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A direct comparison of the American Academy of Pediatrics (AAP), American Psychiatric Association (APA), Finnish Medical Society Duodecim (FMSD), and National Collaborating Centre for Mental Health/National Institute for Health and Clinical Excellence (NCCMH/NICE) recommendations for the management of eating disorders is provided in the tables below.
Some guidelines are broader in scope than others. For example, in addition to management, AAP, FMSD, and NCCMH/NICE also address the screening for and identification of eating disorders. These topics, however, are beyond the scope of this synthesis (See the NGC synthesis, Screening for and Identification of Eating Disorders). The AAP guideline differs from the others in that it focuses specifically on the primary care pediatrician's role in the assessment and management of eating disorders. The APA guideline includes a discussion of clinical features influencing the treatment plan, including the chronicity of eating disorders, other psychiatric factors, concurrent general medical conditions, and demographic variables. These topics, however, are also beyond the scope of this synthesis.
While FMSD focuses on anorexia and bulimia nervosa, AAP, APA, and NCCMH/NICE also address atypical eating disorders such as binge eating disorder and eating disorders not otherwise specified (EDNOS). The APA and NCCMH/NICE guidelines address areas where more research is needed. In formulating its conclusions, APA reviewed the NCCMH/NICE guideline and NCCMH/NICE reviewed the previous (2000) version of the APA guideline.
The tables below provide a side-by-side comparison of key attributes of each guideline, including specific interventions and practices that are addressed. The language used in these tables, particularly that which is used in Table 4, Table 5, and Table 6, is in most cases taken verbatim from the original guidelines:
A summary discussion of the areas of agreement and areas of differences among the guidelines is presented following the content comparison tables.
Abbreviations
TABLE 3: COMPARISON OF METHODOLOGY | |
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Methods Used to Collect/Select the Evidence | |
AAP |
Described Process: Not stated Number of Source Documents: Not stated Number of References: 78 |
APA |
Described Process: A MEDLINE search, using PubMed, of "anorexia nervosa OR bulimia OR binge eating disorder OR binge eating disorders OR eating disorder OR eating disorders" yielded 15,561 citations, of which 3,596 were published between 1998 and 2004, were written in English, and contained abstracts. Of these, 334 were reports of clinical trials (including randomized controlled trials) or meta-analyses. Abstracts for these articles as well as abstracts for an additional 634 review articles were screened individually for their relevance to the guideline. The Cochrane Library was also searched for relevant abstracts. Additional, less formal literature searches were conducted by American Psychiatric Association (APA) staff and individual members of the Work Group on Eating Disorders. Number of Source Documents: Not stated Number of References: 765 |
FMSD |
Described Process: The evidence reviewed was collected from the Cochrane database of systematic reviews and the Database of Abstracts of Reviews of Effectiveness (DARE). In addition, the Cochrane Library and medical journals were searched specifically for original publications. Number of Source Documents: Not stated Number of References: 8 |
NCCMH/NICE |
Described Process: In conducting the review, the team systematically searched the literature for all English language systematic reviews relevant to the eating disorders scope that were published or updated after 1995. Search filters developed by the review team consisted of a combination of subject heading and free-text phrases. A general filter was developed for eating disorders along with more specific filters for each clinical question. In addition, filters were developed for randomized controlled trials (RCTs) and for other appropriate research designs. (The search filters can be found in Appendix 8 of the original document.) Electronic searches were made of the major bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL), in addition to the Cochrane Database of Systematic Reviews, the National Health Service Research and Development (NHS R&D) Health Technology Assessment database, Evidence-Based Mental Health and Clinical Evidence (Issue 5). Ineligible articles were excluded, and a second independent reviewer crosschecked these for relevance. The remaining references were acquired in full and re-evaluated for eligibility. The most recently published reviews that appropriately addressed a clinical question were selected. For each systematic review used, a search was made for new studies, and the papers for these and for existing studies were retrieved. The search for further evidence included research published after each review's search date, in-press papers identified by experts, and reviewing reference lists and recent contents of selected journals. All reports that were retrieved but later excluded are listed with reasons for exclusion in the appropriate evidence table. Where no relevant systematic reviews were located, the review team asked the Guideline Development Group (GDG) to decide whether a fresh systematic review should be undertaken. Eligible reviews were critically appraised for methodological quality and the reliability of this procedure was confirmed by parallel independent assessment. The eligibility/quality assessment was tested on a representative sample of papers. (Appendix 10 of the original document provides the quality checklist.) Cost Analysis Bibliographic electronic databases and health economic databases were searched for economic evidence using the combination of a specially developed health economics search filter and a general filter for eating disorders. A combination of subject headings and free text searches were used where possible. (The search strategies and the databases searched are presented in Appendix 12 of the full version of the original guideline document.) The search for further evidence included papers from reference lists of eligible studies and relevant reviews. Experts in the field of eating disorders and mental health economics were also contacted to identify additional relevant published and unpublished studies. Studies included in the clinical evidence review and stakeholders' submissions were also screened for economic evidence. Upon completion of the database searches, titles and abstracts of all references were screened for relevance to the scope of the guideline. The health economist then assessed relevant papers using a modified version of the Drummond et al. checklist (see Appendix 13 of the full version of the original guideline document). Number of Source Documents: Not stated Number of References: 408 |
Methods Used to Assess the Quality and Strength of the Evidence | |
AAP |
Not stated |
APA |
Expert Consensus (Committee) |
FMSD |
Weighting According to a Rating Scheme (Scheme Given - Refer to Table 6) |
NCCMH/NICE |
Weighting According to a Rating Scheme (Scheme Given - Refer to Table 6) |
Methods Used to Analyze the Evidence | |
AAP |
Described Process: Not stated |
APA |
Described Process: The Work Group on Eating Disorders constructed evidence tables to illustrate the data regarding risks and benefits for each treatment and to evaluate the quality of the data. These tables facilitated group discussion of the evidence and agreement on treatment recommendations before guideline text was written. Evidence tables do not appear in the guideline; however, they are retained by APA to document the development process in case queries are received and to inform revisions of the guideline. |
FMSD |
Described Process: Not stated |
NCCMH/NICE |
Described Process: Synthesising the Evidence Where possible, outcome data were extracted directly from all eligible studies that met the quality criteria into Review Manager 4.2 (Cochrane Collaboration, 2003). Meta-analysis was then used to synthesise the evidence where appropriate using Review Manager. If necessary, reanalyses of the data or sensitivity analyses were used to answer clinical questions not addressed in the original studies or reviews. Where meta-analysis was not appropriate and/or possible, the reported results from each primary-level study were entered into the Access database. Evidence tables were used to summarise general information about each study. Consultation was used to overcome difficulties with coding. Data from studies included in existing systematic reviews were extracted independently by one reviewer directly into Review Manager and crosschecked with the existing data set. Two independent reviewers extracted data from new studies, and disagreements were resolved by discussion. Where consensus could not be reached, a third reviewer resolved the disagreement. Masked assessment (i.e., blind to the journal from which the article comes, the authors, the institution, and the magnitude of the effect) was not used since it is unclear that doing so reduces bias. Presenting the Data to the Guideline Development Group (GDG) Where possible, the GDG was given a graphical presentation of the results using forest plots generated with the Review Manager software. Each forest plot displayed the effect size and confidence interval (CI) for each study as well as the overall summary statistic. The graphs were organised so that the display of data in the area to the left of the "line of no effect" indicated a "favourable" outcome for the treatment in question. Dichotomous outcomes were presented as relative risks (RR) and the associated 95 percent CI. A relative risk (or risk ratio) is the ratio of the treatment event rate to the control event rate. A RR of 1 indicates no difference between treatment and control. All dichotomous outcomes were calculated on an intention-to-treat basis (i.e., a "once-randomised- always-analyse" basis). This assumes that those participants who ceased to engage in the study -- from whatever group -- had an unfavourable outcome (with the exception of the outcome of "death"). The Number Needed to Treat (NNT) or the Number Needed to Harm (NNH) was reported for each statistically significant outcome where the baseline risk (i.e., control group event rate) was similar across studies. In addition, NNTs calculated at follow-up were only reported where the length of follow-up was similar across studies. When length of follow-up or baseline risk varies (especially with low risk), the NNT is a poor summary of the treatment effect. Both the I2 test of heterogeneity and the chi-squared test of heterogeneity (p<0.10) were used, as well as visual inspection of the forest plots, to look for the possibility of heterogeneity. I2 describes the proportion of total variation in study estimates that is due to heterogeneity. An I2 of less than 30 percent was taken to indicate mild heterogeneity and a fixed effects model was used to synthesise the results. An I2 of more than 50 percent was taken as notable heterogeneity. In this case an attempt was made to explain the variation. If studies with heterogeneous results were found to be comparable, a random effects model was used to summarise the results. In the random effects analysis, heterogeneity is accounted for both in the width of CIs and in the estimate of the treatment effect. With decreasing heterogeneity the random effects approach moves asymptotically towards a fixed effects model. An I2 of 30 to 50 percent was taken to indicate moderate heterogeneity. In this case, both the chi-squared test of heterogeneity and a visual inspection of the forest plot were used to decide between a fixed and random effects model. To explore the possibility that the results entered into each meta-analysis suffered from publication bias, data from included studies were entered, where there was sufficient data, into a funnel plot. Asymmetry of the plot was taken to indicate possible publication bias and investigated further. |
Methods Used to Formulate the Recommendations | |
AAP |
Not stated |
APA |
Expert Consensus (refer to Table 6 for rating scheme) Described Process: This practice guideline was developed under the auspices of the Steering Committee on Practice Guidelines. The development process is detailed in "APA Guideline Development Process," which is available from the APA Department of Quality Improvement and Psychiatric Services. The key features of this process include the following:
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FMSD |
Not stated |
NCCMH/NICE |
Described Process: The Guideline Development Group (GDG) The eating disorders GDG consisted of professionals in psychiatry, clinical psychology, nursing, social work, and general practice; academic experts in psychiatry and psychology; a patient, and a representative from a patient organisation. The carer perspective was provided through focus group discussion with carers; the group was run by the patient on the GDG. The guideline development process was supported by staff from the NCCMH review team, who undertook the clinical and health economics literature searches, reviewed and presented the evidence to the GDG, managed the process, and contributed to the drafting of the guideline. Guideline Development Group Meetings Twenty-three eating disorders GDG meetings were held between March 2002 and October 2003. During the series of day-long meetings, clinical questions were written, clinical evidence was reviewed and assessed, statements were developed, and recommendations were formulated. At each meeting, all GDG members declared any potential conflict of interests, and patient and carer concerns were routinely discussed as part of a standing agenda. Forming and Grading the Statements and Recommendations The evidence tables and forest plots formed the basis for developing clinical statements and recommendations. For intervention studies, the statements were classified according to an accepted hierarchy of evidence. Recommendations were then graded A to C based on the level of associated evidence (see Table 6). In order to facilitate consistency in generating and drafting the clinical statements the GDG utilised a statement decision tree. The flowchart was designed to assist with, but not replace, clinical judgement. Where a statistically significant summary statistic (effect size [ES]) was obtained (after controlling for heterogeneity), the GDG considered whether this finding was of clinical significance (i.e., likely to be of benefit to patients) taking into account the trial population, nature of the outcome, and size of the effect. On the basis of this consideration the ES was characterised as "clinically significant" or not. A further consideration was made about the strength of the evidence by examining the confidence interval (CI) surrounding the ES. For level I evidence, where the ES was judged to be clinically significant and had a CI entirely within a clinical relevant range, the result was characterised as "strong evidence" (S1). For non-level I evidence or in situations where the upper/lower bound of the CI was not clinically significant, the result was characterised as "limited evidence" (S2). Where an ES was statistically significant, but not clinically significant and the CI excluded values judged to be clinically important, the result was characterised as "unlikely to be clinically significant" (S3). Alternatively, if the CI included clinically important values, the result was characterised as "insufficient to determine clinical significance" (S6). Where a non-statistically significant ES was obtained, the GDG reviewed