Delivering evidence-based treatment via telehealth for Anorexia Nervosa in rural health settings: a multi-site feasibility implementation study

Background: Access to evidence-based treatments such as family-based therapy (FBT) is difficult for adolescents diagnosed with Anorexia Nervosa (AN) living in rural or regional areas due to a limited trained workforce, high staff turnover and inconsistent treatment fidelity. Telehealth offers a potential access solution by facilitating care irrespective of family or service location. The disruption to the health system caused by COVID-19 amplified an existing need and increased the use of telehealth to deliver FBT before its efficacy and safety was fully evaluated. This study aimed to evaluate the feasibility, acceptability and preliminary efficacy of telehealth-FBT delivered by community-based clinicians within rural services directly into the home to reduce the eating disorder symptoms of adolescents diagnosed with AN.

Methods: A pre- and post-implementation multi-site case series delivered up to 20 sessions of telehealth-FBT to 28 adolescents (89.29% female, M = 14.68 ± 1.58 years) living in rural or regional Australia. The RE-AIM framework guided the evaluation, with Reach (treatment uptake and completion); Efficacy (change in weight, global eating disorder symptoms, and remission from baseline to end of treatment and six-month follow-up); Adoption (patient characteristics and drop out); Implementation (intervention fidelity) and Maintenance (outcomes and intervention during the follow-up period) used to assess the feasibility and preliminary efficacy of telehealth-FBT.

Results: There was a high level of interest in telehealth-FBT, with two-thirds of eligible families consenting to participate. Both treatment engagement and completion rates were over 60%, and treatment was delivered with acceptable fidelity. Twenty adolescents (71.43%) met the diagnostic criteria for AN (baseline 86.03%mBMI ± 7.14), and eight (28.57%) for Atypical AN (baseline 101.34%mBMI ± 8.28), with an overall mean duration of illness of 8.53 months (SD = 5.39, range 2-24 months). There was a significant increase in %mBMI at the end of treatment compared to the baseline (p = 0.007, 95%CI: 1.04-6.65), with over 68% of adolescents weight restored and 36.8% of these achieving both weight and psychological remission criteria. Weight remained significantly improved at six-month follow-up (p = 0.005, 95%CI: 1.57-8.65). Also, there was a decrease in adolescents' global eating disorder symptoms, as rated by their parents, at the end of treatment compared to the baseline of 0.735 (p = 0.028, 95%CI: 0.079-1.385).

Conclusions: Telehealth-FBT was feasibly implemented into rural services and delivered by community clinicians with reach, adoption, preliminary efficacy, and fidelity scores comparable to those reported by specialist studies.

Trial registration: The study was conducted according to the HREC-approved protocol (HREC 2020/ETH00186) and registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR # 12620001107910).