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Evidence on treatment effects for AN has accumulated with findings that family-based intervention is the treatment of choice for adolescent AN (Eisler, 2005; Lock et al., 2010; National Institute for Clinical Excellence, 2004). Studies suggest that inpatient treatment tends to be ineffective in general (Crisp et al., 1991) and specifically for adolescents, with outpatient services achieving superior outcomes (Eisler, 2005; Gowers, Weetman, Shore, Hossain & Elvins, 2000).
Studies in the adult population suggest that only 50% of patients with AN recover (Steinhausen, 2002), whereas in adolescents, approximately 70% recover in the longer term (Herpertz-Dahlmann et al., 2001; Strober, Freeman & Morrell, 1997). The reason for this is unknown, but may be due to the support provided by families. Time scale for recovery was examined in the Treatment Outcome for Child and Adolescent Anorexia Nervosa (TOuCAN) trial by Gowers et al. (2007), who reported that across settings, fewer than one in five fully recovered within a year and a third by 2 years. Evidence for the effectiveness of AN treatment has reported EOT results in categories of good, intermediate and poor (Morgan & Russell, 1975). In Eisler's review of outcome studies (2005), good outcomes ranged from 9% to 60%, intermediate from 6% to 50% and poor from 10% to 31%. More recently, Lock et al. (2010) reported full remission after 12 months of treatment in 42% of their family-based treatment group, and partial remission (intermediate or better) in 89%. Drop-out rate was 14% at EOT.
Hospital admission rates for adolescents with AN vary between 10% and 40% (Eisler, 2005; Lock et al., 2010), with 32% reported in TOuCAN for generic CAMHS during 1 year of treatment. Research has highlighted outpatient treatment as about a tenth of the cost of inpatient treatment (Byford et al., 2007; Eisler, 2005).
Limited information exists to indicate what actually happens in ‘real-world’ clinical care (Richard, 2005), and various authors (e.g. Baker et al., 2010) have raised concerns that important research findings are not transferring into clinical practice.
Gowers et al. (2002) examined service provision for adolescents across 12 countries and found a great variation in intervention methods and length of stay varying at least four-fold between services.
In their survey of clinical practice in outpatient CAMHS, Kleve and Savile (2011) found that most UK clinicians ensured regular weighing of clients (78.7%), 18.1% used individual therapy only, 14.5% family therapy only and 30% a combination of the two. In a Norwegian survey, 79.6% reported individual therapy to be the most common intervention for AN for adults and adolescents (Petterson & Rosenvinge, 2006).
There is also a surprising lack of practice-based evidence and knowledge base to guide the development of effective ED treatment services (Gowers et al., 2007; Richard, 2005). In the absence of a clear strategy for service delivery, the organisation, delivery and monitoring of care provision is mostly left to individual clinicians and teams. Increasingly it is acknowledged that to improve our understanding and ability to help clients, practising clinicians and researchers need to share perspectives.
Among the few studies concerning consumer satisfaction with ED treatment, a perception of limited professional expertise within generic CAMHS has been highlighted (Newton, 2001). The need for clients to be motivated and practitioners to challenge in nonconfrontational ways, treating clients as individuals and to consider their psychosocial and physical functioning was stressed by Tierney (2008).
The aim of this study was to provide a practice-based perspective, describing the organisation, outcome evaluation and user perspective of an eating disorder service based in a community CAMH service.
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This study presents a model and outcomes of ‘real-world’ community care for adolescents affected by ED. In all, 98% of cases with restrictive ED were treated with a family-based approach – a higher figure than reported previously in Europe. Medication was used in a minority of discharged cases and was more likely to have been prescribed for hospitalised clients. Significant improvements were demonstrated: 77% of AN and 82% of EDNOS achieved good Morgan Russell outcomes and none had poor outcomes. This compares favourably with previous treatment trials and with outcomes reported for CAMHS in the TOuCAN trial, where only 19% of treated AN after 1 year and 36% after 2 years were identified as having achieved a good outcome.
The 2% drop-out rate per year was low compared with the 14% reported by Lock et al. (2010). Admission rates (14% of AN per year and 7% of AN and EDNOS together) compare favourably with the TOuCAN trial, where 32% of treated young people with AN receiving community CAMHS treatment had been admitted during the first year of intervention. Service satisfaction ratings were high both from young people and their parents, indicating that they felt listened to, cared for and satisfied with the help they received.
There may be several explanations for the positive results. The AN sample was less underweight when referred than in the TOuCAN trial, although it was similar to Lock et al. (2010). More families were intact compared with the TOuCAN trial, which may have affected parental motivation and hence outcome. Lastly, the current study used end of intervention as the final point in contrast to the planned end points, including intention-to-treat analysis, in most controlled trials. The above points still do not adequately explain the reason for superior results to previous open follow-up studies [see Eisler (2005) for an overview of these].
This study has several methodological weaknesses. The absence of control and comparison groups, a small sample size and no measures of treatment fidelity are obvious limitations. The lack of a complete set of EDEQs also reduces its power. Such limitations are, however, frequent in real-life investigations and should not detract from the fact that it still serves as a clinically relevant supplement to the limited number of real-world studies available on treatment outcomes and community services for adolescent ED. The user perspective, which has hitherto often been neglected in ED research, is an additional and important component. That evidence-based interventions were adopted and positive results achieved within a generic service (although by highly qualified and experienced clinicians) should also be of interest to commissioners. A clear service development plan, evidence -based interventions underpinned by a clear protocol, peer supervision and early referral are likely to be key elements of the success. The combination of core and extended teams has also served to build up reliable and helpful care pathways.
It is recommended that a follow-up study is conducted to identify long-term clinical outcomes. A multi-site study comparing key components of care and outcomes across different outpatient services would further inform our knowledge of existing tier 2/3 service models and variables linked to clinical and financial success.