- Email: [email protected]
Top 10 research priorities for eating disorders
Correspondence
Sarika Chaturvedi, *Bhushan Patwardhan [email protected] Center for Complementary and Integrative Health, Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Ganeshkhind, Pune 411007, India 1
For more on the Eating Disorder Priority Setting Partnership (in Dutch) see https:// powertorecover.nl/
2
For the James Lind Alliance guidebook see http://www.jla. nihr.ac.uk/guidebook
3
4
5
For Eating Disorder PSP Steering Group members (in Dutch) see https:// powertorecover.nl/over-ons/ For more on Proud2BMe see http://www.Proud2Bme.nl
706
Thirthalli J, Zhou L, Kumar K, et al. Traditional,complementary, and alternative medicine approaches to mental health care and psychological wellbeing inIndia and China. Lancet Psychiatry 2016; published online May 18. http://dx.doi.org/10.1016/S2215366(16)30025-6. Charlson FJ, Baxter AJ, Cheng HG, Shidhaye R, Whiteford HA.The burden of mental, neurological and substance use disorders inChina and India. Lancet Psychiatry 2016; published online May 18. http://dx.doi. org/10.1016/S0140-6736(16)30590-6. Travis FT, Wallace RK. Dosha brain-types: a neural model of individual differences. J Ayurveda Integr Med 2015; 6: 280–85. Patwardhan B. Bridging Ayurveda with evidence-based scientific approaches in medicine. EPMA J 2014; 5: 5–19. Broderick J, Crumlish N, Vancampfort D. Yoga as part of a package of care versus standard care for schizophrenia (Protocol). Cochrane Database Syst Rev 2016; 4: CD012145.
Top 10 research priorities for eating disorders The lifetime prevalence of all eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder, and related syndromes) is about 5%. 1 “Recent comprehensive estimates suggest that 20 million people in the European Union have an eating disorder, with a cost of about €1 trillion per year (financial costs of about €249 billion plus burden of disease costs of about €763 billion)”.2 Eating disorders can be associated with substantial and prolonged physical and psychosocial morbidity. The causes of eating disorders are incompletely understood. New treatments are being developed and tested but progress is slow because of insufficient research funding. 1,2 For example in the UK the funding disparity is reflected by the difference in funding for eating disorders—0·4% of mental health research expenditure—versus 4·9% for psychosis and 7·2% for depression.3 It
is therefore imperative that research funds are directed to the questions that are important to those affected. In collaboration with the James Lind Alliance, a UK National Institute for Health Research-supported initiative, founded in 2004, which aims to identify gaps in knowledge that matter most to patients, carers and clinicians, we convened a multi-disciplinary Priority Setting Partnership that sets the research agenda for eating disorders. The James Lind Alliance priority setting process involves four stages:4 collection of patients’, carers’ and clinicians’ questions, checking of existing research evidence to establish which remained unanswered, interim prioritisation of the verified unanswered questions, and a final consensus priority setting workshop to establish the top ten research priorities. From Feb 1, 2015, to June 3, 2016, we undertook a Priority Setting Partnership to define the research agenda for eating disorders. Via a large Dutch e-community for eating disorders Proud2BMe, the Dutch patient and carer organisation WEET,
and the Dutch Academy for Eating Disorders, we invited individuals with or recovered from an eating disorder, their families and clinicians involved in the treatment of eating disorders, to submit questions via our webportal. The webportal was visited more than 3500 times. We received 956 submissions from 412 respondents (340 patients with an eating disorder). Submissions were collated, grouped into themes, and indicative research questions were generated for prioritisation. If insufficient evidence was indicated by a relevant, reliable systematic review or clinical guidelines, indicative questions were classified as “true uncertainties”. In the interim prioritisation survey patients, carers and clinicians were randomly presented with 77 indicative research questions. They were asked to select all questions they viewed as a high priority for research and were then asked to rank these into a top ten. The results of 375 respondents, of whom 32% had submitted a question in phase 1, were weighted separately for patients, carers and clinicians to ensure equal influence.
