This article was downloaded by: [Brewerton, Timothy D.] On: 24 February 2011 Access details: Access Details: [subscription number 933991266] Publisher Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Eating Disorders Publication details, including instructions for authors and subscription information: http://www.informaworld.com/smpp/title~content=t713666342 Treatment Results of Anorexia Nervosa and Bulimia Nervosa in a Residential Treatment Program Timothy D. Brewerton a ; Carolyn Costin b a Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA b Monte Nido & Affiliates, Malibu, California, USA Online publication date: 24 February 2011 To cite this Article Brewerton, Timothy D. and Costin, Carolyn(2011) 'Treatment Results of Anorexia Nervosa and Bulimia Nervosa in a Residential Treatment Program', Eating Disorders, 19: 2, 117 131 To link to this Article: DOI: 10.1080/10640266.2011.551629 URL: http://dx.doi.org/10.1080/10640266.2011.551629 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
Eating Disorders, 19:117 131, 2011 Copyright Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530x online DOI: 10.1080/10640266.2011.551629 Treatment Results of Anorexia Nervosa and Bulimia Nervosa in a Residential Treatment Program TIMOTHY D. BREWERTON Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA CAROLYN COSTIN Monte Nido & Affiliates, Malibu, California, USA Data on the effectiveness of residential treatment for patients with anorexia nervosa (AN) and bulimia nervosa (BN) are limited. We analyzed patient survey results at admission and discharge from Monte Nido Residential Treatment Program. Of 287 consecutive admissions, 80% (231) graduated (completed 30 days of treatment), and of these (all of whom gave consent), only patients with AN (N = 120) or BN (N = 95) were included (215 of 231, 93%) in this study. Analyses included a comparison of admission vs. discharge variables (paired t-tests) for each diagnosis. At each assessment, graduates completed the Eating Disorders Inventory-2 (EDI-2), the Beck Depression Inventory (BDI), and a structured eating disorder assessment questionnaire. For patients with AN, there were statistically significant improvements in mean BMI. In addition, for both AN and BN patients, there were statistically significant improvements in BDI scores, all 11 EDI-2 subscales, and frequencies of bingeing, vomiting, laxative abuse, chewing and spitting, stimulant abuse, and restricting behavior. The great majority of patients completing treatment showed significant improvement at discharge from intensive residential treatment. Address correspondence to Timothy D. Brewerton, M.D., D.F.A.P.A., F.A.E.D., 216 Scott Street, Mt. Pleasant, SC 29464, USA. E-mail: tbrewerton1@comcast.net 117
118 T. D. Brewerton and C. Costin INTRODUCTION Several studies report short-term improvements from inpatient treatment of individuals with anorexia nervosa (AN) and bulimia nervosa (BN) (Andersen, 1986; Andersen, Bowers, & Evans, 1997; Andersen, Morse & Santmyer, 1985; Bowers, Andersen, & Evans, 2004; Garner, Garfinkel & Irvine, 1986; Van dereycken, 1985). However, there are very few published studies of the results of treatment of patients who have been treated in residential treatment programs (RTCs). RTCs offer the advantage of a long-term, structured, and intensive treatment locale outside of the sterile environment of a hospital setting, generally at lower cost. Bean et al. (2008) reported positive shortterm outcomes in 107 patients (72 females and 35 males) with AN treated at the residential program at Rogers Memorial Hospital. The only report on the short-term treatment of BN in a RTC was by Gleaves et al. (1993), who reported on the effectiveness of residential treatment on a consecutive group of 497 patients with BN. All measured subscales of the Eating Disorders Inventory (EDI; Garner, Olmsted, & Polivy, 1983) significantly improved between admission and discharge, although the authors did not measure binge and purge frequency at discharge. Lowe et al. (2003) reported significant improvements in depression and eating disorder symptomatology following residential treatment of 472 patients (279 with AN, 193 with BN). According to the third edition of the Practice Guidelines for the Treatment of Eating Disorders of the American Psychiatric Association (2006), RTCs are appropriate for patients who are medically stable to the extent that intravenous fluids, nasogastric tube feedings, or multiple daily laboratory tests are not needed. In addition, patients appropriate for RTC manifest poorto-fair motivation and are preoccupied with intrusive repetitive thoughts at least 4 6 hours a day. However, they generally are cooperative with highly structured treatment, have failed outpatient interventions, and need supervision at all meals or they will restrict eating, binge and/or purge. They can ask for and use support from others and utilize cognitive and behavioral skills to inhibit purging (APA 2006; LaVia et al., 1998). In addition, an RTC is a good treatment option when: a) patients have severe family conflict or dysfunction, or the absence of family support, such that the patient is unable to receive structured treatment in home; b) the patient lives alone without an adequate support system and/or c) treatment program is too distant for patient to participate from home. The other major eating disorder practice guidelines that are available, those of the National Institute of Clinical Excellence (NICE) (2004), have no reference to the use of RTCs given the lack of data.
Anorexia Nervosa and Bulimia Nervosa in Residential Treatment 119 METHODS Design and Hypothesis This study involved a prospective cohort in design and planning of measures. Our hypothesis was that patients who stayed at least 30 days in treatment (graduates) would show significant improvements in all measures of ED and depressive symptomatology. A cutoff of 30 days was used a priori because it was considered the minimal time period necessary for completing the program and effecting change and because it was a pre-designated admission requirement for all patients. Subjects We analyzed results from a survey of respondents before and after completing at least 30 days or more of treatment at Monte Nido Residential Treatment Program in Malibu, CA. Of 287 consecutive admissions, 80% (231) were eligible for inclusion in the study, including 120 with AN, 95 with BN, and 16 with EDNOS. All of these patients received at least 30 days or more of treatment and are referred to as graduates. The 20% of admissions who were not eligible left treatment before 30 days and did not complete discharge survey measures. These patients are referred to as non-graduates. Because of the low sample size of the EDNOS group, only those graduates with AN and BN were analyzed for the purposes of this study. The analyses included a comparison of admission vs. discharge (DC) assessment variables for each diagnosis. The demographic and clinical characteristics of the graduates and the non-graduates are shown in tables 1 and 2 for AN and BN, respectively. The age range of the graduates with AN was 17 to 55 years, while that of the BN graduates was 22 to 57 years. It is important to note that this was largely a treatment refractory group, with 90% of patients with AN and 93% of patients with BN failing prior outpatient, inpatient, and/or residential treatment. Intervention Individuals in this study received treatment for an eating disorder at Monte Nido, a 24-hour residential care facility operated in a six bed homelike environment. The treatment philosophy and the protocols used were developed by one of the authors (CC), drawing from evidenced based research and extensive clinical experience in both inpatient and outpatient settings.
120 T. D. Brewerton and C. Costin A comprehensive description of the program can be found in the first edition of The Eating Disorder Sourcebook (Costin, 1996). An overview of the program components and program goals are provided below. Weight restoration or stabilization is a primary treatment goal for patients with AN. In addition, interventions for patients focus on the control or reversal of weight and food phobias, and the development of trust in their bodies and the recovery process. Contrary to the rigid protocols of other treatment protocols, patients with AN might be allowed periods of weight gain balanced with periods of weight maintenance, allowing for the psychological component of recovery to keep pace with weight restoration. Additionally, patients are initially allowed to abstain from eating certain fear foods. Increasing the variety of food and the calories consumed may be alternated thereby allowing patients to focus on one aspect of recovery at a time. Clinically, patients report that this process forms a foundation for better tolerance and maintenance of weight gain during treatment, and most notably for the continuation of weight restoration post discharge. A specific goal in the treatment of patients with BN is attaining abstinence from any bingeing or purging behavior. Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) are used to assist patients with their thought patterns and the emotional dysregulation that contributes to these behaviors. Through psychotherapy and by utilizing a level system of decreased monitoring (observation after meals, staff supervision in the kitchen, etc.) along with increased exposure and responsibility, individuals are taught how, and are given the opportunity to replace, unhealthy behaviors with healthy ones. The program and staff teach patients to reach out to people rather than their behaviors to get their needs met. Distinctive components of the Monte Nido program that are notable include: Range of therapeutic interventions. Each week, every patient received individual psychotherapy three times with their assigned therapist, one individual session with the clinical director, one two individual sessions with a dietitian, a session with the psychiatrist, a session with the medical physician, two group sessions with an exercise trainer, and several forms of group therapy, including Body & Soul group, Food & Feelings group, Primary Process group, Nutrition group, Spirituality group, Life Skills group, Goals group, Special Topics group, Meditation group, and Yoga. Use of recovered staff in the treatment team. Recovered staff members openly serve as role models. Patients have consistently reported that speaking with someone who is recovered is a crucial factor in their recovery (Garrett, 1997; 1998; Redenbach & Lawler, 2003). Patients have hands-on experiences with food that simulates real life. Throughout the time frame of the study, patients utilized a kitchen and made their own food.
