Table 2 Types of eating disorder service models

Allen, Mountford, Brown, Richards, Grant, Austin, Glennon & Schmidt (2020)

UK

Yes

Community/ early intervention

All

Young adults (aged 16-25 years old) with a primary diagnosis of an eating disorder <3 years in duration

-

-

-

-

Anderson, Desai, Zalaznik, Zielinski & Loeb (2021)

USA

Yes

Community

Metropolitan

People with an eating disorder across the lifespan

-

-

-

-

Bern, Milliren, Tsang, Mancini, Carmody, Gearhart, Eldredge, Samsel, Crowley & Richmond (2024)

USA

Yes

Hospital

Metropolitan

People with a diagnosis of ARFID aged between 4 and 21 years old

The study had three aims:

To examine the variability in care for people with ARFID across three inpatient units in the same hospital (Adolescent/Young adult Medicine, Gastroenterology and General paediatrics).

To create a standardised inpatient clinical pathway.

To examine changes in care for inpatients with ARFID post the inpatient clinical pathway compared to before initiation of inpatient clinical pathway.

Quantitative:

Retrospective review

Two groups of participants; n=57 people pre- inpatient clinical pathway and n=53 people post-inpatient clinical pathway. All participants were between 4-and 21 years old, with a diagnosis of ARFID.

Overall, participants were mostly female (61.8%) and race classified as white (76.4%). Ethnicity was non-Hispanic (78.2%), Hispanic (7.3%) and unknown (14.5%). SES not reported but 70.9% of participants had private health insurance.

Development of a three step inpatient clinical pathway was completed and implemented.

Following implementation of the inpatient clinical pathway variability in case reduced. More specifically, there was improved consultation between social work, nutrition and psychiatry. There was a minimal reduction in length of stay from 7 days to 6.2 days (on average).

Brown, McClelland, Boysen, Mountford, Glennon & Schmidt (2016)

UK

Yes

Community/ early intervention

Metropolitan

Young adults (aged 18-25 years old) with a primary diagnosis of an eating disorder <3 years in duration

To assess the feasibility and acceptability of the First Episode and Rapid Early Intervention for Eating Disorder Service (FREED) on reducing the duration of time until specialist service contact, duration of untreated eating disorder and waiting time compared with previous practice within the service

Quantitative: repeated measure design

Two groups of participants:

1) FREED cohort = 51 people with a primary diagnosis of an eating disorder for three years or less. Participants were aged between 19-25 years old

2) Audit cohort = 89 people with similar diagnosis, age and illness duration

There was a slight reduction in duration of time between specialist service contact and duration of untreated illness when compared to previous practice. Reduced waiting times were achieved through the implementation of the FREED service

Bryant-Waugh, Loomes, Munuve & Rhind (2021)

UK

Yes

Community

Metropolitan

Children and Adolescents with a diagnosis of ARFID

To describe and share an evidence informed, multidisciplinary, multi-model outpatient care pathway for young people experiencing ARFID (aged between 2-17 years).

-

3 case examples of young people aged between 4-17 years old with a suspected diagnosis of ARFID

67% female, 33% male.

Ethnicity reported as one white British, one Pakistani British, and one black Caribbean.

Race and SES not reported.

The framework could offer a structure to support clinicians in guiding assessment and treatment of young people with an ARFID diagnosis, until further research is conducted in the area.

Clinton, Almlof, Lindstrom, Manneberg & Vestin (2014)

Sweden

Yes

Community

Regional

Adults with an eating disorder

To explore the possible advantages and disadvantages of drop in access to the treatment of eating disorders

Qualitative: semi-structured interviews

11 people with an eating disorder diagnosis. Participants aged between 19-34 years old.

100% female, from a working- or middle-class background

Participants reported that the drop-in program helped overcome their fear of treatment, increased accessibility and allowed participants to feel secure and safe in the program environment

Dror, Kohn, Avichezer, Sapir, Levy, Canetti, Kianski & Zisk-Rony (2015)

Israel

No

Hospital

Metropolitan

Children and adolescents with psychiatric conditions (including eating disorders)

To evaluate treatment success of four-phased reintegration guidelines following hospitalisation

Mixed Methods: cross sectional design (using interviews and a review of medical charts)

Six adolescents and their parents, plus an additional seven parents only (total 13 participants). There were 11 female and 2 male patients.

