Drop-out from adolescent and young adult inpatient treatment for anorexia nervosa

Short-term effects of a multidisciplinary inpatient intensive rehabilitation treatment on body image in anorexia nervosa

BACKGROUND

Positive changes in weight gain and eating pathology were reported after inpatient treatments for anorexia nervosa (AN). However, changes in the physical body do not always mirror changes in the imagined body. Here, the effect of a treatment focused on body image (BI) was described.

METHODS

This retrospective observational study had a quasi-experimental pre-post design without the control group. During the treatment, participants (N = 72) undertake a variety of activities focused on BI. The main outcome was tested through the Body Uneasiness Test.

RESULTS

At the end of the treatment, BI uneasiness decreased with a significant increase in weight gain.

CONCLUSION

This study highlights the positive short-term effect of a multidisciplinary inpatient intensive rehabilitation treatment on BI in AN. We encourage to design of psychological treatments focusing on the cognitive and emotional bodily representation (i.e. the body in the mind) to increase physical well-being.

Inpatient Treatment Outcome in a Large Sample of Adolescents with Anorexia Nervosa

Anorexia nervosa is an illness affecting primarily adolescent girls and young women. Clinical guidelines recommend early intervention, with inpatient treatment for more severe cases. We present an evaluation of a multi-modal cognitive-behavioral inpatient treatment (CBT-E) involving carers in specialized units for adolescents. Routine data of 962 adolescent inpatients (26 boys) (mean age 15.48 [1.26]; range 12-17 years) were analyzed. Predictors of good body weight outcome (achieving a discharge BMI of at least 18.5 kg/m2) were identified by logistic regression analysis. Mean inpatient treatment lasted 96.69 (45.96) days. The BMI increased significantly from 14.93 (1.38) kg/m2 at admission to 17.53 (1.58) kg/m2 at discharge (z = 26.41; p < 0.001; d = 1.708). Drive for thinness decreased from 29.08 (9.87) to 22.63 (9.77; z = 18.41; p < 0.001; d = 0.787). All other subscores of the Eating Disorder Inventory also decreased significantly, with small to medium effect sizes. General psychopathology also showed significant decreases. The Beck Depression Inventory-II score decreased from 26.06 (11.74) to 16.35 (12.51; z = 18.41; p < 0.001; d = 0.883). A good body weight outcome was predicted by a higher BMI at admission (OR = 1.828), age at onset at 15 years or higher (OR = 1.722), and higher Somatization (OR = 1.436), Anxiety (OR = 1.320), and Bulimia (OR = 1.029) scores. CBT-E involving carers is an efficient intervention for adolescents with anorexia nervosa.

Therapeutic outcome and long-term naturalistic follow-up of female adolescent outpatients with AN: clinical, personality and psychopathology evolution, process indicators and outcome predictors

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness of growing prevalence in childhood and adolescence. Despite its severity, there are still no completely satisfactory evidence-based treatments. Follow-up studies represent the most effective attempt to enlighten treatment effectiveness, outcome predictors and process indicators.

METHODS

Seventy-three female participants affected with AN were assessed at intake (T0) and at 6 (T1) and 12 (T2) months of an outpatient multimodal treatment program. Nineteen participants were assessed 15 years after discharge (T3). Changes in diagnostic criteria were compared with the chi-square test. Clinical, personality and psychopathology evolution were tested with ANOVA for repeated measures, using the t-test or Wilcoxon test as post-hoc. T0 features among dropout, stable and healed participants were compared. Healed and unhealed groups at long-term follow-up were compared using Mann-Whitney U test. Treatment changes were correlated to each other and with intake features using multivariate regression.

RESULTS

The rate of complete remission was 64.4% at T2, and 73.7% at T3. 22% of participants maintained a full diagnosis at T2, and only 15.8% at T3. BMI significantly increased at each time-point. A significant decrease of persistence and increase in self-directedness were evidenced between T0 and T2. Interoceptive awareness, drive to thinness, impulsivity, parent-rated, and adolescent-rated general psychopathology significantly decreased after treatment. Lower reward dependence and lower cooperativeness characterized the dropout group. The healed group displayed lower adolescent-rated aggressive and externalizing symptoms, and lower parent-rated delinquent behaviors. BMI, personality and psychopathology changes were related with each other and with BMI, personality and psychopathology at intake.

