Implementation of enhanced cognitive behaviour therapy (CBT-E) for adults with anorexia nervosa in an outpatient eating-disorder unit at a public hospital

Implementation of enhanced cognitive behaviour therapy (CBT-E) for adults with anorexia nervosa... Background: Anorexia nervosa (AN) in adults is difficult to treat, and no current treatment is supported by robust evidence. A few studies, most of which were performed by highly specialized research units, have indicated that enhanced cognitive behaviour therapy (CBT-E) for eating disorders can be effective. However, the dropout rate is high and the evidence from non-research clinical units is sparse. Methods: This quality assessment project implemented CBT-E in an outpatient setting at a public hospital. Forty- four patients with AN started therapy. Each patient received at least 40 sessions of CBT-E over a 12-month period. Their body mass index (BMI) was recorded at baseline and after 3, 6 and 12 months. Reasons for not starting therapy or for leaving therapy prematurely were recorded. Results: Half (n = 22) of the 44 patients who started outpatient CBT-E did not complete the treatment. In the remaining sample there was a large (and statistically significant) weight gain after 12 months. The percentage of patients achieving the target BMI of > 18.5 kg/m was 36.4, 50.0 and 77.3% after 3, 6 and 12 months, respectively. Conclusions: This quality assessment project shows that it is possible to establish effective CBT-E in an outpatient eating-disorder unit at a public hospital. Although half of the patients did not complete CBT-E, the remaining patients achieved a significant increase in BMI at 1 year after the start of therapy. Keywords: Anorexia nervosa, Adults, Cognitive behaviour therapy, Body mass index Plain English summary shows that CBT-E for AN can be implemented success- Anorexia nervosa (AN) in adults is difficult to treat. En- fully in an outpatient setting at a public hospital. hanced cognitive behaviour therapy (CBT-E) for eating disorders has shown promising effects in some studies. Introduction This outpatient method was implemented at a public Anorexia nervosa (AN) is a serious mental disorder with hospital in Bergen, Western Norway. Half of the 44 pa- negative effects on physical, psychological and social tients who started CBT-E did not complete the treat- functioning. The disorder is associated with high risks of ment, but CBT-E was associated with significant and severe medical complications and mortality [1]. While relatively large increases in body mass index in the there has been some progress in treatments for children remaining patients. This quality assessment project and adolescents with AN [2, 3], AN in adults still has a relatively poor prognosis [4, 5] and has been described as “one of the most difficult psychiatric disorders to * Correspondence: stein.frostad@helse-bergen.no treat” [6]. However, in recent years specific psychological Department of Eating Disorders, Psychiatric Clinic, Haukeland University interventions have shown promising results in some co- Hospital, Bergen, Norway Full list of author information is available at the end of the article horts and randomized controlled trials. © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 2 of 8 Fairburn and colleagues studied 99 adults with AN AN directly to the unit if the severity of the eating dis- from the UK and Italy who were treated with enhanced order makes successful treatment in ordinary psychiatric cognitive behaviour therapy (CBT-E) for eating disorders care unlikely. The referrals are evaluated by all members [7]. Their outpatient intervention was completed by 64% of the treatment team in a weekly meeting. The criteria of the patients, who exhibited substantial improvements for acceptance to treatment at the DED are the presence in weight and eating-disorder psychopathology. A vari- of an eating disorder of clinical severity, prior unsuccessful ant of CBT-E has been compared with focal psycho- treatment attempt in other specialist health-care institu- dynamic therapy and “optimized treatment as usual” in a tion or a severity that makes successful treatment in or- multicentre randomized control trial involving 242 dinary psychiatric care unlikely. All patients aged adults with AN [8]. All three treatments produced statis- ≥16 years who fulfil the referral criteria as specified by tically significant improvements in mean body mass guidelines from the Norwegian Health Authorities have index (BMI), with no differences among them. In the the right to publicly funded treatment (all annual costs Strong Without Anorexia Nervosa (SWAN) study, 120 above 2500 NOK [250 euros] are covered). patients with AN were randomized to 3 psychological The treatment was chosen based on the symptom se- treatments for AN: Specialist Supportive Clinical Manage- verity and patients’ age. CBT-E [14] was the standard ment (SSCM), Maudsley Model Anorexia Nervosa Treat- treatment for all patients > 18 years who did not require ment for Adults (MANTRA), and CBT-E [9]. The inpatient treatment (supportive weight normalization or treatments were completed by 60% of patients who intensive CBT-E [15]). Patients younger than 18 years showed equivalent effects on psychopathology and impair- were offered family-based treatment for AN (FBT) if ment. However, CBT-E was superior in helping patients to they fulfilled the inclusion criteria for this treatment achieve a physically healthy weight, which is regarded as a [16]. CBT-E [14] was offered as a standard psychother- fundamental requirement for recovery. These studies led apy intervention for adolescents who were unable to to the recently published NICE (National Institute for benefit from FBT. Health and Care Excellence) guideline for eating Patients with severe psychiatric co-morbidity (e.g. sub- disorders to recommend eating-disorder-focused cog- stance misuse or active psychosis) that precludes them nitive behavioural therapy, MANTRA or SSCM for receiving focused eating-disorder treatment were adults with AN [10]. referred to receive another treatment before the eating Evidence-based psychological treatments are rarely im- disorder is addressed at the DED. If the patient partici- plemented in clinical services for eating disorders in pated actively in outpatient CBT-E but was unable to spite of these recommendations [11]. Moreover, when gain weight, the patient was offered inpatient intensive they are implemented, therapists usually fail to adhere to CBT-E at the DED, as described elsewhere [15]. Patients the manual or may even adopt an eclectic approach [12]. who were unable to benefit from CBT-E and were devel- Problems with adherence to the manual are common in oping a life-threatening condition could enter inpatient a real-world setting than in randomized control trials, supportive