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Identifying youths most at risk to COVID-19-related mental illness is essential for the development of effective targeted interventions.
To compare trajectories of mental health throughout the pandemic in youth with and without prior mental illness and identify those most at risk of COVID-19-related mental illness.
Data were collected from individuals aged 18–26 years (N = 669) from two existing cohorts: IMAGEN, a population-based cohort; and ESTRA/STRATIFY, clinical cohorts of individuals with pre-existing diagnoses of mental disorders. Repeated COVID-19 surveys and standardised mental health assessments were used to compare trajectories of mental health symptoms from before the pandemic through to the second lockdown.
Mental health trajectories differed significantly between cohorts. In the population cohort, depression and eating disorder symptoms increased by 33.9% (95% CI 31.78–36.57) and 15.6% (95% CI 15.39–15.68) during the pandemic, respectively. By contrast, these remained high over time in the clinical cohort. Conversely, trajectories of alcohol misuse were similar in both cohorts, decreasing continuously (a 15.2% decrease) during the pandemic. Pre-pandemic symptom severity predicted the observed mental health trajectories in the population cohort. Surprisingly, being relatively healthy predicted increases in depression and eating disorder symptoms and in body mass index. By contrast, those initially at higher risk for depression or eating disorders reported a lasting decrease.
Healthier young people may be at greater risk of developing depressive or eating disorder symptoms during the COVID-19 pandemic. Targeted mental health interventions considering prior diagnostic risk may be warranted to help young people cope with the challenges of psychosocial stress and reduce the associated healthcare burden.
In the presentations that took place at the Royal College Webinar on 25 and 26 May 2021, there was insufficient time to include one on eating disorders. Subsequently, Professor Ulrike Schmidt has contributed the following piece about binge eating disorder (BED), the condition representing the major change in classification in this group of disorders since ICD-10. This should be taken in conjunction with the more positive comments about binge eating disorder in Chapter 2.
This national pre-pandemic survey compared demand and capacity of adult community eating disorder services (ACEDS) with NHS England (NHSE) commissioning guidance.
Thirteen services in England and Scotland responded (covering 10.7 million population). Between 2016–2017 and 2019–2020 mean referral rates increased by 18.8%, from 378 to 449/million population. Only 3.7% of referrals were from child and adolescent eating disorder services (CEDS-CYP), but 46% of patients were aged 18–25 and 54% were aged >25. Most ACEDS had waiting lists and rationed access. Many could not provide full medical monitoring, adapt treatment for comorbidities, offer assertive outreach or provide seamless transitions. For patient volume, the ACEDS workforce budget was 15%, compared with the NHSE workforce calculator recommendations for CEDS-CYP. Parity required £7 million investment/million population for the ACEDS.
This study highlights the severe pressure in ACEDS, which has increased since the COVID-19 pandemic. Substantial investment is required to ensure NHS ACEDS meet national guidance, offer evidence-based treatment, reduce risk and preventable deaths, and achieve parity with CEDS-CYP.
The aim of this study was to assess barriers and facilitators in the pathways toward specialist care for eating disorders (EDs).
Eleven ED services located in seven European countries recruited patients with an ED. Clinicians administered an adapted version of the World Health Organization “Encounter Form,” a standardized tool to assess the pathways to care. The unadjusted overall time needed to access the ED unit was described using the Kaplan–Meier curve.
Four-hundred-nine patients were recruited. The median time between the onset of the current ED episode and the access to a specialized ED care was 2 years. Most of the participants did not directly access the specialist ED unit: primary “points of access” to care were mental health professionals and general practitioners. The involvement of different health professionals in the pathway, seeking help for general psychiatric symptoms, and lack of support from family members were associated with delayed access to ED units.
Educational programs aiming to promote early diagnosis and treatment for EDs should pay particular attention to general practitioners, in addition to mental health professionals, and family members to increase awareness of these illnesses and of their treatment initiation process.
EDIFY (Eating Disorders: Delineating Illness and Recovery Trajectories to Inform Personalised Prevention and Early Intervention in Young People) is an ambitious research project aiming to revolutionise how eating disorders are perceived, prevented and treated. Six integrated workstreams will address key questions, including: What are young people's experiences of eating disorders and recovery? What are the unique and shared risk factors in different groups? What helps or hinders recovery? How do the brain and behaviour change from early- to later-stage illness? How can we intervene earlier, quicker and in a more personalised way? This 4-year project, involving over 1000 participants, integrates arts, design and humanities with advanced neurobiological, psychosocial and bioinformatics approaches. Young people with lived experience of eating disorders are at the heart of EDIFY, serving as advisors and co-producers throughout. Ultimately, this work will expand public and professional perceptions of eating disorders, uplift under-represented voices and stimulate much-needed advances in policy and practice.
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.
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.
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.
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.
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.
Emotion regulation (ER) impairments are central trans-diagnostic phenomena across the spectrum of eating disorders (EDs) and obesity, where maladaptive eating behaviors act to suppress negative emotions. Self-report assessments are the most commonly used tools for assessing an individual's ER capacity, however, subjective self-reporting is limited by a tendency toward response bias and issues with common method variance. Prior empirical and theoretical research supports the use of heart rate variability (HRV) to objectively assess individual differences in ER capacity. Several studies have examined the association between HRV and ER in EDs and obesity. However, to date, no review synthesising the overall findings exists. This review aimed to summarise the empirical evidence that has examined the relationship between ER and HRV in adults with EDs/obesity, in addition to assessing the validity of HRV as a physiological biomarker of ER in these populations.