Medical records data for 11 of the 13 participants were used in the evaluation.

Seven patients were hospitalised for AN and six for EDNOS. Age ranges between 12.5 – 17 years.

11 parents were married and two were divorced. Two other families were identified as complex.

Eleven young people successfully reintegrated back into the educational system. BMI increased from admission to discharge. Twelve were receiving ongoing treatment for their eating disorder in the community.

Eisler, Simic, Fonagy & Bryant-Waugh (2022)

UK

Yes

Community

All

Children and adolescents with an eating disorder (of any severity)

-

-

-

Research was not presented; however, the authors included some brief outcomes from the ongoing evaluation citing reduced wait times and increased identification and referral of eating disorders

Fenner & Kleve (2014)

UK

Partially

Community

Regional

Children and adolescents

To describe the service model and outcome evaluation of an eating disorder service model based on a community Child and Adolescent Mental Health service

Quantitative: retrospective audit of case files (demographic data, family composition, family involvement in treatment, medication administered, treatment length, inpatient admissions, if menstruation was present, if vomiting was present, height, weight and BMI).

Service user feedback was obtained via a questionnaire

45 children and adolescents with a diagnosis of AN or EDNOS.

Females made up 93% of participants.

Most participants were from an intact two-parent family (n=36)

Ethnicity was recorded for 25 cases, all were White British

Race and SES was not reported

Treatment within the service mostly involved families (n=41, 98%), and 31 people received both individual and family work (76%).

Three cases dropped out of treatment and a further one was referred to adult services.

Authors reported significant improvements against Morgan Russell outcomes for most participants (AN = 77% and EDNOS = 82%)

Service satisfaction ratings were high

Goldstein, Peters, Baillie, McVeagh, Minshall & Fitzjames (2011) Australia

Yes

Community -intensive

Metropolitan

Adolescents aged between 12-18 with an eating disorder

To determine the effectiveness of a day patient program for the treatment of adolescents with AN or EDNOS

Quantitative: multiple measure research design

26 adolescent females with a diagnosis of AN or EDNOS

Race, SES, and ethnicity not reported.

Significant changes were achieved following treatment on measures of weight gain. Some positive changes in behaviour and attitude.

Hayes, Tweedy & Chapman (2024)

UK

Yes

Community - intensive

Metropolitan

Young people aged between 10-18 with a diagnosis of AN

The study aimed to evaluate the effectiveness of a modification in service model and treatment approach from a group based programme to an intensive family based program.

Quantitative: retrospective chart review

Young people (n=190) with AN who accessed the service between March 2017 and April 2023. 

These were split into two groups, depending on which version of the intensive program they accessed:

Original Model n=86 (female n=85, male n=1)

New Model n=104 (female n=97, male n= 7)

Race, ethnicity and SES were not reported.

The new service model resulted in a significant reduction in length of admission from 135 days (original model) to 89 days (new model). There was also a reduction in inpatient admissions after implementation of the new service model, from 29 people (original model) to 11 people (new model).

Herpertz-Dahlmann, Borzikowsky, Altdorf, Heider, Dempfle & Dahmen (2021)

Germany

Yes

Community - intensive

Regional

Children and Adolescents with AN or AAN, who have received treatment on an inpatient unit

To pilot an eating disorder specialist home treatment and to investigate its feasibility, effects, and safety

Quantitative: single centre nonrandomised open-label pilot study

22 young people with a diagnosis of AN or AAN, who had received inpatient treatment for their eating disorder. All participants were female, 20 (90.9%) lived with both parents, and 2 (9.1%) lived with one parent/patchwork family. 18 (81.8%) had a psychiatric co-occurring condition.

Eating disorder symptoms, general psychopathology and weight improved considerably whilst receiving treatment in the service model. Carers skills also increased, and carer burden decreased. Both young people and carers reported high levels of satisfaction with the service model. There was no safety concerns associated with the service model.

Johnson, Cook, Cadman, Anderson, Williamson & Wade (2022)

Australia

Yes

Community

Regional

People with an eating disorder aged 14 years old or above

To evaluate and report on the outcomes of a non-specialist community-based service model for a regional area

Quantitative: case series

143 people who met the DSM-5 diagnostic criteria for an eating disorder (diagnoses not reported, but 21% reported to have a BMI <18.5)

Dropout rates were low, with 103 participants completing treatment (15 transferred to alternative pathways and 25 cases dropped out).

