There is a strong case for early intervention in eating disorders: research suggests that evidence-based treatment applied early in the course of the eating disorder can shape outcomes for the years to come, and a short duration of illness increases the likelihood of recovery. However when left untreated, neurobiological changes in the brain could contribute to the entrenchment of the illness, whilst a number of emotional and psychosocial adaptations function as maintaining factors that reduce prospects of recovery.
Needless to say, early intervention is time critical. People with eating disorders may deteriorate rapidly and this sudden decline is often misinterpreted as the onset of the eating disorder, rather than the cataclysmic culmination of a protracted, undetected struggle. It may provide a catalyst for intervention, but by this stage, the positive outcomes associated with early intervention may be lost to the need for more intensive treatment. A study evaluating the treatment outcomes of adolescents with Anorexia Nervosa who required hospitalisation published in 2000 suggests admission to hospital is the major predictor of a poor outcome. The real-life efficacy of early intervention is limited by a failure to intervene early enough.
Knowing when to intervene isn't easy. The initial symptoms of an eating disorder may be vague, imprecise and almost imperceptible. Anxiety, social withdrawal and alterations in mood or behaviour are easily (and understandably) attributed to specific life stressors, whilst changes in eating habits may emerge with much more subtlety or nuance than stereotypes suggest. People who do not match stereotypical ideas about what someone with an eating disorder looks like, may not be recognised as legitimately experiencing an eating disorder. The diversity amongst people affected by eating disorders and individual differences in the course of the illness make detection a difficult task, which in turn leads to delays in early intervention.
In 2014, South London and Maudsley NHS Foundation Trust (SLaM) conducted the 15-month pilot study FREED (First episode and Rapid Early intervention for Eating Disorders) in southeast London. It aimed to provide rapid assessment and flexible tailored treatment for young adults with eating disorders in the early stages of their illness. Initial results were encouraging, showing that this early intervention made patients much more likely to engage in treatment, reduced treatment drop out, helped patients recover more quickly and was well received by patients and their parents. However, accessing an early intervention programme such as this nonetheless depends on the patient or caregiver having already identified the presence of an eating disorder. This left me wondering: what is going on between the point at which symptoms first emerge, and the point at which people recognise the need for urgent intervention? So I began researching what resources are available in my local area.
Healthcare On Demand is a private clinic in Guildford with an early intervention service for eating disorders, which opened in 2014 - the same year as the FREED pilot study. The clinic is committed to early recognition and early intervention in line with the National Institute for Clinical Excellence (NICE) guidelines. But when I spoke to founder and clinic director, Jane Nathan, she expressed concerns that people were not accessing the early intervention service early enough:
"In setting up the eating disorders clinic, we adopted evidenced based approaches for best practice. However, to our surprise, uptake is currently lower than anticipated. The key reason for this is primarily parents' failure to acknowledge that there is a significant problem - most commonly from one parent in denial, while the other remains seriously worried. This results in significant delays in getting effective help. This is tragic, as it is so much more difficult to achieve recovery when the condition is entrenched".
In addition to the multidisciplinary treatment approach, Healthcare On Demand offers educational resources for families, friends and professionals, including an upcoming workshop, facilitated by a psychotherapist, on understanding and supporting those at risk of eating disorders. Educating caregivers not only increases the likelihood that they will seek professional guidance in the early stages of the illness, workshops like this provide key information about potential treatment options so that they are better equipped to navigate the medical system and pursue appropriate care for their loved one.
"The second major hurdle in delivering an effective early intervention eating disorders service is the variability in GPs' awareness of these conditions. We have some excellent primary care doctors who are mindful that eating disorders, and anorexia in particular, can result in death. However, they often don't know where to refer to, and that is an educational challenge. Our most significant educational challenge lies in the group of "old fashioned" doctors who have been known to say very unhelpful things such as "you don't look that thin to me" or "she is just a picky eater". Such approaches do the young patient a great disservice and can be catastrophic."
It's important to note that not all medical professionals possess a comprehensive understanding of treating eating disorders, nor are they exempt from the negative attitudes, weight bias and popular myths that may delay identification and/or intervention. The constellation of physical and psychological symptoms of an eating disorder frequently require more specialist support than primary care providers can offer, however these doctors often act as gatekeepers to accessing higher levels of care. People who feel that their concerns may not be reciprocated by their GP could benefit from early intervention programmes that do not require having an official diagnosis, and workshops or resources aimed at addressing the early signs of an eating disorder whilst it is at a sub-clinical level.
I am optimistic about what early intervention can achieve for people with eating disorders, but early intervention needs to take place earlier.