Transcript No Slide Title

The Treatment of Chronic Eating Disorders: Predictors of Outcomes
Megan I. Jones, Krista E. Brown, Josie Geller, Suja Srikameswaran, & Erin C. Dunn
St. Paul’s Hospital, The University of British Columbia
Method
Introduction
• Individuals with chronic eating disorders are a challenging group to
treat, as evidenced by high rates of treatment refusal, drop-out, and
relapse (Pike, 1998).
• Despite the widespread use of inpatient treatments for individuals
with chronic eating disorders, little is known about the efficacy of
these treatments (Vandereycken, 2003). Predictors of outcome, such
as early discharge from program, are also unknown (Halmi, Agras,
Crow, Mitchell, Wilson, et al., 2005).
• Previous research has shown that patients at St. Paul’s Hospital who
enroll in intensive residential treatment with non-individualized
symptom-reduction expectations have high baseline readiness for
change.
• Study participants (N = 43) completed measures of readiness and
motivation, eating disorder symptomatology, psychiatric distress, and
quality of life at baseline and post-inpatient treatment.
Objective
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Participants
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• All participants had previously received specialized inpatient and
outpatient treatment for their eating disorder
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0
Baseline
* 15.8
The Quest Program
Post Inpatient
Note: There were significant improvements in eating disorder symptoms over
time: EDI-2 Drive for thinness (p < .001), Body Dissatisfaction (p < .05),
Bulimia (p < .001), and total score (p < .001).
• DSM-IV diagnostic breakdown was as follows:
12.8 %
23.1 %
15.4 %
46.2 %
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% of the EDNOS group met all but one of the diagnostic criteria for AN
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• Age = 32.13 (9.50) years
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Depression
Anxiety
Global Severity Index
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• Socioeconomic status = 2.35 (1.28) indicating upper middle class
(Hollingshead, 1979)
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• Body Mass Index = 18.35 (3.84)
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• Duration of eating disorder = 16.71 (9.53) years
Baseline
• Length of inpatient stay = 14.67 (5.13) weeks
Post Inpatient
Note: Scores represent percentiles relative to female inpatient norms. There
were significant improvements in psychiatric symptoms over time: BSI
Depression (p < .01), Anxiety (p < .05), and Global Severity Index (p < .01).
Note: Restriction Preontemplation at intake for patients admitted to
the EDP’s intensive residential program = 49.44 (28.43)
Readiness for change
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Measures
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• Readiness and Motivation Interview (RMI; Geller & Drab, 1999; Geller,
Cockell, & Drab, 2001). A symptom specific interview measure of readiness
and motivation for change in the eating disorders.
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Restriction
Precontemplation
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• The St. Paul’s Hospital Eating Disorders Program (EDP) provides
tertiary care treatment to individuals with eating disorders in British
Columbia, Canada. The EDP offers a menu of inpatient and
outpatient treatment options that are tailored to patient readiness and
motivation for change.
• Quest is an intensive inpatient treatment designed for individuals
with persistent and unrelenting eating disorders. Quest has two
phases: The inpatient phase addresses symptom reduction and the
outpatient phase focuses on maintenance and integration of change.
• Individuals who did not complete inpatient treatment had more
severe eating disorder and psychiatric symptoms at baseline than
did those who completed treatment.
• Treatment completers reported significant improvements in
readiness for change, quality of life, and eating disorder and
psychiatric symptomatology.
Conclusions
Psychiatric Symptoms
• Readiness for change (Restriction Precontemplation) = 59.07 (28.79)
• The purpose of this research is to evaluate the efficacy of a
voluntary individualized inpatient treatment program for individuals
with chronic eating disorders and to identify patient characteristics
that are associated with early discharge.
Drive for Thinness
Body Dissatisfaction
Bulimia
EDI Total Scores
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20
AN-B/P:
AN-R:
BN:
EDNOS*:
Summary of Results
• Overall, treatment retention in the inpatient phase of the Quest
program was high. Only 16% did not complete treatment.
Eating Disorder Symptoms
Procedure
• In this group, readiness for change (specifically, restriction
precontemplation, or the extent to which clients want to restrict
dietary intake) predicts dropout, symptom change, and relapse
(Geller, Drab-Hudson, Whisenhunt, & Srikameswaran, 2004).
• Predictors of early discharge for individuals with chronic eating
disorders, who are less ready for change and who typically receive
individualized inpatient symptom reduction treatments, are
unknown.
Treatment Outcome
• Quality of Life Inventory (QOLI; Frisch, 1994). A questionnaire measure
of life satisfaction.
Post Inpatient
Note: Higher scores indicate lower readiness for
change. There were significant improvements in
RMI restriction precontemplation ( p < .01).
• Eating Disorders Inventory-2 (EDI-2; Garner, 1991). A questionnaire
measure of eating disorder symptomatology.