CONCLUSION

A 12-months outpatient multimodal treatment encompassing psychiatric, nutritional and psychological approaches is an effective approach for the treatment of mild to moderate AN in adolescence. Treatment was associated not only with increased BMI but also with positive personality development, and changes in both eating and general psychopathology. Lower relational abilities may be an obstacle to healing. Approaches to treatment resistance should be personalized according to these finding.

Drop-out and ineffective treatment in youth with severe and enduring mental health problems: a systematic review

Youth with severe and enduring mental health problems (SEMHP) tend to drop out of treatment or insufficiently profit from treatment in child and adolescent psychiatry (CAP). Knowledge about factors related to treatment failure in this group is scarce. Therefore, the aim of this systematic review was to thematically explore factors associated with dropout and ineffective treatment among youth with SEMHP. After including 36 studies, a descriptive thematic analysis was conducted. Themes were divided into three main categories: client, treatment, and organizational factors. The strongest evidence was found for the association between treatment failure and the following subthemes: type of treatment, engagement, transparency and communication, goodness of fit and, perspective of practitioner. However, most other themes showed limited evidence and little research has been done on organizational factors. To prevent treatment failure, attention should be paid to a good match between youth and both the treatment and the practitioner. Practitioners need to be aware of their own perceptions of youth's perspectives, and transparent communication with youth contributes to regaining their trust.

Being and doing anorexia nervosa: An autoethnography of diagnostic identity and performance of illness

This autoethnography examines my experience of the diagnosis and treatment of anorexia nervosa. Drawing on memory and personal and medical documents relating to inpatient admissions in an adult specialist eating disorder unit, I narrate and analyse my experience in terms of my relationship to the diagnosis of anorexia and the constructions of it I encountered. I show how I came to value an identity based on anorexia and how I learned ways of 'doing' the diagnosis in treatment. This involved me valuing medical markers of illness, including signs of poor health, which became crucial to how I performed my diagnosis and retained the diagnostically-informed sense of self that I valued. I suggest that, ultimately, these diagnostic-dynamics, alongside other effects of long-term inpatient treatment such as detachment from 'normal life', prolonged my struggles with self-starvation. The insights from this autoethnography shed light on potential iatrogenic impacts of diagnosis and treatment for anorexia.

Anorexia Nervosa: Reduction in Depression during Inpatient Treatment Is Closely Related to Reduction in Eating Disorder Psychopathology

Objective: Anorexia nervosa (AN) is a severe mental disorder frequently associated with high scores of depressiveness. We examined the short-term effects of inpatient treatment on depressiveness and eating disorder (ED) psychopathology using the self-rating Major Depression Inventory (MDI) and Eating Disorder Examination questionnaire (EDEq) for patients with AN. Material: Forty-nine patients with AN, all part of the PROspective Longitudinal all-comer inclusion study on EDs (PROLED), were observed over eight weeks with baseline psychometric measures, EDE-q at baseline and endpoint, and weekly MDI self-scoring. Methods: Apart from the weekly Body Mass Index (BMI) measurements, patients were assessed at baseline using the Eating Disorder Inventory (EDI) and the Symptom Check List 92 (SCL-92). Results: Inpatient treatment reduced MDI consistently over 8 weeks (Wilks Lambda = 0.59, F = 4.1, p < 0.01) and this reduction in MDI was positively correlated with a reduction in EDEq (r = 0.44; p < 0.01) during inpatient treatment. Baseline medication did not predict changes in MDI during the inpatient treatment. BMI increased from 14.9 (week 1) to 17.2 (week 8). Conclusions: Inpatient treatment of AN is associated with a reduction in depressiveness. This improvement in depressiveness scores correlates with an improvement in ED psychopathology but not with weight gain.

Predictors of non-completion of a day treatment program for adults with eating disorders

Although treatment dropout is common among patients with eating disorders, very few studies have examined predictors of non-completion in day treatment. We investigated various potential predictors of dropout from adult day treatment. Participants were 295 adult patients with a diagnosis of Anorexia Nervosa (restricting or binge-eating/purging subtype), Bulimia Nervosa (BN), Other Specified Feeding or Eating Disorder, or Avoidant Restrictive Food Intake Disorder. Predictors included eating-disorder characteristics, motivation at the commencement of treatment, Body Mass Index (BMI), time spent in treatment and personality dimensions. Logistic regression analyses showed that for patients with a BMI of less than 20 at the start of treatment, low BMI was a significant predictor of staff-initiated termination due to not meeting weight gain goals. Furthermore, completing less than 6 weeks of treatment was associated with staff-initiated termination. For the whole sample, those with higher changes in weight over the course of treatment were less likely to terminate prematurely. None of the other predictor variables yielded significant results. Results of the current study highlight characteristics of patients who are more likely not to complete day treatment and can help identify patients who may be at risk for not succeeding in multi-diagnostic day treatment programs.

