs) are routinely assessed using standardised patient-reported outcome measures (PROMs). PROMs have been criticised for their lack of patient centeredness and clinical utility. The Psychological Outcome Profiles (PSYCHLOPS) is an individualised PROM that allows patients to specify their own outcomes. AIMS: (1) To validate the use of the PSYCHLOPS in ED treatment, and (2) to identify patient concerns beyond those measured by common ED PROMs. METHODS: Two hundred and seventy-eight emerging adult patients, presenting with a first-episode ED (aged 16-25, illness duration <3 years) completed the PSYCHLOPS and two standardised ED PROMs (the EatingDisorder Examination Questionnaire [EDE-Q] and the Clinical Impairment Assessment Questionnaire [CIA]) at four time points across 12 months. Psychometrics of the PSYCHLOPS were assessed quantitatively against the EDE-Q and CIA. Content analysis assessed unique patient concerns identified by PSYCHLOPS. RESULTS: The PSYCHLOPS had adequate to good psychometric properties. A total of 53.3% of participants reported a concern not addressed by the EDE-Q or the CIA, the most common being depression/anxiety, academic problems, treatment concerns and disturbed sleep. DISCUSSION: PROMs can be complemented by the PSYCHLOPS to identify problems specific to an individual's context. As ED patients are typically ambivalent about change, understanding their concerns is vital in building motivation for change.

Assessing the impact of First Episode Rapid Early Intervention for Eating Disorders on duration of untreated eating disorder: A multi-centre quasi-experimental study.

BACKGROUND: Duration of untreated eating disorder (DUED), that is, the time between illness onset and start of first evidence-based treatment, is a key outcome for early intervention. Internationally, reported DUED ranges from 2.5 to 6 years for different eating disorders (EDs). To shorten DUED, we developed FREED (First Episode Rapid Early Intervention for EDs), a service model and care pathway for emerging adults with EDs. Here, we assess the impact of FREED on DUED in a multi-centre study using a quasi-experimental design. METHODS: Two hundred and seventy-eight patients aged 16-25, with first episode illness of less than 3 years duration, were recruited from specialist ED services and offered treatment via FREED. These were compared to 224 patients, of similar age and illness duration, seen previously in participating services (treatment as usual [TAU]) on DUED, waiting times and treatment uptake. RESULTS: FREED patients had significantly shorter DUED and waiting times than TAU patients. On average, DUED was reduced by ∼4 months when systemic delays were minimal. Furthermore, 97.8% of FREED patients took up treatment, versus 75.4% of TAU. DISCUSSION: Findings indicate that FREED significantly improves access to treatment for emerging adults with first episode ED. FREED may reduce distress, prevent deterioration and facilitate recovery.

Cognitive-behavioral therapy in the time of coronavirus: Clinician tips for working with eating disorders via telehealth when face-to-face meetings are not possible.

OBJECTIVE: The coronavirus pandemic has led to a dramatically different way of working for many therapists working with eating disorders, where telehealth has suddenly become the norm. However, many clinicians feel ill equipped to deliver therapy via telehealth, while adhering to evidence-based interventions. This article draws together clinician experiences of the issues that should be attended to, and how to address them within a telehealth framework. METHOD: Seventy clinical colleagues of the authors were emailed and invited to share their concerns online about how to deliver cognitive-behavioral therapy for eating disorders (CBT-ED) via telehealth, and how to adapt clinical practice to deal with the problems that they and others had encountered. After 96 hr, all the suggestions that had been shared by 22 clinicians were collated to provide timely advice for other clinicians. RESULTS: A range of themes emerged from the online discussion. A large proportion were general clinical and practical domains (patient and therapist concerns about telehealth; technical issues in implementing telehealth; changes in the environment), but there were also specific considerations and clinical recommendations about the delivery of CBT-ED methods. DISCUSSION: Through interaction and sharing of ideas, clinicians across the world produced a substantial number of recommendations about how to use telehealth to work with people with eating disorders while remaining on track with evidence-based practice. These are shared to assist clinicians over the period of changed practice.

Symptom trajectories into eating disorders: A systematic review of longitudinal, nonclinical studies in children/adolescents.

