NICE Guideline for Eating Disorders: Implications for Clinical Practice

Transcription

1 NICE Guideline for Eating Disorders: Implications for Clinical Practice Ivan Eisler Emeritus Professor of Family Psychology and Family Therapy South London and Maudsley NHS Foundation Trust

2 NICE guideline for eating disorders A guideline for identifying the best evidence based treatments? or A guideline for evidence based practice?

3 Evidence based treatments Well defined treatments (operationalised in a treatment manual) Delivered by trained therapists Based on a defined psychological theory Supported by evidence from controlled studies in defined populations Chambless & Hollon Defining empirically supported therapies. Journal of consulting and clinical psychology, 66, Laska, Gurman, and Wampold Expanding the lens of evidence-based practice in psychotherapy: a common factors perspective. Psychotherapy, 51(4), p.467.

4 Evidence based practice 1. Informed by the best available empirical evidence 2. Expert clinical judgment 3. Client and family preferences Sackett et al (1996) Evidence based medicine: what it is and what it isn't. BMJ. 312, 71-2 Rawlins (2008) De Testimonio. On the Evidence for Decisions about the Use of Therapeutic Interventions. Clinical Medicine, 8, Kazdin (2008) Evidence-Based Treatment and Practice: New Opportunities to Bridge Clinical Research and Practice, Enhance the Knowledge Base, and Improve Patient Care American Psychologist, 63,

5 NICE Guideline for Eating Disorders as a guide to evidence based treatments [The guideline] aims to improve the care people receive by detailing the most effective treatments for anorexia nervosa, binge eating disorder and bulimia nervosa.

6 NICE psychological treatment recommendations for adults AN BN BED Adults 1 st line Individual ED focused CBT (CBT-ED) Maudsley AN Treatment for Adults (MANTRA) Specialist Supportive Clinical Management (SSCM) 2 nd line Either of 1 st line treatments not tried already or AN focused Focal Psychodynamic Therapy (FPT- ED) Comments All treatments moderate outcomes, no clear differences FPT-ED 2 nd line largely for pragmatic reasons 1 st line BN focused guided self-help (GSH-BN) Discontinue if ineffective after four weeks 2 nd line ED focused cognitive behavioural therapy (CBT-ED) If GSH-BN unacceptable or contraindicated, consider CBT-ED 1 st line BED-focused guided self-help (GSH-BED) Discontinue if ineffective after four weeks 2 nd line group ED focused CBT (group CBT-ED) or if unavailable/unacceptable individual CBT-ED)

7 NICE psychological treatment recommendations for children and young people AN BN BED Children and young people Comments 1 st line Anorexia nervosa focused family therapy (FT-AN) Either as single family therapy or a combination of single and multi-family therapy 2 nd line ED focused CBT (CBT-ED) or adolescent-focused psychotherapy for anorexia nervosa (AFP-AN) 1 st line Bulimia nervosa focused family therapy (FT-BN) 2 nd line ED focused cognitive behavioural therapy (CBT-ED) 1 st line Consider treatment recommendations for adults 2 nd line

8 Additional general recommendations include psychoeducation about the disorder include monitoring of weight, mental and physical health, and any risk factors be multidisciplinary and coordinated between services involve the person's family members or carers (as appropriate). only offer dietary counselling as part of a multidisciplinary approach Do not offer medication as a sole treatment for eating disorders do not offer a physical therapy (such as transcranial magnetic stimulation, acupuncture, weight training, yoga or warming therapy) as part of the treatment for eating disorders

9 Why look beyond the narrow focus of empirically supported treatments

10 Methodological limitations Many of the studies relatively small Studies mainly conducted by treatment developers with very limited replications Not all studies had sufficient blinding Comparisons between studies difficult due to: Limited agreement on outcome criteria making comparisons and drawing conclusions about rates of recovery or remission difficult Considerable variability in study context between studies indifferent countries (differences in recruitment, use of hospital admissions

11 Common criticisms of NICE Relies on a narrow definition of what counts as relevant evidence Confuses operational description of psychological treatment (i.e. a manual) with the treatment itself Ignores the role of clinical judgment and patient preferences and values that are crucial in tailoring treatments to specific patients/families Ignores evidence of the complex relationship between treatment adherence and outcome Ignores common factors in therapy Gives insufficient attention to the service context of treatment delivery

12 The role of extra-therapy factors Therapeutic alliance [CATEGORY NAME] (e.g. duration, comorbidity, motivation, family context) [PERCENTAGE] [CATEGORY NAME] (e.g. therapist attributes, expertise, service context) [PERCENTAGE] Model & Techniques 15% Hope & Expectancy 15%

13 NICE Guideline for Eating Disorders The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in the guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian

14 Why a new guideline New research on treatment outcomes New evidence on the role of extra-therapy factors on Case identification Use of inpatient and/or day care management Quality of treatment delivery

15 Improving access to services People with eating disorders should be assessed and receive treatment at the earliest opportunity. If an eating disorder is suspected after an initial assessment, refer immediately to a community-based, age-appropriate eating disorder service for further assessment or treatment

16 London care pathways study In areas with direct access from primary care to specialised multidisciplinary out-patient services, identification of CYP who require treatment is 2-3 times higher than in areas with no specialist care Dedicated community ED CYP Services (CEDS CYP) manage 80-90% of referrals on an outpatient basis compared to 50-60% in generic CAMHS The average cost of treatment of child and adolescent AN are 2-3 times lower in CEDS-CYP than in generic services House et al 2012 Comparison of specialist and non-specialist care pathways for adolescents with anorexia nervosa and related ED, Int J Eat Dis, 45, )

17 The role of extra-therapy factors Early identification and easy access to treatment [CATEGORY NAME] (e.g. duration, comorbidity, motivation, family context) [PERCENTAGE] Therapeutic alliance [CATEGORY NAME] (e.g. therapist attributes, expertise, service context) [PERCENTAGE] Specialist MDT Expertise Model & Techniques 15% Hope & Expectancy 15%

18 Developing Community ED Services for CYP in England

19 Maximizing the reach of interventions Low key (low cost) interventions as part of a stepped care approach Guided self help for adult BN and BED Early identification and and easy access to dedicated community based ED treatments Child and adolescent eating disorders

20 NICE Guideline for Eating Disorders The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in the guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian