A Narrative Review of Outcome Studies for Residential and Partial Hospital-based Treatment of Eating Disorders

Updates in the treatment of eating disorders in 2018: A year in review in eating disorders: The Journal of Treatment & Prevention

Current evidence suggests that the majority of patients with eating disorders will not fully recover during treatment, and little doubt can exist around the urgent need for improved treatment outcomes across the field of eating disorders. While empirical efforts are underway to optimize outcomes, this article reviews treatment-related research findings published in Eating Disorders: The Journal of Treatment & Prevention during 2018. Importantly, this review encapsulates research addressing (i) barriers to access and the uptake of empirically supported treatments, (ii) research assessing the delivery of empirically supported treatments across the full spectrum of patient care, and (iii) research aiming to isolate treatment mechanisms and optimize treatment outcomes across a transdiagnostic array of eating disorders. Ultimately, while much ground has been covered in 2018, further research is needed to enhance the accessibility and uptake existing treatments, since only a fraction of those with eating disorders are currently engaged in treatment. Further, with the expanding scope of non-outpatient eating disorder treatment settings, further research is required to adapt and assess the implementation of empirically supported treatments in higher levels of patient care. Lastly, in aiming to optimize patient outcomes, treatment outcome research must seek to identify (i) mechanisms that underlie illness eating disorder psychopathology, and (ii) the active mechanisms of existing treatments.

A day treatment program for adults with eating disorders: staff and patient experiences in implementation

BACKGROUND

Eating disorders are serious conditions which are increasing in prevalence internationally. The causes of these conditions are complex and incompletely understood, and clinical presentations can vary over time. The complexity of these conditions can also complicate treatment. Therefore, stepped care treatment comprising a hierarchy of interventions, including access to day treatment programs (DTPs), is recommended. While studies have examined patient outcomes and provided narrative accounts of these programs, no published studies describe DTP development. This study aims to address this gap by examining development and implementation of a DTP from service providers and patients' perspectives.

METHODS

This study utilised a mixed-methods design to examine the design and implementation of a publicly funded, closed group DTP in Australia. Data from service records and documents were analysed, alongside interviews with patients and interview and focus groups with service providers conducted between June 2016 and July 2017. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed using the Framework Approach.

RESULTS

Seventeen service providers (n = 4 in managerial and n = 13 clinical positions, with clinical experience of 3 months to 20 years) and 11 patients (100% F, 17-33 years) were interviewed. The service providers reported that implementation was a stressful undertaking due to tight timeframes to achieve multiple tasks. Patients had diverse opinions regarding the DTP content and the group treatment experience. Despite this, all patients reported benefits from attending the DTP, varying from improvements in mood, weight gain, development of personal skills and strengths, to living independently. For further benefit, patients suggested that programs could be shaped and targets towards differing patient groups, with fewer breaks throughout treatment.

CONCLUSIONS

Designing and implementing a DTP is a challenge and can be a time-intensive undertaking, however the result can be beneficial for both service providers and patients. The closed group format was beneficial in creating a supportive environment, though may have led to increases in additional eating disordered behaviours. While the current structure of this DTP may require reconsideration, organisations considering implementing a new DTP may find usefulness in the overall design described in this study, alongside learning from the issues experienced.

Intensive treatment program (ITP): A case series service evaluation of the effectiveness of day patient treatment for adolescents with a restrictive eating disorder

OBJECTIVE

Family Therapy for Anorexia Nervosa (FT-AN) is the first line treatment for adolescents with anorexia nervosa in the UK. However, research suggests between 10 and 40% of young people have a poor outcome. For those for whom FT-AN alone is not effective there is a clear need to develop additional treatments. This paper describes the effectiveness of an additional treatment for adolescents who had not responded to FT-AN, the Intensive Day Treatment Program (ITP) embedded within a comprehensive outpatient service at the Maudsley Hospital.

METHOD

Data from a retrospective chart review of patient files were analyzed for 105 young people aged 11-18 with restrictive eating disorders referred to the program in the first four and a half years of its operation.

RESULTS

Young people attended ITP for only on average 28.41 days. Over this time they made significant improvements in a range of domains, including weight gain, eating disorder symptomatology, motivation to recover, quality of life and comorbid symptomatology. Young people continued to make improvements post ITP in outpatient treatment provided by the same service and 73.2% had a good or an intermediate outcome at the point of discharge from the service.

DISCUSSION

This uncontrolled case series indicates that ITP can contribute to positive outcomes for young people who require intensification of treatment. ITP outcomes are discussed in comparison to the published literature concerning day programs for adolescents with a diagnosis of an eating disorder.