Participants experienced significant improvements in eating disorder cognitions. Underweight participants, 36.4% of completers achieved a normative BMI.

Kaplan, Hutchinson, Hooper, Gwee, Khaw, Valent & Willcox (2024)

Australia

No

Hospital

Metropolitan

People with a primary mental health diagnosis and a co-occurring eating disorder (AN BN, OSFED) or significant disordered eating behaviours

The aim of the study was to evaluate the implementation of a multidisciplinary, evidence informed screening and care pathway for people with a co-occurring eating disorder on general inpatient units

Mixed Methods: file audit and interviews, mapped to the RE-AIM framework

Audits of 632 patient files (pre and post pathway implementation) were conducted. 65% (n=411) were female and 3.3% (n=21) had an eating disorder diagnosis. Age, race, ethnicity and SES were not reported.

 In addition, 7 people with a co-occurring eating disorder (All female, diagnosed with AN [n=5], OSFED [n=1] and disordered eating behaviours [n=1]) and 18 clinicians were interviewed.

Clinicians were from a range of disciplines, including nursing, allied health and psychiatry. No further demographics such as age, gender, race, ethnicity or SES were reported.

50 clinicians (27 mental health nurses, 19 allied health and 4 intake clinicians) completed the training modules. No further demographics were reported.

Identification of disordered eating behaviours was three times more likely (OR =3.3, 95% CI (1.6-7.1) p=.002) following implementation of the new service model. People with an eating disorder were also significantly more likely to be referred to a dietitian and more structured person-centred care.

An eating disorders pathway can feasibly and successfully be implemented into an existing general mental health inpatient unit.

Milton, Hambledon, Dowling, Roberts, Davenport & Hickie (2021)

Australia

Yes

Telehealth

All

Across the lifespan

To customize and configure a technological, non-traditional service model (web-based, phone, email) that provides support for eating disorders and body image issues

Qualitative: participatory design

45 people aged 15 or older across six workshops. Participants had a lived experience of eating disorders, disordered eating, body image and related issues (n=13), significant other (n=7), health professionals with a lived experience of an eating disorder (4), health professionals (n= 21)

Gender, race, SES, and ethnicity not reported 

Participants highlighted that there is a critical need to address some of the barriers to care.

Seven themes were identified from the workshops: 1. identified barriers to care within the current system; 2. need for people to be able to access the right care anywhere, anytime; 3. recommendations for the technological solution (i.e., InnoWell Platform features and functionality); 4. need for communication, coordination, and integration of a technological solution embedded in Butterfly's National Helpline; 5. need to consider engagement and tone within the technological solution; 6. identified challenges and areas to consider when implementing a technological solution in the Helpline; 7.and potential outcomes of the technological solution embedded in the Helpline relating to system and service reform.

Moron-Nozaleda, Yanez, Camarneiro, Gutierrez-Priego, Munoz-Domenjo, Garcia-Lopez, Garcia, Garcia, Trujillo, Faya & Graell (2023)

Spain

Yes

Community – intensive

Metropolitan

Children and Adolescents with an eating disorder (AN, ARFID, BN, AAN, OSFED), who required hospitalisation as a result of their eating disorder.

To explore the feasibility and acceptability of a Hospital in the Home program for adolescents with a severe eating disorder

Quantitative: Retrospective data collection (demographics, clinical variables, chart reviews) and a satisfaction survey (for families of participants) compromising 13 questions with a Likert scale for response

59 females (mean age = 14.69 years). Diagnosis was Restrictive AN (n=30), AAN (n=7), Purging AN (n=3), BN (n=5), ARFID (n=3) and OSFED (n=11)

28 participants had one or more cooccurring condition and 47 participants lived with both parents, while the parents were divorced for 12 participants.

Race, SES and ethnicity not reported.

Authors concluded that the service model was feasible and had a high retention rate (90%). Families of participants (n=43) were very satisfied with the service model (score 4.95/5, SD = 0.5) and perceived the model as ‘very safe’.

