Family-Based Treatment in Primary Care: A New Horizon in Eating Disorder Care?

Family-based treatment (aka FBT or the Maudsley Method) is considered the first-line treatment for adolescents with anorexia nervosa. It is also commonly relied upon in the treatment of ‘atypical’ anorexia nervosa. Though FBT is a well-established, effective intervention, finding a therapist trained in this approach can be challenging.

The Problem

There are only 101 certified FBT therapists worldwide. The shortage of providers is an important factor contributing to delays in young patients receiving care. Inaccessibility of the treatment and associated delays may, by extension, increase the severity of the symptoms and worsen prognosis for adolescents with anorexia nervosa — an illness with high mortality and relapse rates. Plus, it is now well established that rates of restrictive eating disorders in youth – and adolescent girls, specifically – have been on the rise over the past five years.

Involving Primary Care, a Potential Solution

Family-Based Treatment for Primary Care (FBT-PC) is a modified version of FBT. Traditionally, FBT is facilitated by a mental health professional such as a psychologist, social worker, or therapist. In FBT-PC,  the eating disorders therapy is provided by a medical provider in primary care. Think: pediatricians, family physicians, nurse practitioners or physician’s assistants.  The adaptation was born out of necessity, and is now being studied for its helpfulness in the real-world setting.

Eating disorders are complex conditions with psychiatric and medical consequences. Medical monitoring is a critical component of care for people with anorexia nervosa. In fact, most adolescents with eating disorders are first identified by their pediatrician or family doctor. This can occur during a routine annual “well” visit or due to associated medical symptoms of the eating disorder. Many families – parents and children alike – also have a longstanding relationship with their provider. Taken together, this could make the primary care setting an ideal place to receive eating disorder treatment, particularly very early on in illness. Researchers who evaluated this treatment are hopeful that receiving care in this setting will improve early and effective intervention.

FBT-PC incorporates the foundational principles of FBT, including:

• weight restoration using a child’s growth curve,
• supporting caregivers in supervising meals and snacks,
• improving compassion for the adolescent by separating the illness, and
• reducing guilt and blame for caregivers.

Along the way, families are provided with information about these brain-based disorders, and the profound impact of starvation on the body and mind.

Preliminary Research

In one initial study, researchers conducted a retrospective chart review. Fifteen adolescents who received FBT from a psychologist certified in FBT were compared with fifteen adolescents who received FBT from a primary care provider. The medical providers received two 90-minute training sessions from therapists specialized in FBT. They also participated in hourlong monthly case consultations from these therapists.

Some changes were made to FBT to make it easier to carry out in a primary care setting. For example, visits were shorter, nurses did the weigh-ins before each session, and siblings were not expected to be involved. Also, the “family meal session” (where parents bring food to the therapy office and eat a meal while the therapist observes and provides feedback) was eliminated from the FBT plan.

Adolescents were seen for a 45-minute intake appointment with their parents. This meeting included education about the medical and psychological consequences of eating disorders and instilled parental confidence in their ability to help their child. The following visits involved problem-solving with parents around how to reach weight restoration, including improving caloric density of meals and snacks, and decreasing or eliminating exercise. Time was also spent aligning parents on their plan. Similar to traditional FBT, appointments were scheduled weekly and then decreased in frequency as progress was made. Follow-up appointments were scheduled for 30 minutes.

Studies have pointed to the importance of early weight gain. If patients in either group did not gain at least 1.8 kg (approximately 4 lbs) in their first 4 weeks, they were referred for more support. This included to traditional FBT, intensive outpatient care, or residential treatment if in FBT-PC and to intensive outpatient or residential if in FBT.

Initial Results

The researchers found no significant clinical differences between the two groups at baseline, with the exception of more purging behaviors in the FBT group. At the end of treatment, 10 patients in the FBT-PC group and 9 patients in the standard FBT group no longer met criteria for an eating disorder according to the DSM-5 (the diagnostic manual used in the U.S.). Twelve patients in the FBT-PC and 13 patients in FBT were weight restored at the end of treatment. Dropout rates and referrals to higher levels of care were similar in each group. Overall, the duration of treatment was shorter in FBT-PC compared to FBT.

There are so many obstacles to accessing eating disorder treatment for adolescents and their parents. FBT-PC may allow more patients and families to connect early and meaningfully with an effective intervention earlier, improving outcomes and decreasing burden on patients, families and our healthcare system. Certainly, more research is needed to learn more.

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