Short-Term Outcome of Inpatient Treatment for Adolescents with Anorexia Nervosa Using DSM-5 Remission Criteria

This study evaluated the short-term outcome of a multimodal inpatient treatment concept for adolescents with anorexia nervosa (AN). In this prospective observational study, a cohort of 126 female adolescents with AN (age range: 11–17, mean age: 14.83) was longitudinally followed from admission to discharge (average duration of stay: 77 days). We used gold-standard clinical interviews and self-report data, as well as DSM-5 remission criteria, to evaluate the treatment outcome. From admission to discharge, body-mass-index (BMI) significantly improved by 2.6 kg/m². Data from clinical interviews and self-reports yielded similar improvements in restraint eating and eating concerns (large effects). Lower effects were observed for variables assessing weight/shape concerns and drive for thinness. At discharge, 23.2% of patients showed full remission of AN, 31.3% partial remission, and 45.5% no remission according to DSM-5 criteria. Differences in remission groups were found regarding AN severity, age at admission, and use of antidepressant medication. Living with both parents, longer duration of inpatient treatment and the use of antipsychotic medication were significantly associated with higher BMI change. The findings provide evidence for the short-term effectiveness of our inpatient treatment concept. We recommend using DSM-5 based remission criteria to evaluate the treatment outcome to improve the comparability of studies.

Health in adulthood after severe anorexia nervosa in adolescence: a study of exposed and unexposed women

OBJECTIVE

To compare the global health status, frequency of somatic and psychological problems, and alcohol use in adulthood among women hospitalized in adolescence for severe anorexia nervosa (AN), with a matched control sample from the general population.

METHOD

Women (n = 86) who had been hospitalized for AN 9.31 ± 1.82 years previously were compared with 258 controls matched for gender, age, and socio-professional category. Data were retrieved from a French survey on health and social insurance coverage, and was mainly collected by self-report, except for the assessment of current eating disorders for those previously hospitalized for AN (assessed with the MINI).

RESULTS

The women who had been hospitalized for AN reported significantly poorer current health status compared to controls (OR 2.9, 95% CI 1.5-5.79). According to the MINI, 13 women previously hospitalized with severe AN still presented an eating disorder (ED). Women with past AN reported more frequent acute throat infections (OR 4.9, 95% CI 1.81-13.51), gastralgia (OR 3.6, 95% CI 1.9-6.83), gastro-oesophageal reflux (OR 5.279, 95%CI 2.11-13.22), excess blood cholesterol or triglyceride levels (OR 2.55, 95% CI 1.03-6.33), anxiety (OR 8.7, 95% CI 3.48-21.8) and depression (OR 5.02 (2.8-9.01). These differences remained significant and of the same order of magnitude in sensitivity analyses among subjects with previous AN but without current ED, except for perceived health status and excess cholesterol and triglyceride levels.

DISCUSSION

Women who had been hospitalized for severe AN reported more symptoms 10 years after treatment, implies psychological and somatic follow-up in the long term.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

[What factors explain the length of hospitalization for anorexia nervosa: A systematic review]

OBJECTIVES

The cost of hospital treatment for anorexia nervosa (AN) is very high given its duration. Identifying factors related to length of hospital stay (LOS) would make it possible to consider targeted therapeutic strategies that, by optimizing care, would reduce their duration and costs. The objective of this work is to identify the factors related (predictive and associated) to LOS for AN.

METHODS

Systematic review of existing literature up to October 2020, based on Pubmed, according to PRISMA recommendations (Preferred Reported Items for Systematic reviews and Meta-Analysis). Factors related to LOS have been described in two categories: factors related to clinical aspects ; and factors related to therapeutic aspects and management modalities. We distinguished predictive factors (identified as pre-hospitalization or contemporaneous with hospital admission) and associated factors (observed during hospitalization) for each category.