Anorexia Nervosa and Bulimia Nervosa in Residential Treatment 121 The home like environment with 6 patients can easily simulate life before and after treatment. Staff and patients eat the same food and sit together around a small dining room table. This is also a unique feature for a few reasons: a) many treatment programs are so large that patients have to eat their food from a cafeteria setting; b) some treatment programs have staff attending meals but not eating with the patients; c) at other treatment programs, the staff members at meals are not necessarily the same therapists doing the individual sessions. A graduated level system allows for patients to gradually get increased responsibilities for taking care of their own nourishment. With help from the staff, eventually patients learn to portion, shop for, prepare, and cook their own snacks and then meals. Once each week, the higher-level patients organize for, shop, prepare, and cook a meal for the rest of the patients. All of these experiences require certain skill sets that are important for successful transition to after care and for long-term recovery. These experiences are not available in larger programs using institutionalized kitchens and dining rooms. Level system. The level system provides structure for the entire treatment process. Patients collaborate with their therapist and the treatment team by means of a weekly contract with goals in a variety of treatment categories, e.g., nutrition, exercise, cognitive, behavioral, relationship, family, medical, and discharge. Patients must successfully complete what is expected on each level to progress to the next level with its associated responsibilities and privileges. Medication management. All patients meet weekly with the program psychiatrist for medication evaluation and management. Evaluation for possible use of medication is based on available practice guidelines (American Psychiatric Association, 2006) and in some cases results from quantitative electroencephalographic (EEG) analysis (Bares et al., 2007; 2008; Hunter, Cook & Leuchter, 2007; Leuchter et al., 2009a; 2009b). Assessment At each assessment, graduates completed the Eating Disorders Inventory- 2 (EDI-2) (Garner, 1991; Garner, Olmsted, & Polivy, 1983), the Beck Depression Inventory (BDI) (Beck, Steer, & Brown 1996), and a structured eating disorder assessment questionnaire developed for outcome assessment of eating disorder behaviors. Possible responses for each behavior were as follows: 0) Not at all; 1) Once a month or less; 2) A few times a month; 3) At least once a week; 4) At least twice a week; 5) Daily; 6) More than once a day. All graduates gave written informed consent for their responses to be used for both clinical and research purposes. To protect the client s
122 T. D. Brewerton and C. Costin confidentiality and anonymity, each respondent was identified with a computer-generated number. The mean duration of treatment was 96.0 ± 53.8 days for the AN subjects and 78.9 ± 49.1 days for the BN subjects. Classification of Outcomes Outcomes of AN were classified as per Morgan and Russell (1975) as good, intermediate, and poor. A good outcome was defined by the return of normal weight (BMI 18.0) and normal menstrual function. Intermediate outcome or partial recovery was indicated by either weight restoration (BMI 18.0) or resumption of normal menstrual function. Poor outcome was indicated by the absence of both. For BN, a good outcome was defined by the complete cessation of binge eating and purging behaviors. An intermediate outcome or partial recovery was defined by at least a 50% reduction in binge eating and purging, and a poor outcome was defined by the failure to meet either of the above goals. Statistics Means are presented with standard deviations (SD). Comparisons of parametric independent samples were completed using analyses of variance (ANOVA) and for nonparametric independent samples Kruskal-Wallis tests were used. Related parametric data were analyzed using paired t-tests, and related nonparametric data were analyzed using Wilcoxon Signed Ranks Tests. Post-hoc Bonferroni corrections were made for multiple comparisons. RESULTS Baseline Group Comparisons We compared Monte Nido graduates with AN and BN on a number of demographic and clinical variables by diagnosis, and these results are shown in Table 1. Significant differences between the groups were found in length of stay (AN > BN), number of past hospitalizations (AN > BN), admission and discharge BMI (BN > AN), and bulimia subscale scores of the EDI-2 (BN > AN). We also compared graduates with non-graduates on the same set of demographic and clinical variables, and these results are shown in Table 2 for the AN group and Table 3 for the BN group. Discharge assessment surveys were only completed by a small minority of non-graduates and are therefore not presented.
