NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Centre for Clinical Practice Review of Clinical Guideline (CG9) - Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders.
Background information Guideline issue date: 2004 3 year review: 2008 (Update not required after review of evidence) 7 year review: 2011 National Collaborating Centre: Mental Health
Review recommendation The guideline should not be updated at this time.
Factors influencing the decision Literature search 1. From initial intelligence gathering and a high-level randomised control trial (RCT) search clinical areas were identified to inform the development of clinical questions for focused searches. Through this stage of the process 59 studies were identified relevant to the guideline scope. The identified studies were related to the following clinical areas within the guideline: Anorexia nervosa (AN): psychological treatments, pharmacological treatments, settings for treatment, and economic analysis in both adults and children. Bulimia nervosa (BN): psychological treatments, pharmacological treatments, settings for treatment, and economic analysis in both adults and children
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2. Two clinical questions were developed based on the clinical areas above, qualitative feedback from other NICE departments and the views expressed by the Guideline Development Group, for more focused literature searches. They included: Clinical and cost-effectiveness of psychological or any pharmacological intervention in people (both adults and children) with binge eating disorder Clinical and cost-effectiveness of psychological or any pharmacological interventions in treating children only with anorexia nervosa and bulimia nervosa?
3. In total, 58 studies were identified through the focused searches. New evidence was identified in the following areas; Pharmacological treatments for patients (adults only) with binge eating disorder. A combination of psychological and pharmacological therapy for treating patients (adults only) with binge eating disorder. 4. However, the new evidence identified is insufficient to warrant a formal update of the guideline at this time. The areas of new evidence identified will be taken into consideration in the next review, when the results of ongoing trials (publication dates unknown) on family based treatment for patients with anorexia nervosa, pharmacological treatment options (different classes of drugs) for patients with binge eating disorder and bulimia nervosa, and olanzapine for treatment of adolescents with anorexia nervosa become available. 5. No new evidence was identified which directly answered the research recommendations presented in the original guideline.
6. Few ongoing clinical trials (publication dates unknown) were identified focusing on family based treatment for patients with anorexia nervosa, pharmacological treatment options (different classes of drugs) for CG9 Eating disorders review recommendation July 2011
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patients with binge eating disorder and bulimia nervosa, and olanzapine for treatment of adolescents with anorexia nervosa. Guideline Development Group and National Collaborating Centre perspective 7. A questionnaire was distributed to GDG members and the National Collaborating Centre to consult them on the need for an update of the guideline. Three responses were received with respondents highlighting that since publication of the guideline more literature has become available on the treatment of binge eating disorder, a small amount on anorexia nervosa and bulimia nervosa, and the evidence supporting use of family based treatment for adolescents has become much stronger. This feedback contributed towards the development of the clinical questions for the focused searches.
8. Ongoing research was cited by GDG members including large multicentre treatment studies from Germany, Australia and UK, and Tom Lynch-DBT for AN and Mantra (IoP) trials. Several large scale trials of psychological treatment of anorexia nervosa are currently being conducted that should produce much needed evidence to make clearer recommendations on dose and type of psychological treatment recommended.
9. All three respondents agreed that there is insufficient evidence at this time to warrant an update of the current guideline. Implementation and post publication feedback 10. In total 95 enquiries were received from post-publication feedback, most of which were routine. Key themes emerging from postpublication feedback included queries on where to get audit sheets for eating disorders guideline and what is the treatment for eating disorders in the elderly.
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11. No new evidence was identified through post publication enquiries or implementation feedback that would indicate a need to update the guideline.
Relationship to other NICE guidance None. Summary of Stakeholder Feedback Review proposal put to consultees: The guideline should not be updated at this time. The guideline will be reviewed again according to current processes.
