Addressing the gap of early intervention for eating disorders in primary health care.

AIM: Only one in four individuals with eating disorders (EDs) seek help, with many barriers to treatment-seeking present. Placing an early intervention model in primary mental health care settings is one approach to reducing these barriers. To date, only one model (emerge-ED) has been evaluated in the literature. METHODS: We aimed to replicate findings from the initial emerge-ED evaluation. We report on treatment outcomes in a new cohort and their views on barriers to treatment-seeking. We then examine how this early intervention model in primary health care has evolved to overcome the barriers to treatment delivery cited by health professionals in the initial evaluation. RESULTS: Eighty participants commenced treatment between July 2020 and March 2022 and completed a mean of 8.98 sessions, 70 (87.5%) completed >1 sessional measure on ED cognitions and behaviours, but only 31% (n = 24) completed lengthier assessments. Findings replicated initial emerge-ED outcomes, with small to moderate effect size decreases in the ED sessional measure at 70 days since treatment commencement for cognitions (d = .63) and ED behaviours (d = .09., .69). The most cited barrier by participants was "belief that my problem is not bad enough", reflective of denial of illness. Lastly, to overcome barriers to treatment delivery clinicians had to deviate from treatment protocols and work collaboratively with other healthcare providers. CONCLUSIONS: Our findings replicated the initial emerge-ED evaluation and highlight the importance of considering primary health care settings as an essential site in delivering early intervention services for EDs.

A systematic review and meta-analysis of intensive treatment options for adults with eating disorders.

Eating disorders (EDs) are complex conditions with one of the highest mortality rates among psychiatric illnesses. While outpatient evidence-based treatments for EDs in adults exist, there is often utilisation of more intensive interventions as part of treatment. However, a comprehensive analysis of the impacts of intensive treatment (inpatient, residential and day program) on physical and psychosocial outcomes is lacking. Thus, the current systematic review and meta-analysis aimed to investigate the effectiveness of intensive treatments in adults with EDs for the outcomes of body mass index (BMI), disordered eating, depression, and quality of life, as well as a moderation analysis investigating a range of clinical characteristics. Overall, 62 studies were included in the meta-analysis. The results revealed that intensive treatment in adults yielded significant improvements in BMI (for underweight patients), disordered eating, depression, and quality of life. Treatment setting, length of stay and geographical region of the study all served as moderators for disordered eating and depression. Nevertheless, given the high heterogeneity in the meta- and moderation analyses, these results should be interpreted with caution. Future high-quality research is needed to determine the most beneficial elements of intensive treatment (compared to outpatient) in adults with EDs.

Towards an understanding of help-seeking behaviour for disordered eating: Refinement of a barriers to help-seeking measure.

AIM: Early intervention in eating disorders (EDs) is hampered by a lack of validated measures of barriers to treatment seeking. The present study examined the factor structure of the Perceived Barriers to Psychological Treatment scale (PBPT) and a combination of PBPT and Barriers to Seeking Help for ED items (BATSH-ED) with respect to treatment-seeking for an ED. METHOD: Participants were 456 female university students aged 17-25 reporting a wide range of disordered eating severity. Confirmatory factor analyses were conducted with the whole sample followed by correlational and regression analyses with a high-risk sample to assess validity of the selected questionnaire items. RESULTS: Four models were tested. First, we replicated the original PBPT 8-factor structure in our sample with comparable fit indices. Second, the addition of six ED items comprising a Denial and Ambivalence subscale improved model fit. Third and fourth, when only significant subscales predicting treatment seeking were retained, with removal of items with weak loadings, a 15-item six-factor solution provided a best fit. A range of psychosocial measures had relationships in the expected directions with the questionnaire subscales. In addition to disordered eating, the denial subscale was uniquely associated with treatment seeking. CONCLUSIONS: While the present study contributes to refining the assessment of barriers to help-seeking, future studies should consider co-design with lived experience to further improve the model fit of the questionnaire and improve predictiveness of help-seeking.

Pathways to improve early intervention for eating disorders: Findings from a systematic review and meta-analysis.