Anorexia Nervosa and Bulimia Nervosa in Residential Treatment 123 TABLE 1 Demographic and Baseline Clinical Characteristics of Study Graduates With AN and BN (Mean ± SD). Uncorrected p-values are Provided, and When Appropriate, Corrected p-values are Given in Parentheses AN graduates BN graduates p-value Samplesize(N ) 120 95 Age (years) 31.4 ± 8.3 29.8 ± 8.0.016 (.3 corrected) Length of illness (years) 8.4 ± 6.2 8.5 ± 7.5 Length of stay (days) 97.6 ± 65.2 72.1 ± 45.1 0.0001 ( 0.0019 corrected) Admit BMI 15.9 ± 1.8 20.8 ± 3.4 0.0001 ( 0.0019 corrected) Discharge BMI 18.2 ± 1.4 21.6 ± 4.0 0.0001 ( 0.0019 corrected) Admit BDI 28.9 ± 11.8 28.9 ± 12.6.64 Discharge BDI 12.6 ± 9.4 10.6 ± 9.0.34 # Past hospitalizations 1.7 ± 1.8 0.8 ± 1.4.001 (.019 corrected) Drive for thinness (EDI-2) 14.1 ± 6.1 15.2 ± 5.1.22 Bulimia (EDI-2) 4.2 ± 5.2 11.4 ± 5.7.001 (.019 corrected) Body dissatisfaction (EDI-2) 15.2 ± 8.0 18.2 ± 8.2.003 (.057 corrected) Ineffectiveness (EDI-2) 13.0 ± 8.0 14.2 ± 8.1.86 Perfectionism (EDI-2) 9.2 ± 4.6 9.6 ± 4.7.75 Interpersonal distrust (EDI-2) 6.5 ± 4.4 6.1 ± 4.4.5 Interoceptive awareness (EDI-2) 11.0 ± 6.5 13.2 ± 7.2.09 Maturity fears (EDI-2) 6.0 ± 5.4 6.1 ± 5.8.61 Asceticism (EDI-2) 9.5 ± 5.5 9.1 ± 4.9.64 Impulse regulation (EDI-2) 5.7 ± 5.4 7.5 ± 5.8.023 (.44 corrected) Social insecurity (EDI-2) 9.0 ± 4.7 9.4 ± 4.8.91 Note. = Significance at the p.05 level (corrected). TABLE 2 Demographic and Baseline Clinical Characteristics of Study Graduates and Non- Graduates With AN (Mean ± SD). Uncorrected p-values are Provided, and When Appropriate, Corrected p-values are Given in Parentheses Graduates Non-graduates p-value (unpaired t-test) Samplesize(N ) 120 46 Age (years) 31.4 ± 8.3 41.2 ± 11.3.001 (.019 corrected) Length of illness (years) 8.4 ± 6.2 13.8 ± 7.5.002 (.038 corrected) Length of stay (days) 97.6 ± 65.2 15.6 ± 9.3.001 (.019 corrected) Admit BMI 15.9 ± 1.8 15.6 ± 1.7.6 Discharge BMI 17.8 ± 1.5 16.2 ± 1.8.001 (.019 corrected) Admit BDI 28.9 ± 11.8 27.4 ± 15.0.69 Discharge BDI 12.6 ± 9.4 8.1 ± 11.5.07 (>.7 corrected) # Past hospitalizations 1.7 ± 1.8 0.6 ± 1.0.004 (.078 corrected) Drive for thinness (EDI-2) 14.1 ± 6.1 13.6 ± 7.8.82 Bulimia (EDI-2) 4.2 ± 5.2 2.9 ± 3.6.37 Body dissatisfaction (EDI-2) 15.2 ± 8.0 13.4 ± 8.9.46 Ineffectiveness (EDI-2) 13.0 ± 8.0 13.0 ± 8.0.69 Perfectionism (EDI-2) 9.2 ± 4.6 10.2 ± 5.4.48 Interpersonal distrust (EDI-2) 6.5 ± 4.4 5.7 ± 5.3.57 Interoceptive awareness (EDI-2) 11.0 ± 6.5 11.5 ± 8.9.81 Maturity fears (EDI-2) 6.0 ± 5.4 6.2 ± 6.8.9 Asceticism (EDI-2) 9.5 ± 5.5 8.2 ± 4.1.44 Impulse regulation (EDI-2) 5.7 ± 5.4 4.8 ± 4.0.56 Social insecurity (EDI-2) 9.0 ± 4.7 8.6 ± 5.4.76 Note. = Significance at the p.05 level (corrected).