12. In total ten stakeholders commented on the review proposal recommendation during the 2 week consultation period.
13. Six stakeholders agreed with the review proposal recommendation that this guideline should not be updated at this time, while two did not agree and two did not respond either way. 14. Those stakeholders that disagreed with the review proposal commented that: There are issues regarding management of severe AN patients with BMI of less than 14 by specialist inpatient medical team rather than psychiatric inpatient team or managed by both working together in close cooperation. However, no evidence was identified to support the above statement. Another issue raised was use of formal psychiatric interventions, including CBT for weight restoration in patients with BMI less than 15 which may be ineffective to help patients gain weight. Currently in the guideline, psychological interventions including CBT are recommended for use in weight restoration irrespective of the severity of the disease. However, there was no evidence
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identified during the high level RCT search in severe eating disorders patients. There should be further guidance on coordinated regional working involving medical and psychiatric input because there is variation in the access to specialist eating disorder services across regions in the United Kingdom. However, no evidence was identified to support the above statement. There should be guidance on neuropsychological interventions such as cognitive remediation therapy (CRT) which currently is outside the remit of the guideline. The guideline should provide recommendations on re-feeding syndrome and its prevention and management. But the MARSIPAN report (2010) from the Royal College of Psychiatrists is based on expert opinion and they acknowledged that there is no evidence for patients with severe AN and re-feeding syndrome at this time.
15. During consultation, stakeholders suggested new areas to consider that were not included in the original scope: DXA scanning for severely affected individuals. In the current review, evidence was not sought for on this area because it was outside the remit of the original scope. This will be considered at the next review. 16. Individual stakeholder comments can be viewed in Appendix 1. Anti-discrimination and equalities considerations 17. No evidence was identified to indicate that the guideline scope does not comply with anti-discrimination and equalities legislation. The original scope contains recommendations for all patients, both adults and children (above 8 years of age), undergoing treatment for eating disorders (anorexia nervosa, bulimia nervosa and atypical eating disorders).
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18. Through the process no additional areas were identified which were not covered in the original guideline scope or would indicate a significant change in clinical practice. There are no factors described above which would invalidate or change the direction of current guideline recommendations. 19. The Women‘s and Children‘s Topic Selection Consideration Panel had requested the NICE Referral Oversight Group (ROG) in March 2010 to expand current guideline scope to include children under 8-year-old. The Panel proposed that the expansion of the scope should be carried out as part of the guideline update, or as a separate short clinical guideline. This proposal has led to the formulation of clinical questions for focused searches on children with no age restrictions). However, no new evidence was identified for the treatment and management of children with eating disorders (no age restrictions) which would invalidate current recommendations or warrant addition of new recommendations in the guideline at this time. 20. The guideline should not be considered for an update at this time.
Relationship to quality standards 21. This topic is not currently being considered for a quality standard.
Fergus Macbeth – Centre Director Sarah Willett – Associate Director Faisal Siddiqui – Technical Analyst Centre for Clinical Practice July 2011
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APPENDIX 1 NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE CG9 Eating Disorders Review Consultation Comments Table 13-27 June 2011 Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
Association for Family Therapy
Agree
I have a number of concerns about the way in which the Eating Disorders review consultation has been done as it shows a lack of understanding of many of the issues and is likely to reinforce concerns that exist about the way NICE develops its guidelines. The first problem concerns the way that the literature has been reviewed. a. Some papers have been quoted more than once and seem to have been counted more than once, as if they were different papers; b. Several papers by Le Grange, D have been quoted as being by Le GD; c. Different papers from the same study are reported as if they were from different studies; d. A single case study is quoted as
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Comments on equality issues
Response to Stakeholder comments Thank you very much for your comment. In the process of preparing this document, we do not order the full papers and just use the information from the abstracts. These will be rechecked and amended as appropriate.
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
Comments on equality issues
Response to Stakeholder comments
evidence of a ―promising treatment‖ this would be fine if sufficient caution accompanied such a claim, but there is no attempt to review the very many other such studies - there are many of a variety of different treatments. This problem is compounded by the fact that larger case series with longer follow-ups are then missed. All of the above give little confidence in how this preliminary review has been done. Association for Family Therapy
Agree
The second problem concerns the fact that those conducting the review seem to have a very limited understanding of the treatments being used and have relied entirely on descriptive labels used by authors in different papers which misses the fact that different labels often refer to conceptually very similar treatments. For example papers on Enhanced CBT and Focused CBT are described in the review without making any connection between the two. Similarly no clear connection is made between US studies of Family Based Treatment and studies of Family Therapy in the UK when these are essentially the same treatments. These similarities should be reasonably clear just from reading the literature reviews and
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Thank you very much for your comment. In the process of preparing this document, we do not order the full papers and just use the information from the abstracts.
