Issue 4 | Evidence Based Practice and Implementation Principles
About this resource
Issue Four | October 2012
Welcome to our October issue of the NEDC e-Bulletin. The theme for this month's issue reflects one of the implementation principles from the NEDC National Framework, "evidence informed and evidence generating" and our content focuses on questions surrounding evidence based practice and implementation principles. We have also highlighted international events promoting eating disorders research. We hope you enjoy this edition and if you would like to suggest topics or events to be featured in future editions of the e-bulletin, please contact us at firstname.lastname@example.org
Feature article: interview with an expert
Last month the NEDC National Eating Disorders Framework: An Integrated Reponse to Complexity 2012 was approved by the Department of Health and Ageing. We have a unique opportunity to explore and test these national standards through the medium of the e-bulletin and e-network . This month, we are profiling the implementation principle: Evidence Informed and Evidence Generating Approaches, through an interview with the Deputy Chair of the NEDC, Professor Phillipa Hay.
Q: What is the difference between evidence informed and evidence generating and why are both needed for eating disorders?
PH: Evidence informed practice is based on what is known about what works, with respect to the treatment of eating disorders. Basing clinical practice on scientific evidence is the hallmark of “Western” medicine. Long before the advent of Randomised Controlled Trials (RCT’s) in clinical practice, doctors have been basing their practice on science. Traditionally, this was what differentiated Western medicine from more complementary approaches. But today, even complementary medicine is basing studies on RCT’s, in an effort to keep up with more widely accepted forms of medical practice.
Evidence generating practice is done without hard evidence, but is practice that is continually assessed, evaluated, and reviewed collaboratively with the patient and treatment team, in accordance with the scientist-practitioner model. In clinical practice, this involves, for example, taking measurements before and after treatment with a view to helping inform the state of knowledge about the efficacy of treatments.
Both approaches are needed in the field of eating disorders, because while we do have quite a robust understanding of treatment options for Bulimia Nervosa, and how to establish recovery in a physical sense for Anorexia Nervosa, no one specialist psychotherapy stands out for Anorexia Nervosa. In addition, we have limited understanding of some of the mixed presentations of the eating disorders under Eating Disorder Not Otherwise Specified, for example, Binge Eating Disorder.
Q: How would implementing the principle of evidence informed and evidence generating approaches change the experience of treatment for people who have an eating disorder?
PH: Theoretically, this approach should enhance the outcome for people with an eating disorder as in this context, it creates a milieu where the goal is continual improvement and there is an expectation of either a good outcome or a critical appraisal as to why outcomes were poor.
Clinical data collected throughout treatment can also contribute towards clinical research. However, it is important to conduct any clinical research within treatment with respect and sensitivity, so that patients do not feel that they are merely “data” being used for evaluation. Evidence based practice should always be based on science, but also tailored to an individual’s unique presenting problems and specific treatment goals. Clinicians should be using evidence informed practice where it is available, to ensure that the treatment tools they are using are considered up-to-date and efficacious. In lieu of hard evidence, continuous evaluation of practices is in the spirit of evidence generating approaches.
Q: How are people with a personal experience of an eating disorder involved in evidence informed and evidence generating practices?
PH: A collaborative approach to the treatment of an eating disorder is advocated as best practice, so by this measure, the individual with a personal experience is necessarily involved in both evidence informed and evidence generating approaches, to reduce the burden of illness.
There are a couple of ways that the individual’s personal experience can be used to inform the evidence and practice:
- Involvement in a research project (e.g. clinical trial)
- Active collaboration with the therapeutic team during treatment for practice appraisal and in quality assurance
- Heading their own research into broader based outcomes
Q: Who is responsible for determining the quality of evidence based practice? How do we ensure the safety and appropriateness of these strategies?
PH: There is no one body responsible for oversight of this practice. Quality of assessment and practice is a key feature of professionalism, and there are various quality assurance methodologies used by different sectors (in terms of professions, and public and private domains). For example, the Royal College of Psychiatrists (UK) requires clinicians to complete a quality assurance project during their training.
With respect to ensuring the safety and appropriateness of these strategies, currently we don’t have a good answer to this, as it is much more difficult to determine. The Australian Health Practitioner Regulation Agency (AHPRA) requires practitioners to engage in continuous professional development, but this is not akin to determining the safety and appropriateness of the evidence based practices they use.