OBJECTIVE: Treatment-seeking rates among eating disorder (ED) populations are relatively low, with only one in four individuals seeking help. Previous research has identified many factors that might be associated with help-seeking in EDs, but to date no review has investigated the quantitative association between these factors and actual help-seeking behavior. The aim of the current review was to synthesize the relevant quantitative literature on factors (i.e., perceived barriers, characteristics associated with treatment seeking, demographic variables) associated with help-seeking using meta-analytic strategies, as well as provide recommendations on future early intervention research strategies to promote early help-seeking. METHOD: Overall, 19 studies were included, identifying 141 perceived barriers (e.g., stigma) or individual characteristics (e.g., BMI, duration of illness) and 56 demographic variables (e.g., ethnicity), which were synthesized into 24 unique variables. RESULTS: Less help-seeking was predicted by higher levels of denial and less perceived ability of others to provide help. DISCUSSION: Given the small number of studies these results should be considered preliminary. Future studies should consider barriers to help-seeking when creating early intervention approaches. To improve help-seeking rates we suggest the use of targeted psychoeducational materials and co-design with people with lived experience when developing new strategies. PUBLIC SIGNIFICANCE: The present study addresses a significant gap in the literature by synthesizing factors associated with help-seeking, with the aim of informing early intervention strategies to promote early help-seeking in eating disorder populations. Denial of illness and perceived inability of others to provide help were associated with lower help-seeking. Future studies should consider barriers to help-seeking and co-design with people with lived experience when creating new early intervention strategies.

OBJETIVO: Los índices de búsqueda de tratamiento entre las poblaciones con trastornos de la conducta alimentaria (TCA) son relativamente bajas, con solo una de cada cuatro personas que buscan ayuda. Investigaciones previas han identificado muchos factores que podrían estar asociados con la búsqueda de ayuda en los TCA, pero hasta la fecha ninguna revisión ha investigado la asociación cuantitativa entre estos factores y el comportamiento real de búsqueda de ayuda. El objetivo de la presente revisión fue sintetizar la bibliografía cuantitativa relevante sobre los factores (es decir, las barreras percibidas, las características asociadas con la búsqueda de tratamiento, las variables demográficas) asociados con la búsqueda de ayuda mediante estrategias metaanalíticas, así como proporcionar recomendaciones sobre futuras estrategias de investigación de intervención temprana para promover la búsqueda temprana de ayuda. MÉTODO: En general, se incluyeron 19 estudios, que identificaron 141 barreras percibidas (p.ej., estigma) o características individuales (p.ej., IMC, duración de la enfermedad) y 56 variables demográficas (p.ej., origen étnico), que se sintetizaron en 24 variables únicas. RESULTADOS: Se predijo una menor búsqueda de ayuda por niveles más altos de negación y menos capacidad percibida de otros para proporcionar ayuda. DISCUSIÓN: Dado el pequeño número de estudios, estos resultados deben considerarse preliminares. Los estudios futuros deben considerar las barreras para la búsqueda de ayuda durante la creación de enfoques de intervención temprana. Para mejorar los índices de búsqueda de ayuda, sugerimos el uso de materiales psicoeducativos específicos y el diseño conjunto con personas con experiencia vivida al desarrollar nuevas estrategias.

Evaluating evidence-based interventions in low socio-economic-status populations.

OBJECTIVE: Socio-economic-status (SES) has rarely been reported or investigated in eating disorders (EDs) research. This Research Forum considers, from various perspectives, how SES may impact on evaluating evidence-based treatments for EDs. METHOD: We first reviewed previous literature that informs how SES impacts prevalence of EDs, help-seeking, and treatment outcome. We then present findings from a case series effectiveness study of an early intervention program in low SES areas for EDs and discuss implications about the impact of SES on the effectiveness of evidence-based interventions. Finally, we examine barriers to conducting rigorous evaluations in this population and discuss directions for future treatment outcome research. RESULTS: Evidence suggests a higher level of disordered eating but less help seeking in lower SES groups. In our case series, 96 participants started treatment and completed a mean of 13.85 sessions, 84 (87.5%) completed a mean of 6.40 sessional measures on ED cognitions and behaviors, but only 31% completed more extensive pre-treatment and post-treatment measures. The completer effect size decrease for the global Eating Disorder Examination-Questionnaire score was 2.05 (95% CI: 1.43, 2.68) commensurate with other effectiveness studies in mixed SES groups. The high rates of missing data related to more extensive assessment present a barrier to evaluating evidence-based treatments in this population. DISCUSSION: Evidence from the present study revealed individuals from low SES can achieve similar treatment outcomes to other populations when receiving evidence-based ED treatment. Future studies should investigate a range of approaches to maximizing data collection, including use of shorter sessional measures.

