Transition support for patients admitted to intensive treatment for anorexia nervosa: qualitative study of patient and carer experiences of a hybrid online guided self-help intervention (ECHOMANTRA).

BACKGROUND: Adults with anorexia nervosa experience high levels of relapse following in-patient treatment. ECHOMANTRA is a novel online aftercare intervention for patients and carers, which provides psychoeducation and support to augment usual care. AIMS: To explore patient and carer experiences of receiving the ECHOMANTRA intervention. METHOD: This is part of the process evaluation of the ECHOMANTRA intervention as delivered in the TRIANGLE trial (ISRCTN: 14644379). Semi-structured interviews were conducted with 20 participants randomised to the ECHOMANTRA (ten patients and ten carers). Thematic analysis was used to analyse the interview transcripts. RESULTS: Five major themes were identified: (1) Mixed experience of the intervention; (2) tailoring the intervention to the stage of recovery; (3) involvement of carers; (4) acceptability of remote support; and (5) impact of self-monitoring and accountability. CONCLUSIONS: Participants were mostly positive about the support offered. The challenges of using remote and group support were counterbalanced with ease of access to information when needed. Components of the ECHOMANTRA intervention have the potential to improve care for people with eating disorders.

The Patient Health Questionnaire (PHQ-9) as a tool to screen for depression in people with multiple sclerosis: a cross-sectional validation study.

BACKGROUND: Depression has a point prevalence of 25% and lifetime prevalence of 50% in people with multiple sclerosis (pwMS). Due to accessibility and brevity, the 9-item Patient Health Questionnaire (PHQ-9) may be a useful tool in clinical practice for screening and monitoring of depressive symptoms in people with MS (pwMS). METHODS: The objective of this study was to evaluate the reliability, validity and acceptability of the PHQ-9 as a screening tool for depressive symptoms in pwMS. PwMS completed online questionnaires at 3 time-points over 4-weeks. The PHQ-9, Multiple Sclerosis Impact Scale (MSIS-29), Centre for Disease Control Health-Related Quality of Life Measure (CDC-HQOL-4) and clinical history. RESULTS: 103 participants completed the PHQ-9 at three time points, 43% were categorised as depressed on at least one response. The PHQ-9 exhibited high internal reliability (Cronbach's α = 0.89), and test-re-test agreement (ICC 0.89, 95% CI 0.85-0.91). Convergent validity was indicated through positive correlation with the mental health items on the MSIS-29 (r = 0.46 and r = 0.50) and CDC-HQOL-4 (r = 0.79 and r = 0.73) at both assessment points. Positive correlations between the PHQ-9 and the MSIS-29 (r = 0.86 and r = 0.84) and CDC-HQOL-4 (r = 0.55 and r = 0.37) physical symptom sub-scores did not indicate divergent validity. 93% of ratings evaluated the PHQ-9 as "Very" or "Completely" acceptable. CONCLUSION: The PHQ-9 is a reliable and valid measure of depressive symptoms in people with MS. Given its accessibility, ease of administration, and acceptability, we recommend the PHQ-9 as a tool to screen for depressive symptoms in people with MS.

Transitions from intensive eating disorder treatment settings: qualitative investigation of the experiences and needs of adults with anorexia nervosa and their carers.

BACKGROUND: Relapse rates for individuals with anorexia nervosa after intensive hospital treatment (in-patient or full-time day care) are high. Better knowledge about the difficulties and opportunities that arise during this transition is needed to identify factors that support or hinder continued recovery upon discharge. AIMS: The aim of this study was to explore the experiences of adult patients and their chosen carers on the process of transitioning from intensive eating disorder treatment settings to the community. METHOD: Semi-structured interviews were conducted with patients with anorexia nervosa (n = 11) discharged from day or in-patient care from specialised eating disorder units across the UK, and their chosen carers (n = 20). Data were analysed with inductive thematic analysis. RESULTS: Four interrelated themes were identified for both groups. For patients, themes were continuity of care, ambivalence about continued recovery, the value of social support and a call for enhanced transition support. For carers, themes were the impact of the eating disorder on themselves and the family, perceptions of recovery and support post-discharge, the impact of previous treatment and care experiences, and desire to create a supportive transition process. CONCLUSIONS: The study provides an insight into the unique challenges that individuals with anorexia nervosa face upon leaving intensive treatment. A lack of post-discharge planning, support system and identity formation outside of anorexia nervosa were perceived as barriers to continued recovery. Patients and carers advocated for transition support that incorporates a phased, inclusive approach with accessible professional and social support in the community.

