Why the high rate of dropout from individualized cognitive-behavior therapy for bulimia nervosa?

Secondary outcomes and qualitative findings of an open-label feasibility trial of lisdexamfetamine dimesylate for adults with bulimia nervosa

BACKGROUND

There is emerging evidence that stimulants warrant further investigation as a treatment for bulimia nervosa (BN) including a recent open-label feasibility trial examining the use of lisdexamfetamine dimestylate (LDX) for BN. The current report presents the secondary outcomes and qualitative interview results from that feasibility trial. These outcomes explore several purported mechanisms that may explain how stimulants affect symptoms of BN: appetite, impulsivity, obsessive and compulsive symptoms, eating disorder psychopathology/impairment and reward-based decision-making.

METHODS

Twenty-three participants with BN received LDX for eight weeks. Questionnaires assessing appetite, impulsivity, obsessive and compulsive symptoms, eating disorder psychopathology and impairment were administered at baseline and post-treatment. Participants also completed a two-step reinforcement learning task to assess their decision-making. Semi-structured interviews took place at baseline, week 5, and follow-up.

RESULTS

Reductions in hunger, food-related impulsivity, obsessive and compulsive features, eating disorder psychopathology and impairment were found. However, reward learning, as far as it is assessed by the task, did not seem to contribute to the effect of LDX on BN symptoms. Qualitative analysis suggested four themes: (1) reprieve from the eating disorder, (2) improvement in function and quality of life, (3) renewed hope for recovery, and (4) ability to normalize eating.

CONCLUSIONS

This report suggests several potential mechanisms by which LDX may reduce symptoms of binging and purging in those with BN. Importantly, due to the open-label design, we are unable to attribute findings to the medication. Instead, our results should be interpreted as hypothesis generating to inform future studies such as adequately powered randomized controlled trials. Trial registration NCT03397446.

A Randomized Controlled Trial of CBT+: A Clinician-Controlled, Just-In-Time, Adjunctive Intervention for Bulimia-Spectrum Disorders

Cognitive Behavior Therapy (CBT) for bulimia nervosa (BN) requires patient skill utilization (use of treatment skills) and skill acquisition (successful skill use) for symptom improvement. Treatment outcomes are unsatisfactory, possibly due to poor skill acquisition and utilization by post-treatment. Just-in-time adaptive interventions (JITAIs), momentary interventions delivered at opportunities for skill practice, may improve skill acquisition and utilization. Participants (N = 56 individuals with bulimia-spectrum eating disorders) completed electronic self-monitoring in CBT+ and received JITAIs or no JITAIs alongside 16 sessions of CBT. Feasibility, acceptability, target engagement, and treatment outcomes were evaluated. JITAIs demonstrated feasibility and acceptability. Treatment outcomes and target engagement did not differ between conditions. The lack of group differences in target engagement and treatment outcomes may be explained by skill use self-monitoring promoting skill utilization and acquisition or low statistical power. Our findings suggest that JITAIs are feasible and acceptable during CBT for BN and warrant additional study.

Using Continuous Glucose Monitoring to Detect and Intervene on Dietary Restriction in Individuals With Binge Eating: The SenseSupport Withdrawal Design Study

BACKGROUND

Dietary restraint is a key factor for maintaining engagement in binge eating among individuals with binge eating disorder (BED) and bulimia nervosa (BN). Reducing dietary restraint is a mechanism of change in cognitive behavioral therapy (CBT) for individuals with BN and BED. However, many individuals who undergo CBT fail to adequately reduce dietary restraint during treatment, perhaps owing to difficulty in using treatment skills (eg, regular eating) to reduce dietary restraint during their daily lives. The SenseSupport system, a novel just-in-time, adaptive intervention (JITAI) system that uses continuous glucose monitoring to detect periods of dietary restraint, may improve CBT to reduce dietary restraint during treatment by providing real-time interventions.