the trial population, nature of the outcome, size of the effect and, in particular, the CI surrounding the result. If the CI was narrow and excluded a clinically significant ES, this was seen as indicating evidence of "no clinically significant difference" (S4), but where the CI was wide this was seen as indicating 'insufficient evidence' to determine if there was a clinically significant difference or not (S5). Once all evidence statements relating to a particular clinical question were finalised and agreed by the GDG, the associated recommendations were produced and graded. Grading the recommendations allowed the GDG to distinguish between the level of evidence and the strength of the associated recommendation. It is possible that a statement of evidence would cover only one part of an area in which a recommendation was to be made or would cover it in a way that would conflict with other evidence. In order to produce more comprehensive recommendations suitable for people in England and Wales, the GDG had to extrapolate from the available evidence. This led to a weaker level of recommendation (i.e. B, as data were based upon level I evidence). It is important to note that the grading of the recommendation is not a reflection of its clinical significance or relevance. A number of issues relating to the study of eating disorders meant that the outcomes available for analysis were classified as primary or secondary. When making recommendations, the primary outcomes were given more weight during the decision process. The process also allowed the GDG to moderate recommendations based on factors other than the strength of evidence. Such considerations include the applicability of the evidence to people with eating disorders, economic considerations, values of the development group and society, or the group's awareness of practical issues. Method Used to Answer a Clinical Question in the Absence of Appropriately Designed, High-Quality Research Where it was not possible to identify at least one appropriately designed study or high-quality systematic review, or where the GDG was of the opinion (on the basis of previous searches or their knowledge of the literature) that there was unlikely to be appropriately designed primary-level research that directly addressed the clinical question, an informal consensus process was adopted. This process focused on those questions that the GDG considered a priority. The starting point for this process of informal consensus was that a member of the topic group identified, with help from the systematic reviewer, a narrative review that most directly addressed the clinical question. Where this was not possible a new review of the recent literature was initiated. This existing narrative review or new review was used as a basis for identifying lower levels of evidence relevant to the clinical question. This was then presented for discussion to the GDG. On the basis of this, additional information was sought and added to the information collected. This may include studies that did not directly address the clinical question but were thought to contain relevant data. This led to the development of an initial draft report that addressed the following issues:
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Outcomes | |
AAP |
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APA |
Anorexia Nervosa
Bulimia Nervosa
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FMSD |
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NCCMH/NICE |
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Financial Disclosures/Conflicts of Interest | |
AAP |
Not stated |
APA |
This practice guideline has been developed by psychiatrists who are in active clinical practice. In addition, some contributors are primarily involved in research or other academic endeavors. It is possible that through such activities some contributors, including work group members and reviewers, have received income related to treatments discussed in this guideline. A number of mechanisms are in place to minimize the potential for producing biased recommendations due to conflicts of interest. Work group members are selected on the basis of their expertise and integrity. Any work group member or reviewer who has a potential conflict of interest that may bias (or appear to bias) his or her work is asked to disclose this to the Steering Committee on Practice Guidelines and the work group. Iterative guideline drafts are reviewed by the Steering Committee, other experts, allied organizations, APA members, and the APA Assembly and Board of Trustees; substantial revisions address or integrate the comments of these multiple reviewers. The development of the APA practice guidelines is not financially supported by any commercial organization. |
FMSD |
Not stated |
NCCMH/NICE |
All Guideline Development Group (GDG) members made formal declarations of interest at the outset, which were updated at every GDG meeting. |
TABLE 4: COMPARISON OF RECOMMENDATIONS FOR THE MANAGEMENT/TREATMENT OF EATING DISORDERS | |
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Comprehensive Assessment and Coordination of Care | |
AAP |
Initial evaluation of the child or adolescent with a suspected eating disorder includes establishment of the diagnosis (Note from NGC: The diagnosis of eating disorders is outside the scope of this synthesis); determination of severity, including evaluation of medical and nutritional status; and performance of an initial psychosocial evaluation. Each of these initial steps can be performed in the pediatric primary care setting. In general, determination of total weight loss and weight status (calculated as percent below ideal body weight and/or as BMI), along with types and frequency of purging behaviors (including vomiting and use of laxatives, diuretics, ipecac, and over-the-counter or prescription diet pills as well as use of starvation and/or exercise) serve to establish an initial index of severity for the child or adolescent with an eating disorder. The medical complications associated with eating disorders are listed in Table 4 of the original guideline document, and details of these complications have been described in several reviews. It is uncommon for the pediatrician to encounter most of these complications in a patient with a newly diagnosed eating disorder.
It should be noted, however, that most test results will be normal in most patients with eating disorders, and normal laboratory test results do not exclude serious illness or medical instability in these patients.
A differential diagnosis for the adolescent with symptoms of an eating disorder can be found in Table 5 of the original guideline document. Several treatment decisions follow the initial evaluation, including the questions of where and by whom the patient will be treated.
Recommendations:
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APA |
Psychiatric Management
Coordinating Care and Collaborating with Other Clinicians In treating adults with eating disorders, the psychiatrist may assume the leadership role within a program or team that includes other physicians, psychologists, registered dietitians, and social workers or may work collaboratively on a team led by others.
Assessing and Monitoring Eating Disorder Symptoms and Behaviors
Assessing and Monitoring the Patient's General Medical Condition
Assessing and Monitoring the Patient's Safety and Psychiatric Status
Providing Family Assessment and Treatment
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FMSD |
Treatment
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NCCMH/NICE |
Care Across All Conditions Assessment and Coordination of Care C - Assessment of people with eating disorders should be comprehensive and include physical, psychological, and social needs and a comprehensive assessment of risk to self. C - The level of risk to the patient's mental and physical health should be monitored as treatment progresses because it may change--for example, following weight gain or at times of transition between services in cases of anorexia nervosa. C - For people with eating disorders presenting in primary care, general practitioners (GPs) should take responsibility for the initial assessment and the initial coordination of care. This includes the determination of the need for emergency medical or psychiatric assessment. C - Where management is shared between primary and secondary care, there should be clear agreement among individual health care professionals on the responsibility for monitoring patients with eating disorders. This agreement should be in writing (where appropriate using the care programme approach) and should be shared with the patient and, where appropriate, his or her family and carers. Providing Good Information and Support C - Health care professionals should acknowledge that many people with eating disorders are ambivalent about treatment. Health care professionals should also recognise the consequent demands and challenges this presents. Getting Help Early C - People with eating disorders seeking help should be assessed and receive treatment at the earliest opportunity. C - Whenever possible patients should be engaged and treated before reaching severe emaciation. This requires both early identification and intervention. Effective monitoring and engagement of patients at severely low weight or with falling weight should be a priority. Additional Considerations for Children and Adolescents C - Family members, including siblings, should normally be included in the treatment of children and adolescents with eating disorders. Interventions may include sharing of information, advice on behavioural management, and facilitating communication. C - In children and adolescents with eating disorders, growth and development should be closely monitored. Where development is delayed or growth is stunted despite adequate nutrition, paediatric advice should be sought. C - Health care professionals assessing children and adolescents with eating disorders should be alert to indicators of abuse (emotional, physical and sexual) and should remain so throughout treatment. C - The right to confidentiality of children and adolescents with eating disorders should be respected. C - Health care professionals working with children and adolescents with eating disorders should familiarise themselves with national guidelines and their employers' policies in the area of confidentiality. Anorexia Nervosa Assessment and Management of Anorexia Nervosa in Primary Care C - In anorexia nervosa, although weight and BMI are important indicators of physical risk they should not be considered the sole indicators (as they are unreliable in adults and especially in children). C - Patients with enduring anorexia nervosa not under the care of a secondary care service should be offered an annual physical and mental health review by their GP. Identification of Eating Disorders in Primary Care Screening Initial Physical Assessment The rationale for physical assessment is more to determine the presence and severity of emaciation and secondary physical consequences of the anorexia nervosa than to ascertain the primary diagnosis. It should include as a minimum:
The following may also be helpful to assess the risk of physical instability:
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Determination of Treatment Setting | |
AAP |
Several treatment decisions follow the initial evaluation, including the questions of where and by whom the patient will be treated. Patients who have minimal nutritional, medical, and psychosocial issues and show a quick reversal of their condition may be treated in the pediatrician's office, usually in conjunction with a registered dietitian and a mental health practitioner. Pediatricians who do not feel comfortable with issues of medical and psychosocial management can refer these patients at this early stage. Pediatricians can choose to stay involved even after referral to the team of specialists, as the family often appreciates the comfort of the relationship with their long-term care provider. Pediatricians comfortable with the ongoing care and secondary prevention of medical complications in patients with eating disorders may choose to continue care themselves. More severe cases require the involvement of a multidisciplinary specialty team working in outpatient, inpatient, or day program settings. The Pediatrician's Role in the Treatment of Eating Disorders in Outpatient Settings Pediatricians have several important roles to play in the management of patients with diagnosed eating disorders. These aspects of care include medical and nutritional management and coordination with mental health personnel in provision of the psychosocial and psychiatric aspects of care. Most patients will have much of their ongoing treatment performed in outpatient settings. Although some pediatricians in primary care practice may perform these roles for some patients in outpatient settings on the basis of their levels of interest and expertise, many general pediatricians do not feel comfortable treating patients with eating disorders and prefer to refer patients with anorexia or bulimia nervosa for care by those with special expertise. A number of pediatricians specializing in adolescent medicine have developed this skill set, with an increasing number involved in the management of eating disorders as part of multidisciplinary teams. Other than the most severely affected patients, most children and adolescents with eating disorders will be managed in an outpatient setting by a multidisciplinary team coordinated by a pediatrician or subspecialist with appropriate expertise in the care of children and adolescents with eating disorders. Pediatricians generally work with nursing, nutrition, and mental health colleagues in the provision of medical, nutrition, and mental health care required by these patients. The Role of the Pediatrician in Hospital and Day Program Settings Criteria for the hospitalization of children and adolescents with eating disorders have been established by the Society for Adolescent Medicine (Table 6 in the original guideline document). These criteria, in keeping with those published by the American Psychiatric Association, acknowledge that hospitalization may be required because of medical or psychiatric needs or because of failure of outpatient treatment to accomplish needed medical, nutritional, or psychiatric progress. Unfortunately, many insurance companies do not use similar criteria, thus making it difficult for some children and adolescents with eating disorders to receive an appropriate level of care. Children and adolescents have the best prognosis if their disease is treated rapidly and aggressively (an approach that may not be as effective in adults with a more long-term, protracted course). Hospitalization, which allows for adequate weight gain in addition to medical stabilization and the establishment of safe and healthy eating habits, improves the prognosis in children and adolescents. Day treatment (partial hospitalization) programs have been developed to provide an intermediate level of care for patients with eating disorders who require more than outpatient care but less than 24-hour hospitalization. In some cases, these programs have been used in an attempt to prevent the need for hospitalization; more often, they are used as a transition from inpatient to outpatient care. Day treatment programs generally provide care (including meals, therapy, groups, and other activities) 4 to 5 days per week from 8 or 9 am until 5 or 6 pm. An additional level of care, referred to as an "intensive outpatient" program, has also been developed for these patients and generally provides care 2 to 4 afternoons or evenings per week.