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
Comments on equality issues
Response to Stakeholder comments
discussion sections of these papers as the authors are generally very aware of the issues.
Association for Family Therapy
Agree
The third concern has to do with the unfortunate casual use of the phrase ―other than CBT‖ as if CBT was the accepted comparison treatment in each subgroup. While this might be justified to a degree for adults suffering from bulimia nervosa (BN), where evidence for CBT as reviewed in the existing guidelines is strongest, it did not apply to the earlier review of treatments for adolescent BN and certainly did not apply to the treatment of anorexia nervosa (AN). One of the frequent concerns that many people voice about the way NICE guidelines are developed and written is that CBT is unjustifiably privileged. There are many examples in existing guidelines that one can point to showing that such concerns are not entirely justified but it is very unhelpful if NICE puts out documents of this kind which will reinforce these fears.
Thank you very much for your comment. This information will be passed on to the technical team when the guideline will be updated in the future.
Association for Family Therapy
Agree
In spite of the concerns about the way in which this consultation document has been written and the rather poor review on which it seems to be based, I agree
Thank you very much for your comment.
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Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
with the recommendation that the full review should be delayed. It is certainly the case that there are a number of larger studies in the pipeline (some completed but not yet published, some near completion) which include family therapy and multifamily therapy with children and adolescents, psychodynamic psychotherapies (including mentalisation based therapy) and CBT for adults suffering both from AN and BN. While one could argue that it will always be the case that new studies are just beyond the horizon it is likely that at present the new evidence published since the last guideline would probably not lead to major new recommendations. The evidence in support of family therapy for child and adolescent AN is stronger and might justify moving the recommendation from B to A but that is already largely reflected in practice anyhow. There is new evidence for both CBT and family therapy but again this simply strengthens what previous guidelines have said rather than suggesting a change in direction. This may be different with the new studies that are reaching completion as these may well lead to new and broader recommendations.
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Comments on equality issues
Response to Stakeholder comments
Stakeholder
Agree with proposal to not update?
Comments
British Society of Gastroenterolog y
Update to clarify guidance on illness severity.
Clinical area 3: Anorexia Nervosa – Settings for treatment. The main paper cited (Gowers et al.) relates to adolescents and excluded some of the most severely ill patients. To generalise to adults is therefore potentially dangerous. The economic analysis completely fails to include discussion about the severity of the underlying AN. Inpatient treatment tends to be offered to the most severely ill and includes those admitted to general medical wards for refeeding, and is therefore intrinsically more expensive, but may result in lower death rates for those with the most severe malnutrition who are at risk of life threatening complications such as refeeding syndrome. Keeping the most severely ill alive is bound to be more expensive. The fact that the differences in cost are not statistically significantly different, is therefore remarkable. To suggest that outpatient treatment has the highest probability of being cost effective based, on weak secondary considerations such as ―uncertainty associated with the costs and effects of the three treatments.. being cost effective‖ is therefore potentially very misleading and should not be included in the analysis.
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Comments on areas excluded from original scope
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Comments on equality issues
Response to Stakeholder comments Thank you very much for your comment. This information will be passed on to the technical team when the guideline will be updated in the future.
Stakeholder
Agree with proposal to not update?
British Society of Gastroenterolog y
Do not update: Evidence unclear
British Society of Gastroenterolog y British Society of Gastroenterolog y
Update for clarity.
Comments
Comments on areas excluded from original scope
The economic analysis must include disease severity and effect on mortality / morbidity rates before drawing any conclusions. Clinical area 4: Bulimia nervosa, Psychological treatments: p13 Economic analysis, is misleading. The cost savings in telemedicine are mainly due to reduced travelling costs. To recommend when clinical efficacy evidence is weak and based on 1 study is potentially unsafe, particularly when acceptability vs. efficacy has not been explored. Clinical area 6: BN – settings for treatment. Term ―exceptional circumstances‖ needs definition. Too vague at present.