A path to defining excellence in intensive treatment for eating disorders

In the United States, the past decade has seen rapid growth in treatment centers providing specialty care to patients with eating disorders. Much of this growth has been in higher levels of care, including hospital-based and residential treatment. Despite this expansion, there remains lack of agreement regarding the most important components of care, such as staff training or specifics of treatment delivery. Additionally there is no consensus on how best to assess outcome and compare performance across programs. This leaves patients, families, public and private insurance programs, and policy makers with limited information to help facilitate treatment decisions. The present paper considers implications of these changes in the eating disorder treatment landscape and examines two ideas that, if implemented, may enhance the quality of eating disorder care. First, we explore the proposal to develop a network of centers of excellence in eating disorder treatment and the value this may have for improving overall treatment quality. This idea was discussed at an expert meeting held at SAMSHA in 2017 regarding issues important to the field following passage of the 21st Century Cures Act. Second, we consider the potential utility of a study using the Delphi method to promote expert consensus regarding clinical outcome assessments.

Outcomes of low-weight patients with avoidant/restrictive food intake disorder and anorexia nervosa at long-term follow-up after treatment in a partial hospitalization program for eating disorders

OBJECTIVE

To assess long-term outcomes of patients with avoidant/restrictive food intake disorder (ARFID) treated in a partial hospitalization program (PHP) for eating disorders (ED).

METHOD

A cross-sectional study comparing patients with ARFID to those with anorexia nervosa (AN) who had been discharged from a PHP for at least 12 months was performed. Percent median body mass index (%MBMI), scores on the Children's Eating Attitudes Test (ChEAT), and treatment utilization were assessed, with intake and discharge data collected via retrospective chart review.

RESULTS

Of the 137 eligible patients, 62 (45.3%) consented to follow-up data collection. Patients with ARFID and AN exhibited similar increases in %MBMI from intake to discharge and reported low scores on the ChEAT by discharge. Patients with ARFID and AN maintained good weight outcomes and low ChEAT scores at follow-up. Most participants were still receiving outpatient treatment from a variety of providers, although fewer with ARFID than AN continued to receive services from our multidisciplinary ED clinic.

DISCUSSION

Patients with ARFID and AN exhibit similar improvements in %MBMI when treated in the same PHP and appear to maintain treatment gains at long-term follow-up. Additionally, most patients continue to utilize outpatient services after being discharged from a PHP.

Psychotherapeutic Treatment for Anorexia Nervosa: A Systematic Review and Network Meta-Analysis

Background: The aim of the study was a systematic review of studies evaluating psychotherapeutic treatment approaches in anorexia nervosa and to compare their efficacy. Weight gain was chosen as the primary outcome criterion. We also aimed to compare treatment effects according to service level (inpatient vs. outpatient) and age group (adolescents vs. adults). Methods:The data bases PubMed, Cochrane Library, Web of Science, Cinahl, and PsychInfo were used for a systematic literature search (until Feb 2017). Search terms were adapted for data base, combining versions of the search terms anorexia, treat^*/therap^* and controlled trial. Studies were selected using pre-defined in- and exclusion criteria. Data were extracted by two independent coders using piloted forms. Network-meta-analyses were conducted on all RCTs. For a comparison of service levels and age groups, standard mean change (SMC) statistics were used and naturalistic, non-randomized studies included. Results: Eighteen RCTs (trials on adults: 622 participants; trials on adolescents: 625 participants) were included in the network meta-analysis. SMC analyses were conducted with 38 studies (1,164 participants). While family-based approaches dominate interventions for adolescents, individual psychotherapy dominates in adults. There was no superiority of a specific approach. Weight gains were more rapid in adolescents and inpatient treatment. Conclusions: Several specialized psychotherapeutic interventions have been developed and can be recommended for AN. However, adult and adolescent patients should be distinguished, as groups differ in terms of treatment approaches considered suitable as well as treatment response. Future trials should replicate previous findings and be multi-center trials with large sample sizes to allow for subgroup analyses. Patient assessment should include variables that can be considered relevant moderators of treatment outcome. It is desirable to explore adaptive treatment strategies for subgroups of patients with AN. Identifying and addressing maintaining factors in AN remains a major challenge.

Augmentative Approaches in Family-Based Treatment for Adolescents with Restrictive Eating Disorders: A Systematic Review

OBJECTIVE

To systematically review the literature reporting outcomes of augmentative family-based treatment (FBT) interventions for adolescents with restrictive eating disorders (EDs).

