Clinical, biological and neurobiological studies have shown that the first three years of illness provide a critical window for early effective intervention in eating disorders.
There are three main reasons for this:
Eating disorders tend to persist over time. The longer a young person is unwell, the more likely it is that brain changes will occur and persist. In addition, they are more likely to experience disruptions to social, educational and emotional development.
Early intervention is consistent with a stage of model illness, for which there is considerable support for anorexia nervosa in particular and all eating disorders to some degree.
Key to early intervention is the concept of ‘Duration of an Untreated Eating Disorder’ (DUED). This is the time between onset of an eating disorder and starting eating disorder treatment. There are several major barriers to shortening DUED and providing early intervention:
Recent data from Germany and the UK report an average duration of DUED of between 25 to 41 months for first episode eating disorder cases. This suggests that many people only access treatment after the critical window of the first 3 illness years.
FREED aims to address each set of barriers but was developed to overcome service-related barriers in particular.
Currin L, Schmidt U (2005). A critical analysis of the utility of an early intervention approach in the eating disorders. Journal of Mental Health, 14, 611‐624.
Keverne EB (2004). Understanding well‐being in the evolutionary context of brain development. Philosophical Transactions ‐Royal Society of London Series B Biological Sciences, 359, 1349‐1358.
O’Hara CB, Campbell IC, Schmidt U (2015). A reward-centred model of anorexia nervosa: a focussed narrative review of the neurological and psychophysiological literature. Neuroscience Biobehavioural Reviews, 52, 131-152.
Seitz J, Herpertz‐Dahlmann B, Konrad K (2016). Brain morphological changes in adolescent and adult patients with anorexia nervosa. Journal of Neural Transmission, 123, 949‐959.
Schmidt U, Brown A, McClelland J, Glennon D, Mountford VA (2016). An idea worth researching: Will a comprehensive, person-centered, team-based early intervention approach to first episode illness improve outcomes in eating disorders? International Journal of Eating Disorders, 49, 374-377.
Steinhausen H‐C (2002). The outcome of anorexia nervosa in the 20th century. American Journal of Psychiatry, 159, 1284-1293.
Treasure J, Stein D, Maguire S (2015). Has the time come for a staging model to map the course of eating disorders from high risk to severe enduring illness? An examination of the evidence. Early Intervention in Psychiatry, 9, 173-184.
Van den Eynde F, Suda M, Broadbent H, et al (2012). Structural magnetic resonance imaging in eating disorders: a systematic review of voxel‐based morphometry studies. European Eating Disorder Review, 20, 94‐105.
Emerging adulthood has been proposed as a new way of thinking about the developmental period from roughly age 18 to 25 years. This period is distinct in terms of demographic characteristics, subjective experiences, and identity formation and exploration. Five key characteristics of emerging adulthood include:
Most eating disorders will develop in adolescence or emerging adulthood. Eating disorders can heighten a sense of instability, an uncertain identity and feeling ‘in between’.
Emerging adults with eating disorders may need help navigating major transitions in their lives (e.g., in education, work, living circumstances, relationships) and to form an identity and adult life separate to their eating disorder.
FREED was developed with emerging adults in mind. We are continuing to research the defining features and needs of this particular group.
FREED was first evaluated across 2014-2015 by the South London and Maudsley NHS Foundation Trust and King’s College London, with support from The Health Foundation. The initial evaluation involved 56 FREED patients aged 18 to 25 with an eating disorder duration of < 3 years. These patients were compared to 86 audit patients, who were seen in the 2 years prior to FREED being introduced and who were matched for age and illness duration. Key findings from FREED:
Figure 1. Body Mass Index (BMI) trajectories from assessment to 12-months after starting treatment, for patients with anorexia nervosa treated through FREED compared to a matched Audit control sample.
After the initial evaluation, FREED scaled to three new eating disorder services in the UK: Central and North West London NHS Foundation Trust, Leeds and York Partnership NHS Foundation Trust, and North East London NHS Foundation Trust. This project is called FREED-Up and has run from 2016 to 2018, again with support from The Health Foundation. Over 250 patients have taken part.