weight-normalization treatment. In both such which could reduce the therapeutic effects [11, 13]. cases the outpatient CBT-E was regarded as not Studies of the implementation of CBT-E as standard completed. treatment for AN in non-research clinical settings are This quality assessment project performed a longitu- therefore needed to evaluate the utility of the treatment dinal evaluation of the implementation of outpatient in normal clinical practice. The primary aim of this qual- CBT-E for AN in during 2013 and 2014. The patients ity assessment project was to measure the pre-post did not receive any other eating-disorder psychotherapy changes in BMI in a sample of consecutive adult patients while they were receiving CBT-E. receiving outpatient CBT-E for AN. Therapist training Methods The treatment team consisted of six clinical psycholo- Setting and design gists, one physician, one physiotherapist and one psychi- This quality-improvement project was performed at the atric nurse. All of the team members were trained Department of Eating Disorders (DED) of the Psychiatric CBT-E therapists who had attended a 2-day CBT-E Clinic at Haukeland University Hospital, Bergen, Western workshop taken by the treatment developer Christopher Norway. The DED is a specialist eating-disorder unit that Fairburn, followed by regular supervision by an experi- forms part of the public health-care system in Norway. enced CBT-E psychotherapist. The team members also The DED consists of a small inpatient unit and an out- received weekly individual supervision from an experi- patient unit. Referrals are accepted from specialist enced CBT-E therapist on-site during their first year at health-care institutions, but general practitioners in pri- the DED. The implementation of CBT-E in individual mary health care can also refer a patient suffering from patients is discussed in weekly 2-h team meetings. One Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 3 of 8 of the main topics at these meetings is ensuring that all scale while wearing normal clothing, and height was of the therapists adhere to the manual. measured using a wall-mounted height board. Height and weight were measured by the individual therapists. The intervention If the BMI at the start of treatment was unknown, the CBT-E is an individualized and flexible treatment specifically BMI at referral was used as the baseline. designed to address the eating-disorder psychopathology in the patient. The psychotherapy intervention has the follow- Demographic and illness characteristics ing three main goals: (i) to remove the eating-disorder psy- The following information was collected as part of the chopathology (i.e. disturbed way of eating and low weight [if screening interview by the CBT-E therapists: age, gender, present]; extreme weight-control behaviours; and concerns number of years with eating disorder before being re- about eating, shape and weight), (ii) to correct the mecha- ferred to DED, other axis-I disorders and symptoms, nisms that have been maintaining the psychopathology spe- previous treatments for eating disorders, living situation, cified in the patient’s formulation, and (iii) to ensure that the marital status, occupation and whether the patient was changes are long-lasting, by helping patients respond on sick leave or receiving a disability pension. promptly to any setbacks [14]. The treatment is described in detail in the complete treatment guide [14]. Diagnostic evaluation The outpatient CBT-E for underweight patients is de- Eating disorders were diagnosed based on a clinical livered individually by the same trained therapist over evaluation by an experienced psychologist or physician about 40 sessions, and it is organized into 3 main steps. at the DED according to criteria in the Diagnostic and In Step 1 the aim is to engage patients and help them ar- Statistical Manual of Mental Disorders, Fifth Edition rive at the decision to regain weight as well as address 2 (DSM-5) [17]. This study applied a BMI of < 18.5 kg/m the eating-disorder psychopathology. This step lasts up as an inclusion criterion. The Mini International Neuro- to 8 weeks and involves providing personalized educa- psychiatric Interview (MINI, version 6.0) [18] was used tion on the effects of being underweight, creating the to screen for co-morbid psychiatric disorders at baseline. formulation with emphasis on the role of low weight in Suicidality was defined as reporting any suicidal maintaining the disorder and a focus on helping the pa- thoughts or behaviours on the MINI. tient to make the decision to change and regain weight. The patients participate in twice-weekly sessions until Medical evaluation they consistently gain weight. The patients were assessed by a physician before they re- Step 2 focuses on achieving weight regain at the same ceived health care at the DED. If the patient had severe time as addressing the key mechanisms that maintain AN, complications or co-morbid diseases, a senior med- the eating-disorder psychopathology. The goal is to help ical specialist (S.F.) performed the medical assessment. patients reach a body weight that can be maintained without dietary restriction and without symptoms of be- Reasons for not starting or not continuing treatment ing underweight. This will allow a normal social life. For If the patient decided to not start treatment, the therap- most patients these goals can be achieved with a BMI of ist documented the background of this choice. Similarly, 19.0–20.0 kg/m . One session every 4 weeks is dedicated the reasons for ending prematurely were assessed in de- to reviewing the progress and the obstacles, and design- tail with patients during the sessions. Patients remaining ing the subsequent 4 weeks of treatment. in therapy for 12 months were regarded as completers. Step 3 focuses on helping patients to maintain their weight. This step usually lasts for 8 weeks, with appoint- ments towards the end of treatment occurring at inter- Statistics vals of 2–3 weeks. The aim is to ensure that progress is Analyses were conducted using the IBM SPSS Statistics maintained and that the risk of relapse is minimized. program (version 24). Paired-samples t-tests were con- In addition to CBT-E, all underweight patients were ad- ducted to compare the BMI between at the start of treat- vised to take standard dietary supplements: two omega-3 ment (baseline) and after 12 months among the capsules, one 500-mg calcium tablets, and one multivita- completers, as well as among all patients who started min tablet daily. Patients with severe clinical depression CBT-E (intention to treat – last observation carried for- were treated with fluoxetine or similar antidepressants. ward). Cohen’s d effect sizes for within-sample changes in BMI from baseline to 12 months were calculated. Assessment Cohen’s d values of 0.2, 0.5 and 0.8 are considered to in- Outcome measure dicate small, moderate and large effects, respectively The primary outcome measure was the pre-post changes [19], while a value of 1.2 is considered to indicate a very in BMI. Weight was measured using a balance beam large effect [20]. Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 4 of 8 Results 18.3±2.2 kg/m at baseline and after 3, 6 and 12 months, Patient flow respectively. There were missing data from several pa- During 2013 and 2014, 257 patients were referred to the tients at 3, 6 and 12 months, and the weight gain and ef- DED, of which 108 referrals (42%) were not accepted. fect size of this change was therefore not computed. The The main reason for not accepting a referral was that percentage of patients presenting with BMI ≥ 18.5 kg/m the patient had not received treatment at a general psy- at the last observation was 31.8% (n = 7). chiatric outpatient unit (81% of all cases). Among the patients accepted for treatment, 78 (52%) were referred Outcome among patients with severe AN from primary health care and 71 (48%) were referred Seventeen of the 44 patients who started CBT-E pre- from specialized health care. sented with severe AN (BMI < 16 kg/m according to A flowchart for the patients seeking treatment at the DSM-5), of which 7 were completers. Five of these seven DED is shown in Fig. 1. Among the 149 patients 44 pa- patients had a BMI of ≥18.5 kg/m at 12 months after tients started CBT-E (the intention-to-treat sample); starting CBT-E: the BMI in this group of patients was 2 2 their sociodemographic background and illness charac- 14.0±1.1 kg/m at baseline and 18.9±2.1 kg/m after teristics are presented in Table 1. A considerable propor- 12 months. tion of the patients struggled with suicidality thoughts or behaviours and depressive as well as anxiety disor- Discussion ders, as determined by the MINI (version 6.0) and clin- This quality assessment study aimed to describe the pre- ical assessments. post changes in BMI in a sample of consecutive patients treated with CBT-E for AN at a specialized outpatient Intention-to-treat findings eating-disorder unit at a public hospital. There were two The BMI increased from 16.3±1.6 kg/m (mean±SD) at main findings: (i) more than two-thirds of the patients baseline to 18.3±2.2 kg/m (last observation carried for- who completed the treatment achieved a normal weight ward) among all the patients who started treatment (p < after 12 months, and (ii) half of the patients ended the 0.001). Cohen’s d for this change was 1.0 and thus it was treatment prematurely and did not recover to the same classified as a large effect. The percentage of patients level as those who completed the treatment. In addition, presenting with BMI ≥ 18.5 kg/m at the last observation there was a relatively large effect on BMI in this out- was 54.5% (24 of 44 patients). patient setting among a substantial subgroup of the pa- tients with severe AN. These are typical patients who Proportion of patients who completed CBT-E usually are referred to inpatient care or other intensive Half of the patients (n = 22) completed the treatment, medical stabilization treatments, and not to outpatient while 22 patients (50%) ended the treatment prematurely psychological treatment. The implementation of CBT-E for reasons listed in Fig. 1. Completers were significantly for AN allowed patients who previously would have older than non-completers, while their BMI, number of been treated as inpatients to live their ordinary lives years with eating disorder, rate of psychiatric while they were receiving treatment. co-morbidity, number of previous eating-disorder treat- CBT-E for AN was relatively easy to implement in our ment attempts and living situation were all similar (as hospital outpatient unit. Moreover, the results of the listed in Table 1). present quality-assessment study are promising and are in line with those reported for clinical trials that have Outcomes among completers assessed the efficacy of CBT-E [9, 14]. The BMI over the course of treatment for the 22 com- The main problem to address in the future is to reduce pleters is shown in Fig. 2: it was 16.4±1.9, 17.7±1.7, 18.7 the proportion of non-completers. Indeed, the percent- ±1.6 and 19.3±1.4 kg/m at baseline and after 3, 6 and age of non-completers was higher than both that for 12 months, respectively. There was a significant weight CBT-E in the study in UK and Italy (36.4% were gain after 12 months (BMI difference of 2.9±2.3 kg/m , non-completers) and in the CBT-E arm of the SWAN range 0.0–9.8 kg/m , p < 0.001). The effect size for this study (33.3% were non-completers), while it was identi- change was very large (Cohen’s d= 1.7) and the percent- cal to that reported for an Australian effectiveness study age of patients achieving the target BMI of ≥18.5 kg/m on CBT-E in patients with AN [21]. While 77% of the was 36.4, 50.0 and 77.3% after 3, 6 and 12 months, patients who completed the treatment achieved the tar- respectively. get BMI, the high dropout-rate implies that this repre- sents only 39% of all the patients starting CBT-E. Outcomes among non-completers However, it should be stated that the rate of non-mutual The BMI over the course of treatment for the 22 premature termination of treatment was only 34% in the non-completers was 16.2±1.3, 17.2±1.9, 18.0±1.5 and current sample, which is similar to reported rates for Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 5 of 8 Fig. 1 Flow chart over the patients referred to the Department of Eating Disorders during 2013 and 2014 research clinical trials; seven of our patients were re- the top priority for the entire course of the treatment. ferred by our team to intensive treatments or to address Further, factors related to the treatment process itself other co-morbid conditions. It is also possible that some (such as therapeutic alliance and early patient engage- elements of randomized clinical trials missing in our ment in the treatment) warrant attention, and should be clinical settings—such as excluding patients with severe investigated in future studies [24]. AN and actively recalling patients who missed some ses- This study was subject to the following limitations: there sions—might explain the non-completer rate being were missing data, especially from patients dropping out higher for our treatment than for CBT-E research trials. from treatment; no systematic data were obtained on Several studies have indicated that it is difficult to pre-post changes in eating-disorder symptomatology or identify reliable predictors of attrition [22, 23]. In our on a possible diagnostic switch to bulimia nervosa; and we sample non-completers were younger than completers obtained no long-term data describing the clinical situa- (25.6 versus 21.1 years p = 0.03), suggesting that CBT-E tions