BACKGROUND: Eating disorders (EDs) are serious mental illnesses that can be life-threatening. Stage of illness models and early intervention strategies could be informed by a better understanding of symptomatology that precedes the onset of an ED. This review aims to explore which symptoms (both ED and other psychiatric disorder-related) exist prior to the onset of an ED and whether there any prospective associations between these symptomatologies. METHODS: A systematic literature review was conducted in MEDLINE, Embase, and PsycINFO for large, longitudinal, prospective studies in nonclinical cohorts of children/adolescents that report symptoms prior to the onset of an ED. A quality assessment of included studies was conducted using the Newcastle-Ottawa Quality Assessment Scale. RESULTS: A total of 22 studies were included, and over half were assessed to be of good quality. Studies identified the presence of a broad range of ED and other psychiatric disorder-related symptoms prior to ED onset. Possible prospective associations were identified, including early eating and feeding difficulties in childhood, to ED-related symptoms (e.g., dieting and body dissatisfaction) and other psychiatric disorder-related symptoms (e.g., anxiety and depression) in childhood/early adolescence, progressing to severe symptomatology (e.g., extreme weight control behaviors and self-harm) in mid-adolescence/emerging adulthood. CONCLUSION: The trajectory of symptoms identified to precede and possibly predict onset of an ED may inform early intervention strategies within the community. Suggestions for further research are provided to establish these findings and the clinical implications of these discussed, in order to inform how best to target prodromal stages of EDs.

First episode rapid early intervention for eating disorders (FREED): From research to routine clinical practice.

AIMS: Eating disorders are serious psychiatric disorders with high rates of morbidity and mortality. Early intervention can improve treatment outcomes and reduce disruption to psychosocial development. However, early intervention is not well established in the eating disorder field. First episode rapid early intervention for eating disorders (FREED) was developed to address barriers to early, effective eating disorder treatment in emerging adults aged 16 to 25 years. Since 2014, FREED has progressed from a single-site research project to an evidence-based care approach in nine eating disorder services. This paper aims to summarize key learning from the scaling of FREED to date, with attention to how this learning may generalizes to other models of care. METHODS: We describe the development, scaling and implementation of FREED with reference to the RE-AIM (reach; effectiveness/efficacy; adoption; implementation; maintenance) framework. We also summarize challenges and learning in each of the RE-AIM domains. RESULTS: FREED has demonstrated real-world validity across diverse clinical contexts, geographical regions and populations. Key outcomes are seen for each of the RE-AIM domains. CONCLUSIONS: FREED provides an example of effective, non-commercial scaling of an early intervention eating disorder care pathway. This work is likely to be particularly relevant to others looking to scale-up early intervention models and for those working in secondary and tertiary mental health settings.

Evaluation of Teen BodyWise: A pilot study of a body image group adapted for adolescent inpatients with anorexia nervosa.

PURPOSE: Body image disturbance is a key characteristic of anorexia nervosa (AN); however, research into these difficulties among adolescents with AN is limited and is yet to assess the best treatments for this population. METHODS: Fifty-two adolescents receiving inpatient treatment for AN attended Teen BodyWise, an eight-session body image group adapted for adolescents. Measures assessing shape and weight concerns, ability to discuss body image, sociocultural attitudes, body avoidance, body checking, and motivation were given before and after the group, and participant feedback was elicited. RESULTS: Significant improvements were found for shape and weight concerns, ability to discuss body image, body checking and sociocultural attitudes. Participants were generally satisfied with the group and found it helpful, yet some aspects were experienced as challenging. CONCLUSIONS: Teen BodyWise has potential benefits for adolescents with AN. Controlled research is needed to determine the effectiveness of Teen BodyWise. LEVEL OF EVIDENCE: Evidence obtained from multiple time series with or without the intervention, such as case studies, Level IV.

First episode rapid early intervention for eating disorders: A two-year follow-up.