The experiential perspectives of siblings and partners caring for a loved one with an eating disorder in the UK.

BACKGROUND: Caring for a loved one with an eating disorder typically comes with a multitude of challenges, yet siblings and partners are often overlooked. It is important to understand if current clinical guidance for supporting carers are effective and being utilised for these groups, to help meet their needs. AIMS: To identify the experiential perspectives of siblings and partners of a loved one with an eating disorder compared with guidance for improving the adequacy of support provided to carers published by Beat and Academy for Eating Disorders. METHOD: Three online focus groups were held for ten siblings and five partners from across the UK (12 females and three males). Carers had experience of caring for a loved one with anorexia nervosa (13 carers) or bulimia nervosa (two carers), across a range of therapeutic settings. Focus group transcriptions were analysed with thematic analysis. RESULTS: Four key themes were identified: (a) role-specific needs, (b) challenges encountered by siblings and partners, (c) generic needs and helpful strategies or approaches, and (d) accounts of service provision and family support. CONCLUSIONS: Overall, the majority of experiences reported by siblings and partners did not meet the published guidance. Consequently, clinical practice recommendations were identified for services, alongside the charity sector, to take a proactive approach in detecting difficulties, providing skills training and emotional/practical support, adapting/tailoring peer support groups and supporting online facilitation. Our findings part-informed the design of our national online survey on loved ones' experiences of care in eating disorders.

Targeting binge eating in bulimia nervosa and binge eating disorder using inhibitory control training and implementation intentions: a feasibility trial.

BACKGROUND: This trial examined the feasibility, acceptability, and effect sizes of clinical outcomes of an intervention that combines inhibitory control training (ICT) and implementation intentions (if-then planning) to target binge eating and eating disorder psychopathology. METHODS: Seventy-eight adult participants with bulimia nervosa or binge eating disorder were randomly allocated to receive food-specific, or general, ICT and if-then planning for 4 weeks. RESULTS: Recruitment and retention rates at 4 weeks (97.5% and 79.5%, respectively) met the pre-set cut-offs. The pre-set adherence to the intervention was met for the ICT sessions (84.6%), but not for if-then planning (53.4%). Binge eating frequency and eating disorder psychopathology decreased in both intervention groups at post-intervention (4 weeks) and follow-up (8 weeks), with moderate to large effect sizes. There was a tendency for greater reductions in binge eating frequency and eating disorders psychopathology (i.e. larger effect sizes) in the food-specific intervention group. Across both groups, ICT and if-then planning were associated with small-to-moderate reductions in high energy-dense food valuation (post-intervention), food approach (post-intervention and follow-up), anxiety (follow-up), and depression (follow-up). Participants indicated that both interventions were acceptable. CONCLUSIONS: The study findings reveal that combined ICT and if-then planning is associated with reductions in binge eating frequency and eating disorder psychopathology and that the feasibility of ICT is promising, while improvements to if-then planning condition may be needed.

App-based food-specific inhibitory control training as an adjunct to treatment as usual in binge-type eating disorders: A feasibility trial.