RESULTS

Thirteen articles were selected. Samples from the selected studies ranged from 35 to 381 subjects, mostly women with restrictive type AN (R-AN), but some samples included all types of AN, or focused on purging-type forms. The mean age at admission ranged from 13.6 years (Standard Deviation-SD:±1.6) to 30.3 years (SD :±13.9), corresponding to adolescent, adult or mixed samples. Mean body mass indices at admission ranged from 12.3 (SD±1.4) to 16.6 (SD:±2.1). The duration of disease progression ranged from 11.7 months±2.2 to 9.7 years. Mean LOS are short for studies conducted in pediatrics or in medical services (ranging from 13.0 days [SD±7.3] to 22.1 days [SD±9.4]); they are more variable for studies conducted in psychiatry: from 15.6 days (SD±1.0) to 150.2 days (SD±80.8). Among the factors related to an increase in LOS, clinical predictors included: older age at onset or admission; longer duration of the disorder; low minimum body weight during AN; low BMI at admission; purgative form of anorexia nervosa; and high levels of dietary symptoms (asceticism and ineffectiveness dimensions on Eating Disorder Inventory-2). Therapeutic and management modality predictive factors were: a higher number of hospitalizations for AN; the use of enteral nutrition (nasogastric or percutaneous gastric tube) on admission or during hospitalization; the use of intravenous renutrition coupled with oral renutrition; hospitalization far from the patient's home; absence of hospital care in psychiatry after medical stabilization in a somatic unit; compulsory hospitalization. Associated factors were: the presence of psychiatric comorbidities; greater weight gain during hospitalization. Among the factors related to a decrease in LOS, the clinical predictive factor were: greater self-confidence at admission (measured by the Eating Disorder Recovery Self-Efficacy Questionnaire). Therapeutic and management modality predictors included: increased caloric intake of oral renutrition on admission; intake of oral nutritional supplements on admission; and hospitalization in urban areas. The associated factor was: compliance with the weight contract in the adolescent population.

DISCUSSION

Factors related to an increase in LOS are explained by: higher resistance to treatment, higher severity of the disease, the time required for weight gain in services using cognitive-behavioural therapy, complications associated with renutrition modalities such as parenteral renutrition, difficulties in organising outpatient follow-up which require better consolidation of inpatient treatment and the lack of multidisciplinary care in medical services. Factors related to a decrease in LOS are due to: faster weight gain, the presence of a greater number of outpatient follow-up structures close to the hospital and better adherence to treatment to complete the weight contract.

CONCLUSIONS

Taking these factors into account during hospitalization for AN would help optimize care, duration and costs. This situation therefore requires the development of therapeutic trials targeting the identified factors in order to reduce LOS in the treatment of AN.

Length of stay for anorexia nervosa: Systematic review and meta-analysis

OBJECTIVE

Evidence regarding global trends in length of stay for patients with anorexia nervosa is limited. The aim of this study is to conduct a meta-analysis examining the length of stay for anorexia nervosa patients globally, and to investigate moderators of the variance.

METHOD

Medline, EMBASE and PsycINFO were searched for studies published up to January 2019. Two independent reviewers assessed the eligibility of each report based on predefined inclusion criteria. A meta-analysis was performed to calculate a pooled mean length of stay using the random-effects model. Subgroup analyses and meta-regression were conducted to explore potential sources of heterogeneity between studies.

RESULTS

Of 305 abstracts reviewed, 71 studies met the inclusion criteria, generating 111 datasets. The pooled mean length of stay (95% confidence interval) was 76.3 days (73.3, 79.4) using the random-effects model, with marked variation across countries and time. Heterogeneity between studies was explained by age and admission body mass index.

CONCLUSIONS

This meta-analysis found that although clinical features do contribute to length of admissions for anorexia nervosa, there are also global and temporal variations. Future research should provide an in-depth analysis of why and how this variation exists and what the impact is on the well-being of people with anorexia nervosa.

Factors associated with weight gain in anorexia nervosa inpatients

OBJECTIVE

Nutrition restoration in inpatients with anorexia nervosa (AN) is a core element in treatment, enabling recovery of cognitive functions essential for psychological care. This study aims to identify factors associated with inpatient weight gain.

METHODS

Medical records from 107 inpatients aged 13-55 years with AN, hospitalized for more than 7 days at a specialized unit, were examined in a retrospective study. Weight evolution graphs were created for each patient and graded independently as optimal, moderate, and inadequate weight gain after 2 weeks and increasing, flat or decreasing weight in the first 2 weeks by expert clinicians. Driven by explicit hypotheses, bivariable analyses were carried out to detect relevant factors associated with weight gain during and after the first 2 weeks of admission.