Munro, Thomson, Corr, Randell, Davies, Gittoes, Honeyman & Freeman (2014)

UK

Yes

Community - intensive

Regional

People with an AN. Age range targeted not reported.

To describe a service model for eating disorders and present primary evidence of the program efficacy

Mixed Methods: cross sectional survey design

Not described

Overall, participants were satisfied with the service. Qualitative data showed that staff were perceived to be supportive, caring and genuine. In addition, participants valued the holistic approach to treatment and individualised care.

Newell (2023)

UK

Yes

Community

Regional

Across the lifespan

-

-

-

-

Newton, Bosanac, Mancusa & Castle (2013)

Australia

Yes

Community and community intensive

Metropolitan

Adults (aged 16 years +)

To report on the development of a community eating disorder specialist program and its initial 18-month evaluation

Quantitative: pre-post design

208 people with an eating disorder who had attended the program. Participants aged 16+ years old. There were 188 (90.4%) females and 20 (9.6%) males. Only 197 of the 208 participants were included in the analysis (as there were 11 unplanned discharges), however the genders of this smaller group were not reported. Most had a diagnosis of AN (n=97, 53.3%), BN (n=41, 22.5%) and EDNOS (n=43, n=23.6)

For the day program, there were 47 participants, 43 females (91.5%) and 4 males (8.5%) and 80.6% were aged under 25 years old. Diagnosis included AN (n=36, 76.6%) and BN (n=6, 12.8%) and EDNOS (n=5, 10.6%).

Race, SES and ethnicity not reported

Attendance at the community service model led to statistically significant differences between baseline and follow up scores on a range of self-report measures that showed improvements in eating disorder symptoms, quality of life, and mood symptoms. Increased BMI and weight (for people this was indicated for) also achieved.

Painter, Ward, Gibbon & Emmerson (2010)

Australia

Yes

Community, community intensive and hospital

Metropolitan based, servicing all locations (metropolitan, regional and rural)

Adults with an eating disorder

-

-

-

-

Penfold (2015)

UK

Yes

Community - intensive

Regional

Adults with a diagnosis of AN (aged 16+)

-

-

-

Anecdotal reports of lower admission rates, improved eating disorder behaviours and increased weight

Simic, Stewart, Eisler, Baudinet, Hunt, O’Brien & McDermott (2018)

UK

Yes

Community - intensive

Metropolitan

Adolescent aged between 11-18 years old with a restrictive eating disorder diagnosis

There were two study aims:

To report of participant outcomes following a short day program

And to describe the longer-term outcomes of the participants, 6 months following completion of the program and discharge from the outpatient eating disorder service model (within the wider service system)

Quantitative: retrospective uncontrolled case series

Adolescents aged between 11-18 years old (n=105). Predominantly females (95.2%) and white British ethnicity (88.6%).

Race and SES not reported.

Following attendance at the day patient program, young people reported lower levels of depression and an increased ability to regulate emotions. In addition, there was improved self-esteem, quality of life and motivation. Participants achieved weight gain and a reduction in eating disorder pathology. Most participants in the day patient program went on to successfully complete outpatient treatment and 73% achieved a good or intermediate outcome

Strand, Gustafsson, Bulik & Hausswolff-Juhlin (2015)

Sweden

Yes

Hospital

Metropolitan

Adults with longstanding eating disorders

-

-

-

-

Suetani, Yui & Batterham (2015)

Australia

Yes

Hospital

Metropolitan

Children with an eating disorder

-

-

-

-

Tantillo, Starr & Kreipe (2020)

USA

Yes

Telehealth

All

Across the lifespan

To describe an innovative tele mentoring project and evaluate the programs acceptability, practitioner satisfaction,

and impact on knowledge gained and intended practice changes.