Current treatments for binge eating disorder (BED) and bulimia nervosa (BN) only show moderate efficacy, warranting the need for novel interventions. Impairments in food-related inhibitory control contribute to BED/BN and could be targeted by food-specific inhibitory control training (ICT). The aim of this study was to establish the feasibility and acceptability of augmenting treatment for individuals with BN/BED with an ICT app (FoodT), which targets motor inhibition to food stimuli using a go/no-go paradigm. Eighty patients with BED/BN receiving psychological and/or pharmacological treatment were randomly allocated to a treatment-as-usual group (TAU; n = 40) or TAU augmented with the 5-min FoodT app daily (n = 40) for 4 weeks. This mixed-methods study assessed feasibility outcomes, effect sizes of clinical change, and acceptability using self-report measures. Pre-registered cut-offs for recruitment, retention, and adherence were met, with 100% of the targeted sample size (n = 80) recruited within 12 months, 85% of participants retained at 4 weeks, and 80% of the FoodT + TAU group completing ≤8 sessions. The reduction in binge eating did not differ between groups. However, moderate reductions in secondary outcomes (eating disorder psychopathology: SES = -0.57, 95% CI [-1.12, -0.03]; valuation of high energy-dense foods: SES = -0.61, 95% CI [-0.87, -0.05]) were found in the FoodT group compared to TAU. Furthermore, small greater reductions in food addiction (SES = -0.46, 95% CI [-1.14, 0.22]) and lack of premeditation (SES = -0.42, 95% CI [-0.77, -0.07]) were found in the FoodT group when compared to TAU. The focus groups revealed acceptability of FoodT. Participants discussed personal barriers (e.g. distractions) and suggested changes to the app (e.g. adding a meditation exercise). Augmenting treatment for BED/BN with a food-specific ICT app is feasible, acceptable, and may reduce clinical symptomatology with high reach and wide dissemination.

Exploring the ways in which COVID-19 and lockdown has affected the lives of adult patients with anorexia nervosa and their carers.

OBJECTIVE: This qualitative study explores the ways in which the coronavirus disease 2019 (COVID-19) pandemic and associated lockdown measures have affected the lives of adult patients with anorexia nervosa (AN) and their carers. METHOD: Semi-structured interviews were conducted with patients with AN (n = 21) and carers (n = 28) from the start of UK Government imposed lockdown. Data related directly to the impact of lockdown and COVID-19 were analysed using thematic analysis. RESULTS: Four broad themes were identified for patients and carers separately. Patients experienced: 1. reduced access to eating disorder (ED) services; 2. disruption to routine and activities in the community; 3. heightened psychological distress and ED symptoms; 4. increased attempts at self-management in recovery. Carer themes included: 1. concern over provision of professional support for patients; 2. increased practical demands placed on carers in lockdown; 3. managing new challenges around patient wellbeing; 4. new opportunities. CONCLUSIONS: Reduced access to ED services, loss of routine and heightened anxieties and ED symptoms resulting from COVID-19 and lockdown measures presented challenges for patients and carers. Increased remote support by ED services enabled the continuation of treatment and self-management resources and strategies promoted self-efficacy in both groups.

The Feasibility of Using Guided Self-Help in Anorexia Nervosa: An Analysis of Drop-Out From the Study Protocol and Intervention Adherence.

The implementation of online technologies to promote wellbeing is increasingly becoming a worldwide priority. This study includes secondary analyses of data and examined drop-out rates in an online guided self-help intervention for patients with anorexia nervosa. Specifically, rates of drop-out at end of treatment (i.e., 6 weeks assessment), as well as intervention adherence (minimum of four of six online guided sessions) and differences between completers and drop-outs were examined. Motivation to change and associated patient variables were assessed as predictors of drop-out using structural equation modeling. Ninety-nine patients were randomized to the intervention arm of the trial. Data were available for 82 individuals, 67 of whom completed the 6 weeks assessment and attended a minimum of four online sessions. No significant differences were found between completers and drop-outs at baseline. At the end of the first week of participation, drop-outs from the 6 weeks assessment or the intervention reported less satisfaction with their work with the mentor delivering online guidance. Greater confidence in own ability to change and higher controlled motivation (willingness to change due to pressure from others) predicted lower drop-out rates from the 6 weeks assessment. Stronger alliance with the therapist at the treatment center and lower psychological distress were associated with greater autonomous motivation (self-directed motivation) and importance and ability to change. Data demonstrate that a novel online guided self-help intervention for patients with anorexia nervosa is feasible. Early satisfaction with the program and external pressure to change have a protective role against drop-out rates. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02336841.

A multicenter audit of outpatient care for adult anorexia nervosa: Symptom trajectory, service use, and evidence in support of "early stage" versus "severe and enduring" classification.