RESULTS

Initial weight gain in the first 2 weeks of hospitalization and the introduction of a protocol harmonizing treatment procedures around rapid refeeding were strong factors associated with optimal weight gain after 2 weeks of hospitalization, whereas prior hospitalization in a psychiatric unit, diagnosis with binge-eating/purging subtype and age over 18 years were significantly associated with inadequate weight gain (p < 0.001-0.05).

CONCLUSION

To promote weight gain during hospitalization, clinicians should consider the following therapeutic measures: rapid refeeding strategies, renutrition protocols, and controlling purging behaviors.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Obstacles and facilitators of therapeutic alliance among adolescents with anorexia nervosa, their parents and their psychiatrists: A qualitative study

BACKGROUND

Therapeutic alliance is one of the most important aspects of treatment of adolescents with anorexia nervosa. Little is known about the facilitators and obstacles of its process in this situation. We aimed to explore the experience of therapeutic alliance in inpatient treatment among adolescents with anorexia nervosa, their parents and their psychiatrists.

METHODS

This qualitative study, using semi-structured interviews, took place in France. Data collection by purposive sampling continued until we reached theoretical sufficiency. Data analysis was thematic.

RESULTS

Forty-one participants were included, 15 teenaged girls, 18 parents and 8 psychiatrists. Analysis showed two themes: (1) what facilitates an alliance in treatment - with four facilitators: (a) human qualities, (b) an active role in the treatment, (c) taking time and (d) taking care of the entire family and (2) what impedes an alliance in treatment with four obstacles: (a) being too close or too distant, (b) focusing on weight, (c) control and constraints and (d) psychiatrization.

CONCLUSION

Collaborative work between paediatricians and psychiatrists could facilitate therapeutic alliance with parents. Definition of therapeutic alliance in this situation should be enlarged to include the adolescent-parent relationship. It is necessary to construct specific items to integrate these specific aspects to existing scales.

Stationäre Behandlung von Kindern und Jugendlichen mit Anorexia nervosa und Bulimia nervosa

Zusammenfassung. Anorexia nervosa und Bulimia nervosa betreffen vor allem Jugendliche sowie junge Erwachsene, wobei das Ersterkrankungsalter sinkt, und bei Anorexia nervosa bereits 8-Jährige betroffen sein können. Häufig ist der Verlauf chronisch und kann sowohl schwere körperliche als auch psychische Komorbiditäten nach sich ziehen. Schlimmstenfalls enden Essstörungen tödlich (je nach Schweregrad der Erkrankung Mortalitätsraten bis zu 15 % bei Anorexia nervosa). Ein frühzeitiger Therapiebeginn geht mit einer verbesserten Prognose einher, weshalb die rasche Diagnosestellung von großer Bedeutung ist. Wesentlich hierfür ist die sichere Kenntnis der Diagnosekriterien sowie der essstörungstypischen Folgen. Es werden Aspekte der Symptomatik, Diagnostik, Differentialdiagnostik, Epidemiologie, Pathogenese, Funktionalität, sowie Therapiemöglichkeiten und eigene sowie internationale Studienergebnisse mit Schwerpunkt auf der stationären Therapie von Jugendlichen mit Anorexia nervosa und Bulimia nervosa ausgeführt.

Willingness of individuals with eating disorders to participate in health research

BACKGROUND/AIMS

This study examines the association between eating disorders (EDs) and willingness to participate in health research studies among community members.

MATERIALS & METHOD

Data were collected from Health Street, a University of Florida community engagement initiative which aims to reduce disparities in healthcare and health research by direct engagement of community members.

RESULTS

Among 8,226 community members, 3.9% (n = 324) reported a lifetime ED. For all six types of health research studies queried, individuals with a lifetime ED reported a higher willingness to participate in health research compared to individuals without a history. After adjusting for selected covariates, individuals with ED were significantly more likely than individuals without ED to say they would be willing to volunteer for research studies that: ask questions about health (OR: 7.601, 95% CI: [1.874, 30.839]); require an overnight stay in a hospital (OR: 2.041, 95% CI: [1.442, 2.889]); and provide no remuneration (OR: 1.415, 95% CI: [1.022, 1.958]). Furthermore, when compared to individuals with anxiety or depression, individuals with ED reported increased interest in research participation and increased willingness to participate in most types of research studies assessed. After stratifying by gender and race, we observed few differences in willingness to participate in research among individuals with ED.