Pediatricians can play an active role in the development of objective, evidence-based criteria for the transition from one level of care to the next. Additional research can also help clarify other questions, such as the use of enteral versus parenteral nutrition during refeeding, to serve as the foundation for evidence based guidelines. Note: Refer to the AAP Physical Management/Nutritional Rehabilitation section of this synthesis for specific aspects of providing treatment in these settings. |
APA |
Psychiatric Management Choosing a Treatment Site Services available for treating eating disorders can range from intensive inpatient programs (in which general medical care is readily available) to residential and partial hospitalization programs to varying levels of outpatient care (in which the patient receives general medical treatment, nutritional counseling, and/or individual, group, and family psychotherapy). Because specialized programs are not available in all geographic areas and their financial requirements are often significant, access to these programs may be limited; petition, explanation, and follow-up by the psychiatrist on behalf of patients and families may help procure access to these programs.
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FMSD |
Treatment
Related Resources
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NCCMH/NICE |
Service Interventions for Anorexia Nervosa This section considers those aspects of the service system relevant to the treatment and management of anorexia nervosa. C - Most people with anorexia nervosa should be treated on an outpatient basis. C - Where inpatient management is required, this should be provided within reasonable travelling distance to enable the involvement of relatives and carers in treatment, to maintain social and occupational links, and to avoid difficulty in transition between primary and secondary care services. This is particularly important in the treatment of children and adolescents. C - Inpatient treatment should be considered for people with anorexia nervosa whose disorder is associated with high or moderate physical risk. C - People with anorexia nervosa requiring inpatient treatment should be admitted to a setting that can provide the skilled implementation of refeeding with careful physical monitoring (particularly in the first few days of refeeding), in combination with psychosocial interventions. C - Inpatient treatment or day patient treatment should be considered for people with anorexia nervosa whose disorder has not improved with appropriate outpatient treatment, or for whom there is a significant risk of suicide or severe self-harm. C - Health care professionals without specialist experience of eating disorders, or in situations of uncertainty, should consider seeking advice from an appropriate specialist when contemplating a compulsory admission for a patient with anorexia nervosa, regardless of the age of the patient. C - Health care professionals managing patients with anorexia nervosa, especially that of the binge purging sub-type, should be aware of the increased risk of self-harm and suicide, particularly at times of transition between services or service settings. Additional Considerations for Children and Adolescents C - Admission of children and adolescents with anorexia nervosa should be to age-appropriate facilities (with the potential for separate children and adolescent services), which have the capacity to provide appropriate educational and related activities. C - When a young person with anorexia nervosa refuses treatment that is deemed essential, consideration should be given to the use of the Mental Health Act 1983 or the right of those with parental responsibility to override the young person's refusal. C - Relying indefinitely on parental consent to treatment should be avoided. It is recommended that the legal basis under which treatment is being carried out should be recorded in the patient's case notes, and this is particularly important in the case of children and adolescents. C - For children and adolescents with anorexia nervosa, where issues of consent to treatment are highlighted, health care professionals should consider seeking a second opinion from an eating disorders specialist. C - If the patient with anorexia nervosa and those with parental responsibility refuse treatment, and treatment is deemed to be essential, legal advice should be sought in order to consider proceedings under the Children Act 1989. Service Interventions for Bulimia Nervosa The great majority of patients with bulimia nervosa can be treated as outpatients. There is a very limited role for the inpatient treatment of bulimia nervosa. This is primarily concerned with the management of suicide risk or severe self-harm. C - The great majority of patients with bulimia nervosa should be treated in an outpatient setting. C - For patients with bulimia nervosa who are at risk of suicide or severe self-harm, admission as an inpatient or day patient, or the provision of more intensive outpatient care, should be considered. C - Psychiatric admission for people with bulimia nervosa should normally be undertaken in a setting with experience of managing this disorder. C - Health care professionals should be aware that patients with bulimia nervosa who have poor impulse control, notably substance misuse, may be less likely to respond to a standard programme of treatment. As a consequence treatment should be adapted to the problems presented. |
Physical Management/Nutritional Rehabilitation | |
AAP |
The Pediatrician's Role in the Treatment of Eating Disorders in Outpatient Settings As listed in Table 4 of the original guideline document, medical complications of eating disorders can occur in all organ systems. Pediatricians need to be aware of several complications that can occur in the outpatient setting.
The components of nutritional rehabilitation required in the outpatient management of patients with eating disorders are presented in several reviews. These reviews highlight the dietary stabilization that is required as part of the management of bulimia nervosa and the weight gain regimens that are required as the hallmark of treatment of anorexia nervosa.
Similarly, the pediatrician must work with mental health experts to provide the necessary psychologic, social, and psychiatric care. The model used by many interdisciplinary teams, especially those based in settings experienced in the care of adolescents, is to establish a division of labor such that the medical and nutritional clinicians work on the issues described in the preceding paragraph and the mental health clinicians provide such modalities as individual, family, and group therapy. It is generally accepted that medical stabilization and nutritional rehabilitation are the most crucial determinants of short-term and intermediate-term outcome. Individual and family therapy, the latter being especially important in working with younger children and adolescents, are crucial determinants of the long-term prognosis. It is also recognized that correction of malnutrition is required for the mental health aspects of care to be effective. The Role of the Pediatrician in Hospital and Day Program Settings
Some programs use this approach frequently, and others apply it more sparingly. Also, because these patients are generally more malnourished than those treated as outpatients, more severe complications may need to be treated. These include the possible metabolic, cardiac, and neurologic complications listed in Table 2 of the original guideline document. Of particular concern is the refeeding syndrome that can occur in severely malnourished patients who receive nutritional replenishment too rapidly. The refeeding syndrome consists of cardiovascular, neurologic, and hematologic complications that occur because of shifts in phosphate from extracellular to intracellular spaces in individuals who have total body phosphorus depletion as a result of malnutrition. Recent studies have shown that this syndrome can result from use of oral, parenteral, or enteral nutrition.
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APA |
Choice of Specific Treatments for Anorexia Nervosa The aims of treating anorexia nervosa are to 1) restore patients to a healthy weight (associated with the return of menses and normal ovulation in female patients, normal sexual drive and hormone levels in male patients, and normal physical and sexual growth and development in children and adolescents); 2) treat physical complications; 3) enhance patients' motivation to cooperate in the restoration of healthy eating patterns and participate in treatment; 4) provide education regarding healthy nutrition and eating patterns; 5) help patients reassess and change core dysfunctional cognitions, attitudes, motives, conflicts, and feelings related to the eating disorder; 6) treat associated psychiatric conditions, including deficits in mood and impulse regulation and self-esteem and behavioral problems; 7) enlist family support and provide family counseling and therapy where appropriate; and 8) prevent relapse. Nutritional Rehabilitation
Choice of Specific Treatments for Bulimia Nervosa The aims of treatment for patients with bulimia nervosa are to 1) reduce and, where possible, eliminate binge eating and purging; 2) treat physical complications of bulimia nervosa; 3) enhance patients' motivation to cooperate in the restoration of healthy eating patterns and participate in treatment; 4) provide education regarding healthy nutrition and eating patterns; 5) help patients reassess and change core dysfunctional thoughts, attitudes, motives, conflicts, and feelings related to the eating disorder; 6) treat associated psychiatric conditions, including deficits in mood and impulse regulation, self-esteem, and behavior; 7) enlist family support and provide family counseling and therapy where appropriate; and 8) prevent relapse. Nutritional Rehabilitation Counseling
Eating Disorder not Otherwise Specified
Binge Eating Disorder Nutritional Rehabilitation and Counseling
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FMSD |
No specific recommendations offered. The treatment is divided into:
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NCCMH/NICE |