Body Mass Index
• Brief Symptom Inventory (BSI; Derogatis & Spencer, 1982). A
questionnaire measure of psychiatric symptom severity.
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Early Discharge
BMI
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• Flexibility regarding pace of recovery (i.e., Quest patients were not
required to meet group-based/standardized expectations for change)
may also have influenced patients’ ability to complete inpatient
treatment.
• Although previous research has shown that restriction
precontemplation predicts outcome in a non-individualized
residential treatment, readiness did not predict early discharge for
individuals enrolled in Quest.
• Early discharge from Quest was associated with more severe eating
disorder and psychiatric symptoms. This suggests that for programs
tailored to individuals who have high ambivalence about normalizing
eating, other factors, such as global distress, may be more important
in determining patients’ capacity to engage in treatment.
• These findings suggest that global symptom severity may be
important to consider in determining when individuals are most
likely to benefit from programs like Quest.
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Baseline
• High treatment retention in Quest may have resulted from the use
of collaborative pre-care interventions that targeted symptom
reduction and readiness and motivation for change prior to admission
to the inpatient program.
• Despite a lengthy duration of illness, individuals who participated
in Quest experienced significant improvements in overall
functioning. It is not known whether these favourable outcomes are
representative of other programs providing inpatient treatment to
individuals with chronic eating disorders. Follow-up data collection
is currently underway to determine longer term Quest outcomes.
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• In both phases of Quest, group, individual, and family interventions
address the function of the eating disorder, readiness for change and
alternative ways of coping.
• Unlike other intensive treatments at the EDP that require high
motivation for change prior to admission, Quest accepts individuals
with varying degrees of readiness for change. As such, treatment
goals are tailored to individual need, resulting in variable length of
stay and pace of recovery.
• Prior to admission, Quest patients engage in pre-care sessions that
address readiness and motivation for change. In these addition, they
experiment with symptom reduction and collaboratively develop and
agree upon treatment goals and non-negotiables.
• This research focuses on the inpatient phase of Quest. Early
discharge occurs if the patient is no longer wanting or able to make
changes and/or adhere to the treatment non-negotiables that they
established in pre-care.
References
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Baseline
• Seven individuals (16%) were discharged early from inpatient treatment.
In 3 cases (43%) the patient and care provider came to a mutual decision
regarding discharge, in 3 cases (43%) the patient decided to leave, and in
one case (14%) the patient was asked to leave.
Eating Disorder Symptoms
Psychiatric Symptoms
Post Inpatient
Note: There were significant improvements in
BMI (p < .001) over time for individuals who
were underweight at baseline.
Quality of Life
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18
90
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Completer
14
85
75
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Early Discharge
10
Completers
31
Early Discharge
30
80
70
65
8
60
6
55
4
50
2
45
29
28
27
40
0
Drive for Thinness
Bulimia
Note: EDI-2 Drive for Thinness (p < .01), and
Bulimia (p < .05) scores were significantly higher at
baseline for the early discharge group.
Quality of Life
BSI Global Severity Index
Note: Scores represent percentiles relative to female
inpatient norms. BSI Global Severity Index (p < .05)
scores were significantly higher at baseline for the early
discharge group.
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Baseline
Post Inpatient
Note: There were significant improvements in quality
of life over time: QOLI (p < .05).
Derogatis, L. R. & Spencer, P. M. (1982). The brief symptom inventory (BSI):
Administration, scoring, and procedures manual. Towson, MD: Clinical
Psychometric Research.
Frisch, M. B. (1994). Quality of life inventory (QOLI): Manual and treatment guide.
Minneapolis, MN: National Computer Systems.
Garner, D. (1991). Eating disorder inventory-2: Professional manual. Odessa, FL:
Psychological Assessment Resources.
Geller, J. & Drab, D. (1999). The Readiness and Motivation Interview: A symptomspecific measure of readiness to change in the Eating Disorders. European Eating
Disorders Review, 7, 259-278.
Halmi, K.A., Agras, W.S., Crow, S., Mitchell, J., Wilson, T.G., Bryson, S.W., &
Kraemer, H.C. (2005). Predictors of treatment acceptance and completion in
anorexia nervosa. Archives of General Psychiatry, 62, 776-781.
Hollingshead, A.B. (1979). Four Factor Index of Social Status. New Haven, CN:
privately printed.
Pike, K. (1998). Long-term course of anorexia nervosa: Response, relapse, remission,
and recovery. Clinical Psychology Review, 18, 447-475.
Vandereycken, W. (2003). The place of inpatient care in the treatment of anorexia
nervosa: Questions to be answered. International Journal of Eating Disorders,
Please address correspondence to: Megan I. Jones
34, 409-422.
E-mail: [email protected]