DISCUSSION

These findings contribute to our current understanding of participant recruitment and enrollment in ED health research. Underrepresented populations who often do not seek treatment for EDs endorsed a high willingness to participate.

CONCLUSION

Future studies will likely benefit from including community members in ED research.

Treatment dropout in a family-based partial hospitalization program for eating disorders

Treatment dropout is a significant challenge in the treatment of eating disorders. In day hospital/partial hospitalization program settings, little is known about factors associated with treatment dropout. The purpose of the present study was to assess factors associated with treatment dropout in a partial hospitalization program for adolescents and young adults with anorexia nervosa. Patients and parents completed self-report and interview-based measures at baseline and at end of treatment in the partial hospitalization program. Few factors were found that differentiated the two groups. Those who dropped out had lower body weight at end of treatment, were less likely to have purged in the previous month, and had fathers who scored higher on the criticism subscale of expressed emotion. Patients who are purging may be seen as having more severe symptoms, thus possibly reducing the chances of parents prematurely discontinuing treatment. Parental criticism is a potentially modifiable factor in treatment. Further research is needed to identify effective ways to reduce parental criticism, and to identify additional modifiable factors associated with treatment dropout to reduce dropout rates in this population.Level IV: Evidence obtained from multiple time series with or without the intervention, such as case studies.

Pre-treatment patient characteristics as predictors of drop-out and treatment outcome in individual and family therapy for adolescents and adults with anorexia nervosa: A systematic review and meta-analysis

Understanding variables predicting drop-out or unfavourable outcome following treatment for anorexia nervosa (AN) may help to improve upon intervention efforts. However, the current literature has demonstrated sparse and inconsistent significant findings. The current systematic review and meta-analysis summarised the evidence base examining baseline predictors of drop-out and outcome in AN treatment. A literature search was conducted to identify research investigating predictors of drop-out and outcome in individuals treated for AN. Four online databases were searched, and predictors were organised by category and dependent variable (outcome versus drop-out). 27 studies were included. Lower motivation, lower BMI, and having the binge-purge subtype of AN predicted drop-out. Greater ED pathology and poorer motivation predicted poorer outcome. Clinical recommendations include taking particular care during assessment stages to identify patients at risk of drop-out and/or poor outcome based on their clinical profile and level of motivation for recovery. At-risk patients should be receiving tailored treatment to enhance engagement and reduce risk of drop-out. In conclusion, there's some evidence that motivation, BMI, subtype, and ED pathology predicts drop-out and/or outcome in individual and family-based therapy for AN amongst adolescents and adults; however, research incorporating carefully designed multi-site studies is required to further examine these findings.

[Anorexia, the passage from adolescence to adulthood]

Anorexia engages all those close to the patient in accepting and following the treatment process. Indeed, the continuity of the treatment depends on the quality of the connections which the person with anorexia develops with his or her parents or partner. The caregivers must be involved and understand what is at play notably with the passage from adolescence to adulthood.

[Bipolar disorders and anorexia nervosa: A clinical study]

PURPOSE

Anorexia nervosa is often accompanied by comorbid mood disorders, in particular depression, but individual or family history of bipolar disorders has not frequently been explored in anorexia nervosa. The objectives of the present study were: (1) to assess the frequency of bipolar disorders in patients with anorexia nervosa hospitalized in adolescence and in their parents, (2) to determine whether the patients with a personal or family history of bipolar disorders present particular characteristics in the way in which anorexia nervosa manifests itself, in their medical history, in the secondary diagnoses established, and in the treatments prescribed.

METHOD

Overall, 97 female patients aged 13 to 20 hospitalized for anorexia nervosa and their parents were assessed. The diagnoses of anorexia nervosa and bipolar disorders were established on the basis of DSM-IV-TR criteria.

RESULTS

A high frequency of type II and type V bipolar disorders was observed. The patients with anorexia nervosa and presenting personal or family histories of bipolar disorder had an earlier onset of anorexia nervosa, more numerous hospitalizations, a longer time-lapse between anorexia nervosa onset and hospitalization, more suicide attempts and more psychiatric comorbidities.