Care Across All Conditions Management of Physical Aspects C - Where laxative abuse is present, patients should be advised to gradually reduce laxative use and informed that laxative use does not significantly reduce calorie absorption. C - Treatment of both subthreshold and clinical cases of an eating disorder in people with diabetes is essential because of the greatly increased physical risk in this group. C - People with type 1 diabetes and an eating disorder should have intensive regular physical monitoring because they are at high risk of retinopathy and other complications. C - Pregnant women with eating disorders require careful monitoring throughout the pregnancy and in the postpartum period. C - Patients with an eating disorder who are vomiting should have regular dental reviews. C - Patients who are vomiting should be given appropriate advice on dental hygiene, which should include avoiding brushing after vomiting; rinsing with a non-acid mouthwash after vomiting; and reducing an acid oral environment (for example, limiting acidic foods). C - Health care professionals should advise people with eating disorders and osteoporosis or related bone disorders to refrain from physical activities that significantly increase the likelihood of falls. Additional considerations for children and adolescents C - In children and adolescents with eating disorders, growth and development should be closely monitored. Where development is delayed or growth is stunted despite adequate nutrition, paediatric advice should be sought. Anorexia Nervosa Physical Management of Anorexia Nervosa Anorexia nervosa carries considerable risk of serious physical morbidity. Awareness of the risk, careful monitoring, and, where appropriate, close liaison with an experienced physician are important in the management of the physical complications of anorexia nervosa. Managing Weight Gain C - In most patients with anorexia nervosa, an average weekly weight gain of 0.5 to 1 kg in inpatient settings and 0.5 kg in outpatient settings should be an aim of treatment. This requires about 3,500 to 7,000 extra calories a week. C - Regular physical monitoring, and in some cases treatment with a multi-vitamin/multi-mineral supplement in oral form, is recommended for people with anorexia nervosa during both inpatient and outpatient weight restoration. C - Total parenteral nutrition should not be used for people with anorexia nervosa, unless there is significant gastrointestinal dysfunction. Managing Risk C - Health care professionals should monitor physical risk in patients with anorexia nervosa. If this leads to the identification of increased physical risk, the frequency of the monitoring and nature of the investigations should be adjusted accordingly. C - People with anorexia nervosa and their carers should be informed if the risk to their physical health is high. C - The involvement of a physician or paediatrician with expertise in the treatment of physically at-risk patients with anorexia nervosa should be considered for all individuals who are physically at risk. C - Pregnant women with either current or remitted anorexia nervosa may need more intensive prenatal care to ensure adequate prenatal nutrition and fetal development. C - Oestrogen administration should not be used to treat bone density problems in children and adolescents as this may lead to premature fusion of the epiphyses. Feeding Against the Will of the Patient C - Feeding against the will of the patient should be an intervention of last resort in the care and management of anorexia nervosa. C - Feeding against the will of the patient is a highly specialized procedure requiring expertise in the care and management of those with severe eating disorders and the physical complications associated with it. This should only be done in the context of the Mental Health Act 1983 or Children Act 1989. C - When making the decision to feed against the will of the patient, the legal basis for any such action must be clear. Additional Considerations for Children and Adolescents C - Health care professionals should ensure that children and adolescents with anorexia nervosa who have reached a healthy weight have the increased energy and necessary nutrients available in their diet to support further growth and development. C - In the nutritional management of children and adolescents with anorexia nervosa, carers should be included in any dietary education or meal planning. Other Physical Interventions Physical monitoring is necessary during periods of refeeding. A range of electrolyte disturbances can occur during refeeding, which are sometimes referred to collectively as the "refeeding syndrome." Hypophosphataemia may develop rapidly during refeeding; if severe, it can cause cardiac and respiratory failure, delirium, and fits. Ingestion of large quantities of carbohydrates, during rapid refeeding, may result in a precipitate drop in serum phosphate levels. Therefore, in the first few days of refeeding patients who have had very low or absent intakes for long periods, no attempt should be made to achieve net weight gain. Instead they should receive energy and protein provision at levels at or less than their estimated basal requirements with generous provision of balanced multi-vitamins and minerals especially thiamine, potassium, magnesium, and phosphate. Bulimia Nervosa Management of Physical Aspects of Bulimia Nervosa Patients with bulimia nervosa can experience considerable physical problems as a result of a range of behaviours associated with the condition. Awareness of the risks and careful monitoring should be a concern of all health care professionals working with people with this disorder. C - Patients with bulimia nervosa who are vomiting frequently or taking large quantities of laxatives (especially if they are also underweight) should have their fluid and electrolyte balance assessed. C - When electrolyte disturbance is detected, it is usually sufficient to focus on eliminating the behaviour responsible. In the small proportion of cases where supplementation is required to restore electrolyte balance, oral rather than intravenous administration is recommended, unless there are problems with gastrointestinal absorption. |
Psychological Interventions | |
AAP |
The Pediatrician's Role in the Treatment of Eating Disorders in Outpatient Settings Behavioral interventions are often required to encourage otherwise reluctant (and often resistant) patients to accomplish necessary caloric intake and weight gain goals. Although some pediatric specialists, pediatric nurses, or dietitians may be able to handle this aspect of care alone, a combined medical and nutritional team is usually required, especially for more difficult patients. Similarly, the pediatrician must work with mental health experts to provide the necessary psychologic, social, and psychiatric care. The model used by many interdisciplinary teams, especially those based in settings experienced in the care of adolescents, is to establish a division of labor such that the medical and nutritional clinicians work on the issues described in the preceding paragraph (see Physical Management section of this synthesis) and the mental health clinicians provide such modalities as individual, family, and group therapy. It is generally accepted that medical stabilization and nutritional rehabilitation are the most crucial determinants of short-term and intermediate-term outcome. Individual and family therapy, the latter being especially important in working with younger children and adolescents, are crucial determinants of the longterm prognosis. It is also recognized that correction of malnutrition is required for the mental health aspects of care to be effective. |
APA |
Choice of Specific Treatments for Anorexia Nervosa Psychosocial Interventions The goals of psychosocial interventions are to help patients with anorexia nervosa 1) understand and cooperate with their nutritional and physical rehabilitation, 2) understand and change the behaviors and dysfunctional attitudes related to their eating disorder, 3) improve their interpersonal and social functioning, and 4) address comorbid psychopathology and psychological conflicts that reinforce or maintain eating disorder behaviors. Acute Anorexia Nervosa
Anorexia Nervosa after Weight Restoration Once malnutrition has been corrected and weight gain has begun, psychotherapy can help patients with anorexia nervosa understand 1) their experience of their illness; 2) cognitive distortions and how these have led to their symptomatic behavior; 3) developmental, familial, and cultural antecedents of their illness; 4) how their illness may have been a maladaptive attempt to regulate their emotions and cope; 5) how to avoid or minimize the risk of relapse; and 6) how to better cope with salient developmental and other important life issues in the future.
Although families and patients are increasingly accessing worthwhile, helpful information through online web sites, newsgroups, and chat rooms, the lack of professional supervision within these resources may sometimes lead to users' receiving misinformation or create unhealthy dynamics among users.
Chronic Anorexia Nervosa Patients with chronic anorexia nervosa generally show a lack of substantial clinical response to formal psychotherapy.
Choice of Specific Treatments for Bulimia Nervosa Psychosocial Interventions
Eating Disorder not Otherwise Specified
Binge Eating Disorder Nutritional Rehabilitation and Counseling
Other Psychosocial Treatments
Combining Psychosocial and Medication Treatments
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FMSD |
Treatment
Related Resources
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NCCMH/NICE |
Psychological Interventions for Anorexia Nervosa The delivery of psychological interventions should be accompanied by regular monitoring of a patient's physical state including weight and specific indicators of increased physical risk. Common Elements of the Psychological Treatment of Anorexia Nervosa C - Therapies to be considered for the psychological treatment of anorexia nervosa include CAT, CBT, IPT, focal psychodynamic therapy, and family interventions focused explicitly on eating disorders. C - Patient and, where appropriate, carer preference should be taken into account in deciding which psychological treatment is to be offered. C - The aims of psychological treatment should be to reduce risk, to encourage weight gain and healthy eating, to reduce other symptoms related to an eating disorder, and to facilitate psychological and physical recovery. Outpatient Psychological Treatments in First Episode and Later Episodes C - Most people with anorexia nervosa should be managed on an outpatient basis, with psychological treatment (with physical monitoring) provided by a health care professional competent to give it and to assess the physical risk of people with eating disorders. C - Outpatient psychological treatment and physical monitoring for anorexia nervosa should normally be of at least 6 months' duration. C - For patients with anorexia nervosa, if during outpatient psychological treatment there is significant deterioration, or the completion of an adequate course of outpatient psychological treatment does not lead to any significant improvement, more intensive forms of treatment (for example, a move from individual therapy to combined individual and family work or day care or inpatient care) should be considered. C - Dietary counselling should not be provided as the sole treatment for anorexia nervosa. Psychological Aspects of Inpatient Care C - For inpatients with anorexia nervosa, a structured symptom-focused treatment regimen with the expectation of weight gain should be provided in order to achieve weight restoration. It is important to carefully monitor the patient's physical status during refeeding. C - Psychological treatment should be provided which has a focus both on eating behaviour and attitudes to weight and shape and on wider psychosocial issues with the expectation of weight gain. C - Rigid inpatient behaviour modification programmes should not be used in the management of anorexia nervosa. Post-Hospitalisation Psychological Treatment C - Following inpatient weight restoration, people with anorexia nervosa should be offered outpatient psychological treatment that focuses both on eating behaviour and attitudes to weight and shape and on wider psychosocial issues, with regular monitoring of both physical and psychological risk. C - The length of outpatient psychological treatment and physical monitoring following inpatient weight restoration should typically be at least 12 months. Additional Considerations for Children and Adolescents with Anorexia Nervosa B - Family interventions that directly address the eating disorder should be offered to children and adolescents with anorexia nervosa. C - Children and adolescents with anorexia nervosa should be offered individual appointments with a health care professional separate from those with their family members or carers. C - The therapeutic involvement of siblings and other family members should be considered in all cases because of the effects of anorexia nervosa on other family members. C - In children and adolescents with anorexia nervosa, the need for inpatient treatment and the need for urgent weight restoration should be balanced alongside the educational and social needs of the young person. Bulimia Nervosa Psychological Interventions for Bulimia Nervosa B - As a possible first step, patients with bulimia nervosa should be encouraged to follow an evidence-based self-help programme. B - Health care professionals should consider providing direct encouragement and support to patients undertaking an evidence-based