In the future, the NEDC could take the lead in facilitating, monitoring and creating a professional environment for evaluating practices. In essence, this would involve providing safe and appropriate tools for practitioners and having oversight for how these tools are used in practice. This would be quite an ambitious undertaking nonetheless.
Q: Fairburn (2005) suggests that the evidence supporting the efficacy of treatments for Anorexia Nervosa is limited. How do we propose to fill these “gaps”? What do we rely on in the meantime?
PH: We need to encourage research across the spectrum, from case studies and clinical trials right through to randomised controlled trials. In the meantime, we practice what we do know works:
- Specialist care for most adults with Anorexia Nervosa, and family-based treatment in adolescents and children
- Treatment within multidisciplinary teams
- Intervening early
We also have a good idea of what doesn’t work:
- Leaving patients alone to get better on their own – eating disorders often become chronic if untreated and less responsive to interventions
Q: Is there scope for a national data collection strategy (from the perspective of the NEDC)?
PH: A national database across clinics in Australia would provide rich data for answering more questions about the effectiveness of treatments in the “real world”. If we could link primary care, hospital and specialist eating disorder databases, we could potentially reduce the gap in the continuum of care.
For example, the Centre for Health Services Research at the University of Western Sydney in collaboration with other institutes is involved with a population health database linking hospital services with Medicare data and private health care. While this approach will still not capture all the information on who is accessing treatment, it does provide an insight into the relevant pathways into care.
A project to set up a national eating disorder specialist database with potential for data linkage would be an ambitious undertaking for the NEDC, but one to consider in the future.
For more information on this and the ten other principles that make up the National Eating Disorders Framework, please visit our publications page.
For the latest research evidence on eating disorders, please visit the NEDC Research & Resources.
Join in a discussion of the challenges and benefits of using evidence generating approaches in practice by joining the Clinicians e-Network.
Research article review
Evidence and clinical judgement: finding the right balance
Evidence-based medicine has ancient origins, but is proving a contemporary topic of debate for clinicians, researchers, public health planners and the public. A movement towards evidence-based practice (EBP) has recently gained momentum within the field of psychology and across all major health disciplines that emphasises the importance of basing clinical practice on scientific foundation. Within EBP, treatment providers are encouraged to integrate “the best available research with clinical expertise in the context of patient characteristics, culture and preferences” (APA, 2006, p. 273).
Across the field of mental health, considerable progress has been made over the last 30 years in developing efficacious psychological treatments that have received support through controlled research trials. This has been followed by wide-spread support for the dissemination of these treatments, particularly among policy-makers and governmental organisations.
However, despite the increasing pressure to use EBP, a research survey by Wallace and von Ranson (2012) has identified what they consider to be a well-recognised split within clinical psychology, between research and practice in professional work and training.
They suggest clinicians tend to give more weight to their personal experiences than to science when making treatment decisions. This may be because key conditions and characteristics of treatment research depart markedly from those in clinical practice and bring into question how and whether to generalise the results to practice. Clinicians’ underutilisation of EBPs may also be attributable to a lack of knowledge of available empirically-based treatments.
The efforts and need to integrate research and practice are timely and more important than ever before because of the stakes involved in academic and clinical training, research, practice, and health care in general. Without clinical expertise, practice risks becoming tyrannised by evidence. Without evidence from experience (consumer participation) and current best practice, practice risks becoming rapidly out of date, to the detriment of patients.
At the end of the day research and practice share a commitment to providing the best knowledge about psychological methods and treatments in order to improve patient care. Coupled with this is a need to acknowledge that patient values and preferences – which are reflected in patient goals, beliefs and preferred models of treatment – are a central component of EBP.
Perhaps the next frontier should focus on recognising that clinical expertise is essential for identifying and integrating the best research evidence with clinical data, which is obtained through a relationship with the patient over the course of treatment. Generating and incorporating such knowledge into EBP development and service provision may help improve overall effectiveness in the real world.
Article: Conducting research (with a small ‘r’)
Written by Dr Anthea Fursland, Principal Clinical Psychologist, Eating Disorders Programme, Centre for Clinical Interventions (CCI)
In the world of clinical research, the highest valued research studies are randomised controlled trials (RCTs). Conducting an RCT usually requires funding (research grants) and a staff of clinicians and research assistants to carry out the treatments and administer the tests that evaluate the treatments. For most clinicians it is impossible to conduct an RCT as few clinicians work in settings with opportunities for data collection and the establishment of a large database.