BACKGROUND: We explored the utility of "staging" anorexia nervosa (AN) by duration of illness and psychological wellbeing. We also investigated 12-month symptom trajectories and service usage in a large cohort of patients with AN assessed for outpatient treatment. METHOD: We conducted secondary analyses on data from a multisite clinical trial of adults with AN (n = 187) recruited from 22 NHS England specialist eating disorder (ED) services into a digital treatment augmentation study. Clinical outcomes and service use were measured at postintervention (six weeks), 6 and 12 months. We grouped patients into two categories: "early stage" (illness duration <3 years; n = 60) and "severe and enduring" stage (SE-AN; n = 41) indicated by distress (Depression Anxiety and Stress Scales, DASS ≥60) and illness duration (≥7 years). RESULTS: At 12 months, patients reported large improvements in body mass index, small to moderate improvements in ED symptoms, mood, and work/social adjustment, and 23.6% met criteria for recovery. However, patients classified as SE-AN reported higher rates of accessing intensive services, higher ED symptomatology, and poorer work/social adjustment at baseline, and lower rates of improvement in work/social adjustment at 12 months compared to "early stage" respondents. DISCUSSION: Although present findings suggest overall symptomatic improvements, exploratory results highlight marked differences in course and service use between people at different stages of AN, suggesting a need to consider staging for clinical decision-making. Further research differentiating between clinical subtypes of AN and adoption of a more personalized approach may ensure that services and care pathways better fit patient needs.

A randomised clinical trial to evaluate the acceptability and efficacy of an early phase, online, guided augmentation of outpatient care for adults with anorexia nervosa.

BACKGROUND: Outpatient interventions for adult anorexia nervosa typically have a modest impact on weight and eating disorder symptomatology. This study examined whether adding a brief online intervention focused on enhancing motivation to change and the development of a recovery identity (RecoveryMANTRA) would improve outcomes in adults with anorexia nervosa. METHODS: Participants with anorexia nervosa (n = 187) were recruited from 22 eating disorder outpatient services throughout the UK. They were randomised to receiving RecoveryMANTRA in addition to treatment as usual (TAU) (n = 99; experimental group) or TAU only (n = 88; control group). Outcomes were measured at end-of-intervention (6 weeks), 6 and 12 months. RESULTS: Adherence rates to RecoveryMANTRA were 83% for the online guidance sessions and 77% for the use of self-help materials (workbook and/or short video clips). Group differences in body mass index at 6 weeks (primary outcome) were not significant. Group differences in eating disorder symptoms, psychological wellbeing and work and social adjustment (at 6 weeks and at follow-up) were not significant, except for a trend-level greater reduction in anxiety at 6 weeks in the RecoveryMANTRA group (p = 0.06). However, the RecoveryMANTRA group had significantly higher levels of confidence in own ability to change (p = 0.02) and alliance with the therapist at the outpatient service (p = 0.005) compared to the control group at 6 weeks. CONCLUSIONS: Augmenting outpatient treatment for adult anorexia nervosa with a focus on recovery and motivation produced short-term reductions in anxiety and increased confidence to change and therapeutic alliance.

An examination of the clinical outcomes of adolescents and young adults with broad autism spectrum traits and autism spectrum disorder and anorexia nervosa: A multi centre study.

OBJECTIVES: To compare the clinical outcomes of adolescents and young adults with anorexia nervosa (AN) comorbid with broad autism spectrum disorder (ASD) or ASD traits. METHOD: The developmental and well-being assessment and social aptitude scale were used to categorize adolescents and young adults with AN (N = 149) into those with ASD traits (N = 23), and those who also fulfilled diagnostic criteria for a possible/probable ASD (N = 6). We compared both eating disorders specific measures and broader outcome measures at intake and 12 months follow-up. RESULTS: Those with ASD traits had significantly more inpatient/day-patient service use (p = .015), as well as medication use (p < .001) at baseline. Both groups had high social difficulties and poorer global functioning (strengths and difficulties questionnaire) at baseline, which improved over time but remained higher at 12 months in the ASD traits group (p = .002). However, the improvement in eating disorder symptoms at 12 months was similar between groups with or without ASD traits. Treatment completion rates between AN only and ASD traits were similar (80.1 vs. 86.5%). DISCUSSION: Adolescents with AN and ASD traits show similar reductions in their eating disorder symptoms. Nevertheless, their social difficulties remain high suggesting that these are life-long difficulties rather than starvation effects.

A Pilot, Multicentre Pragmatic Randomised Trial to Explore the Impact of Carer Skills Training on Carer and Patient Behaviours: Testing the Cognitive Interpersonal Model in Adolescent Anorexia Nervosa.