self-help programme, as this may improve outcomes. This may be sufficient treatment for a limited subset of patients. A - CBT-BN, a specifically adapted form of CBT, should be offered to adults with bulimia nervosa. The course of treatment should be for 16 to 20 sessions over 4 to 5 months. B - When people with bulimia nervosa have not responded to or do not want CBT, other psychological treatments should be considered. B - Interpersonal psychotherapy should be considered as an alternative to CBT, but patients should be informed it takes 8-12 months to achieve results comparable with CBT. Additional Considerations for Children and Adolescents C - Adolescents with bulimia nervosa may be treated with CBT-BN adapted as needed to suit their age, circumstances, and level of development, and including the family as appropriate. Atypical Eating Disorders Including Binge Eating Disorder General Treatment of Atypical Eating Disorders C - In the absence of evidence to guide the management of atypical eating disorders (eating disorders not otherwise specified) other than binge eating disorder, it is recommended that the clinician considers following the guidance on the treatment of the eating problem that most closely resembles the individual patient's eating disorder. Psychological Treatments for Binge Eating Disorder B - As a possible first step, patients with binge eating disorder should be encouraged to follow an evidence-based self-help programme. B - Health care professionals should consider providing direct encouragement and support to patients undertaking an evidence-based self-help programme as this may improve outcomes. This may be sufficient treatment for a limited subset of patients. A - CBT-BED, a specifically adapted form of CBT, should be offered to adults with binge eating disorder. B - Other psychological treatments (interpersonal psychotherapy for binge eating disorder and modified dialectical behaviour therapy) may be offered to adults with persistent binge eating disorder. A - Patients should be informed that all psychological treatments for binge eating disorder have a limited effect on body weight. C - When providing psychological treatments for patients with binge eating disorder, consideration should be given to the provision of concurrent or consecutive interventions focusing on the management of comorbid obesity. C - Suitably adapted psychological treatments should be offered to adolescents with persistent binge eating disorder. |
Pharmacological Interventions | |
AAP |
The Pediatrician's Role in the Treatment of Eating Disorders in Outpatient Settings Psychotropic medications have been shown to be helpful in the treatment of bulimia nervosa and prevention of relapse in anorexia nervosa in adults. These medications are also used for many adolescent patients and may be prescribed by the pediatrician or the psychiatrist, depending on the delegation of roles within the team. |
APA |
Choice of Specific Treatments for Anorexia Nervosa Medications and Other Somatic Treatments Weight Restoration
Relapse Prevention
Chronic Anorexia Nervosa
Choice of Specific Treatments for Bulimia Nervosa Medications Initial Treatment
Maintenance Phase
Combining Psychosocial Interventions and Medications
Other Treatments
Eating Disorder not Otherwise Specified Binge Eating Disorder Medications
Combining Psychosocial and Medication Treatments
Night Eating Syndrome
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FMSD |
Medical Treatment
Related Evidence
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NCCMH/NICE |
Anorexia Nervosa Pharmacological Interventions for Anorexia Nervosa There is a very limited evidence base for the pharmacological treatment of anorexia nervosa. A range of drugs may be used in the treatment of comorbid conditions but caution should be exercised in their use given the physical vulnerability of many people with anorexia nervosa. C - Medication should not be used as the sole or primary treatment for anorexia nervosa. C - Caution should be exercised in the use of medication for comorbid conditions such as depressive or obsessive-compulsive features, as they may resolve with weight gain alone. C - When medication is used to treat people with anorexia nervosa, the side effects of drug treatment (in particular, cardiac side effects) should be carefully considered because of the compromised cardiovascular function of many people with anorexia nervosa. C - Health care professionals should be aware of the risk of drugs that prolong the QTc interval on the ECG (for example, antipsychotics, tricyclic antidepressants, macrolide antibiotics, and some antihistamines). In patients with anorexia nervosa at risk of cardiac complications, the prescription of drugs with side effects that may compromise cardiac functioning should be avoided. C - If the prescription of medication that may compromise cardiac functioning is essential, ECG monitoring should be undertaken. C - All patients with a diagnosis of anorexia nervosa should have an alert placed in their prescribing record concerning the risk of side effects. Bulimia Nervosa Pharmacological Interventions for Bulimia Nervosa B - As an alternative or additional first step to using an evidence-based self-help programme, adults with bulimia nervosa may be offered a trial of an antidepressant drug. B - Patients should be informed that antidepressant drugs can reduce the frequency of binge eating and purging, but the long-term effects are unknown. Any beneficial effects will be rapidly apparent. C - SSRIs (specifically fluoxetine) are the drugs of first choice for the treatment of bulimia nervosa in terms of acceptability, tolerability, and reduction of symptoms. C - For people with bulimia nervosa, the effective dose of fluoxetine is higher than for depression (60 mg daily). B - No drugs, other than antidepressants, are recommended for the treatment of bulimia nervosa. Atypical Eating Disorders Including Binge Eating Disorder General Treatment of Atypical Eating Disorders C - In the absence of evidence to guide the management of atypical eating disorders (eating disorders not otherwise specified) other than binge eating disorder, it is recommended that the clinician considers following the guidance on the treatment of the eating problem that most closely resembles the individual patient's eating disorder. Pharmacological Interventions for Binge Eating Disorder B - As an alternative or additional first step to using an evidence based self-help programme, consideration should be given to offering a trial of an SSRI antidepressant drug to patients with binge eating disorder. B - Patients with binge eating disorders should be informed that SSRIs can reduce binge eating, but the long-term effects are unknown. Antidepressant drug treatment may be sufficient treatment for a limited subset of patients. |
EDUCATION | |
AAP |
No recommendations offered. |
APA |
Basic psychiatric management includes support through the provision of educational materials, including self-help workbooks; information on community-based and Internet resources; and direct advice to patients and their families (if they are involved) [I] |
FMSD |
No recommendations offered. |
NCCMH/NICE |
Providing Good Information and Support C - Patients and, where appropriate, carers should be provided with education and information on the nature, course and treatment of eating disorders. C - In addition to the provision of information, family and carers may be informed of self-help groups and support groups and offered the opportunity to participate in such groups where they exist. Management of Physical Aspects C - Patients who are vomiting should be given appropriate advice on dental hygiene, which should include avoiding brushing after vomiting; rinsing with a non-acid mouthwash after vomiting; and reducing an acid oral environment (for example, limiting acidic foods). |
Selected Supporting References Note from NGC: Bolded references are cited in more than one guideline. Refer to the original guideline document for a complete listing of supporting references. |
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AAP (2003) |
American Psychiatric Association, Work Group on Eating Disorders. Practice guideline for the treatment of patients with eating disorders (revision). Am J Psychiatry. 2000;157(1 suppl):1-39 Baran SA, Weltzin TE, Kaye WH. Low discharge weight and outcome in anorexia nervosa. Am J Psychiatry. 1995;152:1070-1072 Birmingham CL, Alothman AF, Goldner EM. Anorexia nervosa: refeeding and hypophosphatemia. Int J Eat Disord. 1996;20:211-213 Castro J, Lazaro L, Pons F, Halperin I, Toro J. Predictors of bone mineral density reduction in adolescents with anorexia nervosa. J Am Acad Child Adolesc Psychiatry. 2000;39:1365-1370 Eisler I, Dare C, Russell GF, Szmukler G, le Grange D, Dodge E. Family and individual therapy in anorexia nervosa: a 5-year follow-up. Arch Gen Psychiatry. 1997;54:1025-1030 Fisher M. Medical complications of anorexia and bulimia nervosa. Adolesc Med. 1992;3:487-502 Fisher M, Golden NH, Bergeson R, et al. Update on adolescent health care in pediatric practice. J Adolesc Health. 1996;19:394-400 Fisher M, Simpser E, Schneider M. Hypophosphatemia secondary to oral refeeding in anorexia nervosa. Int J Eat Disord. 2000;28:181-187 Fisher M, Golden NH, Katzman DK, et al. Eating disorders in adolescents: a background paper. J Adolesc Health. 1995;16:420-437 Geist R, Heinmaa M, Stephens D, Davis R, Katzman DK. Comparison of family therapy and family group psychoeducation in adolescents with anorexia nervosa. Can J Psychiatry. 2000;45:173-178 Golden NH, Shenker IR. Amenorrhea in anorexia nervosa: etiology and implications. Adolesc Med. 1992;3:503-518 Grinspoon S, Thomas E, Pitts S, et al. Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa. Ann Intern Med. 2000;133:790-794 Howard WT, Evans KK, Quintero-Howard CV, Bowers WA, Andersen AE. Predictors of success or failure of transition to day hospital treatment for inpatients with anorexia nervosa. Am J Psychiatry. 1999;156: 1697-1702 Jimerson DC, Wolfe BE, Brotman AW, Metzger ED. Medications in the treatment of eating disorders. Psychiatry Clin North Am. 1996;19:739-754 Kaplan AS, Olmstead MP, Molleken L. Day treatment of eating disorders. In: Jimerson D, Kaye WH, eds. Bailliere's Clinical Psychiatry, Eating Disorders. Philadelphia, PA: Bailliere Tindall; 1997:275-289 Kaplan AS, Olmstead MP. Partial hospitalization. In: Garner DM, Garfinkel PE, eds. Handbook of Treatment for Eating Disorders. 2nd ed. New York, NY: Guilford Press; 1997:354-360 Kaye WH, Kaplan AS, Zucker ML. Treating eating-disorder patients in a managed care environment. Contemporary American issues and Canadian response. Psychiatry Clin North Am. 1996;19:793-810 Kohn MR, Golden NH, Shenker IR. Cardiac arrest and delirium: presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa. J Adolesc Health. 1998;22:239-243 Kreipe RE, Golden NH, Katzman DK, et al. Eating disorders in adolescents. A position paper of the Society for Adolescent Medicine. J Adolesc Health. 1995;16:476-479 Kreipe R, Uphoff M. Treatment and outcome of adolescents with anorexia nervosa. Adolesc Med. 1992;3:519-540 Mehler PS, Gray MC, Schulte M. Medical complications of anorexia nervosa. J Womens Health. 1997;6:533-541 Nicholls D, Stanhope R. Medical complications of anorexia nervosa in children and young adolescents. Eur Eat Disord Rev. 2000;8:170-180 North C, Gowers S, Byram V. Family functioning in adolescent anorexia nervosa. Br J Psychiatry. 1995;167:673-678 Palla B, Litt IF. Medical complications of eating disorders in adolescents. Pediatrics. 1988;81:613-623 Robin AL, Gilroy M, Dennis AB. Treatment of eating disorders in children and adolescents. Clin Psychol Rev. 1998;18:421-446 Rock CL, Curran-Celentano J. Nutritional disorder of anorexia nervosa: a review. Int J Eat Disord. 