SEATTLE – Initial improvements in anorexia nervosa and bulimia nervosa achieved in an intensive residential treatment program are largely sustained 4-5 years later, Dr. Timothy D. Brewerton reported.
“Data on long-term follow-up of individuals with anorexia nervosa and bulimia nervosa following intensive inpatient or residential treatment are limited,” said Dr. Brewerton, a psychiatrist at the Medical University of South Carolina, Charleston, who also is in private practice in Mt. Pleasant, S.C. “Many studies are primarily on adolescents and/or outpatients, and others have included individuals who have not received any treatment.”
The investigators surveyed patients with eating disorders who had received at least 30 days of treatment in a residential program in Malibu, Calif. Outcomes on the Eating Disorder Inventory-2 (EDI-2), the Beck Depression Inventory (BDI), and a structured eating disorder assessment were evaluated at three time points: admission, discharge, and the most recent of 13 postgraduate follow-ups, which ranged from 1 to 10 years.
Analyses were based on 85 patients with anorexia and 71 patients with bulimia. The mean time between discharge and postgraduate follow-up was 4.5 and 4.1 years, respectively. On average, the patients in each group were about 30 years old (range, 17-57).
In the anorexia group, mean BMI scores (reported by a physician, therapist, or dietician) increased significantly between admission and discharge (from 16 to 18), Dr. Brewerton told those attending an international conference sponsored by the Academy for Eating Disorders. Moreover, a further significant increase was seen from discharge to postgraduate follow-up (from 18 to 19).
By discharge, the patients with anorexia had significant improvements in 9 of 11 subscales of the EDI-2. They had further significant improvements in five of the subscales–drive for thinness, body dissatisfaction, interoceptive awareness, maturity fears, and asceticism–between discharge and postgraduate follow-up.
The percentage of anorexia patients with a good outcome, defined as a return of body mass index (BMI) to at least 18 and normal menses, increased between discharge and postgraduate follow-up (from 19% to 41%). At the same time, there was a decrease in the percentages with an intermediate outcome, defined as restoration of BMI or normal menses (from 48% to 46%), and a poor outcome, defined as restoration of neither BMI nor menses (from 33% to 12%).
The frequency of 3 of 10 eating-disordered behaviors–bingeing, vomiting, and laxative use–was significantly higher at postgraduate follow-up than at discharge. “This is not terribly surprising,” Dr. Brewerton said at the conference, which was cosponsored by the University of New Mexico. Moreover, the values remained significantly or marginally lower than those at admission.
Scores on the BDI decreased significantly between admission and discharge, and remained so at postgraduate follow-up. About 85% of patients reported that they were improved or significantly improved at the latter assessment.
Turning to the bulimia group, Dr. Brewerton reported that these patients had significant improvements in all 11 EDI-2 subscales by discharge, and the benefits persisted to postgraduate follow-up. Their BMIs were in the normal range at all three assessments.
Between discharge and postgraduate follow-up, there was a decrease in the percentage of bulimic patients with a good outcome, defined as complete cessation of bingeing, purging, and other compensatory behaviors (from 97% to 62%) and an increase in the percentages with an intermediate outcome, defined as a reduction in those behaviors by at least half (from 3% to 19%), and a poor outcome, defined as a reduction of less than half (from 0% to 19%).
The frequency of 7 of the 10 eating-disordered behaviors decreased significantly by discharge and remained at that level at the postgraduate follow-up. As in the group with anorexia, BDI scores fell by discharge in this group and remained at this level thereafter. Similarly, about 85% of patients reported themselves to be improved or significantly improved.
“The great majority of clients in this program showed significant improvement at long-term follow-up after intensive residential care,” Dr. Brewerton said, while noting that receipt of therapy during follow-up is still being analyzed. He observed that many of the patients entering the program had treatment-refractory eating disorders and had previously received care as inpatients or outpatients, or in other residential programs.
“Residential treatment using this particular treatment philosophy can be an effective and less costly alternative to inpatient treatment,” he concluded. He said this philosophy is best described in The Eating Disorder Sourcebook (New York: McGraw-Hill, 2007), by Carolyn Costin. Ms. Costin is the founder and director of the Monte Nido Residential Treatment Program, the program studied. Dr. Brewerton reported that he was paid as a consultant by Monte Nido to collate, analyze, and present the survey data.