124 T. D. Brewerton and C. Costin TABLE 3 Demographic and Baseline Clinical Characteristics of Study Graduates and Non- Graduates With BN (Mean ± SD). Uncorrected p-values are Provided, and When Appropriate, Corrected p-values are Given in Parentheses Graduates Non-graduates p-value (unpaired t-test) Samplesize(N ) 95 54 Age (years) 29.8 ± 8.0 32.1 ± 7.0.28 Length of illness (years) 8.7 ± 7.5 9.4 ± 7.5.75 Length of stay (days) 72.1 ± 45.1 21.4 ± 8.6 0.0001 ( 0.0019 corrected) Admit BMI 20.8 ± 3.4 20.4 ± 2.1.61 Discharge BMI 21.4 ± 3.6 20.8 ± 1.9.49 Admit BDI 28.9 ± 12.5 23.1 ± 14.3.17 Discharge BDI 10.6 ± 9.0 11.6 ± 6.6.76 # Past hospitalizations 0.8 ± 1.4 0.6 ± 1.6.03 (.57corrected) Drive for thinness (EDI-2) 13.7 ± 6.3 15.3 ± 5.1.36 Bulimia (EDI-2) 11.4 ± 5.7 11.1 ± 5.9.87 Body dissatisfaction (EDI-2) 18.1 ± 8.2 18.2 ± 7.4.98 Ineffectiveness (EDI-2) 14.1 ± 8.1 10.5 ± 7.2.12 Perfectionism (EDI-2) 9.2 ± 4.6 9.6 ± 4.7.16 Interpersonal distrust (EDI-2) 6.1 ± 4.2 5.5 ± 4.6.66 Interoceptive awareness (EDI-2) 13.2 ± 7.2 10.4 ± 6.2.18 Maturity fears (EDI-2) 6.1 ± 5.8 3.9 ± 3.0.15 Asceticism (EDI-2) 9.1 ± 4.9 8.5 ± 3.1.61 Impulse regulation (EDI-2) 7.5 ± 5.8 6.0 ± 6.0.39 Social insecurity (EDI-2) 9.4 ± 4.8 7.7 ± 4.4.23 Note. = Significance at the p.05 level (corrected). For those with a diagnosis of AN, statistically significant differences between the groups were only found for age (non-graduates > graduates), length of stay (graduates > non-graduates), duration of illness (non-graduates > graduates), and number of hospitalizations (graduates > non-graduates; see Table 2). Graduates endorsed significantly more frequent restricting behavior (3.6 ± 2.5 v. 1.5 ± 1.5) and significantly less frequent enema abuse (1.5 ± 1.5 v. 2.9 ± 2.4) than non-graduates (p <.01, Mann-Whitney U test). There were no significant differences in any of the admission EDI-2 subscale scores, admission and discharge BDI scores, and self-reported frequencies of bingeing, vomiting, chewing and spitting, laxative abuse, diuretic abuse, ipecac abuse, stimulant abuse, and compulsive exercise. For those with a diagnosis of BN, statistically significant differences between the groups were found for length of stay (graduates > nongraduates; see Table 3). In addition, there was a significant difference between the 2 groups that remained after post-hoc corrections for frequencies of stimulant abuse (graduates > non-graduates, 1.95 ± 1.7 v. 0.86 ± 1.6, p <.01, Mann-Whitney U test). The two groups did not significantly differ in age, length of illness, mean number of past hospitalizations, mean admit and discharge BMI s, mean admit and discharge BDI s, mean EDI subscale
Anorexia Nervosa and Bulimia Nervosa in Residential Treatment 125 scores, and mean self-reported frequencies of bingeing, vomiting, chewing and spitting, laxative abuse, diuretic abuse, ipecac abuse, enema abuse, restricting behavior, and compulsive exercise. Clinical Outcome: AN In the AN group, there was a statistically significant increase in mean BMI from 15.9 ± 1.7 to 18.2 ± 1.4 (p <.0001, paired t-test) following treatment. In addition, 11 of 11 EDI-2 subscales significantly increased from admission to discharge (see Figure 1). Frequencies of bingeing, vomiting, chewing and spitting, laxative abuse, compulsive exercising, stimulant abuse, and restricting behavior were all significantly reduced at the time of discharge (p.05, Wilcoxon Signed Rank Tests, see Figure 2). There were no significant differences between admission and discharge frequencies for diuretic abuse, ipecac abuse, and enema abuse, largely due to low base rates of and/or large variations in the frequencies of these behaviors in the AN group. Mean BDI scores significantly improved from admission (28.3 ± 12.1) to discharge (14.2 ± 9.5, p <.0001, paired t-test). 16 14 12 10 8 6 4 AN @ Admission AN @ Discharge 2 0 Drive for thinness Bulimia Body dissatisfaction Ineffectiveness Perfectionism Interpersonal distrust Interoceptive awareness Maturity fears Asceticism Impulse regulation Social insecurity FIGURE 1 EDI-2 subscale scores in respondents with anorexia nervosa (AN) at admission and discharge. Significant differences between admission and discharge scores are indicated by an asterisk ( ), p <.05, paired t-test following post-hoc Bonferroni corrections.
