Riccardo Dalle Grave, Arianna Banderali, Sara Campagna, Lucia Camporese, Domenico Filardo, Francesco Iarrera, Marco Massa, Massimiliano Sartirana, Selvaggia Sermattei, Monica Bacchetta, Simona Calugi for AIDAP Scientific Commission
Position paper is presented in English and in Italian language
Guidelines for the treatment of eating disorders are not yet available in Italy, however some documents of clinical appropriateness and consensus have recently been published by the Italian Ministry of Health and the National Institute of Health. These documents recommend with strong emphasis a multidisciplinary treatment for eating disorders and discourage a mono-professional treatment. These recommendations, although they are the result of a broad clinical consensus, do not take in consideration that some evidence-based psychological treatment for eating disorders (e.g., enhanced cognitive behavior therapy (CBT-E) and interpersonal psychotherapy (IPT)) are delivered by a single therapist and not by multidisciplinary teams. On the contrary, the recommended multidisciplinary eclectic intervention has no evidence of efficacy, having never been tested in randomized controlled trials. In this position paper, the Associazione Italiana Disturbi dell’Alimentazione e del Peso (AIDAP) recommends to the Italian eating disorder clinical services to deliver, as first-line intervention, and according to the age and the eating disorder diagnosis of the patient, the following evidence-based psychological treatment: CBT-E (for all the eating disorder diagnostic categories and age), IPT (for adults with bulimia nervosa), family-based treatment (FBT) (for adolescents with anorexia nervosa or bulimia nervosa), and Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) (for adults with anorexia nervosa). The position paper also recommends multidisciplinary treatments should be only implemented and evaluated in some high specialized clinical centers delivering intensive treatments, such as intensive outpatient treatment, day hospital and inpatients, when the patients do not respond to well delivered outpatient evidence-based psychological treatments.
Medicine is not an exact science, and medical and psychotherapeutic practices are even less exact. This explains why a serious health problem, such as eating disorders, can be treated in very different and often contradictory ways. The uncertainty of medical “science” must be added to the different degree of professionals’ update who exercises it. Unfortunately, inadequate treatments can have negative effects on the health and quality of life of the patients and consequently increase the total country’s health cost. To address these problems, for each disease, the indications for the most suitable and effective treatments are provided by a set of tools (i.e., guidelines, consensus conferences, appropriateness assessment) that should be periodically updated. Although the theory indicates that these instruments should represent the fruit of shared work among scientific societies, professional and patients, this rarely happens and often the recommendations are strongly influenced by health, pharmaceutical and political lobbies.
Guidelines for the treatment of eating disorders are not yet available in Italy, however some documents of clinical appropriateness and consensus have recently been published. The Italian Ministry of Health has published two documents. The first describes the clinical, structural and operational appropriateness in the prevention, diagnosis and treatment of eating disorders (Bevere et al., 2013). The second reports the clinical national recommendations for the nutritional rehabilitation in eating disorders (Ruocco et al., 2017). Furthermore, the Italian National Institute of Health published a consensus conference on eating disorders (De Virgilio et al., 2012).
The Associazione Italiana Disturbi dell’Alimentazione e del Peso (AIDAP), which has among its objectives to spread scientific knowledge in the field of prevention, education, treatment and research of eating disorders and weight problems, judges these initiatives important and worthy of attention within the Italian scientific world. However, AIDAP believes that there is the need to make some clarifications and additions to these documents with the aim to provide a correct information to health professionals, patients affected by eating disorders and their families.
The Italian Ministry of Health documents recommend that controlled studies be carried out to compare the various individual and family psychological interventions, both at short- and long-term, and to disseminate evidence-based therapies (Bevere et al., 2013). The Italian Consensus Conference, but also the Italian Ministry of Health documents, claims that mono-professional treatment is not recommended and that the approach for patients with eating disorders should be multidimensional, interdisciplinary, multi-professional integrated, with the involvement of medical doctors (psychiatrists/child psychiatrists, internists/pediatricians), psychologists, psychotherapists, dietitians, nurses, and professional educators). In our opinion, in these recommendations there are some contradictions that deserve to be explained.
Psychological treatments, such as Enhanced Cognitive Behavioral Therapy (CBT-E), Family-Based Treatment (FBT), Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) and Interpersonal Psychotherapy (IPT), are the only evidence-based therapies available for eating disorders and recommended by international guidelines (Hay et al., 2014; National Institute for Health and Care and Clinical Excellence, 2017). It should be emphasized that some evidence-based psychological treatments for eating disorders (e.g., CBT-E and IPT) are delivered by a single therapist and not by multidisciplinary teams. On the contrary, the multidisciplinary eclectic intervention recommended by the Italian Ministry of Health and the Consensus Conference documents has no evidence of efficacy, having never been tested in rigorous randomized controlled trials. This intervention, although unavoidable in severely underweight and complex patients and in intensive settings of care (i.e, intensive outpatient therapy, day hospital and inpatient), presents advantages and disadvantages.