Panel: Top ten research priorities for eating disorders 1 Which factors influence the duration of recovery and the possibility of complete recovery? 2 Which patient and disorder-related features can be used to provide more personalised treatment? 3 Is it more effective to address the eating disorder symptoms first or the underlying problems? 4 What is the most effective treatment (and order of treatment) for patients with an eating disorder and a co-morbid disorder? 5 Which treatment setting (outpatient, at home, day treatment, inpatient or residential, with or without parents) provides the best treatment outcome? 6 How can loved ones contribute to the recovery process of the eating disorder? 7 Are there specific risk factors for the development of an eating disorder, and if so, how can prevention target these? 8 What is the influence of the quality of the working relationship between the treatment team and the patient on treatment outcome? 9 Is it better to use a protocol based on a guideline or to tailor treatment to the individual? 10 What causes the need for self-destructive behaviour in patients with an eating disorder?
www.thelancet.com/psychiatry Vol 3 August 2016
Correspondence
The overall collated top 22 questions, each mentioned by more than 100 respondents, were then taken to the final prioritisation workshop. At the final prioritisation workshop, patients, carers and clinicians, using an inclusive facilitated approach developed by the James Lind Alliance, agreed the final order of the 22 presented research questions in a series of three rounds of discussion and decision-making. The final top ten research priorities for eating disorders focus on important aspects of treatment, prevention, and the role of carers in the recovery process (panel). All true uncertainties identified via this Priority Setting Partnership will be uploaded to the James Lind Alliance website, where it publishes the output of all its Priority Setting Partnerships. This research agenda for eating disorders should now inform the scope and future activities of funders and researchers. We declare no competing interests. This project was supported by funding provided by the Netherlands Foundation for Mental Health (Fonds Psychische Gezondheid, 2014 6837). EvF was involved in all phases of this research project and had the idea for the project. AvdM was involved in data collection, data analysis, data interpretation and writing. KC was involved in the planning of the project, study design, data interpretation and writing.
Eric F van Furth, Angela van der Meer, Katherine Cowan [email protected] Rivierduinen Eating Disorders Ursula, POB 405, 2300 AK Leiden, the Netherlands (EFvF, AvdM); Department of Psychiatry, Leiden University Medical Centre, Leiden, the Netherlands (EFvF); and James Lind Alliance, National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, Southampton, UK (KC) 1 2
3
4
Treasure J, Claudina AM, Zucker N. Eating disorders. Lancet 2010; 375: 583–93. Schmidt U, Adan R, Böhm I, et al. Eating disorders: the big issue. Lancet Psychiatry 2016; 3: 313–15. MQ Landscape Analysis. UK Mental Health Research Funding, April 2015. http://b.3cdn. net/joinmq/1f731755e4183d5337_ apm6b0gll.pdf (accessed June 3, 2016). The James Lind Alliance Guidebook, version 6, 2016. http://www.jla.nihr.ac.uk/guidebook (accessed June 3, 2016).
www.thelancet.com/psychiatry Vol 3 August 2016
Investment in mental health services urgently needed in Nepal We applaud Dan Chisholm and colleagues1 for their work on scaling up treatment for depression and anxiety as published in The Lancet Psychiatry. The researchers used the global point prevalence rate of 7·3% for anxiety disorders, 3·2% for depression in men, and 5·5% for depression in women.1 For countries in crisis, the burden of mental health illness might be higher. In Nepal, a decade-long armed conflict was responsible for more than 10 000 deaths, and displacement of more than 100 000 people between 1996 and 2006.2 Violent agitations, killings, and destruction of public property continued to 2015. On April 25, 2015, a major earthquake followed by several aftershocks left the country with more than 9000 deaths, 23 000 injured,2 and more than 2 million homeless people. This disaster was exacerbated