OBJECTIVE

This study aimed to describe the feasibility, acceptability, and initial evaluation of SenseSupport. We presented feasibility, acceptability, target engagement, and initial treatment outcome data from a small trial using an ABAB (A=continuous glucose monitoring data sharing and JITAIs-Off, B=continuous glucose monitoring data sharing and JITAIs-On) design (in which JITAIs were turned on for 2 weeks and then turned off for 2 weeks throughout the treatment).

METHODS

Participants (N=30) were individuals with BED or BN engaging in ≥3 episodes of ≥5 hours without eating per week at baseline. Participants received 12 sessions of CBT and wore continuous glucose monitors to detect eating behaviors and inform the delivery of JITAIs. Participants completed 4 assessments and reported eating disorder behaviors, dietary restraint, and barriers to app use weekly throughout treatment.

RESULTS

Retention was high (25/30, 83% after treatment). However, the rates of continuous glucose monitoring data collection were low (67.4% of expected glucose data were collected), and therapists and participants reported frequent app-related issues. Participants reported that the SenseSupport system was comfortable, minimally disruptive, and easy to use. The only form of dietary restraint that decreased significantly more rapidly during JITAIs-On periods relative to JITAIs-Off periods was the desire for an empty stomach (t₄₃=1.69; P=.049; Cohen d=0.25). There was also a trend toward greater decrease in overall restraint during JITAs-On periods compared with JITAIs-Off periods, but these results were not statistically significant (t₄₃=1.60; P=.06; Cohen d=0.24). There was no significant difference in change in the frequency of binge eating during JITAIs-On periods compared with JITAIs-Off periods (P=.23). Participants demonstrated clinically significant, large decreases in binge eating (t₂₄=10.36; P<.001; Cohen d=2.07), compensatory behaviors (t₂₄=3.40; P=.001; Cohen d=0.68), and global eating pathology (t₂₄=6.25; P<.001; Cohen d=1.25) from pre- to posttreatment.

CONCLUSIONS

This study describes the successful development and implementation of the first intervention system combining passive continuous glucose monitors and JITAIs to augment CBT for binge-spectrum eating disorders. Despite the lower-than-anticipated collection of glucose data, the high acceptability and promising treatment outcomes suggest that the SenseSupport system warrants additional investigation via future, fully powered clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04126694; https://clinicaltrials.gov/ct2/show/NCT04126694.

Increased Interval From Initial Evaluation to Initial Voice Therapy Session is Associated With Missed Voice Therapy Appointments

BACKGROUND

Voice therapy (VT) is an essential component to a successful treatment of laryngological disorders and thus patient outcomes depend on patient compliance with VT. As volume of VT patients' ebb and flow, there is often variation in wait times for initial VT sessions. There is a paucity research evaluating VT latency and missed appointments. It is important to find associations between latency and patient compliance to assist with increasing the quality of patient care in all voice and swallowing clinics and decreasing missed appointments for VT following. Should a clinical setting be able to make changes to better care for the patients, it may show a substantial change in missed appointments and patient outcomes.

OBJECTIVE/HYPOTHESIS

To determine what factors contribute to missed initial VT session and specifically whether patients who have a time interval of >4 weeks from their initial interdisciplinary evaluation to their initial VT session are more likely to not attend.

STUDY DESIGN

Retrospective analysis of a database, at a tertiary academic voice and swallowing center.

METHODS

A prospective voice and swallowing database was evaluated for new voice patient evaluations starting from January 1, 2014 to December 31, 2017. Patients with a primary diagnosis of dysphonia or dyspnea and scheduled for VT after the initial patient evaluation in an interdisciplinary laryngology clinic were included.