The main advantage is that the presence of clinicians with multiple and heterogeneous skills can facilitate the management of patients with serious medical and psychiatric problems coexisting with the eating disorder, a subgroup of patients typically treated in intensive settings of care places such as day hospital or inpatient. The disadvantages can be divided into four main categories. First, treatment with multiple therapists encourages patients to talk about specific problems with specific therapists. The result is that no therapist observes and appreciates the entire clinical picture of the patient. Second, the application of treatment by therapists who share their knowledge, without a shared theoretical and clinical model, facilitates the communication of contradictory information to the patients about their disorder and the strategies and procedures to address it. This can create confusion in patients about problems to be addressed in order to overcome the eating disorder and to develop of the feeling of not being in control during the treatment. Moreover, it increased the risks to develop divisions and conflicts between team members who may have different beliefs about the strategies to use and the problems to address to treat the patients with eating disorders. The division and conflicts of the team can be used by patients to increase their resistance to treatment. Third, multidisciplinary treatments are very expensive, a fact that should always be taken into great consideration at a time of economic and financial crisis. Finally, eclectic multidisciplinary treatments are difficult to replicate and disseminate.
With the evidence-based psychological treatments delivered by a single therapist in 20-40 sessions, two thirds of the patients who complete the treatment (about 80%) achieve a complete and lasting remission from their eating disorder. For this reason, AIDAP recommends to the Italian eating disorder clinical services to deliver, as first-line intervention and according to the age and the eating disorder diagnosis of the patient, the following evidence- based psychological treatment:
- CBT-E for all the eating disorder diagnostic categories and age
- IPT for adults with bulimia nervosa
- MANTRA for adults with anorexia nervosa
- FBT for adolescents with anorexia nervosa or bulimia nervosa
The advantages of evidence-based psychological interventions, in addition to their effectiveness, are the low costs and the coherent and not contradictory information delivered to the patients. In this way it is possible to obtain an improvement of the standards of care without increasing the financial resources dedicated to the clinical services that treat eating disorders. Unfortunately, as underlined by the Italian Ministry of Health documents, “despite the important progress made with the development of evidence-based psychotherapies, these treatments are rarely applied outside research sites and, most patients continue to receive suboptimal interventions in Italy”.
Multidisciplinary treatments should only be implemented in some high specialized clinical centers delivering intensive treatments, such as intensive outpatient treatment, day hospital and inpatients, when the patients do not respond to well delivered outpatient evidence-based psychological treatments. Even in these centers, however, it is recommended, in order to provide a coherent and non-contradictory approach, that therapists, while maintaining their specific professional roles, share the same philosophy and theory, use evidence-based psychological strategies and a common language with patients, and perform periodic meetings between clinicians and the patient to discuss the various elements of the treatment and the relationship between them.
Finally, AIDAP recommends that all the clinical centers adopting a multidisciplinary approach assess the outcome of their intervention with longitudinal assessment studies made by neutral operators, to understand if and when it is convenient to invest economic resources in these expensive and complex treatments.
- Several studies, some done also in Italy, have showed the efficacy of outpatient psychological treatments, such as CBT-E and IPT, administered by a single therapist in the management of eating disorders.
- With evidence-based psychological treatments, two thirds of patients with eating disorders that conclude the treatment reach a lasting remission in 20-40 sessions.
- The multidisciplinary approach is potentially more useful for severely underweight and complex patients and in intensive care settings, such as intensive outpatient therapy, day hospital or inpatient.
- The multidisciplinary approach should preferably be delivered by teams that adopt a common theoretical orientation based on psychological evidence-based treatments.
- The outcome of the treatment delivered in clinical services using a multidisciplinary and eclectic approach should be assessed.
Bevere, F., Borrello, S., Brambilla, F., Dalle Grave, R., De Lorenzo, A., Di Fiandra, T., … Siracusano, A. (2013). Appropriatezza clinica, strutturale e operativa nella prevenzione, diagnosi e terapia dei disturbi dell’alimentazione. Quaderni del Ministero della Salute(17/22).
De Virgilio, G., Coclite, D., Napoletano, A., Barbina, D., Dalla Ragione, L., Spera, G., & Di Fiandra, T. (2012). Conferenza di consenso. Disturbi del Comportamento Alimentare (DCA) negli adolescenti e nei giovani adulti. Roma: Istituto Superiore di Sanità.
Hay, P., Chinn, D., Forbes, D., Madden, S., Newton, R., Sugenor, L., … Ward, W. (2014). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Australian and New Zealand Journal of Psychiatry, 48(11), 977-1008. doi:10.1177/0004867414555814
National Institute for Health and Care and Clinical Excellence. (2017). Eating disorders: recognition and treatment | Guidance and guidelines | NICE. Retrieved from https://www.nice.org.uk/guidance/ng69
Ruocco, G., Andrioli Stagno, R., Ballardini, D., Cotugno, A., Dalla Ragione, L., Dalle Grave, R., … Vincenzi, M. (2017). Linee di indirizzo nazionali per la riabilitazione nutrizionale nei disturbi dell’alimentazione. Quaderni del Ministero della Salute(29).