by economic blockade that further hampered recovery. We searched MEDLINE on Feb 25, 2016, using the search terms: “mental health” or “mental disorder” and “Nepal”, limiting the search to studies published in the English language. We identified two reviews (2010 and 2015)3,4 that included eight individual studies and summarised that there was a high (37·5%) prevalence of mental health disorders in the general population in Nepal: 4 depression (30%), anxiety (28%), and distress (42%) in rural community settings.3 Among specific groups, there were similar high rates of disorders;4 for example, 3–4% of Bhutanese refugees had post-traumatic stress disorder (PTSD); 34% had anxiety, and 14% had depression; 53% of internally displaced people had PTSD, 81% had anxiety, and 80% had depression; 60% of torture survivors had PTSD
60%, 86% had anxiety, 81% had depression; and 55% former child soldiers had PTSD, 46% had anxiety, and 53% had depression. Chisholm and colleagues1 estimated that total economic returns would be 2·3 to 3·0 times higher than the investment and 3·3 to 5·7 times higher if all health benefits were included. Their estimates did not include PTSD; therefore, the figures could be an underestimation for a country like Nepal with a high PTSD burden. However, the current health system of Nepal does not have a major focus on mental illness. Lack of institutional and financial capacity, no insurance system, and inadequate human resources compound the problem. We argue that mental health problems should no longer be treated only as a health problem but as a socioeconomic concern. Therefore, there is a need for increased political commitment, resource mobilisation, and integration of mental health services in primary health care in Nepal. Such investment in mental health services in a crises-stricken country such as Nepal is imperative for higher health and economic gains. Both authors have equally contributed in designing the idea of the manuscript, data collection and analysis via review, and interpretation of findings. Both authors agreed on the opinion expressed on the final version of manuscript. We declare no competing interests.
*Vishnu Khanal, Shiva Raj Mishra [email protected] Nepal Development Society, Bharatpur, Chitwan, Nepal 1
2 3
4
Chisholm D, Sweeny K, Sheehan P, et al. Scaling-up treatment of depression and anxiety: a global return on investment analysis. Lancet Psychiatry 2016; 3: 415–24. Mullan Z. Rebuilding Nepal. Lancet Global Health 2015; 3: e654. Tol WA, Kohrt BA, Jordans MJ, et al. Political violence and mental health: a multi-disciplinary review of the literature on Nepal. Soc Sci Med 2010; 70: 35–44. Mishra SR, Neupane D, Bhandari PM, Khanal V, Kallestrup P. Burgeoning burden of non-communicable diseases in Nepal: a scoping review. Global Health 2015; 11: 32.
707
Sarika Chaturvedi, *Bhushan Patwardhan [email protected] Center for Complementary and Integrative Health, Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Ganeshkhind, Pune 411007, India 1
For more on the Eating Disorder Priority Setting Partnership (in Dutch) see https:// powertorecover.nl/
2
For the James Lind Alliance guidebook see http://www.jla. nihr.ac.uk/guidebook
3
4
5
For Eating Disorder PSP Steering Group members (in Dutch) see https:// powertorecover.nl/over-ons/ For more on Proud2BMe see http://www.Proud2Bme.nl
706
Thirthalli J, Zhou L, Kumar K, et al. Traditional,complementary, and alternative medicine approaches to mental health care and psychological wellbeing inIndia and China. Lancet Psychiatry 2016; published online May 18. http://dx.doi.org/10.1016/S2215366(16)30025-6. Charlson FJ, Baxter AJ, Cheng HG, Shidhaye R, Whiteford HA.The burden of mental, neurological and substance use disorders inChina and India. Lancet Psychiatry 2016; published online May 18. http://dx.doi. org/10.1016/S0140-6736(16)30590-6. Travis FT, Wallace RK. Dosha brain-types: a neural model of individual differences. J Ayurveda Integr Med 2015; 6: 280–85. Patwardhan B. Bridging Ayurveda with evidence-based scientific approaches in medicine. EPMA J 2014; 5: 5–19. Broderick J, Crumlish N, Vancampfort D. Yoga as part of a package of care versus standard care for schizophrenia (Protocol). Cochrane Database Syst Rev 2016; 4: CD012145.