of the patients after the 12-month assessment. We might be more suitable for older patients. However, also did not assess therapist competence and treatment fi- there were adolescents in both groups, and CBT-E has delity. However, since treatment fidelity was regarded as shown to be a promising treatment also for adolescents crucial for treatment success and essential for the feasibil- with AN [3]. Although we have no data indicating how ity of setting up this treatment, during the weekly 2-h to reduce attrition when implementing CBT-E in a real team meetings adherence to the manual was regularly ad- world clinical setting, the clinical experience that we dressed. However, the main strength of the study is that it gained by this quality improvement project leads us to demonstrated the possibility of effectively implementing suggest the following strategies on how to reduce treat- an evidence-based outpatient treatment for AN in a ment attrition. First, more time and effort should be real-world clinical setting. dedicated to prepare the patients for CBT-E, stressing the importance of giving treatment priority, playing an Conclusion active role and completing the treatment. Second, a CBT-E can be implemented relatively easily in an out- great store should be placed on establishing and main- patient setting at a public hospital. Patients who remain taining therapeutic momentum, stressing the importance in therapy are likely to exhibit a substantial increase in to avoid breaks in treatment. Third, since patients with BMI and thereby avoid costly and life-disruptive in- AN come to treatment with varying degrees of reluc- patient treatments. However, a large subgroup of pa- tance and ambivalence engaging the patient should be tients does not complete the treatment, and the most Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 6 of 8 Table 1 Characteristics of 44 consecutive patients starting CBT-E (enhanced cognitive behaviour therapy) for anorexia nervosa Characteristic All patients Completers Non-completers p n =44 n =22 n =22 Age, years 23.3±6.9 25.6±8.4 21.1±4.2 0.030 Gender, male 1 (2.3%) 0 1 (4.5%) Number of years with ED 6.1 ± 6.0 8.0 ± 6.9 4.3 ± 4.3 n.s. One or more other axis-I disorders 25 (59.5%) 13 (61.9%) 12 (57.1%) n.s. Most-frequent other axis-I disorders and symptoms Current major depressive episode 13 (31.0%) 8 (38.1%) 5 (23.8%) n.s. Recurrent major depressive episode 21 (50.0%) 13 (61.9%) 8 (38.1%) n.s. Suicidality (thoughts or behaviors) 25 (59.5%) 10 (47.6%) 15 (71.4%) n.s. Anxiety disorders 15 (35.7%) 8 (38.1%) 7 (33.3%) n.s. Previous treatment of ED Previous inpatient treatment 13 (31.0%) 6 (27.3%) 7 (35.0%) n.s. Previous outpatient treatment in specialist health care 19 (45.2) 10 (45.5%) 9 (45.0%) Previous outpatient treatment in primary health care 6 (14.3%) 4 (18.2%) 2 (10.0%) No prior ED treatment 4 (9.5%) 2 (9.1%) 2 (10.0%) Living situation With one parent 6 (13.6%) 1 (4.5%) 5 (22.7%) n.s. With both parents 9 (20.5%) 3 (13.6%) 6 (27.3%) Alone 12 (27.3%) 7 (31.8%) 5 (22.7%) With partner 4 (9.1%) 1 (4.5%) 3 (13.6%) With partner and children 5 (11.4%) 3 (13.6%) 2 (9.1%) Without partner but with children 2 (4.5%) 2 (9.1%) – Other 6 (13.6%) 5 (22.7%) 1 (4.5%) Marital status Single 29 (67.4%) 15 (68.2%) 14 (66.7%) n.s. Girlfriend/Boyfriend 5 (11.6%) 3 (13.6%) 2 (9.5%) Partner/Co-habitant 5 (11.6%) 3 (13.6%) 2 (9.5%) Married 4 (9.3%) 1 (4.5%) 3 (14.3%) Occupation Full-time work 2 (4.5%) 1 (4.5%) 1 (4.5%) n.s. Part-time work 6 (13.6%) 3 (13.6%) 3 (13.6%) Labour-market measures 5 (11.4%) 2 (9.1%) 3 (13.6%) School student/apprentice 10 (22.7%) 3 (13.6%) 7 (31.8%) College/University student 17 (38.6%) 11 (50%) 6 (27.3%) On sick leave 3 (6.8%) 2 (9.1%) 1 (4.5%) Disability pension 0 0 0 Other 1 (2.3%) 0 1(4.5%) Baseline body mass index 16.3±1.6 16.4±1.9 16.2±1.3 n.s. Data are mean±SD or n (%) values ED eating disorder, n.s. not significant n = 42 (21 completers, 21 non-completers) n = 42 (22 completers, 20 non-completers) n = 43 (22 completers, 21 non-completers) Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 7 of 8 Author details Department of Eating Disorders, Psychiatric Clinic, Haukeland University Hospital, Bergen, Norway. Department of Clinical Psychology, University of Bergen, Bergen, Norway. Department of Eating and Weight Disorders, Villa Garda Hospital, Garda, VR, Italy. Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway. Institute of Clinical Medicine, University of Oslo, Oslo, Norway. Department of Clinical Psychiatry, University of Bergen, Bergen, Norway. Psychiatric Department, Haukeland University Hospital, Bergen, Norway. Received: 22 February 2018 Accepted: 18 May 2018 References 1. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Fig. 2 BMI over the course of treatment for 22 patients who Arch Gen Psychiatry. 2011;68(7):724–31. completed CBT-E 2. Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B. Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry. 2010;67(10):1025–32. challenging problem for future research to address is 3. 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Behav Res Ther. 2011;49(4):219–26. 22. Fassino S, Piero A, Tomba E, Abbate-Daga G. Factors associated with dropout from treatment for eating disorders: a comprehensive literature review. BMC Psychiatry. 2009;9:67. 23. Linardon J, Hindle A, Brennan L. Dropout from cognitive-behavioral therapy for eating disorders: a meta-analysis of randomized, controlled trials. Int J Eat Disord. 2018;00:1–11. 24. Danielsen YS, Ardal Rekkedal G, Frostad S, Kessler U. Effectiveness of enhanced cognitive behavioral therapy (CBT-E) in the treatment of anorexia nervosa: a prospective multidisciplinary study. BMC Psychiatry. 2016;16(1):342. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Eating Disorders Springer Journals

Implementation of enhanced cognitive behaviour therapy (CBT-E) for adults with anorexia nervosa in an outpatient eating-disorder unit at a public hospital

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Psychology; Psychology, general; Health Promotion and Disease Prevention; Psychiatry; Clinical Psychology
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Abstract