CONCLUSION

The occurrence of anorexia nervosa-bipolar disorders comorbidity appears to be considerable and linked to the severity of anorexia nervosa, raising the issue of the relationship between anorexia nervosa and bipolar disorders.

First Sociodemographic, Pretreatment and Clinical Data from a German Web-Based Registry for Child and Adolescent Anorexia Nervosa

Abstract. Objective: The first web-based registry for childhood and adolescent anorexia nervosa (AN) in Germany was established to systematically collect demographic and clinical data. These data as well as information on how young individuals with AN can find access to healthcare services are presented. Method: Patients´ data from child and adolescent psychiatry departments of 12 university hospitals and two major nonuniversity hospitals in Germany were collected between January 2015 and December 2016. All patients met the ICD-10 diagnostic criteria for (atypical) AN. Sociodemographic data, type and amount of healthcare utilization before admission, and clinical data at admission and discharge were compiled. Results: 258 patients with a mean age of 14.7 years and a mean BMI at admission of 15.3 kg/m2 were included. The parents and patients had a higher educational level than the general German population. More than 80 % of the patients reported having utilized healthcare before hospitalization. The mean duration of outpatient treatment before hospitalization was 7 months. Conclusions: There seem to be major barriers to specialist treatment for young patients with AN in Germany, which should be analyzed in future studies.

Metasynthesis of the Views about Treatment of Anorexia Nervosa in Adolescents: Perspectives of Adolescents, Parents, and Professionals

BACKGROUND

Anorexia nervosa in adolescents can be a difficult-to-treat disease. Because qualitative research is a well-established method for deepening our understanding of subjective experiences, such as eating disorders and their treatment, we sought to perform a systematic review of qualitative studies to synthesize the views of adolescents with this disease, their parents, and their healthcare providers about its treatment.

METHODS

We performed a thematic synthesis to develop the central themes that summarize all of the topics raised in the articles included in our review. The quality of the articles was assessed by the Critical Appraisal Skills Program.

RESULTS

We included 32 articles from seven different countries. Two central themes were inductively developed from the analysis: (1) the treatment targets (i.e., symptoms and patients in context), and (2) a therapeutic tool-a relationship, specifically the core concept of the therapeutic relationship.

CONCLUSION

Our results underline the difficulty in establishing a therapeutic alliance, the barriers to it, especially the risk that professionals, adolescents, and parents will not converse about treatment; although such a dialogue appears to be an essential component in the construction of a therapeutic alliance.

Predictive factors of dropout from inpatient treatment for anorexia nervosa

BACKGROUND

Patients with severe Anorexia Nervosa (AN) whose condition is life-threatening or who are not receiving adequate ambulatory care are hospitalized. However, 40 % of these patients leave the hospital prematurely, without reaching the target weight set in the treatment plan, and this can compromise outcome. This study set out to explore factors predictive of dropout from hospital treatment among patients with AN, in the hope of identifying relevant therapeutic targets.

METHODS

From 2009 to 2011, 180 women hospitalized for AN (DSM-IV diagnosis) in 10 centres across France were divided into two groups: those under 18 years (when the decision to discharge belongs to the parents) and those aged 18 years and over (when the patient can legally decide to leave the hospital). Both groups underwent clinical assessment using the Morgan & Russell Global Outcome State questionnaire and the Eating Disorders Examination Questionnaire (EDE-Q) for assessment of eating disorder symptoms and outcome. Psychological aspects were assessed via the evaluation of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). Socio-demographic data were also collected. A number of factors identified in previous research as predictive of dropout from hospital treatment were tested using stepwise descending Cox regressions.

RESULTS

We found that factors predictive of dropout varied according to age groups (being under 18 as opposed to 18 and over). For participants under 18, predictive factors were living in a single-parent family, severe intake restriction as measured on the "dietary restriction" subscale of the Morgan & Russell scale, and a low patient-reported score on the EDE-Q "restraint concerns" subscale. For those over 18, dropout was predicted from a low depression score on the HADS, low level of concern about weight on the EDE-Q subscale, and lower educational status.

CONCLUSION

To prevent dropout from hospitalization for AN, the appropriate therapeutic measures vary according to whether patients are under or over 18 years of age. Besides the therapeutic adjustments required in view of the factors identified, the high dropout rate raises the issue of resorting more frequently to compulsory care measures among adults.