Yet there are other ways of conducting research. ‘Effectiveness studies’ measure the effectiveness of a treatment, often in a real-world setting. One example is a 2011 study (Byrne, Fursland, Allen & Watson, 2011) which evaluated a treatment (Enhanced Cognitive Behaviour Therapy or CBT-E) in a public outpatient clinic, the Centre for Clinical Interventions (CCI), in Perth, Western Australia. Yet if an effectiveness study is to be published, it requires someone with advanced statistical skills and writing skills.
Not all clinicians have the resources or the desire to publish their data. Nevertheless, all clinicians can – and, I would say – should conduct research. Most clinicians aim to conduct high quality therapy with their patients and continue offering the interventions they believe work best. But clinicians may not be good judges of the success of their interventions and may not be able to tell whether their interventions are working better for some patients than for others.
Good clinical practice involves being curious about one’s therapeutic successes and failures, and it is incumbent upon responsible clinicians to gather objective evidence for the effectiveness of their interventions. It is quite possible to conduct research (with a small “r”) in everyday clinical practice. There are several questionnaires in the public domain that can be used by clinicians to rate the progress of their patients during treatment to assess change over time. Individual clinicians can quickly build up a body of ‘evidence’ for their own work and examine their treatment methods in terms of effectiveness with particular presentations (e.g., low weight patients).
Some commonly used questionnaires are listed below. Their use is recommended for people trained in eating disorder assessment. A useful reference is
Assessment of Eating Disorders by James Mitchell, & Carol Peterson (2007), published by Guildford Press
Update on the Journal of Eating Disorders
The new international journal had its first Editors meeting on 20 September in Porto with 23 attendees and seven linking in via by video-conference. Editors-in-Chief Phillipa Hay and Stephen Touyz briefed the meeting on submission processes, launch dates and the benefits and challenges of the Open Access format. The Editorial Board is considering special editions and lay focussed articles, as well as research and clinical publications. In attendance were Associate Editors Janet Treasure, Daniel Le Grange, Jonathan Mond, and Stephan Zipfel, Advisory Board members Christopher Fairburn, and Caroline Meyer as well as NEDC members Jeremy Freeman, Richard Newton, Karina Allen, Sloane Madden, Susan Paxton, Susan Hart, Tracey Wade and Sue Byrne.
One of the aims of the journal is to involve research from beyond the traditional US and European hubs. The journals has Board members from Eastern Europe, Asia, India and the middle east, In attendance at the meeting were Professor Danny Stein from Israel and Dr Angélica Claudino from Brazil. The journal also offers support for researchers in developing countries,
Sara Ho from the publisher, Biomed Central advised that the journal is on track for a January launch date with already 7 articles submitted. Further information from can be found on the journal website or by emailing Phillipa Hay and Stephen Touyz.
Report: Eating Disorders Research Society Annual Meeting
Written by Richard Newton, Susan Paxton, Philippa Hay & Jeremy Freeman
The Eating Disorders Research Society is an international organisation of researchers in the field of eating disorders interested in Anorexia nervosa, Bulimia Nervosa, Binge-Eating Disorder and obesity. The purpose of the organisation is to hold an annual scientific meeting during which the most recent research in the field can be presented and discussed.
The last meeting was recently held on 22-2 September in Porto, Portugal.
The meeting began with the Jim Mitchell Lecture presented by Hans Hoek who reviewed our current knowledge of the epidemiology of eating disorders. His careful review concluded that the prevalence of Anorexia Nervosa and Bulimia Nervosa has remained stable. The increase in EDNOS presentations is likely due to both increased recognition as well as increase in community prevalence.
The plenary session following this Jim Mitchell lecture was devoted to issues arising from DSM 5. It seems certain that the criteria for both BN and AN will be broadened somewhat. This will include the removal of the amenorrhea criterion for AN, a BMI cut for diagnosis of AN at 18.5 and for BN, a frequency rate for weight control behaviours halved to at least once per week from twice per week. This will significantly reduce the number of consumers with otherwise typical eating disorders who are currently diagnosed under the rubric EDNOS.