AIM: The aim of the study is to establish the acceptability, feasibility and approximate size of the effect of adding a carer intervention [Experienced Caregivers Helping Others (ECHO)] to treatment as usual (TAU) for adolescents with anorexia nervosa. METHODS: The study is a pilot randomised trial comparing TAU (n = 50) alone or TAU plus ECHO with (n = 50) or without (n = 49) telephone guidance. Effect sizes (ESs) were regression coefficients standardised by baseline standard deviations of measure. RESULTS: Although engagement with ECHO was poor (only 36% of carers in the ECHO group read over 50% of the book), there were markers of intervention fidelity, in that caregivers in the ECHO group showed a moderate increase in carer skills (ES = 0.4) at 12 months and a reduction in accommodating and enabling behaviour at 6 months (ES = 0.17). In terms of efficacy, in the ECHO group, carers spent less time care giving (ES = 0.40, p = 0.04) at 1 year, and patients had a minor advantage in body mass index (ES = 0.17), fewer admissions, decreased peer problems (ES = -0.36) and more pro-social behaviours (ES = 0.53). The addition of telephone guidance to ECHO produced little additional benefit. CONCLUSIONS: The provision of self-management materials for carers to standard treatment for adolescent anorexia nervosa shows benefits for both carers and patients. This could be integrated as a form of early intervention in primary care. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Transition Care in Anorexia Nervosa Through Guidance Online from Peer and Carer Expertise (TRIANGLE): Study Protocol for a Randomised Controlled Trial.

TRIANGLE is a multicentre trial investigating whether the addition of a novel intervention for patients and carers (ECHOMANTRA) to treatment as usual (TAU) improves outcomes for people with anorexia nervosa (AN). ECHOMANTRA is based on the cognitive interpersonal model of AN and includes assessments, workbooks, videos, online groups and joint Skype sessions for patients and carers. People receiving intensive hospital treatment (N = 380) will be randomised to TAU or TAU plus ECHOMANTRA. Participants will be assessed over an 18-month period following randomisation. The primary outcome is patient psychological well-being at 12 months postrandomisation. Secondary outcomes include (i) patient's weight, eating disorder symptoms, motivation to change, quality of life and number of days in hospital at 12 months postrandomisation and (ii) carer's psychological well-being, burden and skills at 12 months (some outcomes will be assessed at 18 months postrandomisation). The results from this trial will establish the effectiveness of ECHOMANTRA. TRIAL REGISTRATION: ISRCTN registry ISRCTN14644379, 08/12/2016. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

A longitudinal examination of dyadic distress patterns following a skills intervention for carers of adolescents with anorexia nervosa.

Family interventions in anorexia nervosa (AN) have been developed to ameliorate maladaptive patterns of patient-carer interaction that can play a role in illness maintenance. The primary aim of this study is to examine the inter-relationship between baseline and post-treatment distress in dyads of carers and patients with AN to examine the interdependence between carers and patients. The secondary aim is to examine whether a carer skills intervention [Experienced Carer Helping Others (ECHO)] impacts on this inter-relationship. Dyads consisting of treatment-seeking adolescents with AN and their primary carer (n = 149; mostly mothers) were randomised to receive a carer skills intervention (ECHO) in addition to treatment as usual (TAU), or TAU alone, as part of a larger clinical trial. Carers and patients completed a standardised measure of psychological distress (The Depression, Anxiety, and Stress Scale) at baseline and 12 months post-treatment. The Actor Partner Interdependence Model was used to examine longitudinal changes in interdependence by treatment group. As expected, post-treatment levels of distress were related to baseline levels in both groups (actor effects). Moreover, carer distress at 12 months was related to patient distress at baseline for the TAU (partner effects), but not for the ECHO group. Finally, carers' distress change was not a significant predictor of patients' body mass index (BMI) change in the two treatment conditions. These findings are limited to predominantly mother-offspring dyads and may not generalise to other relationships. The ECHO intervention which is designed to teach carers skills in illness management and emotion regulation may be an effective addition to TAU for ameliorating interdependence of distress in patients and their primary carers over time.

The Objective and Subjective Caregiving Burden and Caregiving Behaviours of Parents of Adolescents with Anorexia Nervosa.