Data from FREED-Up are still being collected, but so far they support the effectiveness of FREED in diverse treatment settings. Full outcomes will be available in late 2019. Feedback from patients, clinicians and services has been very positive.
From 2018 on, the effectiveness of FREED will be evaluated using ‘real world’ clinical data rather than through a research trial.
Brown A, McClelland J, Boysen E, Mountford V, Glennon D, Schmidt U (2016). The FREED Project (first episode and rapid early intervention in eating disorders): service model, feasibility and acceptability. Early Intervention in Psychiatry, 12, 250-257.
McClelland J, Hodsoll J, Brown A, Lang K, Boysen E, Flynn M, Mountford VA, Glennon D, Schmidt U (2018). A pilot evaluation of a novel First Episode and Rapid Early Intervention service for Eating Disorders (FREED). European Eating Disorders Review, 26, 129-140.
The First Episode Rapid Early Intervention for Eating Disorders‐Upscaled study: Clinical outcomes
Austin et al. (2021)Read more
Assessing implementation fidelity in the First Episode Rapid Early Intervention for Eating Disorders service model
Richards et al. (2021)Read more
“I’m truly free from my eating disorder”: Emerging adults’ experiences of FREED, an early intervention service model and care pathway for eating disorders.
Potterton et al. (2021)Read more
Assessing the impact of First Episode Rapid Early Intervention for Eating Disorders on duration of untreated eating disorder: A multi‐centre quasi‐experimental study.
Flynn, et al. (2020)Read more
First episode rapid early intervention for eating disorders: A two‐year follow‐up.
Fukutomi et al., 2020Read more
The FREED Project (first episode and rapid early intervention in eating disorders): Service model, feasibility and acceptability.
Brown et al., 2018Read more
A pilot evaluation of a novel First Episode and Rapid Early Intervention service for Eating Disorders (FREED).
McClelland et al., 2018Read more
Eating Disorders During Emerging Adulthood: A Systematic Scoping Review.
Potterton et al. (2020)Read more
“I’m not a teenager, I’m 22. Why can’t I snap out of it?”: a qualitative exploration of seeking help for a first-episode eating disorder during emerging adulthood.
Potterton et al., (2020)Read more
An idea worth researching: Will a comprehensive, person-centered, team-based early intervention approach to first episode illness improve outcomes in eating disorders?
Schmidt et al., 2016Read more
Meta-analysis of theory of mind in anorexia nervosa and bulimia nervosa: A specific impairment of cognitive perspective taking in anorexia nervosa?
Bora & Köse, 2016Read more
A systematic review and meta-analysis of ‘systems for social processes’ in eating disorders.Read more
A critical analysis of the utility of an early intervention approach in the eating disorders.
Currin & Schmidt, 2005Read more
Facial expression to emotional stimuli in non-psychotic disorders: A systematic review and meta-analysis.
Davies et al., 2016Read more
Understanding well‐being in the evolutionary context of brain development.
Keverne, 2004Read more
A reward-centred model of anorexia nervosa: a focussed narrative review of the neurological and psychophysiological literature.Read more
Emotion generation and regulation in anorexia nervosa: a systematic review and meta-analysis of self-report data.
Oldershaw et al., 2015Read more
Brain morphological changes in adolescent and adult patients with anorexia nervosa.
Seitz et al., 2016Read more
The outcome of anorexia nervosa in the 20th century.
Steinhausen, 2002Read more
Has the time come for a staging model to map the course of eating disorders from high risk to severe enduring illness? An examination of the evidence.
Treasure et al., 2015Read more
Structural magnetic resonance imaging in eating disorders: a systematic review of voxel‐based morphometry studies.
Van den Eynde et al., 2012Read more
Access helpful guides for GPs and other health professionals (no registration required) or register for our online training platform if you are interested in using FREED in your service.
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