A comprehensive search was performed on PubMed, MEDLINE and PsycINFO, with identified studies screened against a priori inclusion/exclusion criteria. Eligible studies underwent quality-assessment using the Joanna Briggs Institute Critical Appraisal Tools, and data were synthesised qualitatively.
17 publications were included, consisting of data on participants with obesity, binge eating disorder (BED), bulimia nervosa (BN), anorexia nervosa (AN), and/or subclinical presentations. Studies were small (average sample size n = 46.4), predominantly female (87.9%), and were highly variable in methodology, with different diagnostic tools, self-report measures, and emotional tasks/paradigms used.
The evidence suggests that HRV is a valid, objective biomarker of ER impairments in AN, BN, BED, emotional eating, and obesity. Despite some inconsistencies, likely attributable to methodological heterogeneity, EDs/obesity appear to be characterised by irregular resting state vagal activity and abnormal stress reactivity. Furthermore, the autonomic dysfunction observed across EDs/obesity may be reversible by novel effective interventions such as HRV-biofeedback or PlayMancer videogame therapy.
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.
This study evaluated fidelity to the FREED service model during the multicentre FREED-Up study.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Despite their use in clinical practice, there is little evidence to support the use of therapist written goodbye letters as therapeutic tools. However, preliminary evidence suggests that goodbye letters may have benefits in the treatment of anorexia nervosa (AN).
This study aimed to examine whether therapist written goodbye letters were associated with improvements in body mass index (BMI) and eating disorder symptomology in patients with AN after treatment.
Participants were adults with AN (n = 41) who received The Maudsley Model of Anorexia Treatment for Adults (MANTRA) in a clinical trial evaluating two AN out-patient treatments. As part of MANTRA, therapists wrote goodbye letters to patients. A rating scheme was developed to rate letters for structure and quality. Linear regression analyses were used to examine associations between goodbye letter scores and outcomes after treatment.
Higher quality letters and letters that adopted a more affirming stance were associated with greater improvements in BMI at 12 months. Neither the overall quality nor the style of goodbye letters were associated with improvements in BMI at 24 months or reductions in eating disorder symptomology at either 12 or 24 months.
The results highlight the potential importance of paying attention to the overall quality of therapist written goodbye letters in the treatment of AN, and adopting an affirming stance.
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.
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.
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.
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.
Families express a need for information to support people with severe anorexia nervosa.
To examine the impact of the addition of a skills training intervention for caregivers (Experienced Caregivers Helping Others, ECHO) to standard care.
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.
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.
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.
The illegal killing and taking of wild birds remains a major threat on a global scale. However, there are few quantitative data on the species affected and countries involved. We quantified the scale and scope of this issue in Northern and Central Europe and the Caucasus, using a diverse range of data sources and incorporating expert knowledge. The issue was reported to be widespread across the region and affects almost all countries/territories assessed. We estimated that 0.4–2.1 million birds per year may be killed/taken illegally in the region. The highest estimate of illegal killing in the region was for Azerbaijan (0.2-1.0 million birds per year). Out of the 20 worst locations identified, 13 were located in the Caucasus. Birds were reported to be illegally killed/taken primarily for sport and food in the Caucasus and for sport and predator/pest control in both Northern and Central Europe. All of the 28 countries assessed are parties to the Bern Convention and 19 are also European Union Member States. There are specific initiatives under both these policy instruments to tackle this threat, yet our data showed that illegal killing and taking is still occurring and is not restricted to Mediterranean European countries. Markedly increased effort is required to ensure that existing legislation is adequately implemented and complied with/enforced on the ground. Our study also highlighted the paucity of data on illegal killing and taking of birds in the region. It is a priority, identified by relevant initiatives under the Bern Convention and the European Union, to implement systematic monitoring of illegal killing and taking and to collate robust data, allowing stakeholders to set priorities, track trends and monitor the effectiveness of responses.
Background: Bulimia nervosa (BN) is an eating disorder with many physical, psychological and social consequences. Guided self-help (GSH) is recommended in the treatment of BN (NICE, 2004). One of the ways in which to provide GSH is via the internet using evidence-based packages with regular support from a clinician or trained support worker. Aims: The aim of this community-based survey was to investigate attitudes towards online self-help for eating disorders and the support required whilst using such an approach. Method: Two-hundred and fifty-three participants with bulimic symptoms completed the survey. The sample was recruited primarily online. The mean age was 29.11 years (SD = 8.67; min = 16, max = 64). Results: Attitudes towards online self-help (SH) for eating disorders were very positive. The inclusion of some form of support to accompany such an intervention was important to the majority of participants. Remote mediums of support such as e-mail, a forum and text messaging were most often selected as helpful. Most participants expressed a preference for weekly support contacts and for flexible support lengths that could respond to support needs as required. Conclusions: Online self-help for eating disorders is a desirable treatment option for many individuals. The information gathered regarding preferences in the type, medium, duration and frequency of support could be used in the development of future self-help strategies in order to maximize uptake, retention and outcomes.