Top 10 research priorities for eating disorders The lifetime prevalence of all eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder, and related syndromes) is about 5%. 1 “Recent comprehensive estimates suggest that 20 million people in the European Union have an eating disorder, with a cost of about €1 trillion per year (financial costs of about €249 billion plus burden of disease costs of about €763 billion)”.2 Eating disorders can be associated with substantial and prolonged physical and psychosocial morbidity. The causes of eating disorders are incompletely understood. New treatments are being developed and tested but progress is slow because of insufficient research funding. 1,2 For example in the UK the funding disparity is reflected by the difference in funding for eating disorders—0·4% of mental health research expenditure—versus 4·9% for psychosis and 7·2% for depression.3 It
is therefore imperative that research funds are directed to the questions that are important to those affected. In collaboration with the James Lind Alliance, a UK National Institute for Health Research-supported initiative, founded in 2004, which aims to identify gaps in knowledge that matter most to patients, carers and clinicians, we convened a multi-disciplinary Priority Setting Partnership that sets the research agenda for eating disorders. The James Lind Alliance priority setting process involves four stages:4 collection of patients’, carers’ and clinicians’ questions, checking of existing research evidence to establish which remained unanswered, interim prioritisation of the verified unanswered questions, and a final consensus priority setting workshop to establish the top ten research priorities. From Feb 1, 2015, to June 3, 2016, we undertook a Priority Setting Partnership to define the research agenda for eating disorders. Via a large Dutch e-community for eating disorders Proud2BMe, the Dutch patient and carer organisation WEET,
and the Dutch Academy for Eating Disorders, we invited individuals with or recovered from an eating disorder, their families and clinicians involved in the treatment of eating disorders, to submit questions via our webportal. The webportal was visited more than 3500 times. We received 956 submissions from 412 respondents (340 patients with an eating disorder). Submissions were collated, grouped into themes, and indicative research questions were generated for prioritisation. If insufficient evidence was indicated by a relevant, reliable systematic review or clinical guidelines, indicative questions were classified as “true uncertainties”. In the interim prioritisation survey patients, carers and clinicians were randomly presented with 77 indicative research questions. They were asked to select all questions they viewed as a high priority for research and were then asked to rank these into a top ten. The results of 375 respondents, of whom 32% had submitted a question in phase 1, were weighted separately for patients, carers and clinicians to ensure equal influence.
Panel: Top ten research priorities for eating disorders 1 Which factors influence the duration of recovery and the possibility of complete recovery? 2 Which patient and disorder-related features can be used to provide more personalised treatment? 3 Is it more effective to address the eating disorder symptoms first or the underlying problems? 4 What is the most effective treatment (and order of treatment) for patients with an eating disorder and a co-morbid disorder? 5 Which treatment setting (outpatient, at home, day treatment, inpatient or residential, with or without parents) provides the best treatment outcome? 6 How can loved ones contribute to the recovery process of the eating disorder? 7 Are there specific risk factors for the development of an eating disorder, and if so, how can prevention target these? 8 What is the influence of the quality of the working relationship between the treatment team and the patient on treatment outcome? 9 Is it better to use a protocol based on a guideline or to tailor treatment to the individual? 10 What causes the need for self-destructive behaviour in patients with an eating disorder?
www.thelancet.com/psychiatry Vol 3 August 2016
Correspondence
The overall collated top 22 questions, each mentioned by more than 100 respondents, were then taken to the final prioritisation workshop. At the final prioritisation workshop, patients, carers and clinicians, using an inclusive facilitated approach developed by the James Lind Alliance, agreed the final order of the 22 presented research questions in a series of three rounds of discussion and decision-making. The final top ten research priorities for eating disorders focus on important aspects of treatment, prevention, and the role of carers in the recovery process (panel). All true uncertainties identified via this Priority Setting Partnership will be uploaded to the James Lind Alliance website, where it publishes the output of all its Priority Setting Partnerships. This research agenda for eating disorders should now inform the scope and future activities of funders and researchers. We declare no competing interests. This project was supported by funding provided by the Netherlands Foundation for Mental Health (Fonds Psychische Gezondheid, 2014 6837). EvF was involved in all phases of this research project and had the idea for the project. AvdM was involved in data collection, data analysis, data interpretation and writing. KC was involved in the planning of the project, study design, data interpretation and writing.
