Identification of barriers and facilitating factors for the treatment initiation of patients with anorexia nervosa: Towards effective secondary prevention strategies and improved prognosis

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Anorexia nervosa is a comparatively rare but serious illness, due to its somatic and psychological consequences. Compared to patients with any other mental illness, patients with AN have a higher mortality rate and are more likely to have a chronic course. Thus far, preventive interventions have not been very effective in reducing eating disorder risk or the duration of untreated illness, probably due to the low prevalence of AN in the general population and patients' limited insight into their illness. Preventive interventions should specifically target those at risk who are at the interface of particular parts of the health care system.The interval between the onset of the disorder and the treatment initiation, i.e. the duration of untreated illness (DUI) has a strong influence on the course of the illness. Specifically, patients with AN have a better prognosis if treated early. A better initial understanding of significant facilitative and hindering factors influencing the DUI is necessary before new targeted interventions can be designed. Primarily, the aim of this study is to identify predictors of the DUI. Based on these results, we aim to guide the development of effective secondary prevention strategies. Thereby, the study has the potential to ultimately encourage earlier treatment initiation of patients with AN and prevent chronic illness courses and associated high health care costs.For the first time in the investigation of factors influencing the DUI, this study will follow a multi-informant strategy: the perspectives of relatives and the primary care physicians will be incorporated in addition to the patients' views. Furthermore, we will specifically focus on factors which are modifiable and precise in their definition. The planned mixed-method study is divided in three consecutive sub-studies. In sub-study 1, we want to identify the modifiable factors influencing the DUI using semi-structured interviews and a multi-informant approach (patients, relatives, primary care physicians). We will determine the most relevant factors by employing a Grounded Theory approach to the qualitative analysis of the interviews. In sub-study 2, the identified factors influencing the DUI in patients with AN will be incorporated into a checklist and we will conduct a first psychometric evaluation of this newly developed instrument. In sub-study 3, we will again use the multi-informant approach and quantitatively (planned N for each type of informant; i.e., GPs, patients, relatives, N=130; 10 co-operating specialized clinics and 4 co-operating outpatient partners) determine the magnitude of the effects of a) a priori determined non-modifiable factors and b) the modifiable factors from the checklist. In conclusion, we aim to give recommendations to guide the conception of effective secondary prevention approaches in order to prospectively improve the prognosis of patients with AN.