Guidance urgently required.
CG9 Eating disorders review recommendation July 2011
Response to Stakeholder comments
Thank you very much for your comment. The conclusion was no new evidence was identified which would invalidate current guideline recommendations.
Thank you very much for your comment.
The guidance as published does not address how the physical condition of patients with severe AN, e.g. with rapid significant weight loss, or BMI less than 14, or with significant comorbid medical conditions should be managed. This is relevant as there has been at least 1 fatal
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Comments on equality issues
Thank you very much for your comment. This information will be passed on to the technical team when the guideline will be updated in the future.
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope accident inquiry in Scotland concerning a potentially preventable death where multiple short admissions to acute medical wards led to a failure to take a strategic longer term view, of the patients treatment, and inadequate nutritional support failed to avert death. Refeeding syndrome, and rare complications such as gastric rupture have very high mortality rates and need specialist medical inpatient (as opposed to ―inpatient psychiatric‖) care. The existing guidance is inadequate in this respect. The original guidelines panel did not include a doctor with general medical, and in particular nutritional expertise. NICE guidance on adult nutritional support is
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Comments on equality issues
Response to Stakeholder comments
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope already published and emphasises the importance of nutrition teams and a coordinated approach to nutritional support. In severe AN close liaison between psychiatric services, and specialist nutrition advice, preferably from a gastroenterologist with a nutrition sub-speciality interest, should be encouraged. In a number of areas in the UK eg Aberdeen, inpatient eating disorder units with specialist medical input are already in existence. NICE should be recommending close cooperative joint medical / psychiatric work in the care of severely ill AN patients. Definitions of severity should be tightened, and closer cross referencing with refeeding guidance
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Comments on equality issues
Response to Stakeholder comments
Stakeholder
British Society of Gastroenterolog y
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope in the NICE Nutrition support guidance made. Finally guidance on managing eating disorder patients in the context of the acute medical ward in non psychiatric hospitals ie DGH or Teaching hospitals is urgently required. Most deaths occur in these units. Although MARSIPAN and Junior MARSIPAN have gone to great lengths to correct this discrepancy, and are very welcome, they are still predominantly psychiatrically focussed. A more formal assessment of the medical issues surrounding severe AN, in particular, is required and would be best convened by NICE. The importance of achieving weight gain in severely malnourished anorexic patients has
Updated guidance urgently required.
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Comments on equality issues
Response to Stakeholder comments
Thank you very much for your comment. This information will be passed on to the
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope been re-emphasised in some studies. There is evidence (Mackintosh et al) that Psychotherapies, particularly CBT, delivered as stand alone treatment for low weight anorexia are inferior to standard supportive treatment. Research from cognitive remediation groups (eg Tchaturia et al, Maudsley group) would also suggest that starved brains can behave in ways that resemble those of people with autism, although this may improve with renutrition. Expert experience would support the idea that sophisticated psychotherapies may make it harder rather than more tolerable to recover from anorexia nervosa. Our
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Comments on equality issues
Response to Stakeholder comments technical team when the guideline will be updated in the future.
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
Comments on equality issues
Response to Stakeholder comments
There is significant
Thank you very much
recommendation is that during the early stages of re-feeding psychological efforts are focussed on supporting the distress of weight gain using distraction, containment and other skilled techniques characteristic of (though not limited to) expert specialist nurses In particular early use of formal psychiatric intervention, including CBT may be ineffective, or possibly detrimental in patients with BMIs less than 15. Achieving weight gain may only possible in an inpatient setting in very severely malnourished patients. Clearly this is a controversial area. More guidance is required.
British Society
Guidance
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Stakeholder
Agree with proposal to not update?
of Gastroenterolog y
required.