RESULTS

Three hundred and eighteen patients (mean age = 5.27, standard deviation 16.0) met the inclusion criteria. Patients were 73% (n = 231) female, and 81% White/Caucasian. Univariate analysis shows that insurance type, profession, body mass index, interval to VT appointment, Reflux Severity Index (RSI), and Eating Assessment Tool-10 scores were associated with missed appointment rates. Multivariate logistic regression model demonstrated interval to VT, RSI, race, and profession were significant factors in missed appointments. Patients with an interval >4 weeks, were more likely to miss their appointment, as compared to patients <4 weeks (odds ratio 2.07 95% confidence interval 1.18-3.60).

CONCLUSION

The data presented suggests that patients who have their first VT appointment greater than 4-weeks from the time of their initial interdisciplinary evaluation have an increased risk of missed appointment. Race, RSI, and professional voice use also appear to play a role in missed appointment rates.

Depressive symptoms, alcohol and other drug use, and suicide risk: Prevention and treatment effects from a two-country online eating disorder risk reduction trial

OBJECTIVE

Eating disorders are known to have high comorbidity, and the current report outlines the impact of an online eating disorder risk reduction program on brief, self-report measures of depressive symptoms, alcohol and other drug use, and suicidality.

METHOD

An online pragmatic, randomized-controlled trial was conducted with N = 316 young-women (M age = 20.80 years) across Australia and New Zealand. Media Smart-Targeted (MS-T) was a 9-module program released weekly while control participants received positive body image tips. Prevention effects (asymptomatic at baseline) and treatment effects (symptomatic at baseline) were investigated.

RESULTS

MS-T participants were 94% and 91% less likely than controls to develop Moderate or higher depressive symptoms at 6-month (MS-T = 3.3%; controls = 35.4%) and 12-month follow-up (MS-T = 3.4%; controls = 29.4%), respectively. MS-T participants did not commence using recreational drugs at any assessment point, compared to 18.2% of controls at a least one assessment point. Regarding treatment effects, MS-T participants were 84% more likely to no longer be using recreational drugs at 12-month follow-up (MS-T = 60%; controls = 21.1%). Mutitvariate logistic regressions revealed group, depressive symptoms and alcohol use to be significant predictors of elevated suicide risk, where being an MS-T participant, without depressive symptoms and not drinking alcohol, significantly lowered likelihood of developing elevated suicide risk. Disordered eating at post-program mediated the relationship between group and depressive symptoms across post-program to 12-mnoth follow-up.

DISCUSSION

MS-T shows promise as a program with important mental health benefits in addition to previous reports of lowered eating disorder diagnosis, risk and impairment.

Early termination of cognitive-behavioural interventions: literature review

Aims and method

The evidence of the efficacy of cognitive-behavioural interventions is well established. Despite this, clinicians often face a consistent number of not attended appointments or early treatment discontinuation rates. This paper reviews the literature to date regarding the possible causes of early termination of cognitive-behavioural interventions. A literature search was done using Medline, PsycINFO, Embase and the Cochrane Library.

Results

We reviewed 14 articles. Out of these, two were randomised controlled trials, one was a controlled trial and the rest were cohort studies. Drop-out was defined differently across papers. There are many factors that may affect early treatment discontinuation rates and they are described individually.

Clinical implications

There does not appear to be a single strong predictor of early treatment discontinuation. Specific literature relating to cognitive-behavioural therapy is scarce. However, some factors such as young age, education level and psychopathology appear to be more strongly associated with early treatment discontinuation than others.

The Role of Regular Eating and Self-Monitoring in the Treatment of Bulimia Nervosa: A Pilot Study of an Online Guided Self-Help CBT Program