Background: Anorexia nervosa (AN) in adults is difficult to treat, and no current treatment is supported by robust evidence. A few studies, most of which were performed by highly specialized research units, have indicated that enhanced cognitive behaviour therapy (CBT-E) for eating disorders can be effective. However, the dropout rate is high and the evidence from non-research clinical units is sparse. Methods: This quality assessment project implemented CBT-E in an outpatient setting at a public hospital. Forty- four patients with AN started therapy. Each patient received at least 40 sessions of CBT-E over a 12-month period. Their body mass index (BMI) was recorded at baseline and after 3, 6 and 12 months. Reasons for not starting therapy or for leaving therapy prematurely were recorded. Results: Half (n = 22) of the 44 patients who started outpatient CBT-E did not complete the treatment. In the remaining sample there was a large (and statistically significant) weight gain after 12 months. The percentage of patients achieving the target BMI of > 18.5 kg/m was 36.4, 50.0 and 77.3% after 3, 6 and 12 months, respectively. Conclusions: This quality assessment project shows that it is possible to establish effective CBT-E in an outpatient eating-disorder unit at a public hospital. Although half of the patients did not complete CBT-E, the remaining patients achieved a significant increase in BMI at 1 year after the start of therapy. Keywords: Anorexia nervosa, Adults, Cognitive behaviour therapy, Body mass index Plain English summary shows that CBT-E for AN can be implemented success- Anorexia nervosa (AN) in adults is difficult to treat. En- fully in an outpatient setting at a public hospital. hanced cognitive behaviour therapy (CBT-E) for eating disorders has shown promising effects in some studies. Introduction This outpatient method was implemented at a public Anorexia nervosa (AN) is a serious mental disorder with hospital in Bergen, Western Norway. Half of the 44 pa- negative effects on physical, psychological and social tients who started CBT-E did not complete the treat- functioning. The disorder is associated with high risks of ment, but CBT-E was associated with significant and severe medical complications and mortality [1]. While relatively large increases in body mass index in the there has been some progress in treatments for children remaining patients. This quality assessment project and adolescents with AN [2, 3], AN in adults still has a relatively poor prognosis [4, 5] and has been described as “one of the most difficult psychiatric disorders to * Correspondence: stein.frostad@helse-bergen.no treat” [6]. However, in recent years specific psychological Department of Eating Disorders, Psychiatric Clinic, Haukeland University interventions have shown promising results in some co- Hospital, Bergen, Norway Full list of author information is available at the end of the article horts and randomized controlled trials. © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 2 of 8 Fairburn and colleagues studied 99 adults with AN AN directly to the unit if the severity of the eating dis- from the UK and Italy who were treated with enhanced order makes successful treatment in ordinary psychiatric cognitive behaviour therapy (CBT-E) for eating disorders care unlikely. The referrals are evaluated by all members [7]. Their outpatient intervention was completed by 64% of the treatment team in a weekly meeting. The criteria of the patients, who exhibited substantial improvements for acceptance to treatment at the DED are the presence in weight and eating-disorder psychopathology. A vari- of an eating disorder of clinical severity, prior unsuccessful ant of CBT-E has been compared with focal psycho- treatment attempt in other specialist health-care institu- dynamic therapy and “optimized treatment as usual” in a tion or a severity that makes successful treatment in or- multicentre randomized control trial involving 242 dinary psychiatric care unlikely. All patients aged adults with AN [8]. All three treatments produced statis- ≥16 years who fulfil the referral criteria as specified by tically significant improvements in mean body mass guidelines from the Norwegian Health Authorities have index (BMI), with no differences among them. In the the right to publicly funded treatment (all annual costs Strong Without Anorexia Nervosa (SWAN) study, 120 above 2500 NOK [250 euros] are covered). patients with AN were randomized to 3 psychological The treatment was chosen based on the symptom se- treatments for AN: Specialist Supportive Clinical Manage- verity and patients’ age. CBT-E [14] was the standard ment (SSCM), Maudsley Model Anorexia Nervosa Treat- treatment for all patients > 18 years who did not require ment for Adults (MANTRA), and CBT-E [9]. The inpatient treatment (supportive weight normalization or treatments were completed by 60% of patients who intensive CBT-E [15]). Patients younger than 18 years showed equivalent effects on psychopathology and impair- were offered family-based treatment for AN (FBT) if ment. However, CBT-E was superior in helping patients to they fulfilled the inclusion criteria for this treatment achieve a physically healthy weight, which is regarded as a [16]. CBT-E [14] was offered as a standard psychother- fundamental requirement for recovery. These studies led apy intervention for adolescents who were unable to to the recently published NICE (National Institute for benefit from FBT. Health and Care Excellence) guideline for eating Patients with severe psychiatric co-morbidity (e.g. sub- disorders to recommend eating-disorder-focused cog- stance misuse or active psychosis) that precludes them nitive behavioural therapy, MANTRA or SSCM for receiving focused eating-disorder treatment were adults with AN [10]. referred to receive another treatment before the eating Evidence-based psychological treatments are rarely im- disorder is addressed at the DED. If the patient partici- plemented in clinical services for eating disorders in pated actively in outpatient CBT-E but was unable to spite of these recommendations [11]. Moreover, when gain weight, the patient was offered inpatient intensive they are implemented, therapists usually fail to adhere to CBT-E at the DED, as described elsewhere [15]. Patients the manual or may even adopt an eclectic approach [12]. who were unable to benefit from CBT-E and were devel- Problems with adherence to the manual are common in oping a life-threatening condition could enter inpatient a real-world setting than in randomized control trials, supportive weight-normalization treatment. In both such which could reduce the therapeutic effects [11, 13]. cases the outpatient CBT-E was regarded as not Studies of the implementation of CBT-E as standard completed. treatment for AN in non-research clinical settings are This quality assessment project performed a longitu- therefore needed to evaluate the utility of the treatment dinal evaluation of the implementation of outpatient in normal clinical practice. The primary aim of this qual- CBT-E for AN in during 2013 and 2014. The patients ity assessment project was to measure the pre-post did not receive any other eating-disorder psychotherapy changes in BMI in a sample of consecutive adult patients while they were receiving CBT-E. receiving outpatient CBT-E for AN. Therapist training Methods The treatment team consisted of six clinical psycholo- Setting and design gists, one physician, one physiotherapist and one