Eric F van Furth, Angela van der Meer, Katherine Cowan [email protected] Rivierduinen Eating Disorders Ursula, POB 405, 2300 AK Leiden, the Netherlands (EFvF, AvdM); Department of Psychiatry, Leiden University Medical Centre, Leiden, the Netherlands (EFvF); and James Lind Alliance, National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, Southampton, UK (KC) 1 2
3
4
Treasure J, Claudina AM, Zucker N. Eating disorders. Lancet 2010; 375: 583–93. Schmidt U, Adan R, Böhm I, et al. Eating disorders: the big issue. Lancet Psychiatry 2016; 3: 313–15. MQ Landscape Analysis. UK Mental Health Research Funding, April 2015. http://b.3cdn. net/joinmq/1f731755e4183d5337_ apm6b0gll.pdf (accessed June 3, 2016). The James Lind Alliance Guidebook, version 6, 2016. http://www.jla.nihr.ac.uk/guidebook (accessed June 3, 2016).
www.thelancet.com/psychiatry Vol 3 August 2016
Investment in mental health services urgently needed in Nepal We applaud Dan Chisholm and colleagues1 for their work on scaling up treatment for depression and anxiety as published in The Lancet Psychiatry. The researchers used the global point prevalence rate of 7·3% for anxiety disorders, 3·2% for depression in men, and 5·5% for depression in women.1 For countries in crisis, the burden of mental health illness might be higher. In Nepal, a decade-long armed conflict was responsible for more than 10 000 deaths, and displacement of more than 100 000 people between 1996 and 2006.2 Violent agitations, killings, and destruction of public property continued to 2015. On April 25, 2015, a major earthquake followed by several aftershocks left the country with more than 9000 deaths, 23 000 injured,2 and more than 2 million homeless people. This disaster was exacerbated by economic blockade that further hampered recovery. We searched MEDLINE on Feb 25, 2016, using the search terms: “mental health” or “mental disorder” and “Nepal”, limiting the search to studies published in the English language. We identified two reviews (2010 and 2015)3,4 that included eight individual studies and summarised that there was a high (37·5%) prevalence of mental health disorders in the general population in Nepal: 4 depression (30%), anxiety (28%), and distress (42%) in rural community settings.3 Among specific groups, there were similar high rates of disorders;4 for example, 3–4% of Bhutanese refugees had post-traumatic stress disorder (PTSD); 34% had anxiety, and 14% had depression; 53% of internally displaced people had PTSD, 81% had anxiety, and 80% had depression; 60% of torture survivors had PTSD
60%, 86% had anxiety, 81% had depression; and 55% former child soldiers had PTSD, 46% had anxiety, and 53% had depression. Chisholm and colleagues1 estimated that total economic returns would be 2·3 to 3·0 times higher than the investment and 3·3 to 5·7 times higher if all health benefits were included. Their estimates did not include PTSD; therefore, the figures could be an underestimation for a country like Nepal with a high PTSD burden. However, the current health system of Nepal does not have a major focus on mental illness. Lack of institutional and financial capacity, no insurance system, and inadequate human resources compound the problem. We argue that mental health problems should no longer be treated only as a health problem but as a socioeconomic concern. Therefore, there is a need for increased political commitment, resource mobilisation, and integration of mental health services in primary health care in Nepal. Such investment in mental health services in a crises-stricken country such as Nepal is imperative for higher health and economic gains. Both authors have equally contributed in designing the idea of the manuscript, data collection and analysis via review, and interpretation of findings. Both authors agreed on the opinion expressed on the final version of manuscript. We declare no competing interests.
*Vishnu Khanal, Shiva Raj Mishra [email protected] Nepal Development Society, Bharatpur, Chitwan, Nepal 1
2 3
4
Chisholm D, Sweeny K, Sheehan P, et al. Scaling-up treatment of depression and anxiety: a global return on investment analysis. Lancet Psychiatry 2016; 3: 415–24. Mullan Z. Rebuilding Nepal. Lancet Global Health 2015; 3: e654. Tol WA, Kohrt BA, Jordans MJ, et al. Political violence and mental health: a multi-disciplinary review of the literature on Nepal. Soc Sci Med 2010; 70: 35–44. Mishra SR, Neupane D, Bhandari PM, Khanal V, Kallestrup P. Burgeoning burden of non-communicable diseases in Nepal: a scoping review. Global Health 2015; 11: 32.
707