OBJECTIVE: The study aimed to examine caregiving burden and levels of distress, accommodating behaviours, expressed emotion (EE) and carers' skills, in parents of adolescents with anorexia nervosa. METHOD: A semi-structured interview assessed the objective burden (time spent across caregiving tasks) in parents (n = 196) of adolescents (n = 144) receiving outpatient treatment for anorexia nervosa. Subjective burden (carers' distress), accommodating behaviours, EE and carers' skills were measured by self-report. RESULTS: Mothers, on average, spent 2.5 h/day of care, mainly providing food and emotional support, compared with 1 h/day by fathers. The level of distress and accommodating behaviour was significantly lower in fathers than in mothers. Accommodating behaviours mediated the relationship between objective burden and subjective burden in mothers, whereas EE and carers' skills did not mediate this relationship for either parent. DISCUSSION: The objective burden for most mothers is high. In order to reduce subjective burden, it may be helpful to target accommodating behaviours. TRIAL REGISTRATION: ISRCTN83003225 - Expert Carers Helping Others (ECHO). Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

An examination of the impact of care giving styles (accommodation and skilful communication and support) on the one year outcome of adolescent anorexia nervosa: Testing the assumptions of the cognitive interpersonal model in anorexia nervosa.

BACKGROUND: The cognitive interpersonal model predicts that parental caregiving style will impact on the rate of improvement of anorexia nervosa symptoms. The study aims to examine whether the absolute levels and the relative congruence between mothers' and fathers' care giving styles influenced the rate of change of their children's symptoms of anorexia nervosa over 12 months. METHODS: Triads (n=54) consisting of patients with anorexia nervosa and both of their parents were included in the study. Caregivers completed the Caregiver Skills scale and the Accommodation and Enabling Scale at intake. Patients completed the Short Evaluation of Eating Disorders at intake and at monthly intervals for one year. Polynomial Hierarchical Linear Modeling was used for the analysis. RESULTS: There is a person/dose dependant relationship between accommodation and patients' outcome, i.e. when both mother and father are highly accommodating outcome is poor, if either is highly accommodating outcome is intermediate and if both parents are low on accommodation outcome is good. Outcome is also good if both parents or mother alone have high levels of carer skills and poor if both have low levels of skills. LIMITATIONS: Including only a sub-sample of an adolescent clinical population; not considering time spent care giving, and reporting patient's self-reported outcome data limits the generalisability of the current findings. CONCLUSION: Accommodating and enabling behaviours by family members can serve to maintain eating disorder behaviours. However, skilful behaviours particularly by mothers, can aid recovery. Clinical interventions to optimise care giving skills and to reduce accommodation by both parents may be an important addition to treatment for anorexia nervosa.

Two-year Follow-up of a Pragmatic Randomised Controlled Trial Examining the Effect of Adding a Carer's Skill Training Intervention in Inpatients with Anorexia Nervosa.

BACKGROUND: Active family engagement improves outcomes from adolescent inpatient care, but the impact on adult anorexia nervosa is uncertain. AIM: The aim of this study was to describe the 2-year outcome following a pragmatic randomised controlled trial in which a skill training intervention (Experienced Caregivers Helping Others) for carers was added to inpatient care. METHOD: Patient, caregiver and service outcomes were measured for 2 years following discharge from the index inpatient admission. RESULTS: There were small-sized/moderate-sized effects and consistent improvements in all outcomes from both patients and carers in the Experienced Caregivers Helping Others group over 2 years. The marked change in body mass index and carers' time caregiving following inpatient care was sustained. Approximately 20% of cases had further periods of inpatient care. CONCLUSION: In this predominately adult anorexia nervosa sample, enabling carers to provide active support and management skills may improve the benefits in all symptom domains that gradually follow from a period of inpatient care.

Self-Help And Recovery guide for Eating Disorders (SHARED): study protocol for a randomized controlled trial.

