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.

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.

Defining and predicting service utilisation in young adulthood following childhood treatment of an eating disorder.

BACKGROUND: Eating disorder services are often separated into child and adolescent eating disorder services (CAEDSs) and adult eating disorder services (AEDSs). Most patients in CAEDSs present with first-episode illness of short duration, which with appropriate treatment, have a good prognosis. However, some individuals receive further treatment as adults. Little is known about service utilisation in adulthood following childhood/adolescent treatment of an eating disorder. AIMS: This study aims (a) to estimate the proportion of patients in a CAEDS who use mental health services as young adults, (b) to delineate service utilisation following treatment in CAEDSs and (c) to identify factors in CAEDSs that predict service utilisation in young adulthood. METHOD: A consecutive cohort of 322 patients (aged 13-17 years) seen in a CAEDS in the UK over a 5-year period were included in this audit. Data regarding their use of UK-wide adult mental health services as young adults (i.e. when aged 18-25) were extracted from local and national hospital records. RESULTS: A total of 68.3% of CAEDS patients received no mental health treatment as young adults. Although 13% of people seen in a CAEDS had brief eating disorder treatment as young adults, 10% received longer/or more intensive eating disorder treatment. Overall, 10.8% transitioned directly to an AEDS and 7.6% were re-referred following discharge from CAEDS. In our sample, older age and increased use of CAEDSs predicted increased eating disorder treatment in young adulthood. CONCLUSIONS: Our results indicate that most people seen in CAEDSs do not receive further mental health treatment as young adults. Several features in CAEDSs distinguish mental health service utilisation in young adulthood, which were identified clinically and could be targeted during treatment.

Physical activity and the drive to exercise in anorexia nervosa.

OBJECTIVES: To investigate physical activity (PA) and drive for exercise in anorexia nervosa (AN) in relation to eating disorder (ED) pathology and anxiety. METHOD: Female participants were recruited into four groups: AN outpatients (n = 37), AN inpatients (n = 18), an anxiety group (n = 34), and healthy controls (HCs; n = 30). PA was measured by actigraphy and self-report together with drive/reasons for exercise, ED pathology, anxiety, depression, stress, BMI, and body composition. RESULTS: ED psychopathology, general psychopathology, and physiological measures were consistent with diagnosis. All groups showed a wide range in activity, especially on self-report. No significant group differences were observed in objective PA levels, yet AN groups reported 57-92% higher total activity than HCs. Outpatients reported more walking and moderate exercise than HCs, and inpatients reported more walking but less moderate and vigorous activity than all other groups. AN groups had significantly higher drive to exercise and valued "improving tone" as important and health and enjoyment as less important reasons to exercise. DISCUSSION: Self-perceived activity rather than objective data may partly explain the increased activity reported in AN. Drive to exercise in AN appears to be more related to ED pathology than to anxiety.

Exposure therapy in eating disorders revisited.

Exposure therapy is a widely used and effective form of treatment in anxiety disorders and addictions but evidence for its usefulness in eating disorders (ED) is inconsistent. This paper systematically reviews the literature on the use of exposure therapy in ED, the theory underpinning its use, and the deficits in current knowledge. Databases were searched to 2012. In addition, potential improvements in the use of exposure techniques in ED are considered by drawing upon theory and research involving neuropharmacology, basic and clinical neuroscience, contemporary behavioural and neurobiological research, and technologies such as virtual reality (VR).

State and trait food craving in people with bulimic eating disorders.

In two studies, we examined trait and state food craving levels in people with a bulimic disorder (BD) (bulimia nervosa and related disorders) and healthy controls (HC) using multidimensional self-report assessments. In study 1, trait food craving was assessed in 70 people with a BD and 69 HC using the Food Craving Questionnaire-Trait. Participants also completed the Eating Disorder Examination-Questionnaire (EDE-Q). In study 2, 45 people with a BD and 29 HC completed the Food Craving Questionnaire-State and the EDE-Q following exposure to visual and real high-caloric food cues. The results showed that both trait and state food cravings were significantly higher in people with a BD, compared to HC. Trait food craving was associated with eating disorder symptomatology in both the HC and BD groups. State food craving was associated with eating disorder psychopathology, but only in the BD group. This research underscores the importance of food craving in the study and conceptualization of BD.

Service providers' perceptions of the strengths and prospective improvements in UK eating disorder services: findings from a Royal College survey.

AIMS AND METHODS: This study aims to explore perceptions of eating disorder service strengths and to develop a clearer picture of improvements clinicians would like to see occur in the services they lead. A survey designed by the Royal College of Psychiatrists' Section of Eating Disorders was completed by 83 lead clinicians in both public and private sector services in the UK and Eire. Content analysis was performed, and common themes were identified. RESULTS: Five main strengths of a service were identified as follows: quality of treatment (n = 36), staff skills (n = 21), continuity of care (n = 15), family involvement (n = 12) and accessibility and availability (n = 11). These themes also arose when clinicians evaluated areas they wished to develop and improve. CONCLUSIONS: Service providers' views were congruent with each other, NICE guidelines and quality standards as proposed by the Royal College. Although clinicians feel that their service fulfils many practice guidelines, there remains areas in which adherence is felt to be lacking.