METHOD

Articles were identified through a systematic search of five electronic databases (PsycINFO, MEDLINE, EMBASE, CINAHL, Cochrane Database).

RESULTS

Thirty articles were included, reporting on FBT augmentations featuring adjunctive treatment components, modified treatment structure and/or content with adherence to FBT principles, and adaptations allowing FBT delivery in different settings. All reported significant improvements in weight and/or ED symptoms at end-of-treatment, although few compared augmentative and standard FBT interventions and good quality follow-up data was generally lacking.

CONCLUSIONS

There is early evidence for the effectiveness of augmentative FBT-based approaches in facilitating weight and/or ED symptom improvements for adolescents with restrictive EDs. There remains a lack of robust evidence demonstrating superior effects of such approaches over standard FBT, and further controlled studies are required to expand on the current evidence. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Treatment of eating disorders in child and adolescent psychiatry

PURPOSE OF REVIEW

Recent research on the multimodal treatment of eating disorders in child and adolescent psychiatry has yielded a significant increase in randomized controlled trials and systematic reviews. This review aims to present relevant findings published during the last 2 years related to medical and psychological treatment of anorexia nervosa, bulimia nervosa and avoidant/restrictive food intake disorder (ARFID).

RECENT FINDINGS

For anorexia nervosa, recent reports described the efficacy of different treatment settings, lengths of hospital stay and high vs. low-calorie refeeding programmes. For both anorexia and bulimia nervosa, a number of randomized controlled trials comparing individual and family-oriented treatment approaches were published. For the newly defined ARFID, only very preliminary results on possible treatment approaches implying a multidisciplinary treatment programme were obtained.

SUMMARY

Although there is some evidence of the effectiveness of new child and adolescent psychiatric treatment approaches to eating disorders, the relapse rate remains very high, and there is an urgent need for ongoing intensive research.

Web-Based Aftercare for Women With Bulimia Nervosa Following Inpatient Treatment: Randomized Controlled Efficacy Trial

Background

Relapse rates in bulimia nervosa (BN) are high even after successful treatment, but patients often hesitate to take up further treatment. An easily accessible program might help maintain treatment gains. Encouraged by the effects of Web-based eating disorder prevention programs, we developed a manualized, Web-based aftercare program (IN@) for women with BN following inpatient treatment.

Objective

The objective of this study was to determine the efficacy of the web-based guided, 9-month, cognitive-behavioral aftercare program IN@ for women with BN following inpatient treatment.

Methods

We conducted a randomized controlled efficacy trial in 253 women with DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) BN and compared the results of IN@ with treatment as usual (TAU). Assessments were carried out at hospital admission (T0), hospital discharge/baseline (T1), postintervention (T2; 9 months after baseline), 9-month follow-up (T3; 18 months after baseline). The primary outcome, abstinence from binge eating and compensatory behaviors during the 2 months preceding T2, was analyzed by intention to treat, using logistic regression analyses. Frequencies of binge eating and vomiting episodes, and episodes of all compensatory behaviors were analyzed using mixed effects models.

Results

At T2, data from 167 women were available. There were no significant differences in abstinence rates between the TAU group (n=24, 18.9%) and the IN@ group (n=27, 21.4%; odds ratio, OR=1.29; P=.44). The frequency of vomiting episodes in the IN@ group was significantly (46%) lower than in the TAU group (P=.003). Moderator analyses revealed that both at T2 and T3, women of the intervention group who still reported binge eating and compensatory behaviors after inpatient treatment benefited from IN@, whereas women who were already abstinent after the inpatient treatment did not (P=.004; P=.002). Additional treatment utilization was high in both groups between baseline and follow-up.

Conclusions

Overall, data from this study suggest moderate effects of IN@. High rates of outpatient treatment utilization after inpatient treatment may have obscured potential intervention effects on abstinence. An aftercare intervention might be more beneficial as part of a stepped-care approach.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 08870215; http://www.isrctn.com/ISRCTN08870215 (Archived by WebCite at http://www.webcitation.org/6soA5bIit)

Treating Eating Disorders at Higher Levels of Care: Overview and Challenges

Higher levels of care (HLC)-including inpatient hospitalization, residential treatment, partial hospitalization, and intensive outpatient treatment-are frequently utilized within routine care for eating disorders. Despite widespread use, there is limited research evaluating the efficacy of HLC, as well as clinical issues related to care in these settings. This review describes the different levels of care for eating disorders and briefly reviews the most up-to-date guidelines and research regarding how to choose a level of care. In addition, as HLC approaches for ED continue to be developed and refined, pragmatic and conceptual challenges have emerged that provide barriers to clinical efficacy and the execution of high-quality treatment research. This review includes a discussion of various issues specific to HLC, as well as a summary of recent literature addressing them.