Background: Despite cognitive behavioural therapy (CBT) being regarded as the first-line treatment option for bulimia nervosa (BN), barriers such as its time-consuming and expensive nature limit patient access. In order to broaden treatment availability and affordability, the efficacy and convenience of CBT could be improved through the use of online treatments and selective emphasis on its most 'potent' components of which behavioural techniques form the focus. Method: Twenty-six individuals with BN were enrolled in an online CBT-based self-help programme and 17 completed four weeks of regular eating and food-monitoring using the online Food Diary tool. Participants were contacted for a weekly check-in phone call and had their bulimic symptom severity assessed at five time points (baseline and weeks 1-4). Results: There was a significant decrease in the frequency of self-reported objective binge episodes, associated loss of control and objective binge days reported between pre- and post-treatment measures. Significant improvements were also observed in most subscales of the Eating Disorder Examination-Questionnaire. Conclusion: This study provides encouraging preliminary evidence of the potential of behavioural techniques of online CBT in the treatment of BN. Online therapy with this focus is potentially a viable and practical form of treatment delivery in this illness group. These preliminary findings support the need for larger studies using control groups.

Predictors of dropout in face-to-face and internet-based cognitive-behavioral therapy for bulimia nervosa in a randomized controlled trial

OBJECTIVE

We sought to identify predictors and moderators of failure to engage (i.e., pretreatment attrition) and dropout in both Internet-based and traditional face-to-face cognitive-behavioral therapy (CBT) for bulimia nervosa. We also sought to determine if Internet-based treatment reduced failure to engage and dropout.

METHOD

Participants (N = 191, 98% female) were randomized to Internet-based CBT (CBT4BN) or traditional face-to-face group CBT (CBTF2F). Sociodemographics, clinical history, eating disorder severity, comorbid psychopathology, health status and quality of life, personality and temperament, and treatment-related factors were investigated as predictors.

RESULTS

Failure to engage was associated with lower perceived treatment credibility and expectancy (odds ratio [OR] = 0.91, 95% CI: 0.82, 0.97) and body mass index (BMI) (OR = 1.10; 95% CI: 1.03, 1.18). Dropout was predicted by not having a college degree (hazard ratio [HR] = 0.55; 95% CI: 0.37, 0.81), novelty seeking (HR = 1.02; 95% CI: 1.01, 1.03), previous CBT experience (HR = 1.77; 95% CI: 1.16, 2.71), and randomization to the individual's nonpreferred treatment format (HR = 1.95, 95% CI: 1.28, 2.96).

DISCUSSION

Those most at risk of failure to engage had a higher BMI and perceived treatment as less credible and less likely to succeed. Dropout was associated with less education, higher novelty seeking, previous CBT experience, and a mismatch between preferred and assigned treatment. Contrary to expectations, Internet-based CBT did not reduce failure to engage or dropout. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:569-577).

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.

Exposure to socioeconomic adversity in early life and risk of depression at 18 years: The mediating role of locus of control

BACKGROUND

Previous studies have linked exposure to early socioeconomic adversity to depression, but the mechanisms of this association are not well understood. Locus of control (LoC), an individual's control-related beliefs, has been implicated as a possible mechanism, however, longitudinal evidence to support this is lacking.

METHODS

The study sample comprised 8803 participants from a UK cohort, the Avon Longitudinal Study of Parents and Children (ALSPAC). Indicators of early socioeconomic adversity were collected from the antenatal period to 5 years and modelled as a latent factor. Depression was assessed using the Clinical Interview Schedule-Revised (CIS-R) at 18 years. LoC was assessed with the Nowicki-Strickland Internal-External (CNSIE) scale at 16 years.

RESULTS

Using structural equation modelling, we found that 34% of the total estimated association between early socioeconomic adversity and depression at 18 years was explained by external LoC at 16 years. There was weak evidence of a direct pathway from early socioeconomic adversity to depression after accounting for the indirect effect via external locus of control. Socioeconomic adversity was associated with more external LoC, which, in turn, was associated with depression.

LIMITATIONS

Attrition may have led to an underestimation of the direct and indirect effect sizes in the complete case analysis.

CONCLUSIONS

Results suggest that external LoC in adolescence is one of the factors mediating the link between early adversity and depression at 18 years. Cognitive interventions that seek to modify maladaptive control beliefs in adolescence may be effective in reducing risk of depression following early life adversity.

