New APA Eating Disorder Treatment Guideline

At a plenary session at the ICED meeting in Barcelona, Dr. Joel Yager, professor at the University of New Mexico and EDR‘s Medical Editor, outlined the third revision of the American Psychiatric Association (APA) Practice Guideline for the Treatment of Eating Disorders.

As Dr. Yager told the audience, the 2006 APA practice guideline is the result of extensive literature reviews, updated evidence-based research and feedback from psychiatrists, internists, pediatricians, psychologists, registered dietitians, social workers, and other professionals involved in the assessment and treatment of patients with eating disorders. The committee also drew upon feedback from a large international group of clinical researchers, and considered guidelines of the British National Institute for Clinical Excellence (NICE), Australia and New Zealand, and the Society for Adolescent Medicine. As an indication of the type of clinical input that went into the recommendations, the committee received an unprecedented 598 pages of comments from reviewers, he said. The final recommendations were also derived from evidence- and clinically based data. Dr. Yager added, “The guidelines reflect the values of the Academy of Eating Disorders as much as those of the American Psychiatric Association.”

Supplement Published in July

The Guideline includes three main parts, A, B, and C. Part A, “Treatment Recommendations,” appears in the July 2006 issue of The American Journal of Psychiatry. This supplement contains general and specific treatment recommendations. Part B, “Background Information and Review of Available Evidence,” and Part C, “Future Research Needs,” will not appear in the Journal, but are available with Part A online (see box).

The practice guidelines are based on available evidence and clinical consensus. Each recommendation falls into one of three categories: I. Recommended with Substantial Clinical Confidence; II. Recommended with Moderate Clinical Confidence; and III. May Be Recommended on the Basis of Individual Circumstances.

Underlying Assumptions and Values

The following assumptions and values are included:

• The evidence base (including data and clinical experience) for children and adolescents differs from that for adults.
• Well-conducted small-scale studies that demonstrate the feasibility or effectiveness of particular interventions cannot define community standards until clinicians trained in the application are generally available.
• Good clinical decisions about anorexia nervosa should not rely primarily on simplistic, artificial categories based on percentages of “healthy” body weights.
• Medical testing should be limited to what is required for clinical decision-making for the individual patient.

Changes from the 2000 Guideline

The 2006 APA Guideline contains new definitions of coordination of care, recommended settings for care, and choice of treatment site.

Coordination of care:

• It is not assumed that the psychiatrist is the leader of the treatment team, although the psychiatrist may be the team leader.
• The team approach is the recommended model of care for children and adolescents.
• A complete assessment usually requires at least several hours.
• A full physical examination is strongly recommended and should be performed by a physician familiar with common findings in patients with eating disorders.
• Family involvement and treatment are essential for children and adolescents with anorexia nervosa.

Settings of care criteria:

The committee received much feedback from clinicians expressing concern that weight criteria included in the 2nd edition were too narrowly interpreted by insurance companies and, as a result, patients, families and clinicians were too much at risk or being boxed into low-weight requirements for residential or inpatient care. Thus, the new APA Guideline no longer includes a precise percentage of body weight as an indication for specified settings of care. This parallels the British (NICE), Australian, and New Zealand practice guidelines, according to Dr. Yager.

Choosing a treatment site:

• Adult patients who weigh less than 85% of individually estimated healthy weights have considerable difficulty gaining weight outside of a highly structured program. Such programs, including inpatient care, may be medically and psychiatrically necessary even for patients who weigh more than 85% of their individually estimated healthy weight.

Finally, the Treatment Plan includes fully revised and updated Tables, with self-help books and Internet resources, descriptions of physical complications of anorexia nervosa and bulimia nervosa, lab assessments for patients with eating disorders, and suggested levels of care for patients with eating disorders.