Comments
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Comments on areas excluded from original scope
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Comments on equality issues
Response to Stakeholder comments
regional variation in the access to specialist eating disorder services, with some regions in the UK having no specialist Psychiatric service for eating disorders, and many having limited access to specialist clinical nutrition teams. Even where clinical nutrition teams exist very few have experience in managing patients with severe AN. In some areas for example the North East of Scotland there is a managed clinical network for eating disorders in place. In England and Wales a move towards coordinated Regional working involving Medical and Psychiatric input should be explored
for your comment. This information will be passed on to the technical team when the guideline will be updated in the future.
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
Comments on equality issues
Response to Stakeholder comments
and guidance on this is required. British Society of Gastroenterolog y
Disagree with proposal not to update
Evidence contained in the review proposal document does indicate areas that would warrant a focussed re-write of certain areas of the guidance.
British Society of Gastroenterolog y
Disagree with proposal not to update
EDNOS and Binge-Eating disorder are linked areas that contain a number of reasonable developments in knowledge with practice implications: Example is Fairburn et al (2009, AmJ Psych) work on EDNOS. It is a mistake to my mind to neglect an area that represents the greatest single percentage group that a referred to specialist services.
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Thank you for your comment. However, the new evidence identified for the areas is considered insufficient to warrant a formal update of the guideline at this time. The areas of new evidence identified will be taken into consideration in the next review, particularly when the results of the ongoing trials become available. Thank you for your comment. However, the new evidence identified for the areas is considered insufficient to warrant a formal update of the guideline at this time. The areas of new evidence identified will be taken into consideration in the next review, particularly when the results of the ongoing trials become
Stakeholder
Agree with proposal to not update?
Comments
British Society of Gastroenterolog y
Disagree with proposal not to update
In respect of BED specifically the review proposal document itself outlines a number of studies that have practice implications, and given the current population health implications of obesity certainly a re-write would benefit by driving further research in this area, as well as guiding onward development of services to meet this need.
British Society of Gastroenterolog y
Disagree with proposal not to update
In the 2004 document the importance of starvation syndrome on cognition and hence likely response to psychological therapies is only briefly touched upon. There is evidence around this issue and any management guideline should offer a fuller summary of this, as it has important implications.
British Society of Gastroenterolog y
Disagree with proposal not to update
CG9 Eating disorders review recommendation July 2011
Comments on areas excluded from original scope
Response to Stakeholder comments available. Thank you for your comment. However, the new evidence identified for the areas is considered insufficient to warrant a formal update of the guideline at this time. The areas of new evidence identified will be taken into consideration in the next review, particularly when the results of the ongoing trials become available. Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated in the future.
Likewise neuropsychological evidence on Eating disorders has evolved considerably since the last revision, and does have treatment implications
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Comments on equality issues
Thank you for your comment.
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
Comments on equality issues
Response to Stakeholder comments
such as via Cognitive remediation therapy. CRT itself has emerging data that may merit inclusion. British Society of Gastroenterolog y British Society of Gastroenterolog y
Disagree with proposal not to update
British Society of Gastroenterolog y
Disagree with proposal not to update
The physical risks of Anorexia nervosa could be described more fully with more thorough management guidelines attached.
Disagree with proposal not to update
Thank you for your comment.
Re-feeding syndrome with respect to prevention and management, because of the high risk attached to it, merits further description and practice guidelines developed or referenced. The RCPsych document MARSIPAN AND Junior MARSIPAN emphasise‘s this more appropriately. The use of atypical antipsychotic medication is now widespread, especially of Olanzapine. The evidence around this has been increased recently and deserves further work in the guidelines. The risks attached to inappropriate usage are significant and further full consideration is thus required.
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Thank you for your comment.
Thank you for your comment. However, the new evidence identified for the areas is considered insufficient to warrant a formal update of the guideline at this time. The areas
Stakeholder
Agree with proposal to not update?
BSPGHAN
Agree – not update
College of Occupational Therapists
I agree with the proposal not to update the clinical guideline given the current evidence base
Comments
Comments on areas excluded from original scope
May I draw your attention to a pilot study called ‗The St George‘s Eating Disorders Service Meal Preparation Group for inpatients and day patients pursing full recovery: A pilot study‘ (Authors: Laura Lock, Hilary Williams, Dr Bryony Bamford and Prof Hubert Lacey) which is due for imminent publication
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Response to Stakeholder comments of new evidence identified will be taken into consideration in the next review, particularly when the results of the ongoing trials become available. Thank you for your comment.