126 T. D. Brewerton and C. Costin 3.5 3 2.5 2 1.5 An @ Admission An @ Discharge 1 0.5 0 Binge frequency Vomiting frequency Laxative frequency Diuretic frequency Ipecac frequency Enema frequency Excercise frequency Chewing frequency Stimulant frequency Restricting frequency FIGURE 2 Frequency of eating disordered behaviors in respondents with anorexia nervosa (AN) at admission and discharge follow-up. Possible responses for each behavior were: 0) Not at all; 1) Once a month or less; 2) A few times a month; 3) At least once a week; 4) At least twice a week; 5) Daily; 6) More than once a day. Significant differences between admission and discharge scores are indicated by an asterisk ( ), p <.05, Wilcoxon Signed Ranks Test following post-hoc corrections for number of comparisons. At the time of discharge 39% of AN graduates achieved weight recovery (BMI 18); in addition, 18% had a good outcome (BMI 18 AND resumption of normal menses), 56% an intermediate outcome (BMI 18 OR resumption of normal menses) and 25% a poor outcome (neither restoration of weight nor menses). None of the graduates treated for AN were obese (BMI > 30) or overweight (BMI between 20 and 25) at the time of discharge. Clinical Outcome: BN In the BN group, there was no statistically significant change in mean BMI between admission (20.8 ± 3.6) and discharge (21.6 ± 4.0; NS, paired t-test). All 11 of 11 EDI-2 subscales significantly improved from admission to discharge (p <.01, Bonferroni corrected paired t-tests; see Figure 3). Frequencies of bingeing, vomiting, laxative abuse, diuretic abuse, chewing and spitting, compulsive exercising, stimulant abuse, and restricting behavior
Anorexia Nervosa and Bulimia Nervosa in Residential Treatment 127 20 18 16 14 12 10 8 6 BN @ Admission BN @ Discharge 4 2 0 Drive for thinness Bulimia Body dissatisfaction Ineffectiveness Perfectionism Interpersonal distrust Interoceptive awareness Maturity fears Asceticism Impulse regulation Social insecurity FIGURE 3 EDI-2 subscale scores in respondents with bulimia nervosa (BN) at admission and discharge. Significant differences between admission and discharge scores are indicated by an asterisk ( ), p <.05, paired t-test following post-hoc Bonferroni corrections. were all significantly reduced at the time of discharge (p <.01, Wilcoxon Signed Rank Tests, see Figure 4). However, there were no significant differences between admission and discharge frequencies for diuretic abuse, ipecac abuse, and enema abuse, in large part due to low base rates of and substantial variations in the frequencies of these behaviors. Mean BDI scores significantly improved from admission (26.8 ± 12.2) to discharge (9.8 ± 8.6, p <.001, paired t-test). At discharge 84% of BN graduates reported a good outcome (100% cessation of their binge, purge, and other compensatory behaviors), 11% an intermediate outcome ( 50% reduction in both) and 5% a poor outcome (< 50% reduction). In terms of weight one of the graduates (1.6%) treated for BN was obese (BMI > 30) and 8 (6.6%) were overweight (BMI between 25 and 30) at the times of both admission and discharge. DISCUSSION The great majority of patients showed significant improvement at discharge after intensive residential care. Specifically, 74% of patients with AN and 95%
128 T. D. Brewerton and C. Costin 5 4.5 4 3.5 3 2.5 2 BN @ Admission BN @ Discharge 1.5 1 0.5 0 Binge frequency Vomiting frequency Laxative frequency Diuretic frequency Ipecac frequency Enema frequency Excercise frequency Chewing frequency Stimulant frequency Restricting frequency FIGURE 4 Frequency of eating disordered behaviors in respondents with bulimia nervosa (BN) at admission and discharge. Possible responses for each behavior were: 0) Not at all; 1) Once a month or less; 2) A few times a month; 3) At least once a week; 4) At least twice a week; 5) Daily; 6) More than once a day. Significant differences between admission