1994;15:187-203 Rock CL, Curran-Celentano J. Nutritional management of eating disorders. Psychiatry Clin North Am. 1996;19:701-713 Rome ES. Eating disorders in adolescents and young adults: what's a primary care clinician to do? Cleveland Clin J Med. 1996;63:387-395 Rome ES, Vazquez IM, Emans SJ. Nutritional problems in adolescence: anorexia nervosa/bulimia nervosa for young athletes. In: Walker WA, Watkins JB, eds. Nutrition in Pediatrics: Basic Science and Clinical Applications. 2nd ed. Hamilton, Ontario: BC Decker Inc; 1997:691-704 Russell GF, Szmukler GI, Dare C, Eisler I. An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch Gen Psychiatry. 1987;44:1047-1056 Schebendach J, Nussbaum MP. Nutrition management in adolescents with eating disorders. Adolesc Med. 1992;3:541-558 Sigman G. How has the care of eating disorder patients been altered and upset by payment and insurance issues? Let me count the ways [letter]. J Adolesc Health. 1996;19:317-318 Silber TJ, Delaney D, Samuels J Anorexia nervosa. Hospitalization on adolescent medicine units and third-party payments. J Adolesc Health. 1989;10:122-125 Silber TJ. Eating disorders and health insurance. Arch Pediatr Adolesc Med. 1994;148:785-788 Solomon SM, Kirby DF. The refeeding syndrome: a review. JPEN J Parenter Enteral Nutr. 1990;14:900-97 Strober M, Freeman R, De Antonio M, Lampert C, Diamond J. Does adjunctive fluoxetine influence the post-hospital course of restrictortype anorexia nervosa? A 24-month prospective, longitudinal follow up and comparison with historical controls. Psychopharmacol Bull. 1997;33: 425-431 Walsh BT, Wilson GT, Loeb KL, et al. Medication and psychotherapy in the treatment of bulimia nervosa. Am J Psychiatry. 1997;154:523-531 Wong JCH, Lewindon P, Mortimer R, Shepherd R. Bone mineral density in adolescent females with recently diagnosed anorexia nervosa. Int J Eat Disord. 2001;29:11-16 Yager J. Psychosocial treatments for eating disorders. Psychiatry. 1994; 57:153-164 |
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APA (2006) |
Agras WS, Telch CF, Arnow B, Eldredge K, Wilfley DE, Raeburn SD, Henderson S, Marnell M: Weight loss cognitive-behavioral and desipramine treatments in binge-eating disorder: an addictive design. Behav Ther 1994; 25:225-238 [A-] American Psychiatric Association: Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 2003; 160(11 suppl):1-60 [G] Appelbaum PS, Rumpf T: Civil commitment of the anorexic patient. Gen Hosp Psychiatry 1998; 20:225-230 [G] Birmingham CL, Beumont PJV: Medical Management of Eating Disorders: A Practical Handbook for Healthcare Professionals. Cambridge, UK, Cambridge University Press, 2004 [G] Carter JC, Fairburn CG: Cognitive-behavioral self-help for binge eating disorder: a controlled effectiveness study. J Consult Clin Psychol 1998; 66:616-623 [A-] Carter JC, Olmsted MP, Kaplan AS, McCabe RE, Mills JS, Aime A: Self-help for bulimia nervosa: a randomized controlled trial. Am J Psychiatry 2003; 160:973-978 [A-] Casper RC, Hedeker D, McClough JF: Personality dimensions in eating disorders and their relevance for subtyping. J Am Acad Child Adolesc Psychiatry 1992; 31:830-840 [D] Dare C, Eisler I, Russell G, Treasure J, Dodge L: Psychological therapies for adults with anorexia nervosa: randomised controlled trial of out-patient treatments. Br J Psychiatry 2001; 178:216-221 [A-] Eisler I, Dare C, Hodes M, Russell G, Dodge E, Le GD: Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family interventions. J Child Psychol Psychiatry 2000; 41:727-736 [A-] Faine MP: Recognition and management of eating disorders in the dental office. Dent Clin North Am 2003; 47:395-410 [F] Farrell E: Lost for Words: The Psychoanalysis of Anorexia and Bulimia. New York, Other Press, 2000 [G] Fennig S, Fennig S, Roe D: Physical recovery in anorexia nervosa: is this the sole purpose of a child and adolescent medical-psychiatric unit? Gen Hosp Psychiatry 2002; 24:87-92 [G] Fernandez-Aranda F, Bel M, Jimenez S, Vinuales M, Turon J, Vallejo J: Outpatient group therapy for anorexia nervosa: a preliminary study. Eat Weight Disord 1998; 3:1-6 [B] Fisher M, Golden NH, Katzman DK, Kreipe RE, Rees J, Schebendach J, Sigman G, Ammerman S, Hoberman HM: Eating disorders in adolescents: a background paper. J Adolesc Health 1995; 16:420-437 [F] Garfinkel PE, Garner DM: Anorexia Nervosa: A Multidimensional Perspective. New York, Brunner/Mazel, 1982 [G] Garfinkel PE, Garner DM: The Role of Drug Treatments for Eating Disorders. New York, Brunner/Mazel, 1987 [G] Golden NH, Katzman DK, Kreipe RE, Stevens SL, Sawyer SM, Rees J, Nicholls D, Rome ES: Eating disorders in adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health 2003; 33:496-503 [G] Golden NH, Meyer W: Nutritional rehabilitation of anorexia nervosa: goals and dangers. Int J Adolesc Med Health 2004; 16:131-144 [F] Goldner E: Treatment refusal in anorexia nervosa. Int J Eat Disord 1989; 8:297-306 [F] Guarda AS, Heinberg LJ: Effective weight gain in step down partial hospitalization program for eating disorders. Paper presented at the annual meeting of the Academy for Eating Disorders, San Diego, June 11-12, 1999 [G] Hebebrand J, Himmelmann GW, Heseker H, Schafer H, Remschmidt H: Use of percentiles for the body mass index in anorexia nervosa: diagnostic, epidemiological, and therapeutic considerations. Int J Eat Disord 1996; 19:359-369 [D] Hornyak LM, Baker EK: Experiential Therapies for Eating Disorders. New York, Guilford Press, 1989 [G] Hudson JI, Hudson RA, Pope HG Jr: Psychiatric comorbidity and eating disorders, in AED Review of Eating Disorders, Part 1. Edited by Wonderlich S, Mitchell J, de Zwann M, Steiger H. Oxford, UK, Radcliffe, 2005 [G] Kaplan AS: Medical and nutritional assessment, in Medical Issues and the Eating Disorders: The Interface. Edited by Kaplan AS, Garfinkel PE. New York, Brunner/Mazel, 1993, pp 1-16 [G] Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K: Comorbidity of anxiety disorders with anorexia and bulimia nervosa. Am J Psychiatry 2004; 161:2215-2221 [C] Kaye WH, Gwirtsman HE, Obarzanek E, George DT: Relative importance of calorie intake needed to gain weight and level of physical activity in anorexia nervosa. Am J Clin Nutr 1988; 47:989-994 [C] Kaye WH, Nagata T, Weltzin TE, Hsu LK, Sokol MS, McConaha C, Plotnicov KH, Weise J, Deep D: Double-blind placebo-controlled administration of fluoxetine in restricting- and restricting-purging-type anorexia nervosa. Biol Psychiatry 2001; 49:644-652 [A] Klibanski A, Biller BM, Schoenfeld DA, Herzog DB, Saxe VC: The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa. J Clin Endocrinol Metab 1995; 80:898-904 [B] Kohn MR, Golden NH, Shenker IR: Cardiac arrest and delirium: presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa. J Adolesc Health 1998; 22:239-243 [G] Kreipe RE, Yussman SM: The role of the primary care practitioner in the treatment of eating disorders. Adolesc Med 2003; 14:133-147 [G] Levitt JL, Sansone RA, Cohn L: Self-Harm Behavior and Eating Disorders: Dynamics, Assessment and Treatment. New York, Brunner-Routledge, 2004 [G] Lock J: Treating adolescents with eating disorders in the family context: empirical and theoretical considerations. Child Adolesc Psychiatr Clin N Am 2002; 11:331-342 [G] Mehler PS, Andersen AE: Eating Disorders: A Guide to Medical Care and Complications. Baltimore, Johns Hopkins University Press, 1999 [G] Miller KK, Grinspoon SK, Ciampa J, Hier J, Herzog D, Klibanski A: Medical findings in outpatients with anorexia nervosa. Arch Intern Med 2005; 165:561-566 [G] Okamoto A, Yamashita T, Nagoshi Y, Masui Y, Wada Y, Kashima A, Arii I, Nakamura M, Fukui K: A behavior therapy program combined with liquid nutrition designed for anorexia nervosa. Psychiatry Clin Neurosci 2002; 56:515-520 [A] Ornstein RM, Golden NH, Jacobson MS, Shenker IR: Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: implications for refeeding and monitoring. J Adolesc Health 2003; 32:83-88 [G] Petrucelli J, Stuart C: Hungers and Compulsions: The Psychodynamic Treatment of Eating Disorders and Addictions. Northvale, NJ, Jason Aronson, 2001 [G] Pike KM, Walsh BT, Vitousek K, Wilson GT, Bauer J: Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa. Am J Psychiatry 2003; 160:2046-2049 [A-] Powers PS, Bannon YS: Medical comorbidity of anorexia nervosa, bulimia nervosa, and binge eating disorder, in Clinical Handbook of Eating Disorders: An Integrated Approach. Edited by Brewerton TD. New York, Marcel Dekker, 2004, pp 231-256 [G] Powers PS: Initial assessment and early treatment options for anorexia nervosa and bulimia nervosa. Psychiatr Clin North Am 1996; 19:639-655 [F] Robin AL, Siegel PT, Moye AW, Gilroy M, Dennis AB, Sikand A: A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa. J Am Acad Child Adolesc Psychiatry 1999; 38:1482-1489 [A-] Rome ES: Eating disorders. Obstet Gynecol Clin North Am 2003; 30:353-377, vii [G] Schmidt U, Tiller J, Treasure J: Self-treatment of bulimia nervosa: a pilot study. Int J Eat Disord 1993; 13:273-277 [B] Solomon SM, Kirby DF: The refeeding syndrome: a review. JPEN J Parenter Enteral Nutr 1990; 14:90-97 [F] Steinhausen HC: The outcome of anorexia nervosa in the 20th century. Am J Psychiatry 2002; 159:1284-1293 [E] Strober M: Managing the chronic, treatment-resistant patient with anorexia nervosa. Int J Eat Disord 2004; 36:245-255 [G] Thiels C, Schmidt U, Treasure J, Garthe R, Troop N: Guided self-change for bulimia nervosa incorporating use of a self-care manual. Am J Psychiatry 1998; 155:947-953 [A-] Thompson-Brenner H, Westen D: A naturalistic study of psychotherapy for bulimia nervosa, part 1: comorbidity and treatment outcomes. J Nerv Ment Dis 2005; 193:573-584 [G] Walsh BT, Agras WS, Devlin MJ, Fairburn CG, Wilson GT, Kahn C, Chally MK: Fluoxetine for bulimia nervosa following poor response to psychotherapy. Am J Psychiatry 2000; 157:1332-1334 [A] Walsh BT, Kaplan AS, Attia E, Carter J, Devlin MJ, Olmsted M, Pike KM, Woodside B, Parides M: Fluoxetine vs placebo to prevent relapse in anorexia nervosa: primary outcome of drug on time to relapse in 93 weight restored subjects. Paper presented at the 11th annual meeting of the Eating Disorders Research Society, Toronto, Canada, September 29-October 1, 2005 [A] Wells LA, Logan KM: Pharmacologic treatment of eating disorders: review of selected literature and recommendations. Psychosomatics 1987; 28:470-479 [F] Wildman P, Lilenfeld LR, Marcus MD: Axis I comorbidity onset and parasuicide in women with eating disorders. Int J Eat Disord 2004; 35:190-197 [D] Zerbe KJ: The crucial role of psychodynamic understanding in the treatment of eating disorders. Psychiatr Clin North Am 2001; 24:305-313 [G] |
FMSD (2007) |
Bacaltchuk J, Hay P, Trefiglio R. Antidepressants versus psychological treatments and their combination for bulimia nervosa. Cochrane Database Syst Rev 2001;(4):CD003385. Bacaltchuk J, Hay P. Antidepressants versus placebo for people with bulimia nervosa. Cochrane Database Syst Rev 2003;(4):CD003391. Claudino AM, Hay P, Lima MS, Bacaltchuk J, Schmidt U, Treasure J. Antidepressants for anorexia nervosa. Cochrane Database Syst Rev 2006;(1):CD004365. [129 references] PubMed Meads C, Burls A, Gold L, Jobanputra P. In-patient versus out-patient care for eating disorders. Birmingham, United Kingdom: Development and Evaluation Service, Department of Public Health and Epidemiology, University of Birmingham; 1999 Sep. 58 p. (West Midlands DES reports; no. 17). Schoemaker C. Does early intervention improve the prognosis in anorexia nervosa? A systematic review of the treatment-outcome literature. Int J Eat Disord 1997 Jan;21(1):1-15. [90 references] PubMed Treasure J, Schmid U. What are the effects of treatments in anorexia nervosa. Clin Evid 2005;13:1151-2. Walsh BT, Kaplan AS, Attia E, Olmsted M, Parides M, Carter JC, Pike KM, Devlin MJ, Woodside B, Roberto CA, Rockert W. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. JAMA 2006 Jun 14;295(22):2605-12. PubMed Whittal MC, Agras WS, Gould RA. Bulimia nervosa: a meta-analysis of psychosocial and pharmacological treatments. Behav Ther 1999;30(1):117-35. |
NCCMH/NICE (2004) |