Negative affect, interpersonal perception, and binge eating behavior: An experience sampling study

OBJECTIVE

Etiological and maintenance models for disordered eating highlight the salience of negative affect and interpersonal dysfunction. This study employed a 14-day experience sampling procedure to assess the impact of negative affect and interpersonal perceptions on binge eating behavior.

METHOD

Young adult women (N = 40) with recurrent binge eating and significant clinical impairment recorded their mood, interpersonal behavior, and eating behaviors at six stratified semirandom intervals daily through the use of personal digital assistants.

RESULTS

Although momentary negative affect was associated with binge eating behavior, average levels of negative affect over the experience sampling period were not, and interpersonal problems moderated the relationship between negative affect and binge eating. Interpersonal problems also intensified the association between momentary interpersonal perceptions and binge eating behavior. Lagged analyses indicated that previous levels of negative affect and interpersonal style also influence binge eating.

DISCUSSION

The study findings suggest there may be important differences in how dispositional versus momentary experiences of negative affect are associated with binge eating. Results also highlight the importance of interpersonal problems for understanding relationships among negative affect, interpersonal perception, and binge eating behavior. These results offer several possibilities for attending to affective and interpersonal functioning in clinical practice.

Pre-treatment attachment anxiety predicts change in depressive symptoms in women who complete day hospital treatment for anorexia and bulimia nervosa

OBJECTIVES

Individuals with eating disorders are prone to depressive symptoms. This study examines whether depressive symptoms can change in women who complete intensive day treatment for anorexia and bulimia nervosa (BN), and whether these changes are associated with pre-treatment attachment insecurity.

DESIGN

Participants were 141 women with anorexia nervosa restricting type (n = 24), anorexia nervosa binge purge type (n = 30), and BN (n = 87) who completed a day hospital treatment programme for eating disorders. They completed a pre-treatment self-report measure of attachment, and a pre-treatment and post-treatment self-report measure of depressive symptoms.

RESULTS

Participants experienced significant reductions in depressive symptoms at post-treatment. Eating disorder diagnosis was not related to these improvements. However, participants lower in attachment anxiety experienced significantly greater improvement in depressive symptoms than those who were higher in attachment anxiety.

CONCLUSIONS

These results suggest that clinicians may tailor eating disorders treatments to patients' attachment patterns and focus on their pre-occupation with relationships and affect regulation to improve depressive symptoms.

PRACTITIONER POINTS

That depressive symptoms can decrease in women who complete day hospital treatment for anorexia and BN. That improvements in depressive symptoms do not vary according to eating disorder diagnosis in these women. That patients who complete treatment and who have higher attachment anxiety experience less improvements in depressive symptoms compared to those lower in attachment anxiety. That clinicians may attend to aspects of attachment anxiety, such as need for approval and up-regulation of emotions, to improve depressive symptoms in female patients with eating disorders.

Internet-based motivation program for women with eating disorders: eating disorder pathology and depressive mood predict dropout

BACKGROUND

One of the main problems of Internet-delivered interventions for a range of disorders is the high dropout rate, yet little is known about the factors associated with this. We recently developed and tested a Web-based 6-session program to enhance motivation to change for women with anorexia nervosa, bulimia nervosa, or related subthreshold eating pathology.

OBJECTIVE

The aim of the present study was to identify predictors of dropout from this Web program.

METHODS

A total of 179 women took part in the study. We used survival analyses (Cox regression) to investigate the predictive effect of eating disorder pathology (assessed by the Eating Disorders Examination-Questionnaire; EDE-Q), depressive mood (Hopkins Symptom Checklist), motivation to change (University of Rhode Island Change Assessment Scale; URICA), and participants' age at dropout. To identify predictors, we used the least absolute shrinkage and selection operator (LASSO) method.

RESULTS

The dropout rate was 50.8% (91/179) and was equally distributed across the 6 treatment sessions. The LASSO analysis revealed that higher scores on the Shape Concerns subscale of the EDE-Q, a higher frequency of binge eating episodes and vomiting, as well as higher depression scores significantly increased the probability of dropout. However, we did not find any effect of the URICA or age on dropout.