and discharge scores are indicated by an asterisk ( ), p <.05, Wilcoxon Signed Rank Test following post-hoc corrections for number of comparisons. of patients with BN achieved a good or intermediate outcome by discharge. Residential treatment using this particular treatment philosophy may be an effective and less costly alternative to inpatient treatment (Costin, 2007). Although our results are compelling, there are a number of limitations to this study, the greatest of which is that it lacks a control or comparison group. This makes it impossible to definitely conclude that residential treatment was the cause of these patients improvement. However, it is very unlikely that our patients would have improved to the extent that they did on their own. Over 90% had been treatment refractory in that they had failed prior outpatient, inpatient and/or residential programs. Secondly, our results do not bear directly upon the question of whether the program s treatment philosophy has anything to do with the patient improvements reported. The methods of this study did not allow for an analysis of the active ingredients which may have contributed to improvements.
Anorexia Nervosa and Bulimia Nervosa in Residential Treatment 129 Thirdly, not all of the patients who were admitted into the program were studied at discharge. Although approximately 20% of patients admitted to Monte Nido chose to leave or were asked to leave before completing 30 days of treatment, which was for a variety of reasons, e.g., lack of readiness, insurance denial, financial difficulties, and rule breaking, there were very few significant differences in baseline demographic or clinical variables between the graduates and the non-graduates. For the AN group, the graduates were significantly younger than the non-graduates. They had also been ill for a significantly shorter period of time but had a higher rate of past hospitalizations than the non-graduates. The graduates with AN also endorsed more frequent restricting behaviors and less frequent enema abuse than the non-graduates. It appears that patients with enema abuse find it harder to tolerate the constraints of residential care and are more likely to leave treatment prematurely. Otherwise, there were no significant differences in any of the baseline EDI-2 subscale scores, BDI scores, or self-reported frequencies of bingeing, vomiting, chewing and spitting, exercising, or abuse of laxatives, diuretics, ipecac or stimulants. For the BN group, the two groups were also very similar in terms of clinical and demographic variables. The only difference was a greater mean frequency of stimulant abuse in the graduates compared to the non-graduates. Overall, these findings suggest that the graduates were just as sick as or sicker than the non-graduates. Lastly, we do not report any follow-up data in this article, so it is unknown at this time whether the improvements reported in this sample have any long-lasting therapeutic effects. However, we plan to analyze results of assessment surveys following long-term follow-up after discharge to investigate the extent to which patients maintain their recovery. In addition, we plan to explore the role of a number of possible positive and negative prognostic factors, including comorbid diagnoses, age of onset, duration of illness, length of stay, and attendance at our transitional treatment program. In addition, once our sample sizes expand, we intend to analyze the effects of residential treatment on patients with eating disorder not otherwise specified (EDNOS), as our current sample size was too small and diverse to show meaningful statistical results. REFERENCES American Psychiatric Association (2006). Treatment of patients with eating disorders, third edition. American Journal of Psychiatry, 163(7 Suppl), 4 54. Andersen, A. E. (1986). Inpatient and outpatient treatment of anorexia nervosa. In K. D. Brownell & J. P. Foreyt (Eds.), Handbook of eating disorders: Physiology, psychology, and treatment of obesity, anorexia and bulimia. NewYork,NY: Basic Books.
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