Inpatient Treatment for Adolescents with Anorexia Nervosa: Clinical Significance and Predictors of Treatment Outcome

This study evaluated the clinical significance as well as predictors of outcome for adolescents with severe anorexia nervosa (AN) treated in an inpatient setting. Body mass index (BMI), eating disorder (ED) symptoms [Eating Disorder Inventory-2 (EDI-2)], general psychopathology and depression were assessed in 238 patients at admission and discharge. BMI increased from 14.8 + 1.2 to 17.3 + 1.4 kg/m(2). Almost a fourth (23.6%) of the patients showed reliable changes, and 44.7% showed clinically significant changes (EDI-2). BMI change did not significantly differ between those with reliable or clinically significant change or no reliable change in EDI-2. Length of stay, depression and body dissatisfaction were negative predictors of a clinically significant change. Inpatient treatment is effective in about two thirds of adolescents with AN and should be considered when outpatient treatment fails. About one third of patients showed significant weight gain, but did not improve regarding overall ED symptomatology. Future studies should focus on treatment strategies for non-responders.

Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta-analysis

OBJECTIVE

Understanding the factors that predict a favourable outcome following specialist treatment for an eating disorder may assist in improving treatment efficacy, and in developing novel interventions. This review and meta-analysis examined predictors of treatment outcome and drop-out.

METHOD

A literature search was conducted to identify research investigating predictors of outcome in individuals treated for an eating disorder. We organized predictors first by statistical type (simple, meditational, and moderational), and then by category. Average weighted mean effect sizes (r) were calculated for each category of predictor.

RESULTS

The most robust predictor of outcome at both end of treatment (EoT) and follow-up was the meditational mechanism of greater symptom change early during treatment. Simple baseline predictors associated with better outcomes at both EoT and follow-up included higher BMI, fewer binge/purge behaviors, greater motivation to recover, lower depression, lower shape/weight concern, fewer comorbidities, better interpersonal functioning and fewer familial problems. Drop-out was predicted by more binge/purge behaviors and lower motivation to recover. For most predictors, there was large interstudy variability in effect sizes, and outcomes were operationalized in different ways. There were generally insufficient studies to allow analysis of predictors by eating disorder subtype or treatment type.

DISCUSSION

To ensure that this area continues to develop with robust and clinically relevant findings, future studies should adopt a consistent definition of outcome and continue to examine complex multivariate predictor models. Growth in this area will allow for stronger conclusions to be drawn about the prediction of outcome for specific diagnoses and treatment types.

ESCAP Expert Paper: New developments in the diagnosis and treatment of adolescent anorexia nervosa--a European perspective

Anorexia nervosa is a potentially life-threatening disorder with a typical onset in adolescence and high rates of medical complications and psychiatric comorbidity. This article summarizes issues relating to classification in DSM-5 and presents a narrative review of key evidence-based medical and behavioral interventions for adolescent AN and subthreshold restricting eating disorders, mainly, but not exclusively published between 2012 and 2014. In addition, it systematically compares the clinical guidelines of four European countries (Germany, Spain, The Netherlands, and United Kingdom) and outlines common clinical practice, in relation to treatment settings, nutritional rehabilitation, family-oriented and individual psychotherapy, and psychopharmacological treatment. With the exception of family-based treatment, which is mainly evaluated and practiced in Anglo-American countries, the evidence base is weak, especially for medical interventions such as refeeding and pharmacological intervention. There is a need for common European research efforts, to improve the available evidence base and resulting clinical guidance.

Clinical characteristics associated with premature termination from outpatient psychotherapy for anorexia nervosa

AIM

The literature on clinical characteristics associated with premature termination of treatment (PTT) is beset with conflicting and non-replicated findings. This study explores clinical characteristics potentially associated with PTT in a randomised controlled outpatient psychotherapy trial for anorexia nervosa (AN).

METHODS

Participants were 56 women aged 17-40 years with spectrum AN. The completer group (n = 35) included those completing at least 15/20 planned sessions with the remainder of the sample comprising the PTT group (n = 21). Variables examined included demographic factors, psychosocial functioning, psychiatric history, lifetime comorbidity, temperament and eating disorder characteristics. Logistic regression was used to examine significant variables. A Kaplan-Meier survival curve was used to illustrate time taken to PTT.

RESULTS

The mean number of sessions in the PTT group was 8.1. Lower self-transcendence scores on the Temperament and Character Inventory were associated with PTT.

CONCLUSIONS

Recognising and addressing personality factors have the potential to enhance retention in treatment.