CONCLUSIONS

Women with more severe eating disorder pathology and depressive mood had a higher likelihood of dropping out from a Web-based motivational enhancement program. Interventions such as ours need to address the specific needs of women with more severe eating disorder pathology and depressive mood and offer them additional support to prevent them from prematurely discontinuing treatment.

Web-based treatment program using intensive therapeutic contact for patients with eating disorders: before-after study

Background

Although eating disorders are common in the Netherlands, only a few patients are treated by mental health care professionals. To reach and treat more patients with eating disorders, Tactus Addiction Treatment developed a web-based treatment program with asynchronous and intensive personalized communication between the patient and the therapist.

Objective

This pilot study evaluated the web-based treatment program using intensive therapeutic contact in a population of 165 patients with an eating disorder.

Methods

In a pre-post design with 6-week and 6-month follow-ups, eating disorder psychopathology, body dissatisfaction, Body Mass Index, physical and mental health, and quality of life were measured. The participant’s satisfaction with the web-based treatment program was also studied. Attrition data were collected, and participants were classified as noncompleters if they did not complete all 10 assignments of the web-based treatment program. Differences in baseline characteristics between completers and noncompleters were studied, as well as reasons for noncompletion. Furthermore, differences in treatment effectiveness, treatment adherence, and baseline characteristics between participants of the three major eating disorder diagnostic groups EDNOS (n=115), BN purging (n=24), and BN nonpurging (n=24) were measured.

Results

Of the 165 participants who started the web-based treatment program, 89 participants (54%) completed all of the program assignments (completers) and 76 participants (46%) ended the program prematurely (noncompleters). Severe body dissatisfaction and physical and mental health problems seemed to have a negative impact on the completion of the web-based treatment program. Among the participants who completed the treatment program, significant improvements were found in eating disorder psychopathology (F=54.6, df = 68, P<.001, d=1.14). Body dissatisfaction, quality of life, and physical and mental health also significantly improved, and almost all of these positive effects were sustained up to 6 months after the participants had completed the web-based treatment program. Body Mass Index improved only within the group of participants suffering from obesity. The improvement in eating disorder psychopathology occurred in all three eating disorder diagnostic groups, and the percentage of completers did not differ significantly between these groups. Participants’ satisfaction with the treatment program, as well as with their therapist, was high, and participants indicated that they would recommend the program to other patients with eating disorders.

Conclusions

The results of this study suggest that the web-based treatment program has the potential to improve eating disorder psychopathology in patients with different types of eating disorders.

A randomised controlled pilot study: the effectiveness of narrative exposure therapy with adult survivors of the Sichuan earthquake

BACKGROUND

Post-Traumatic Stress Disorder (PTSD) is a common psychological reaction after large-scale natural disasters. Given the number of people involved and shortage of resources in any major disaster, brief, pragmatic and easily trainable interventions are needed. The aim of this study is to evaluate the efficacy of Narrative Exposure Therapy (NET) as a short-term treatment for PTSD using Chinese earthquake survivors.

METHODS

A randomized waiting-list control pilot study was conducted between December 2009 and March 2010, at the site of the Sichuan earthquake in Beichuan County, China. Adult participants with newly diagnosed Post Traumatic Stress Disorder (PTSD) were randomly allocated to Narrative Exposure Therapy (NET) or a Waiting-List (WL) condition. The latter received NET treatment after a two-week waiting period. To compare the effectiveness of NET in traumatised earthquake survivors, both groups were assessed on PTSD symptoms, general mental health, anxiety and depression, social support, coping style and posttraumatic change before and after treatment and two months post treatment.

