Beyond screening in primary practice settings: Time to stop fiddling while Rome is burning

Abstract

Objective: This forum presents the current state of research in the screening and identification of people with eating disorders in community and primary care, taking a longer-term perspective that highlights the slow rate of progression in development of instruments, and impact on polices and practice.Method: An historical overview is presented, followed by a critique of contemporary instruments and practice, and barriers to case detection and appropriate referral pathways.Results: There are now many instruments but all lack high levels of positive predictive power. However, some do have high sensitivity. Barriers contributing to poor detection and the treatment gap include need for improved education and support for primary care professionals and lack of confidence of individuals with eating disorders to initiate a discussion with health professionals. The best screening instrument would not overcome either of these barriers.Discussion: We purport there is an urgent need to improve current screening instruments (not to develop more), particularly those with high sensitivity. These should be being employed alongside programs to both improve primary care professionals' skills in assessment and management of people with eating disorders, and to empower consumers to navigate care pathways.Public Significance Statement: We argue that further screening instruments for eating disorders are not needed. Rather, it is more urgent to have a greater research focus on how to encourage primary care workers to ask about eating and body image and how to best translate that to more individuals with eating disorders being offered treatment. This work needs to be linked with tools that empower consumers to navigate care pathways.

Current approaches in the recognition and management of eating disorders

“…Despite the availability of numerous screening instruments for eating disorders, all screening measures lack high levels of positive predictive power (Box 3). 20,46,[48][49][50][51][52] Eating disorder features and BMI may be assessed for diagnostic purposes using the Eating Disorder Examination (EDE) diagnostic interview, 46 which is viewed as the gold standard for eating disorder diagnosis and psychopathology, and its self-report derivative, the 28-item self-report EDE Questionnaire (EDE-Q). 46 At present, the EDE-Q is a compulsory component of the MBS for all eating disorders except for anorexia nervosa.…”

“…† There are several brief (eight to 13 items) versions of the EDE-Q measuring features over shorter time periods (eg, weekly). 51 ◆…”

Evidence-Based Assessments for Transdiagnostic Eating Disorder Symptoms: Guidelines for Current Use and Future Directions

“…Morgan and colleagues (1999) created the five-item SCOFF questionnaire, which is the most frequently used transdiagnostic ED screening tool in primary care settings, possibly due to its brevity and satisfactory ability to discriminate between individuals with and without EDs (Hay et al, 2022). SCOFF is an acronym based on the first letter of the five questions assessing for ED symptoms: Sick (self-Induced vomiting), control (feeling out of control around food), One (weight loss of one or more European Stones), Fat (belief that oneself is larger than others claim), and Food (feeling that food dominates one’s life).…”

“…While the USPSTF (2022) concluded that the evidence was insufficient to assess the balance of benefits and harms of screening for EDs in adolescent and adults, they identified several screening questionnaires that could be used in primary care settings for individuals without obvious signs and symptoms of EDs, including the SCOFF (Hill et al, 2010; Morgan et al, 1999; Peat & Feltner, 2022). The SCOFF questionnaire is a brief, validated five-item tool designed to address core features of AN and BN, and has been the dominant screening tool used in primary care settings over the past three decades (Hay et al, 2022; Hill et al, 2010; Morgan et al, 1999). The USPSTF found adequate evidence on the accuracy of the SCOFF for screening EDs in adult females; however, the evidence is insufficient for other populations, including adolescents and males (USPSTF, 2022).…”

“…Overall, there is a strong need for the additional studies on the benefits and harms of screening in diverse populations to better reflect the demographics of patients presenting to primary care and emergency department settings (Feltner et al, 2022; Hay et al, 2022; Peat & Feltner, 2022). In addition, most of the existing screening tools were designed to detect AN and BN, but not EDs that were introduced in the DSM-5 , including ARFID and atypical anorexia, or EDs in diverse populations, such as racial minorities, males, individuals in larger bodies, and transgender youth (Feltner et al, 2022; Hay et al, 2022; House et al, 2022; Nagata & Golden, 2022).…”