AIM: We describe 2-year outcomes of a novel first episode early intervention service for young adults with a recent onset eating disorder (FREED). Outcomes in FREED patients with anorexia nervosa (AN) were compared with those from patients previously seen in our service [treatment as usual (TAU) cohort], matched for age, illness duration and diagnosis. METHODS: Electronic case records of FREED-AN (n = 22) and TAU-AN patients (n = 35) were examined to identify service utilisation and clinical outcomes over 24 months. RESULTS: Outpatient service utilisation was similar in both groups, but FREED-AN patients needed intensive (in- or day-patient) treatment less frequently than TAU-AN (23% vs 32%). FREED-AN patients had a higher estimated mean body mass index [19.2 kg/m2 ; 95% CI (18.21, 20.16)] than TAU patients [18.0 kg/m2 ; 95% CI (16.90, 19.15)] at last contact. CONCLUSION: Introduction of FREED led to a more complete recovery in patients with AN at 24 months.

A pilot evaluation of a novel First Episode and Rapid Early Intervention service for Eating Disorders (FREED).

This pilot study assesses the impact of FREED (First Episode Rapid Early Intervention for Eating Disorders [ED]), a novel transdiagnostic service for emerging adults with recent ED onset, on clinical outcomes. Data were collected from 56 patients and 19 carers for 12 months following enrolment. FREED patients showed significant improvements in ED and other symptoms across time. Carers also showed psychological improvements. For FREED anorexia nervosa (AN) patients, body mass index (BMI) at initial clinical assessment was similar to that of comparable patients (audit cohort) seen in our service before (16.4 vs 16.1 kg/m2 ). By start of treatment, because of their shorter wait, FREED-AN had gained weight whereas audit patients had lost (16.7 vs 15.8 kg/m2 ). This difference continued throughout treatment, and at 12 months, nearly 60% FREED-AN patients returned to a BMI of 18.5 or greater. FREED shows promise as a service model for emerging adults with EDs.

A 10-session cognitive-behavioral therapy (CBT-T) for eating disorders: Outcomes from a case series of nonunderweight adult patients.

OBJECTIVE: Existing forms of evidence-based cognitive behavior therapy for eating disorders (CBT-ED) are relatively effective for nonunderweight cases. However, they are also expensive compared to CBT for other disorders. This study reports the first outcomes for a shorter, 10-session form of CBT-ED (CBT-T) for such cases, designed to be less demanding of resources. METHOD: A case series of 106 nonunderweight eating disordered cases were considered for this effectiveness study. A protocolized 10-session version of CBT-ED was delivered by clinical assistants, under supervision. Measures assessed eating attitudes and behaviors, anxiety, depression, personality pathology, and the working alliance. Intention-to-treat analyses were used. RESULTS: Suitability, acceptability, working alliance ratings, and retention were all positive. Outcomes by the end of therapy and at three-month follow-up were positive for all symptoms, with levels of change, abstinence and remission that were comparable to those from effectiveness studies of longer forms of CBT. Higher levels of pretreatment anxiety predicted retention in treatment, but no factors predicted poorer response. Early change in eating attitudes and the working alliance were the strongest predictors of a positive response. DISCUSSION: This 10-session form of CBT-ED for nonunderweight eating disorders performed at a level that is comparable to versions of CBT-ED that are twice as long, despite being delivered by nonspecialist therapists. Replication and longer-term follow-ups are needed to ensure retained effects. However, CBT-T has promise as a therapy for use in a range of healthcare settings, to enhance access to treatment for such eating disorders.

The FREED Project (first episode and rapid early intervention in eating disorders): service model, feasibility and acceptability.

AIM: Eating disorders (EDs) are disabling disorders, predominantly affecting adolescents and young adults. Untreated symptoms have lasting effects on brain, body and behaviour. Care pathway-related barriers often prevent early detection and treatment of ED. The aim of this study was to assess the feasibility and acceptability of FREED (First Episode and Rapid Early Intervention for Eating Disorder), a novel service for young people (aged 18-25 years) with recent ED onset (≤3 years), embedded in a specialist adult National Health Service ED service. Specifically, we assessed the impact of FREED on duration of time until specialist service contact (DUSC), duration of untreated ED (DUED) and wait-times for assessment and treatment compared with patients seen earlier in our service. Acceptability of FREED was also assessed. METHODS: Sixty individuals were recruited from September 2014 to August 2015. Fifty-one of these were compared with 89 patients seen earlier. RESULTS: FREED patients, from areas with minimal National Health Service gatekeeping (14/51), had markedly shorter DUSC and DUED than controls (DUSC: 12.4 months vs. 16.2 months; DUED 13.0 months vs. 19.1 months), whereas those with complex gatekeeping (37/51) had shorter DUED (17.7 months), but longer DUSC (16.9 months) than controls. FREED patients waited significantly less time for both assessment and treatment than controls, had significantly better treatment uptake and were highly satisfied with the process of starting treatment. CONCLUSIONS: FREED is a feasible and acceptable service which successfully reduced waiting times. Reductions in DUSC and DUED depend on gatekeeping arrangements. More research is required to establish clinical outcomes of FREED.