RESULTS

Adult participants (n=22) were randomly allocated to receive NET (n=11) or WL (n=11). Twenty two participants (11 in NET group, 11 in WL) were included in the analysis of primary outcomes. Compared with WL, NET showed significant reductions in PTSD symptoms, anxiety and depression, general mental stress and increased posttraumatic growth. The WL group later showed similar improvements after treatment. These changes remained stable for a two-month follow-up. Measures of social support and coping showed no stable effects.

CONCLUSIONS

NET is effective in treating post-earthquake traumatic symptoms in adult Chinese earthquake survivors. The findings help advance current knowledge in the management of PTSD after natural disasters and inform future research. Larger sample sizes are needed to extend the present findings.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-TRC-12002473.

Predictors of dropout from in-patient treatment of eating disorders: an Italian experience

INTRODUCTION

The aim of the study was to examine possible risk factors for dropout from in-patient treatment for eating disorders (ED).

MATERIALS AND METHODS

The present study consisted of a retrospective analysis of clinical and non-clinical available information about 186 patients suffering from ED consecutively admitted into the Villa Maria Luigia Private Hospital (Parma, Italy) in a three-year period (01/01/2006 - 31/12/2009). Sociodemographics, clinical history and current features, and results to the following psychometric instruments were analysed: Eating Disorder Questionnaire (EDQ), Predisposing, On-set and Maintaining risk factors list for Eating Disorders, Eating Disorders Inventory-II, Body Uneasiness Test and SCL-90.

RESULTS

Of the 186 patients, 46 (24.7%) voluntarily left the treatment program prematurely. Predictive factors included poor educational and professional achievements, parents' divorcing, parents' history of substance abuse and difficulties in interpersonal relationships.

DISCUSSION

Dropout is a multifactorial phenomenon with deep clinical consequences: the recognition of possible risk factors may support the choice of specific therapeutic strategies to improve the treatment of ED and its outcomes.

Parent- and adolescent-reported barriers to participation in an adolescent overweight and obesity intervention

This study explored reported barriers to treatment completion in a sample of adolescents and their parents who either completed or did not complete family-based cognitive behavioral lifestyle intervention for overweight and obese adolescents. The sample comprises 56 overweight or obese adolescents (52% female) aged 11.5-18.9 years (mean = 14.5, s.d. = 1.8) and a parent. 57% of families did not complete treatment and maintenance phases of the intervention. A telephone-administered questionnaire assessing barriers to participation was completed by 96% of adolescents and 91% of parent completers and 100% of adolescents and 94% of parent noncompleters. Adolescents and parents most commonly reported barriers to participation related to research demands, treatment approach, program components/strategies, practical barriers, and other individual/family demands. Parents also noted adolescent effort, parent-adolescent conflict, and adolescent unhappiness as barriers to participation. While both completers and noncompleters experienced barriers to participation, families who discontinued treatment reported experiencing more treatment barriers. Findings of the current study suggest that adolescents and parents may find it easier to participate in adolescent overweight and obesity interventions if research and out-of-session program demands are minimized, efforts are made to enhance adolescent motivation, and treatment is offered in a convenient location and scheduled around school holidays and other family demands. Results also suggest that targeting adolescent unhappiness, family stressors, and parent-adolescent conflict in treatment may improve retention. Future research should explore the impact of these modifications on treatment completion and outcomes.

Who benefits most from guided self-help for binge eating? An investigation into the clinical features of completers and non-completers

Guided self-help (GSH) is a recommended first step in treatment for bulimia nervosa (BN) and binge eating disorder (BED) (NICE, 2004). It remains unclear what makes some individuals more likely to respond to this form of treatment than others. Forty-eight patients participated in this study using a GSH programme for binge eating. Profiles of treatment completers and non-completers are compared, and reasons for non-completion explored. Completion of treatment was associated with significant improvements in mood, general functioning and on measures of dietary restraint, frequency of objective binge eating (OBE), laxative misuse, self-induced vomiting (SIV) and driven exercise. Improvements were maintained at follow-up. Treatment non-completers reported significantly higher pre-treatment levels of depression and weight concern, and lower levels of general health and vitality. Reasons for discontinuing treatment were related to perceptions of the GSH programme; practicalities of the programme; and readiness to change. Whilst GSH can be effective for a sub-group of patients, factors such as pre-morbid level of depression, degree of weight concern, perceptions of the programme, and readiness to change may increase the likelihood of non-completion.