BACKGROUND: We describe the theoretical rationale and protocol for Self-Help And Recovery guide for Eating Disorders (SHARED), a trial investigating whether a guided self-care intervention (Recovery MANTRA) is a useful addition to treatment as usual for individuals with anorexia nervosa. Recovery MANTRA, a 6-week self-care intervention supplemented by peer mentorship, is a module extension of the Maudsley Model of Treatment for Adults with Anorexia Nervosa and targets the maintenance factors identified by the cognitive-interpersonal model of the illness. METHODS: Patients accessing outpatient services for anorexia nervosa are randomized to either treatment as usual or treatment as usual plus Recovery MANTRA. Outcome variables include change in body weight at the end of the intervention (primary) and changes in body weight and eating disorder symptoms at immediate and extended follow-up (6-months; secondary). Change is also assessed for the domains identified by the theoretical model, including motivation, hope, confidence to change, positive mood, cognitive flexibility, therapeutic alliance and social adjustment. Feedback from peer mentors is gathered to understand the impact on their own well-being of providing guidance. DISCUSSION: Results from this exploratory investigation will determine whether a larger clinical trial is justifiable and feasible for this affordable intervention, which has potential for high reach and scalability. TRIAL REGISTRATION: ClinicalTrials.gov NCT02336841 .

Development and validation of a scale to measure caregiver skills in eating disorders.

OBJECTIVE: The aim of this study was to develop and validate a new questionnaire designed to measure caregiver skills that, in line with the interpersonal component of the cognitive interpersonal maintenance model (Schmidt and Treasure, J Br J Clin Psychol, 45, 343-366, 2006), may be helpful in the support of people with anorexia nervosa (AN). A further aim is to assess whether this scale is sensitive to change following skills-based caregiver interventions. METHOD: The Caregiver Skills (CASK) scale was developed by a group of clinicians and caregivers. Preliminary versions of the scale devised for both caregivers and parents were given at baseline and at follow-up after two studies of caregiver interventions (a clinical trial of the effectiveness of guided self-help and training workshops). Exploratory and confirmatory factor analyses (CFA) were used to test the factorial structure of the CASK scale. Cronbach's alpha was used to measure internal consistency of the CASK scales. RESULTS: Exploratory Factor Analysis suggested a six component solution (Bigger Picture, Self-Care, Biting-Your-Tongue, Insight and Acceptance, Emotional Intelligence and Frustration Tolerance) and this model was confirmed with CFA. Significant clinically relevant correlations were found between the CASK scales and other standardised measures of caregivers' attitudes and behaviours. Furthermore, greater improvements on abilities measured by the CASK scale were found in caregivers who received skills-training than caregivers assigned to a 'treatment as usual' condition. DISCUSSION: The CASK scale is a measure of the fidelity of interventions based on the cognitive interpersonal maintenance model and is sensitive to the intensity of the intervention provided.

Clinical effectiveness of a skills training intervention for caregivers in improving patient and caregiver health following in-patient treatment for severe anorexia nervosa: pragmatic randomised controlled trial.

BACKGROUND: Families express a need for information to support people with severe anorexia nervosa. AIMS: To examine the impact of the addition of a skills training intervention for caregivers (Experienced Caregivers Helping Others, ECHO) to standard care. METHOD: Patients over the age of 12 (mean age 26 years, duration 72 months illness) with a primary diagnosis of anorexia nervosa and their caregivers were recruited from 15 in-patient services in the UK. Families were randomised to ECHO (a book, DVDs and five coaching sessions per caregiver) or treatment as usual. Patient (n=178) and caregiver (n=268) outcomes were measured at discharge and 6 and 12 months after discharge. RESULTS: Patients with caregivers in the ECHO group had reduced eating disorder psychopathology (EDE-Q) and improved quality of life (WHO-Quol; both effects small) and reduced in-patient bed days (7-12 months post-discharge). Caregivers in the ECHO group had reduced burden (Eating Disorder Symptom Impact Scale, EDSIS), expressed emotion (Family Questionnaire, FQ) and time spent caregiving at 6 months but these effects were diminished at 12 months. CONCLUSIONS: Small but sustained improvements in symptoms and bed use are seen in the intervention group. Moreover, caregivers were less burdened and spent less time providing care. Caregivers had most benefit at 6 months suggesting that booster sessions, perhaps jointly with the patients, may be needed to maintain the effect. Sharing skills and information with caregivers may be an effective way to improve outcomes. This randomised controlled trial (RCT) was registered with Current Controlled Trials ISRCTN06149665. DECLARATION OF INTEREST: J.T. is a co-author of the book used in the ECHO intervention and receives royalties. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.