"What Are You Thinking When You Look at Me?" A Pilot Study of the Use of Virtual Reality in Body Image.

Body image disturbance (BID) is implicated in the etiology, maintenance, and relapse of the eating disorders, and remains challenging to treat. New paradigms such as virtual reality (VR) may offer an ecologically viable method to assess and treat BID. This pilot study aimed to determine if a VR environment could elicit increased BID in a nonclinical group of women who were dieting due to body image concerns or nonclinical women who were not dieting. Forty-one nonclinical females participated in the VR paradigm (a London Bus Journey), completing pre and post measures of body image satisfaction, and social evaluative concerns. Results did not support the hypothesis that the virtual London Bus would elicit increased BID. However, dieters reported significantly higher levels of social evaluative concerns and comparison to avatars during the virtual environment compared with nondieters. Participants reported acceptable levels of sense of presence and enjoyment of the VR environment. Possible explanations for the failure of the VR environment to trigger increased BID are discussed, including choice of environment and avatar fidelity. In conclusion, this pilot study suggests that VR might have potential in the treatment of disturbed body image, while highlighting the need for further research into the required levels of representational and behavioral fidelity of virtual environments and avatars.

Weighing patients within cognitive-behavioural therapy for eating disorders: How, when and why.

While weight, beliefs about weight and weight changes are key issues in the pathology and treatment of eating disorders, there is substantial variation in whether and how psychological therapists weigh their patients. This review considers the reasons for that variability, highlighting the differences that exist in clinical protocols between therapies, as well as levels of reluctance on the part of some therapists and patients. It is noted that there have been substantial changes over time in the recommendations made within therapies, including cognitive-behavioural therapy (CBT). The review then makes the case for all CBT therapists needing to weigh their patients in session and for the patient to be aware of their weight, in order to give the best chance of cognitive, emotional and behavioural progress. Specific guidance is given as to how to weigh, stressing the importance of preparation of the patient and presentation, timing and execution of the task. Consideration is given to reasons that clinicians commonly report for not weighing patients routinely, and counter-arguments and solutions are presented. Finally, there is consideration of procedures to follow with some special groups of patients.

Development, psychometric properties and preliminary clinical validation of a brief, session-by-session measure of eating disorder cognitions and behaviors: The ED-15.

OBJECTIVE: In the treatment research literature on other psychological disorders, there is a move towards session-by-session symptom measurement. The necessary measures need to be brief, focused on core features since the last session, and readily available to clinicians. There is no measure in the eating disorders that meets those criteria. This research reports the development and validation of such a self-report questionnaire. METHOD: The authors generated and refined a brief set of attitudinal and behavioral items. The resulting questionnaire (the ED-15) and an existing measure (Eating Disorders Examination-Questionnaire; EDE-Q) were completed by a large nonclinical adult sample (N = 531), a group of self-reported eating disorder sufferers (N = 63), and a group of women (N = 33) diagnosed with bulimia nervosa or atypical bulimia nervosa and undertaking cognitive-behavioral therapy. RESULTS: Factor analysis identified two scales (Weight and Shape Concerns; Eating Concerns), with strong internal consistency and test-retest reliability. Correlations with the EDE-Q (r = 0.889) indicates that the ED-15 and EDE-Q measure near-identical constructs. The ED-15 differentiated self-reported eating-disordered and nonclinical groups to the same degree as the longer EDE-Q. Session-by-session analysis of the CBT treatment group demonstrated that the different ED-15 scales changed in different patterns across therapy. DISCUSSION: The ED-15 is not proposed as an alternative to existing measures, but as a complementary tool, used to measure session-by-session change for clinical and research purposes. Future research will track changes in ED-15 scores across therapy, to determine the importance of very early response to therapy and sudden changes.