psychi- This quality-improvement project was performed at the atric nurse. All of the team members were trained Department of Eating Disorders (DED) of the Psychiatric CBT-E therapists who had attended a 2-day CBT-E Clinic at Haukeland University Hospital, Bergen, Western workshop taken by the treatment developer Christopher Norway. The DED is a specialist eating-disorder unit that Fairburn, followed by regular supervision by an experi- forms part of the public health-care system in Norway. enced CBT-E psychotherapist. The team members also The DED consists of a small inpatient unit and an out- received weekly individual supervision from an experi- patient unit. Referrals are accepted from specialist enced CBT-E therapist on-site during their first year at health-care institutions, but general practitioners in pri- the DED. The implementation of CBT-E in individual mary health care can also refer a patient suffering from patients is discussed in weekly 2-h team meetings. One Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 3 of 8 of the main topics at these meetings is ensuring that all scale while wearing normal clothing, and height was of the therapists adhere to the manual. measured using a wall-mounted height board. Height and weight were measured by the individual therapists. The intervention If the BMI at the start of treatment was unknown, the CBT-E is an individualized and flexible treatment specifically BMI at referral was used as the baseline. designed to address the eating-disorder psychopathology in the patient. The psychotherapy intervention has the follow- Demographic and illness characteristics ing three main goals: (i) to remove the eating-disorder psy- The following information was collected as part of the chopathology (i.e. disturbed way of eating and low weight [if screening interview by the CBT-E therapists: age, gender, present]; extreme weight-control behaviours; and concerns number of years with eating disorder before being re- about eating, shape and weight), (ii) to correct the mecha- ferred to DED, other axis-I disorders and symptoms, nisms that have been maintaining the psychopathology spe- previous treatments for eating disorders, living situation, cified in the patient’s formulation, and (iii) to ensure that the marital status, occupation and whether the patient was changes are long-lasting, by helping patients respond on sick leave or receiving a disability pension. promptly to any setbacks [14]. The treatment is described in detail in the complete treatment guide [14]. Diagnostic evaluation The outpatient CBT-E for underweight patients is de- Eating disorders were diagnosed based on a clinical livered individually by the same trained therapist over evaluation by an experienced psychologist or physician about 40 sessions, and it is organized into 3 main steps. at the DED according to criteria in the Diagnostic and In Step 1 the aim is to engage patients and help them ar- Statistical Manual of Mental Disorders, Fifth Edition rive at the decision to regain weight as well as address 2 (DSM-5) [17]. This study applied a BMI of < 18.5 kg/m the eating-disorder psychopathology. This step lasts up as an inclusion criterion. The Mini International Neuro- to 8 weeks and involves providing personalized educa- psychiatric Interview (MINI, version 6.0) [18] was used tion on the effects of being underweight, creating the to screen for co-morbid psychiatric disorders at baseline. formulation with emphasis on the role of low weight in Suicidality was defined as reporting any suicidal maintaining the disorder and a focus on helping the pa- thoughts or behaviours on the MINI. tient to make the decision to change and regain weight. The patients participate in twice-weekly sessions until Medical evaluation they consistently gain weight. The patients were assessed by a physician before they re- Step 2 focuses on achieving weight regain at the same ceived health care at the DED. If the patient had severe time as addressing the key mechanisms that maintain AN, complications or co-morbid diseases, a senior med- the eating-disorder psychopathology. The goal is to help ical specialist (S.F.) performed the medical assessment. patients reach a body weight that can be maintained without dietary restriction and without symptoms of be- Reasons for not starting or not continuing treatment ing underweight. This will allow a normal social life. For If the patient decided to not start treatment, the therap- most patients these goals can be achieved with a BMI of ist documented the background of this choice. Similarly, 19.0–20.0 kg/m . One session every 4 weeks is dedicated the reasons for ending prematurely were assessed in de- to reviewing the progress and the obstacles, and design- tail with patients during the sessions. Patients remaining ing the subsequent 4 weeks of treatment. in therapy for 12 months were regarded as completers. Step 3 focuses on helping patients to maintain their weight. This step usually lasts for 8 weeks, with appoint- ments towards the end of treatment occurring at inter- Statistics vals of 2–3 weeks. The aim is to ensure that progress is Analyses were conducted using the IBM SPSS Statistics maintained and that the risk of relapse is minimized. program (version 24). Paired-samples t-tests were con- In addition to CBT-E, all underweight patients were ad- ducted to compare the BMI between at the start of treat- vised to take standard dietary supplements: two omega-3 ment (baseline) and after 12 months among the capsules, one 500-mg calcium tablets, and one multivita- completers, as well as among all patients who started min tablet daily. Patients with severe clinical depression CBT-E (intention to treat – last observation carried for- were treated with fluoxetine or similar antidepressants. ward). Cohen’s d effect sizes for within-sample changes in BMI from baseline to 12 months were calculated. Assessment Cohen’s d values of 0.2, 0.5 and 0.8 are considered to in- Outcome measure dicate small, moderate and large effects, respectively The primary outcome measure was the pre-post changes [19], while a value of 1.2 is considered to indicate a very in BMI. Weight was measured using a balance beam large effect [20]. Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 4 of 8 Results 18.3±2.2 kg/m at baseline and after 3, 6 and 12 months, Patient flow respectively. There were missing data from several pa- During 2013 and 2014, 257 patients were referred to the tients at 3, 6 and 12 months, and the weight gain and ef- DED, of which 108 referrals (42%) were not accepted. fect size of this change was therefore not computed. The The main reason for not accepting a referral was that percentage of patients presenting with BMI ≥ 18.5 kg/m the patient had not received treatment at a general psy- at the last observation was 31.8% (n = 7). chiatric outpatient unit (81% of all cases). Among the patients accepted for treatment, 78 (52%) were referred Outcome among patients with severe AN from primary health care and 71 (48%) were referred Seventeen of the 44 patients who started CBT-E pre- from specialized health care. sented with severe AN (BMI < 16 kg/m according to A flowchart for the patients seeking treatment at the DSM-5), of which 7 were completers. Five of these seven DED is shown in Fig. 1. Among the 149 patients 44 pa- patients had a BMI of ≥18.5 kg/m at 12 months after tients started CBT-E (the intention-to-treat sample); starting CBT-E: the BMI in this group of patients was 2 2 their sociodemographic background and illness charac- 14.0±1.1 kg/m at baseline and 18.9±2.1 kg/m after teristics are presented in Table 1. A considerable propor- 12 months. tion of the patients struggled with suicidality thoughts or behaviours and depressive as well as anxiety disor- Discussion ders, as determined by the MINI (version 6.0) and clin- This quality assessment study aimed to describe the pre- ical assessments. post changes in BMI in a sample of consecutive patients treated with CBT-E for AN at a specialized outpatient Intention-to-treat findings eating-disorder unit at a public hospital. There were two The BMI increased from 16.3±1.6 kg/m (mean±SD) at main findings: (i) more than two-thirds of the patients baseline to 18.3±2.2 kg/m (last observation carried for- who completed the treatment achieved a normal weight ward) among all the patients who started treatment (p < after 12 months, and (ii) half of the patients ended the 0.001). Cohen’s d for this change was 1.0 and thus it was treatment prematurely and did not recover to the same classified as a large effect. The percentage of patients level as those who completed the treatment. In addition, presenting with BMI ≥ 18.5 kg/m at the last observation there was a relatively large effect on BMI in this out- was 54.5% (24 of 44 patients). patient setting among a substantial subgroup of the pa- tients with severe AN. These are typical patients who Proportion of patients who completed CBT-E usually are referred to inpatient care or other intensive Half of the patients (n = 22) completed the treatment, medical stabilization treatments, and not to outpatient while 22 patients (50%) ended the treatment prematurely psychological treatment. The implementation of CBT-E for reasons listed in Fig. 1. Completers were significantly for AN allowed patients who previously would have older than non-completers, while their BMI, number of been treated as inpatients to live their ordinary lives years with eating disorder, rate of psychiatric while they were receiving treatment. co-morbidity, number of previous eating-disorder treat- CBT-E for AN was relatively easy to implement in our ment attempts and living situation were all similar (as hospital outpatient unit. Moreover, the results of the listed in Table 1). present quality-assessment study are promising and are in line with those reported for clinical trials that have Outcomes among completers assessed the efficacy of CBT-E [9, 14]. The BMI over the course of treatment for the 22 com- The main problem to address in the future is to reduce pleters is shown in Fig. 2: it was 16.4±1.9, 17.7±1.7, 18.7 the proportion of non-completers. Indeed, the percent- ±1.6 and 19.3±1.4 kg/m at baseline and after 3, 6 and age of non-completers was higher than both that for 12 months, respectively. There was a significant weight CBT-E in the study in UK and Italy (36.4% were gain after 12 months (BMI difference of 2.9±2.3 kg/m , non-completers) and in the CBT-E arm of the SWAN range 0.0–9.8 kg/m , p < 0.001). The effect size for this study (33.3% were non-completers), while it was identi- change was very large (Cohen’s d= 1.7) and the percent- cal to that reported for an Australian effectiveness study age of patients achieving the target BMI of ≥18.5 kg/m on CBT-E in patients with AN [21]. While 77% of the was 36.4, 50.0 and 77.3% after 3, 6 and 12 months, patients who completed the treatment achieved the tar- respectively. get BMI, the high dropout-rate implies that this repre- sents only 39% of all the patients starting CBT-E. Outcomes among non-completers However, it should be stated that the rate of non-mutual The BMI over the course of treatment for the 22 premature termination of treatment was only 34% in the non-completers was 16.2±1.3, 17.2±1.9, 18.0±1.5 and current sample, which is similar to reported rates for Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 5 of 8 Fig. 1 Flow chart over the patients referred to the Department of Eating Disorders during 2013 and 2014 research clinical trials; seven of our patients were re- the top priority for the entire course of the treatment. ferred by our team to intensive treatments or to address Further, factors related to the treatment process itself other co-morbid conditions. It is also possible that some (such as therapeutic alliance and early patient engage- elements of randomized clinical trials missing in our ment in the treatment) warrant attention, and should be clinical settings—such as excluding patients with severe investigated in future studies [24]. AN and actively recalling patients who missed some ses- This study was subject to the following limitations: there sions—might explain the non-completer rate being were missing data, especially from patients dropping out higher for our treatment than for CBT-E research trials. from treatment; no systematic data were obtained on Several studies have indicated that it is difficult to pre-post changes in eating-disorder symptomatology or identify reliable predictors of attrition [22, 23]. In our on a possible diagnostic switch to bulimia nervosa; and we sample non-completers were younger than completers obtained no long-term data describing the clinical situa- (25.6 versus 21.1 years p = 0.03), suggesting that CBT-E tions of the patients after the 12-month assessment. We might be more suitable for older patients. However, also did not assess therapist competence and treatment fi- there were adolescents in both groups, and CBT-E has delity. However, since treatment fidelity was regarded as shown to be a promising treatment also for adolescents crucial for treatment success and essential for the feasibil- with AN [3]. Although we have no data indicating how ity of setting up this treatment, during the weekly 2-h to reduce attrition when implementing CBT-E in a real team meetings adherence to the manual was regularly ad- world clinical setting, the clinical experience that we dressed. However, the main strength of the study is that it gained by this quality improvement project leads us to demonstrated the possibility of effectively implementing suggest the following strategies on how to reduce treat- an evidence-based outpatient