Agras, W.S., Walsh, B.T., Fairburn, C.G., Wilson, C.T. & Kramer, H.C. (2000a). A multi-centre comparison of Cognitive-Behavioral Therapy and Interpersonal Psychotherapy for bulimia nervosa. Archives of General Psychiatry, 54, 459-465. Agras, W.S., Crow, S.J., Halmi, K.A., Mitchell, J.E., Wilson, G.T. & Kraemer, H.C. (2000). Outcome predictors for the cognitive behavior treatment of bulimia nervosa: Data from a multisite study. American Journal of Psychiatry, 157(8), 1302-1308. APA (1994). American Psychiatric Association Work Group on Eating Disorders. Practice guideline for the treatment of patients with eating disorders (revision 2000). American Journal of Psychiatry, 157, 1-39. Arii, I., Yamashita, T., Kinoshita, M., Shimizu, H., Nakamura, M. & Nakajima, T. (1996). Treatment for inpatients with anorexia nervosa: Comparison of liquid formula with regular meals for improvement from emaciation. Psychiatry & Clinical Neurosciences, 50, 55-59. Arnold, L.M., McElroy, S., Hudson, J.I., Welge, J.A., Bennett, A.J. & Keck, P.E. (2002). A placebo controlled, randomised trial of fluoxetine in the treatment of binge-eating disorder. Journal of Clinical Psychiatry, 63, 1028-1033. Attia, E., Haiman, C., Walsh, B.T. & Flater, S.R. (1998). Does Fluoxetine augment the inpatient treatment of anorexia nervosa? American Journal of Psychiatry, 155, 548-551. Bachar, E., Latzer, Y., Kreitler, S. & Berry, E.M. (1999). Empirical comparison of two psychological therapies. Journal of Psychotherapy Practise and Research, 8, 115-128. Biederman, J., Herzog, D., Rivinus, T.M., Harper, G.P., Ferber, R.A., Rosenbaum, J.F., Harmatz, J.S., Tondorf, R., Orsulak, P.J. & Schildkraut, J.J. (1985). Amitriptyline in the treatment of anorexia nervosa: A double-blind, placebo-controlled study. Journal of Clinical Psychopharmacology, 5, 10-16. Birchall, H., Palmer, R.L., Waine, J., Gadsby, K. & Gatward, N. (2002). Intensive day programme treatment for severe anorexia nervosa - the Leicester experience. Psychiatric Bulletin, 26, 334-336. Brinch, M., Isager, T. & Tolstrup, K. (1988). Anorexia nervosa and motherhood: Reproduction pattern and mothering behaviour of 50 women. Acta Psychiatrica Scandinavica, 77, 611-617. Brinch, M., Isager, T. & Tolstrup, K. (1988). Patients' evaluation of their former treatment for anorexia nervosa (AN). Nordisk psykiatrisk tidsskrift. Nordic Journal of Psychiatry, 42, 445-448. Buston, K. (2002). Adolescents with mental health problems: What do they say about health services? Journal of Adolescence, 25, 231-242. Carter, J. & Fairburn, C.C. (1998). Cognitive behavioral self-help for binge eating disorder: A controlled effectiveness study. Journal of Consulting & Clinical Psychology, 66, 616-623. Castro, J., Lazaro, L., Pons, .F, Halperin, I. & Toro, J. (2001). Adolescent anorexia nervosa: The catch-up effect in bone mineral density after recovery. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1215-1221. Channon, S., de Silva, P., Hemsley, D. & Perkins, R. (1989). A controlled trial of cognitivebehavioural and behavioural treatment of anorexia nervosa. Behavioural Research and Therapy,27, 529-535. Crisp, A.H., Norton, K., Gowers, S., Halek, C., Bowyer, C., Yeldham, D., Levett, G. & Bhat, A. (1991). A controlled study of the effect of therapies aimed at adolescent and family psychopathology in anorexia nervosa British Journal of Psychiatry, 59, 325-333. Dare, C., Eisler, I., Russell, G., Treasure, J. & Dodge, L. (2001). Psychological therapies for adults with anorexia nervosa: Randomised controlled trial of out-patient treatments. British Journal of Psychiatry, 178, 216-221. Eisler, I., Dare, C., Hodes, M., Russell, G., Dodge, E. & Le Grange, D. (2000). Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions. Journal of Child Psychology & Psychiatry & Allied Disciplines, 41, 727-736. Geist, R., Heinmaa, M., Stephens, D., Davis, R. & Katzman, D.K. (2000). Comparison of family therapy and family group psychoeducation in adolescents with anorexia nervosa. Canadian Goldberg, S.C., Eckert, E.D., Casper, R.C., Halmi, K.A., Davis, J.M. & Roper, M.T. (1980). Factors influencing hospital differences in weight gain in anorexia nervosa. Journal of Nervous and Mental Disease, 168(3), 181-183. Grinspoon, S., Thomas, E., Pitts, S., Gross, E., Mickley, D., Miller, K., Herzog, D. & Klibanski, A. (2000). Prevalence and predictive factors for regional osteopenia in women with anorexia nervosa. Annals of Internal Medicine, 133, 790-794. Hay, P.J. & Bacaltchuk, J. (2003). Psychotherapy for bulimia nervosa and binging. Cochrane Database Syst Rev., (1), CD000562. Hudson, J.I., McElroy, S., Raymond, N.C., Crow, S., Keck, P.E., Carter, M.D., Mitchell, J.E., Strakowski, M.D., Pope, H.G., Coleman, B.S. & Jonas, J.M. (1998). Fluvoxamine in the treatment of binge-eating disorder: A multicenter placebo-controlled, double-blind trial. American Journal of Psychiatry, 155, 1756-1762. Journal of Psychiatry - Revue Canadienne de Psychiatrie, 45, 173-178. Hall, A. & Crisp, A.H. (1987). Brief psychotherapy in the treatment of anorexia nervosa. Outcome at one year. British Journal of Psychiatry, 151, 185-191. Loeb, K.L., Wilson, G.T., Gilbert, J.S. & Labouvie, E. (2000). Guided and unguided self-help for binge eating. Behaviour Research and Therapy, 38, 259-272. Lucas, A.R., Melton, L.J. III, Crowson, C.S. & O'Fallon, W.M. (1999). Long-term fracture risk among women with anorexia nervosa: A population-based cohort study. Mayo Clin. Proc, 74, 972-977. McElroy, S.L., Casuto, L.S., Nelson, E.B., Lake, K.A., Soutullo, C.A., Keck, P.E. Jr. & Hudson, J.I. (2000). Placebo-controlled trial of sertraline in the treatment of binge eating disorder. American Journal of Psychiatry, 157, 1004-1006. Nauta, H., Hospers, H., Kok, G. & Jansen, A. (2000). A comparison between a cognitive and a behavioural treatment for obese binge eaters and obese non-binge eaters. Behaviour Therapy, 31, 441-461. Nicholls, D. & Stanhope, R. (2000). Medical complications of anorexia nervosa in children and young adolescents. European Eating Disorders Review, 8, 170-178. Nielsen, S., Emborg, C. & Molbak, A.G. (2002). Mortality in concurrent type 1 diabetes and anorexia nervosa. Diabetes Care, 25, 309-312. Nielsen, S. (2002). Eating disorders in females with type 1 diabetes: An update of a meta-analysis. European Eating Disorders Review, 10, 241-254. Nielsen, S. (2001). Epidemiology and mortality of eating disorders. Eating Disorders, 24, 201-214. Pertschuk, M.J., Forster, J., Buzby, G. & Mullen, J.L. (1981). The treatment of anorexia nervosa with total parenteral nutrition. Biological Psychiatry, 16, 539-550. Robb, A.S., Silber, T.J., Orrell-Valente, J.K., Valadez-Meltzer, A., Ellis, N., Dadson, M.J. & Chatoor, I. (2002). Supplemental nocturnal nasogastric refeeding for better short-term outcome in hospitalised adolescent girls with anorexia nervosa. American Journal of Psychiatry, 159, 1347-1353. Robin, A.L., Siegel, P.T., Moye, A.W., Gilroy, M., Dennis, A.B. & Sikand, A. (1999). A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa. American Academy of Child and Adolescent Psychiatry, 38, 1482-1489. Rosenvinge, J.H. & Klusmeier, A.K. (2000). Treatment for eating disorders from a patient satisfaction perspective: A Norwegian replication of a British study. European Eating Disorders Review, 8, 293-300. Russell, G.F. (1985). Pre-menarchal anorexia nervosa and its sequelae. Journal of Psychiatric Research, 19, 363-369. Russell, G.F., Szmukler, G.I., Dare, C. & Eisler, I. (1987). An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 44, 1047-1056. Russell, G.F., Treasure, J. & Eisler, I. (1998). Mothers with anorexia nervosa who underfeed their children: Their recognition and management. Psychological Medicine, 28, 93-108. Russell, J. & Gross, G. (2000). Anorexia nervosa and body mass index. American Journal of Psychiatry, 157(12), 2060. Russell, G.F. (2001). Involuntary treatment in anorexia nervosa. Psychiatr Clin North Am, 24(2), 337-349. Serfaty, M.A., Turkington, D., Heap, M., Ledsham, L. & Jolley, E. (1999). Cognitive therapy versus dietary counselling in the outpatient treatment of anorexia nervosa: Effects of the treatment phase. European Eating Disorders Review, 7, 334-350. Treasure, J.L., Todd, G., Brolly, M., Tiller, J., Nehmed, A. & Denman, F. (1995). A pilot study of a randomised trial of cognitive analytical therapy vs educational behavioural therapy for adult anorexia nervosa. Behavioural Research and Therapy, 33, 363-367. Wallin, U., Kronovall, P. & Majewski M.L. (2000). Body awareness therapy in teenage anorexia nervosa: Outcome after two years. European Eating Disorders Review, 8, 19-30. |
TABLE 5: BENEFITS AND HARMS | |
---|---|
Benefits | |
AAP (2003) |
|
APA (2006) |
Appropriate treatment of eating disorders with improved clinical outcomes |
FMSD (2007) |
Appropriate diagnosis and treatment of eating disorders among children and adolescents |
NCCMH/NICE (2004) |
Consistent quality of care for patients with eating disorders including anorexia nervosa, bulimia nervosa, and related eating disorders |
Harms | |
AAP (2003) |
Refeeding Syndrome Of particular concern is the refeeding syndrome that can occur in severely malnourished patients who receive nutritional replenishment too rapidly. The refeeding syndrome consists of cardiovascular, neurologic, and hematologic complications that occur because of shifts in phosphate from extracellular to intracellular spaces in individuals who have total body phosphorus depletion as a result of malnutrition. Recent studies have shown that this syndrome can result from use of oral, parenteral, or enteral nutrition. Slow refeeding, with the possible addition of phosphorus supplementation, is required to prevent development of the refeeding syndrome in severely malnourished children and adolescents. Single-episode Educational Programs Single-episode school programs aimed at making changes in the cultural approaches to weight and dieting issues (e.g., 1 visit to a classroom) are clearly not effective and may do more harm than good. Additional curricula are being developed and additional evaluations are taking place in this field. |
APA (2006) |
Treatment of Anorexia Nervosa
Treatment of Bulimia Nervosa
|
FMSD (2007) |
Adverse effects associated with antidepressants |
NCCMH/NICE (2004) |
|
TABLE 6: EVIDENCE RATING SCHEMES | |
---|---|
AAP (2003) |
Not applicable |
APA (2006) |
Each recommendation is identified at falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence regarding the recommendation: [I] Recommended with substantial clinical confidence. [II] Recommended with moderate clinical confidence. [III] May be recommended on the basis of individual circumstances. |
FMSD (2007) |
Classification of the quality of evidence
|
NCCMH/NICE (2004) |
RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE Levels of Evidence I: Evidence obtained from a single randomised controlled trial or a meta-analysis of randomised controlled trials IIa: Evidence obtained from at least one well-designed controlled study without randomisation IIb: Evidence obtained from at least one well-designed quasi-experimental study III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities Strength of Recommendations Grade A - At least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation (evidence level I) without extrapolation Grade B - Well-conducted clinical studies but no randomised clinical trials on the topic of recommendation (evidence levels II or III); or extrapolated from level I evidence Grade C - Expert committee reports or opinions and/or clinical experiences of respected authorities (evidence level IV) or extrapolated from level I or II evidence. This grading indicates that directly applicable clinical studies of good quality are absent or not readily available. |
The American Academy of Pediatrics (AAP), American Psychiatric Association (APA), Finnish Medical Society Duodecim (FMSD), and National Collaborating Centre for Mental Health/National Institute for Health and Clinical Excellence (NCCMH/NICE) present recommendations for the management of eating disorders.