Mixed methods: questionnaire and survey

99 health professionals completed the Project ECHO Eating Disorders Clinic outcome questionnaire, and 30 health professionals completed the Continuing Medical Education surveys

Gender (of those who reported)

Female n=54 (94.6%)

Ethnicity (of those who reported)

White n=57 (87.7%) and of non-Hispanic origin n=61 (95%)

Race and SES was not reported

Female social workers were the most frequent attendees of the program. Participants predominantly worked in primary care or outpatient settings. Participants agreed that the project objectives were met, information was balanced, and evidence based, organised, clear and relevant to stated objectives. In addition, nine themes were identified in the content analysis. Of these, four related to key points learned (1. Eating disorders are complex illnesses, 2. Attending to team relationships, 3. Motivating patient for change and 4. Essential elements of care) and five related to changes you would make in your practice (1. Improving screening practices, 2. Motivating patients for change, 3. Improving treatment, 4. Attending to team relationships and 5. Seeing and treating the whole patient)

Tchanturia, Smith, Glennon, & Burhouse (2020)

UK

Yes

Hospital

Metropolitan

Adults with a diagnosis of AN and Autism

-

-

-

-

Wallis, Alford, Hanson, Titterton, Madden & Kohn (2013)

Australia

Yes

Hospital

Metropolitan

Families with a young person diagnosed with AN, who were from rural areas OR vulnerable families and those with a poor response to outpatient FBT

-

-

-

-

Weber & Davis (2012)

Australia

Yes

Community

Rural

People over the age of 14 years old with a suspected eating disorder

To examine the effectiveness of an assessment and referral model of eating disorder service delivery and its potential utility as a model for rural service delivery

Qualitative: evaluative design

Brief semi-structured interviews n=40 clients of service (2004-2006); extended semi-structured interviews n=4 clients of service; surveys, 2 time points (2005) n=14 & (2006) n=21 with service providers; semi-structured interviews n=20 parents; 2007 & 2008); written survey n=12 parents/carers; (2007); brief semi-structured interviews n= 27 clients and parents (2007); extended semi-structured interviews n=28 service providers (2007 & 2009)

All client participants (except one) were female. Race, SES and ethnicity not reported

Eating disorder assessment was useful, however there was numerous challenges in finding local treatment options. Challenges included a lack of clinicians with expertise in eating disorders and a lack of experienced eating disorder clinical supervisors

Williams, Dobney & Geller (2010)

Canada

Yes

Community

Metropolitan

People with longstanding eating disorders, when recovery focused treatment was shown to have limited impact

To present preliminary outcome research of a community outreach partnership program for people with eating disorders

Quantitative: pre-post design

31 people with an eating disorder who accessed the program for at least four months in duration.

Participants has a diagnosis of AN (n=15, 48%), BN (n=3, 10%) and EDNOS (n=13, 42%)

Mean age of participants was 31.07 years old and duration of eating disorder on average was 15.23 years.

Gender, race, SES and ethnicity not reported

Significant improvements were seen in global distress scores, hopelessness, body mass index and eating disorder symptoms between starting and completing program. Participants reported that they had improved relationships, decreased importance about weight and shape and determinants of self esteem

Williams, O’Reilly & Coelho (2020)

Canada

Yes

Community - intensive

Metropolitan

Transition age youth (16-24 years old)

To understand the clinical characteristics of residents at the residential service model, examine predictors of early treatment and explore residents’ perception and experiences with residential treatment.

Mixed Methods: retrospective review of medical records and qualitative analysis of interviews conducted with residents who had received treatment (for the full duration) from the service model

Retrospective chart review n=193

Most were females (n=186, 96.4%), with less males (n=4, 2.1%) and some participants did not identify their gender or identified and gender nonbinary (n=3, 1.6%).

Most participants had a diagnosis of BN (n=73, 37.8%) or AN restricting type (n=34, 26.9%). Other diagnoses included AN binge-purge type, AAN, atypical BN, EDNOS and BED.

Qualitative interview n= 39

Most participants were female (n=38, 97%) and one person identified as gender neutral (n=1, 3%).

Race, SES and ethnicity not reported

Results from the chart review showed that participants (n=85) who were underweight (<BMI 20) at the start of treatment had a significant increase in weight at discharge.

Qualitative analysis of the interviews found that 35.9% of interviewees self reported no longer engaging in eating disorders behaviours at discharge. A further 48.7% reported improvement in their behaviours since admission. Eating disorder thoughts were also reported to be less frequent (n=31, 79.5%).

Thematic analysis identified what participants perceived to be the most helpful aspects of the service model: a) the benefit of structured eating and gradual exposure to increasing nutritional responsibility and challenges, b) the utility of individual therapy, c) the benefit of therapeutic groups and d) the importance of a multidisciplinary approach