Relationship between eating disorder duration and treatment outcome: Systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis examine the contribution of duration to treatment outcome for eating disorders. METHOD: Studies (n = 31) were identified that examined associations (r) between duration and 45 different outcomes. We were unable to extract r for seven studies (9 outcomes) and extracted r for 36 outcomes across 24 studies (2,349 participants). Indicators of treatment outcome were heterogeneous and thus a series of different meta-analyses, aimed at increasing homogeneity, were conducted. RESULTS: First, we examined the average effect size for one primary eating disorder related outcome from each of the 24 studies. There was no association between duration and treatment outcome (r = .05, 95% CI: -.03:.13), with high heterogeneity. Second, we conducted three sub-group analyses to explore possible sources of heterogeneity (diagnosis: anorexia nervosa versus bulimia nervosa; nature of the outcome: binary versus continuous; or type of outcome: binary indicator of recovery, eating disorder psychopathology, weight gain). There was no significant moderation or associations between duration and outcome (ranging from .02-.08), with low to medium heterogeneity. Third, two stand-alone analyses examined outcomes related to weight gain (n = 8) and eating disorder psychopathology (n = 5), with nonsignificant rs of .23/-.06, respectively. High levels of heterogeneity were present. DISCUSSION: Duration did not influence treatment outcome across any of our meta-analyses. Increasing homogeneity and power will allow more stable estimates of the impact of duration on outcome to be calculated; to this end, future treatment studies should include outcome related to weight gain (anorexia nervosa) and improvements in eating disorder psychopathology.

ANTECEDENTES: Esta revisión sistemática y metaanálisis examinan la contribución de la duración al resultado del tratamiento para los trastornos de la conducta alimentaria. MÉTODOS: Se identificaron estudios (n = 31) que examinaron las asociaciones (r) entre la duración y 45 diferentes resultados. No fue posible extraer r para siete estudios (nueve resultados) y se extrajo r para 36 resultados en 24 estudios (2349 participantes). Los indicadores del resultado del tratamiento fueron heterogéneos y, por lo tanto, se realizaron una serie de diferentes metaanálisis, destinados a aumentar la homogeneidad. RESULTADOS: Primero, examinamos el tamaño del efecto promedio para un resultado primario relacionado con el trastorno de la conducta alimentaria de cada uno de los 24 estudios. No hubo asociación entre la duración y el resultado del tratamiento (r = .05, IC del 95%: −.03: .13), con alta heterogeneidad. En segundo lugar, realizamos tres análisis de subgrupos para explorar posibles fuentes de heterogeneidad (diagnóstico: anorexia nerviosa versus bulimia nerviosa; naturaleza del resultado: binario versus continuo; o tipo de resultado: indicador binario de recuperación, psicopatología del trastorno alimentario, aumento de peso). No hubo moderación significativa o asociaciones entre la duración y el resultado (rango de .02−.08), con heterogeneidad baja a media. En tercer lugar, dos análisis independientes examinaron los resultados relacionados con el aumento de peso (n = 8) y la psicopatología del trastorno de la conducta alimentaria (n = 5), con una rs no significativa de 0,23/−0,06 respectivamente. Se presentaron altos niveles de heterogeneidad. CONCLUSIONES: La duración no influyó en el resultado del tratamiento en ninguno de nuestros metaanálisis. El aumento de la homogeneidad y el poder permitirá calcular estimaciones más estables del impacto de la duración en el resultado; con este fin, los estudios de tratamiento futuros deben incluir resultados relacionados con el aumento de peso (anorexia nerviosa) y mejoras en la psicopatología de los trastornos de la conducta alimentaria.