Some guidelines are broader in scope than others. For example, in addition to management, AAP, FMSD, and NCCMH/NICE also address the screening for and identification of eating disorders. These topics, however, are beyond the scope of this synthesis. The AAP guideline differs from the others in that it focuses specifically on the primary care pediatrician's role in the assessment and management of eating disorders. Two of the guidelines, AAP and APA, address a North American population, while FMSD and NCCMH/NICE address a European population (Finland and the United Kingdome, respectively).
While FMSD focuses on anorexia and bulimia nervosa, AAP, APA, and NCCMH/NICE also address atypical eating disorders such as binge eating disorder and eating disorders not otherwise specified (EDNOS). The APA and NCCMH/NICE guidelines address areas where more research is needed.
In formulating its conclusions, APA reviewed the NCCMH/NICE guideline and NCCMH/NICE reviewed the previous (2000) version of the APA guideline.
Guideline Development Methodology
Regarding the methods used to collect and select the evidence, all four groups performed searches of electronic databases, with FMSD and NCCMH/NICE also performing hand-searches of published literature (both primary and secondary sources). All of the groups with the exception of AAP describe relevant information about the electronic databases searched, with APA and NCCMH/NICE also providing the specific search terms used and the time range over which data were obtained.
To assess the quality and strength of the evidence, both FMSD and NCCMH/NICE weigh the evidence according to a rating scheme, while APA uses expert consensus. AAP does not specify how it assessed the evidence.
APA, FMSD, and NCCMH/NICE all performed a review of published meta-analyses to analyze the evidence, along with a systematic review (FMSD) or systematic review with evidence tables (APA, NCCMH/NICE). APA and NCCMH/NICE describe the processes used. AAP performed a review to analyze the evidence.
Both APA and NCCMH/NICE employed expert consensus to formulate their recommendations, and both use a grading scheme to indicate the strength of each individual recommendation. AAP and FMSD do not provide the methods used to formulate the recommendations.
All groups provided reference lists. APA and NCCMH/NICE stated that work group members were required to provide formal declarations of interest at the outset of the development process, while AAP and FMSD did not disclose potential conflicts of interest.
There is general agreement among the guidelines that a comprehensive initial assessment of patients diagnosed with an eating disorder should be performed and should include an evaluation of physical condition, mental status (including risk to self), and eating disorder attitudes and behaviors.
In terms of coordination of care, there is overall agreement that patients should be managed in a multidisciplinary team fashion, with all involved caregivers (physicians, psychologists, registered dietitians, social workers, physician specialists, dentists, etc.) collaborating to promote the well-being of the patient. Each team member's role should be clearly identified, and open communication between all parties should be encouraged.
There is general agreement that important factors to consider in determining the most appropriate treatment setting include the overall physical condition, psychology, behaviors, and social circumstances of the patient. APA and NCCMH/NICE are in agreement that most patients with uncomplicated bulimia nervosa can be treated as outpatients, but that patients at risk of suicide or severe self-harm or with other risk factors may warrant hospitalization. AAP similarly notes that other than the most severely affected patients, most children and adolescents will be managed in an outpatient setting by a multidisciplinary team coordinated by a pediatrician or subspecialist with appropriate expertise in the care of children and adolescents with eating disorders.
The three guidelines that address nutritional rehabilitation (AAP, APA, and NCCMH/NICE) are in agreement that weight gain regimens are a key component of the treatment of anorexia nervosa. AAP recommends a stepwise caloric increase, leading to an intake of 2000 to 3000 kcal per day and a weight gain of 0.5 to 2 lb. per week. APA similarly recommends a target weight gain of 2 to 3 lbs/week for hospitalized patients and 0.5 to 1 lb/week for outpatients, with a caloric intake beginning at approximately 1,000 to 1,600 kcal/day and increasing to 70 to 100 kcal/kg per day for certain patients. NCCMH/NICE notes that 0.5 to 1 kg (1.1 to 2.2 lbs) in inpatient settings and 0.5 kg (1.1 lbs) in outpatient settings should be aims of treatment, which requires about 3,500 to 7,000 extra calories a week.
AAP, APA, and NCCMH/NICE acknowledge that providing nutrition parentally or via a nasogastric tube may be required in inpatient settings. NCCMH/NICE states that total parenteral nutrition should not be used for people with anorexia nervosa in the absence of significant gastrointestinal dysfunction. While AAP does not distinguish between the two, APA states that nasogastric feeding is preferable to intravenous feeding.
AAP, APA, and NCCMH/NICE are in agreement that refeeding syndrome is a serious concern associated with administration of life-preserving nutrition, and that appropriate monitoring for the associated possible cardiovascular, neurologic, and hematologic complications is necessary. The guidelines agree that slow refeeding, with supplementation of vitamins and minerals as indicated, are important preventive measures to implement.
With regard to involuntary forced feeding, APA and NCCMH/NICE are in agreement that the legal basis and ramifications for doing so must be clear. NCCMH/NICE notes that it is a highly specialized procedure, only to be used as a last resort intervention in the treatment of anorexia nervosa. APA states that the clinical circumstances, family opinion, and relevant legal and ethical dimensions of the patient's treatment must be carefully considered.
APA and NCCMH/NICE agree that appropriate goals of psychological treatment for anorexia nervosa include helping patients to cooperate with their nutritional and physical rehabilitation (including weight gain and/or maintenance), to reduce eating disorder-related behaviors, and to promote psychological recovery.
During the weight gain process, APA recommends individual psychotherapeutic management that is psychodynamically informed, noting that formal psychotherapy may be ineffective. Therapies suggested by NCCMH/NICE include CAT, CBT, IPT, focal psychodynamic therapy, and family interventions focused explicitly on eating disorders. Both groups provide recommendations regarding psychological interventions for inpatient settings, with APA noting that most inpatient-based programs incorporate emotional nurturance and a combination of reinforcers that link exercise, bed rest, and privileges to target weights, desired behaviors, feedback concerning changes in weight, and other observable parameters. NCCMH/NICE recommends a treatment regimen which focuses both on eating behavior and attitudes to weight and shape, as well as to wider psychosocial issues with the expectation of weight gain, but cautions against rigid inpatient behavior modification programs.
APA cites CBT and interpersonal and/or psychodynamically oriented individual or group psychotherapy as appropriate treatments to prevent relapse after weight restoration, adding that overlap between therapies is common. NCCMH/NICE more generally notes that following inpatient weight restoration, people with anorexia nervosa should be offered outpatient psychological treatment lasting at least 12 months that focuses both on eating behavior and attitudes to weight and shape and on wider psychosocial issues, with regular monitoring of both physical and psychological risk.
APA and NCCMH/NICE further agree that psychosocial interventions for bulimia nervosa should be selected based on factors such as patient age, cognitive and psychological development, and family situation. APA, FMSD, and NCCMH/NICE are in agreement that CBT should be offered as the first-line psychosocial intervention. For patients who do not respond initially to CBT, APA and NCCMH/NICE agree that alternative psychological therapies should be considered, or a combination of therapies should be used. FMSD notes that CBT and medication have been successful. APA and NCCMH/NICE also both cite self-help programs as possible treatment options for bulimia nervosa. Both groups also provide recommendations regarding appropriate psychological treatments for binge eating disorder.
All four guidelines stress the efficacy and importance of family therapy and family involvement in the psychological treatment of children and adolescents at all stages of treatment and/or recovery for both anorexia and bulimia nervosa.
With regard to anorexia nervosa, there is general agreement among the three guidelines that provide specific recommendations (APA, FMSD, and NCCMH/NICE), that antidepressants or other psychopharmaceuticals are only indicated for treating comorbid psychiatric conditions, such as depression. In such cases, APA notes that SSRIs in combination with psychotherapy may be effective for both weight restoration and relapse prevention. FMSD states that a combination of antidepressants and psychotherapy is more effective than psychotherapy alone, but that psychotherapy may be more acceptable to patients.
For the treatment of bulimia nervosa, APA, FMSD, and NCCMH/NICE are in agreement that the SSRI fluoxetine is the drug of first choice in terms of acceptability, tolerability, and reduction of symptoms. Both APA and NCCMH/NICE cite SSRIs as an appropriate treatment option for binge eating disorder and address the potential benefits and risks.
There is general agreement that special attention must be paid to the side effects and warnings associated with all prescribed medications, with APA and NCCMH/NICE agreeing that careful cardiac monitoring is necessary when drugs that prolong the QTc interval are prescribed.
There are no significant areas of differences between the guidelines.
This Synthesis was prepared by ECRI on January 17, 2008. The information was verified by AAP on January 30, 2008, and by APA and FMSD on February 8, 2008.
Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Management of Eating Disorders. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD): 2008 Feb. [cited YYYY Mon DD]. Available: http://www.guideline.gov.