Excellent presentations were also made by a number of local researchers. These included presentations from research groups including Tracey Wade, (A longitudinal study of changes in genetic and environmental influences on weight and shape concern across adolescence, Wade, Hansell, Bryant-Waugh, Treasure, Nixon, Byrne & Martin), Sue Byrne (Psychosocial predictors of outcome following bariatric surgery, Byrne, Davis & Hamdorf) Deborah Mitchinson (Time trends in population prevalence of eating disorder behaviors and quality of life, Mitchison, Hay, Mond & Slewa-Younan) and Stephen Touyz (Treating severe and enduring Anorexia Nervosa: a randomized control trial, Touyz, Le Grange, Lacey, Hay, Smith, Maguire, Bamford, Pike & Crosby). In addition there were several poster presentations (a large component of the scientific content at EDRS). These included a population based study of adolescent eating disorders by Karina Allen et al., perfectionism in young people by Anne O’Shea et al., nutrition and disordered eating in community women by Anita Star et al., a pilot sudy of acupuncture in Anorexia Nervosa by Sarah Fogarty et al., oxytocin in Anorexia Nervosa by Jan Russell et al., CBT-E for adolescents by Sue Byrne et al., and an experimental investigation of the addition of disclaimer labels to fashion magazine advertisements on women’s social comparison and body dissatisfaction by Marika Tiggeman et al. Thus research in Australia in our field was very strongly represented.
The full program and abstracts can be found at the Eating Disorders Research Society.
Professional development events and opportunities
As we head towards the end of the year there are plenty of opportunities available for professional development and information sharing.
Advanced psychological management of Eating Disorders workshop
Advanced psychological management of Eating Disorders workshop will be held November 27 in Canberra.
Presented by Chris Thornton this workshop is aimed at practitioners wishing to develop their skills in psychological management of eating disorders. Building on fundamental skills of engagement, motivation and basic CBT techniques
It offers advanced management of cases including working with cognitions and emotions drawing from “Acceptance and Commitment Therapy”, mindfiulness and advanced CBT frameworks.
Visit the ANZAED website for more details.
At home with eating disorders
At Home with Eating Disorders, the 1st Australian Eating Disorders Conference for Families and Carers will be held on May 23-25 2013, in Brisbane. The event promises two days of robust evidence-based treatment options, strategies to empower and support families and carers and a forum for exploring the barriers and enablers to best practice treatment in Australia. Keynote speakers include:
- Professor Daniel Le Grange, professor of psychiatry and behavioural neuroscience and Director of the Eating Disorders Center, University of Chicago Medicine
- Professor Janet Treasure, professor of psychiatry at King’s College London and Head of the Eating Disorders Unit, South London Maudlsey Hospital NHS Trust
Visit the event website for more details.
Just announced: Professor James Lock Australian speaking tour
US child & adolescent psychiatrist and one of the developers of Maudsley Family Based Therapy will be touring major Australian and New Zealand cities in March 2013. Details will be updated on the NEDC website as they become available.
Early Notice: Australia New Zealand Academy for Eating Disorders 11th Annual Conference Melbourne, 23-24 August, 2013. For more details visit the event website.
Israeli Association for Eating Disorders 2013 Conference: "Treatment Modalities for Eating Disorders: Consensus and Controversy". Held February 4-5, 2013 at the Crowne Plaza Hotel, Jerusalem, Israel. For more details visit the event website or contact Professor Yael Latzer.
11th London International Eating Disorders, held March 19-21, 2013. For more details visit the event website or contact Lisa Freeman.
International Conference on Eating Disorders (ICED), held May 2-4, 2013 in Montreal. For more details visit the event website.
Opportunities to get involved
Become a member!
The NEDC welcomes and actively encourages people who are interested in joining the collaboration.
NEDC membership is a mutually beneficial relationship and a vehicle for partnering, shared learning and ensuring everyone has a voice in the discussion of strategic priorities for improving approaches to prevention and treatment of eating disorders in Australia. With the assistance of our members, it is the aim of the National Eating Disorders Collaboration (NEDC) to help ensure:
- Eating disorders are a priority mainstream health issue in Australia
- A healthy, diverse and inclusive Australian society acts to prevent eating disorders
- Every Australian at risk has access to an effective continuum of eating disorders prevention, care and ongoing recovery support
To become a member you just need to fill out our quick online membership form.
Becoming a member is free but the participation and support of our members is priceless! If you are not yet a member we would love to have you involved.
Join the e-Network!
The NEDC clinicians e-Network provides an opportunity for clinicians to join in discussion, problem solve, share evidence and network with frontline clinicians and some of Australia’s leading experts in eating disorders. If you are a professional in clinical practice with an interest in eating disorders and haven't joined our e-Network yet we would love to have you involved.
This month there has been some discussion about how research informs clinical practice. Join the e-Network now to participate in this and other discussions with other clinical professionals.
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