Depression, worry, and psychosocial functioning predict eating disorder treatment outcomes in a residential and partial hospitalization setting

This retrospective study explores depression, worry, psychosocial functioning, and change in body mass index (BMI) as predictors of eating disorder (ED) symptomatology and BMI at discharge and 1-year follow-up from a residential and partial hospitalization ED treatment center. Participants were 423 male and female patients receiving treatment at an ED treatment center. Results indicate significant improvement in ED symptomatology, psychological impairment, and change in BMI (in patients with anorexia nervosa) at treatment discharge and follow-up compared to treatment admission (ps < 0.001). Depression and worry predicted ED symptomatology and psychological impairment at discharge (ps < 0.05). Depression, worry, and psychosocial functioning predicted ED symptomatology and psychological impairment at 1-year follow-up (ps < 0.001). Change in BMI was not a significant predictor of outcome. Depression, worry, and psychosocial functioning each play a role in treatment outcomes and may help clarify who might benefit from treatment. Clinicians in ED treatment centers should consider these as areas of focus for improved outcomes.

Community residential facilities in mental health services: A ten-year comparison in Lombardy

Residential mental health services grew steadily since 2000 in Italy. A reorganisation of residential facilities was implemented in 2007 in Lombardy, introducing supported housing in addition to staffed facilities. We compare the provision and characteristics of residential facilities in the 2007 and 2016. In 2007 there were 3462 beds (35.9/100,000 population) in 276 facilities. In 2016 beds were 4783 (47.8/100,000) in 520 facilities. The increase were unevenly distributed in the public and private sector, and the overall increase was due to a higher increase in the private sector. 72% of beds were in highly supervised facilities in 2007 and 66% in 2016. The public sector managed more facilities with a rehabilitation goal, while the private sector more for long-term accommodation. Mean numbers of beds were higher in facilities managed by the private sector in both years. The 2007 reorganisation and the stop to opening new facilities in the last years were not enough to correct the imbalance between highly supervised and flexible solutions. A wider and more diverse offer might have triggered off an increased demand, rather than a more rational use. Given the costs of highly staffed facilities, and the risk of reproducing custodial models, close evaluation of the use of residential facilities should inform policies.

Intensive treatment for adults with anorexia nervosa: The cost of weight restoration

OBJECTIVE

Weight restoration in anorexia nervosa (AN) is associated with lower relapse risk; however rate of weight gain and percent of patients achieving weight restoration (BMI ≥ 19 at discharge) vary among treatment programs. We compared both cost/pound of weight gained and cost of weight restoration in a hospital-based inpatient (IP)-partial hospitalization (PH) eating disorders program to estimates of these costs for residential treatment.

METHOD

All adult first admissions to the IP-PH program with AN (N = 314) from 2003 to 2015 were included. Cost of care was based on hospital charges, rates of weight gain, and weight restoration data. Results were compared with residential treatment costs extracted from a national insurance claims database and published weight gain data.

RESULTS

Average charge/day in the IP-PH program was $2295 for IP and $1567 for PH, yielding an average cost/pound gained of $4089 and $7050, respectively, with 70% of patients achieving weight restoration. Based on published mean weight gain data and conservative cost/day estimates, residential treatment is associated with higher cost/pound, and both higher cost and lower likelihood of weight restoration for most patients.

DISCUSSION

The key metrics used in this study are recommended for comparing the cost-effectiveness of intensive treatment programs for patients with AN.

Extinction theory & anorexia nervosa: Deepening therapeutic mechanisms

By virtue of adopting the core symptomatic fear (i.e., a fear of weight gain) as a primary treatment target, the treatment of AN centrally involves exposure-driven processes. However, exposure trials targeting the fear of weight gain in AN have been sparse, yielding mixed results to date. In translating extinction theory to the treatment of AN, it is likely that the absence of a clear distinction between what constitutes the core feared cue and the core feared outcome has stymied the application of exposure treatments in AN. This review considers several configurations of the core fear association in AN, noting distinct therapeutic strategies which may allow for more precise efforts in violating fear-based expectancies. Specific guidance is offered in the clinical decision making process as to which strategies might best promote inhibitory learning, and a clinical case is discussed, in which treatment was adjusted to specifically violate the core underlying fear association.