Based on their evidence update, NICE do not see any reason to change the guideline. Given that nutritional strategies are barely considered in the guideline, and it is not a section where there is any new evidence (as has been highlighted and summarised for other interventions), we do not see the need for any specific comments from BSPGHAN.
CG9 Eating disorders review recommendation July 2011
Comments on equality issues
Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated in the future.
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
Comments on equality issues
Response to Stakeholder comments
within the European Eating Disorders Review. This naturalistic cohort study indicates that meal preparation training for inpatients and day patients pursuing full recovery is effective and durable. Department of Health Hertfordshire Partnership Hertfordshire Partnership NHS Foundation Trust .
I wish to confirm that the Department of Health has no substantive comments to make, regarding this consultation (1.4, NICE 2004) The guideline states that there should be a clear agreement between healthcare professionals in monitoring patients.
Thank you for your comment. There are some difficulties in implementing this. Is there any scope to expand this to include more details? i.e who, when, etc.?
Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated in the future. Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated in the future. Thank you for your comment. This information will be passed on to the
Hertfordshire Partnership NHS Foundation Trust .
(3.2, NICE 2004) Where it says severe emaciation,
Would it be better to have an indicative BMI?
Hertfordshire Partnership NHS Foundation Trust .
(4.5 and 4.6, NICE 2004)
Could be coalesced to one single point.
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Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
Comments on equality issues
Response to Stakeholder comments
Hertfordshire Partnership NHS Foundation Trust .
Under Anorexia nervosa
Hertfordshire Partnership NHS Foundation Trust .
(2.4, NICE 2004) Under the aims of therapy,
Can we include one of the aims as to help to understand the meaning of the symptoms e.g. restriction, binge/purging?
Hertfordshire Partnership NHS Foundation Trust .
(5.2, NICE 2004) It is specified that inpatient or day care options should be considered for patients with AN who have not improved.
What about severe and enduring patients who are within the anorexic range but maintaining their BMI between13.517.5. Do we admit them or provide day care?
technical team when the guideline will be updated in the future. Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated in the future. Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated in the future. Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated in the future.
Hertfordshire Partnership NHS Foundation Trust .
Bulimia Nervosa
This might not be the case always. The sentence may be made more tentative. IPT as a model is now structured to typically offer 16
Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated
(1.3, NICE 2004) Guideline specifies an annual health check in severe and enduring eating disorder clients.
(1.5, NICE 2004) Under IPT it says that patient should be informed that it takes 812 months to achieve the results comparable to CBT.
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It may be necessary to do them more frequently e.g once in six months?
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
in the future.
Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated in the future. Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated in the future.
(4.2 & 4.3 , NICE 2004) could be combined.
Could be combined.
Hertfordshire Partnership NHS Foundation Trust .
(1.3.1.4, NICE 2004 &7.2.4 of full guideline) When people with bulimia nervosa have not responded to or do not want CBT, other psychological treatments should be considered.
Based on the new evidence, it would be helpful if NICE could give specific examples of the ‗other psychological treatments‘ that should be offered (e.g. group therapy?, guided selfhelp, etc)
General comment on NICE 2004. Occasionally, the various individual standards have multiple components which mean that clinicians/services can be compliant with some but not all components of a specific individual standard (e.g. 1.2.4.2 Regular physical
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Response to Stakeholder comments
sessions (i.e. 4-6 months). Hertfordshire Partnership NHS Foundation Trust .
Hertfordshire Partnership NHS Foundation Trust . Hertfordshire Partnership NHS Foundation Trust .
Comments on equality issues
Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated in the future.
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
Comments on equality issues
Response to Stakeholder comments
monitoring, and in some cases treatment with a multi-vitamin/multi-mineral supplement in oral form, is recommended for people with anorexia nervosa during both inpatient and outpatient weight restoration.)
Hertfordshire Partnership NHS Foundation Trust .