treatment for AN in a ment attrition. First, more time and effort should be real-world clinical setting. dedicated to prepare the patients for CBT-E, stressing the importance of giving treatment priority, playing an Conclusion active role and completing the treatment. Second, a CBT-E can be implemented relatively easily in an out- great store should be placed on establishing and main- patient setting at a public hospital. Patients who remain taining therapeutic momentum, stressing the importance in therapy are likely to exhibit a substantial increase in to avoid breaks in treatment. Third, since patients with BMI and thereby avoid costly and life-disruptive in- AN come to treatment with varying degrees of reluc- patient treatments. However, a large subgroup of pa- tance and ambivalence engaging the patient should be tients does not complete the treatment, and the most Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 6 of 8 Table 1 Characteristics of 44 consecutive patients starting CBT-E (enhanced cognitive behaviour therapy) for anorexia nervosa Characteristic All patients Completers Non-completers p n =44 n =22 n =22 Age, years 23.3±6.9 25.6±8.4 21.1±4.2 0.030 Gender, male 1 (2.3%) 0 1 (4.5%) Number of years with ED 6.1 ± 6.0 8.0 ± 6.9 4.3 ± 4.3 n.s. One or more other axis-I disorders 25 (59.5%) 13 (61.9%) 12 (57.1%) n.s. Most-frequent other axis-I disorders and symptoms Current major depressive episode 13 (31.0%) 8 (38.1%) 5 (23.8%) n.s. Recurrent major depressive episode 21 (50.0%) 13 (61.9%) 8 (38.1%) n.s. Suicidality (thoughts or behaviors) 25 (59.5%) 10 (47.6%) 15 (71.4%) n.s. Anxiety disorders 15 (35.7%) 8 (38.1%) 7 (33.3%) n.s. Previous treatment of ED Previous inpatient treatment 13 (31.0%) 6 (27.3%) 7 (35.0%) n.s. Previous outpatient treatment in specialist health care 19 (45.2) 10 (45.5%) 9 (45.0%) Previous outpatient treatment in primary health care 6 (14.3%) 4 (18.2%) 2 (10.0%) No prior ED treatment 4 (9.5%) 2 (9.1%) 2 (10.0%) Living situation With one parent 6 (13.6%) 1 (4.5%) 5 (22.7%) n.s. With both parents 9 (20.5%) 3 (13.6%) 6 (27.3%) Alone 12 (27.3%) 7 (31.8%) 5 (22.7%) With partner 4 (9.1%) 1 (4.5%) 3 (13.6%) With partner and children 5 (11.4%) 3 (13.6%) 2 (9.1%) Without partner but with children 2 (4.5%) 2 (9.1%) – Other 6 (13.6%) 5 (22.7%) 1 (4.5%) Marital status Single 29 (67.4%) 15 (68.2%) 14 (66.7%) n.s. Girlfriend/Boyfriend 5 (11.6%) 3 (13.6%) 2 (9.5%) Partner/Co-habitant 5 (11.6%) 3 (13.6%) 2 (9.5%) Married 4 (9.3%) 1 (4.5%) 3 (14.3%) Occupation Full-time work 2 (4.5%) 1 (4.5%) 1 (4.5%) n.s. Part-time work 6 (13.6%) 3 (13.6%) 3 (13.6%) Labour-market measures 5 (11.4%) 2 (9.1%) 3 (13.6%) School student/apprentice 10 (22.7%) 3 (13.6%) 7 (31.8%) College/University student 17 (38.6%) 11 (50%) 6 (27.3%) On sick leave 3 (6.8%) 2 (9.1%) 1 (4.5%) Disability pension 0 0 0 Other 1 (2.3%) 0 1(4.5%) Baseline body mass index 16.3±1.6 16.4±1.9 16.2±1.3 n.s. Data are mean±SD or n (%) values ED eating disorder, n.s. not significant n = 42 (21 completers, 21 non-completers) n = 42 (22 completers, 20 non-completers) n = 43 (22 completers, 21 non-completers) Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 7 of 8 Author details Department of Eating Disorders, Psychiatric Clinic, Haukeland University Hospital, Bergen, Norway. Department of Clinical Psychology, University of Bergen, Bergen, Norway. Department of Eating and Weight Disorders, Villa Garda Hospital, Garda, VR, Italy. Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway. Institute of Clinical Medicine, University of Oslo, Oslo, Norway. Department of Clinical Psychiatry, University of Bergen, Bergen, Norway. Psychiatric Department, Haukeland University Hospital, Bergen, Norway. Received: 22 February 2018 Accepted: 18 May 2018 References 1. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Fig. 2 BMI over the course of treatment for 22 patients who Arch Gen Psychiatry. 2011;68(7):724–31. completed CBT-E 2. Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B. Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry. 2010;67(10):1025–32. challenging problem for future research to address is 3. 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Treatment protocols for eating disorders: Clinicians’ attitudes, The authors will make de-identified data available on request. concerns, adherence and difficulties delivering evidence-based psychological interventions. Curr Psychiatry Rep. 2016;18(4):36. Authors’ contributions 12. Wallace LM, von Ranson KM. Perceptions and use of empirically-supported YSD, GÅR and CJ contributed to data collection and analysis. UK and YSD psychotherapies among eating disorder professionals. Behav Res Ther. analysed the data. OR and RDG contributed to the research questions, the 2012;50(3):215–22. data interpretation and discussion. YSD, UK and SF drafted the first version 13. Waller G, Stringer H, Meyer C. What cognitive behavioral techniques do of the manuscript. SF, YSD, RDG, OR and UK prepared the final version of the therapists report using when delivering cognitive behavioral therapy for the manuscript. All authors read and approved the final manuscript. eating disorders? 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Consent to participate is not required for quality improvement projects. 18. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development Competing interests and validation of a structured diagnostic psychiatric interview for DSM-IV The authors declare that they have no competing interests. and ICD-10. J Clin Psychiatry. 1998;59(Suppl 20):22–33. 19. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. New Publisher’sNote Jersey: Lawrence Erlbaum Associates; 1988. Springer Nature remains neutral with regard to jurisdictional claims in published 20. Sawilowsky SS. New effect size rules of thumb. J Mod Appl Stat Meth. 2009; maps and institutional affiliations. 8(2):597–9. Frostad et al. Journal of Eating Disorders (2018) 6:12 Page 8 of 8 21. Byrne SM, Fursland A, Allen KL, Watson H. The effectiveness of enhanced cognitive behavioural therapy for eating disorders: an open trial. Behav Res Ther. 2011;49(4):219–26. 22. Fassino S, Piero A, Tomba E, Abbate-Daga G. Factors associated with dropout from treatment for eating disorders: a comprehensive literature review. BMC Psychiatry. 2009;9:67. 23. Linardon J, Hindle A, Brennan L. Dropout from cognitive-behavioral therapy for eating disorders: a meta-analysis of randomized, controlled trials. Int J Eat Disord. 2018;00:1–11. 24. Danielsen YS, Ardal Rekkedal G, Frostad S, Kessler U. Effectiveness of enhanced cognitive behavioral therapy (CBT-E) in the treatment of anorexia nervosa: a prospective multidisciplinary study. BMC Psychiatry. 2016;16(1):342.

Journal

Journal of Eating DisordersSpringer Journals

Published: May 29, 2018

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