Having individual standards with multiple components complicates auditing of the NICE guidelines. For example with standard 1.2.4.2, a clinician/service could routinely ensure that regular physical monitoring was carried out but be (non)compliant with other components of the same standard (i.e. considering treatment with multi-vitamin/multi-mineral supplement in oral form in inpatients but not outpatients)? Perhaps the new guidelines should attempt to have fewer components (ideally only one) in every individual guideline even if it increases the total number of guidelines. (NICE, 2004, key interventions, page 4) states: ―Family interventions that directly address the eating disorder should be offered to children and adolescents with anorexia nervosa‖.
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Should NICE expand this statement to include ―young adults‖ based on the evidence – the current guidance implies that family therapy is only indicated till a day th before the patient‘s 18
Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated in the future.
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
Comments on equality issues
Response to Stakeholder comments
birthday. Including ―young adults‖ in the guidance will ensure that family work can continue in adult services which would improve transition between services as well as ensure that family therapy is more regularly commissioned in adult services.
Hertfordshire Partnership NHS Foundation Trust .
(1.2.2.1, NICE 2004)Therapies to be considered for the psychological treatment of anorexia nervosa include cognitive analytic therapy (CAT), cognitive behaviour therapy (CBT), interpersonal psychotherapy (IPT), focal psychodynamic therapy and family interventions focused explicitly on eating disorders.
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Young adults are often still dependent on their parents/carers which means that families need to be included in treatment by adult services. Based on the evidence, would NICE perhaps consider replacing the words ―family interventions‖ with ―family therapy‖ throughout the guidance. The current guidance creates the perception that ―Interventions‖ (as
Thank you for your comment. This information will be passed on to the technical team when the guideline will be updated in the future.
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
Comments on equality issues
Response to Stakeholder comments
opposed to) ―therapy‖ suffice - meaning less robust levels of family treatment could be offered by less skilled/trained clinicians. Formal family therapy as treatment modality (rather than low level informal family interventions) are used in the treatment and most research trials for people with eating disorders. Similarly, ‗therapy‘ (rather than ‗interventions‘) are recommended by the guidelines for other treatment modalities i.e. CAT, CBT, IPT and focal psychodynamic therapy. Nottinghamshire healthcare NHS Trust
Agree guidelines need updating
Nottinghamshire
Agree
Previous guidelines very non-specific in part due to poor evidence base within eating disorders. However over time, better studies emerging and more specific guidelines would be useful. Physical health-care pathways could be
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Thank you for your comment.
Thank you for your
Stakeholder
Agree with proposal to not update?
Comments
healthcare NHS Trust
guidelines need updating Agree
more specific.
comment.
At present, as the review authors state, there is not a great deal of new information which would markedly change the current guidelines. I therefore agree to delay BUT would add the caveat that this delay be not too long, as there are pieces of research currently being done which could usefully be included in the future near future.
Thank you for your comment.
Agree
I would just take exception to the implication that there is nothing new that could be added to the guidelines from the paper: McIntosh VV, Jordan J, Carter FA et al. (2005) Three psychotherapies for anorexia nervosa: a randomized, controlled trial. American Journal of Psychiatry 162: 741-7. This piece of work shows the benefit of combined supportive psychotherapy and clinical management and is valuable because this is what many therapists end up doing out of the impracticality of sticking to one pure model. This is a new addition to the current 5 pure models in the NICE guidelines, and I would hope this be included in the updated guidelines.
Thank you for your comment. However, the new evidence identified for the areas is considered insufficient to warrant a formal update of the guideline at this time. The areas of new evidence identified will be taken into consideration in the next review, particularly when the results of the ongoing trials become available.
Nottinghamshire healthcare NHS Trust
Nottinghamshire healthcare NHS Trust
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Comments on areas excluded from original scope
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Response to Stakeholder comments
Stakeholder
Agree with proposal to not update?
Comments
Royal College of Nursing
Disagree with proposal to not update
We consider that the guideline would benefit from an update particularly with regards to the management of eating disorder in children and adolescents.
Royal College of Nursing
Comments on areas excluded from original scope
We are aware of the Maudsley Model, based on the work of Ivan Eisler and colleagues and that the outcome studies recently produced demonstrate significantly better results than research available when the guidelines were published. Eisler I, Simic M, Russell GF et al. (2007) A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-year follow-up. Journal of Child Psychology & Psychiatry & Allied Disciplines 48: 552-60. The evidence is robust and the wider NHS including commissioners could benefit from guidance to replicate this in all
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Comments on equality issues
Response to Stakeholder comments Thank you for your comment. However, the new evidence identified for the areas is considered insufficient to warrant a formal update of the guideline at this time. The areas of new evidence identified will be taken into consideration in the next review, particularly when the results of the ongoing trials become available. Thank you for your comment. This study has been included in this review. However, the new evidence identified for the areas is considered insufficient to warrant a formal update of the guideline at this time. The areas of new evidence identified will be taken into consideration in the next review, particularly when the results of the ongoing trials become
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
service delivery to children and young people. There has been significant development in the evidence round CBT. The evidence in the original guideline was sourced in 1993 and there have been new developments since then.
Royal College of Nursing
Fairburn CG, Cooper Z, Doll HA, O‘Connor ME, Bohn K, Hawker DM, Wales JA, Palmer RL (2009). Transdiagnostic cognitive behavioral therapy for patients with eating disorders: A two-site trial with 60-week follow-up. American Journal of Psychiatry 2009; 166: 311-319.
Royal College of Nursing
Royal College of Paediatrics and Child Health
Yes
There is a shared viewed among health professionals that one particular area that could benefit from the tightening up of the recommendation is that relating to CBT. The College notes there is no new evidence to suggest altering the guideline at the present time. The review document is a very useful summary of recent relevant research. There is promising new evidence
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Response to Stakeholder comments available. Thank you for your comment. This study has been excluded in this review, as it wasn‘t looking at a specific type of eating disorder but generically looking at eating disorders which is one of the exclusion criteria in this review..
Thank you for your comment.
Thank you for your comment.
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
Comments on equality issues
Response to Stakeholder comments
regarding family-based therapies and possibly psychopharmacological treatments for adolescents, but larger trials are ongoing.
Royal College of Paediatrics and Child Health
Royal College of Paediatrics and Child Health Royal College of Paediatrics and Child Health
We think it would be more sensible to wait until the results of current ongoing research trials have become available. In relation to children, the evidence on the effectiveness of family therapy in bulimia seems to imply a stronger emphasis on family therapy than is expressed in the guideline. Otherwise, it is disappointing how little this profuse body of research has expanded the repertoire of effective treatments.
We note the issue of availability of CBT in regards to implementing the guidance in remote areas. While we do not disagree with the content of the review proposal, we believe that other elements of the published guideline warrant reconsideration – in particular, in regards to the contents on pages 97 to
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Thank you for your comment. However, the new evidence identified for the areas is considered insufficient to warrant a formal update of the guideline at this time. The areas of new evidence identified will be taken into consideration in the next review, particularly when the results of the ongoing trials become available. Thank you for your comment. Thank you for your comment. This information will be passed on to the technical team when the
Stakeholder
Agree with proposal to not update?
Comments
Comments on areas excluded from original scope
100 wherein bone health in eating disorders is dealt with specifically. All below comments pertain to sections 6.4.6 and 6.4.7, pp97-100. Section 6.4.6 (p97) End of 2nd paragraph: BMC accrual" in girls with anorexia nervosa (AN) is different; there is not a ―failure‖ in BMC accrual. Section 6.4.6 (p97) Start of 3rd paragraph: Failure of BMC accretion does not necessarily compound bone loss in children; rather, there is impaired gain in bone mass, similar to what happens in growth retardation. Section 6.4.6 Osteoporosis (p98) 1st paragraph: ―an increased fracture rate‖ but without large control groups. This statement has no evidence backing for children and adolescents with AN. Section 6.4.6 Osteoporosis: Adolescents (p98) 4th sentence: The study of Castro et al 2001 categorized adolescents with "established osteopenia" if z-score