Psychotherapy dropouts: differences by modality, license, and DSM-IV diagnosis

Dropouts are frequent in mental health care. Several client factors have been identified as dropout predictors, including ethnic minority status, race, low SES, and more severe symptoms. Research on therapist and process variables is less common, and findings are inconsistent. This study used administrative data for 434,317 patients from CIGNA Behavioral Health (CIGNA) to examine dropout rates by profession of provider, therapy modality, and DSM-IV diagnosis. Results indicate that among the providers, MFTs have the lowest dropout rates in the CIGNA network. Of the therapy modalities, individual therapy is associated with lower dropout rates than family therapy. Mood and anxiety disorders have lower dropout rates than other diagnosis categories, while schizophrenia, psychotic, and substance use disorders have the highest dropout rates.

Self-efficacy as a robust predictor of outcome in guided self-help treatment for broadly defined bulimia nervosa

OBJECTIVE

To examine predictors of guided self-help (GSH) treatment outcome in bulimia nervosa (BN).

METHOD

Data were included from 87 individuals who participated in one of two randomized controlled trials evaluating GSH interventions for BN. Participants received eight sessions of GSH over a 6- to 8-week period and were assessed at baseline, pretreatment, posttreatment, and 6-month follow-up.

RESULTS

Motivation (confidence in ability to change) proved to be the most robust predictor of outcome, across three of the four outcome measures. Baseline measures of concern over mistakes perfectionism also uniquely predicted outcome at posttreatment. Posttreatment measures of stress, eating disorder-related automatic thoughts, and frequency of binge episodes predicted outcome at 6-month follow-up.

DISCUSSION

This study suggests that tackling motivation early in therapy, with a particular focus on confidence in succeeding in change, could be of benefit to outcome in BN treatment.

A randomized controlled two-stage trial in the treatment of bulimia nervosa, comparing CBT versus motivational enhancement in Phase 1 followed by group versus individual CBT in Phase 2

OBJECTIVE

To conduct a randomized, controlled, two-stage trial in the treatment of bulimia nervosa, comparing cognitive-behavioral therapy (CBT) versus motivational enhancement in Phase 1 followed by group versus individual CBT in Phase 2.

METHODS

A total of 225 patients with bulimia nervosa or eating disorder not otherwise specified (EDNOS) were recruited into a randomized controlled trial lasting 12 weeks with follow-ups at 1 year and 2.5 years.

RESULTS

Patients improved significantly across all of the interventions with no differences in outcome or treatment adherence. Including motivational enhancement therapy rather than a CBT first phase of treatment did not affect outcome.

CONCLUSIONS

Outcome differences between individual and group CBT were minor, suggesting that group treatment prefaced by a short individual intervention may be a cost-effective alternative to purely individual treatment.

Motivation and Autonomy in Counseling, Psychotherapy, and Behavior Change: A Look at Theory and Practice 1ψ7

Motivation has received increasing attention across counseling approaches, presumably because clients’ motivation is key for treatment effectiveness. The authors define motivation using a self-determination theory taxonomy that conceptualizes motivation along a relative-autonomy continuum. The authors apply the taxonomy in discussing how various counseling approaches address client motivation and autonomy, both in theory and in practice. The authors also consider the motivational implications of nonspecific factors such as therapeutic alliance. Across approaches, the authors find convergence around the idea that clients’ autonomy should be respected and collaborative engagement fostered. The authors also address ethical considerations regarding respect for autonomy and relations of autonomy to multicultural counseling. The authors conclude that supporting autonomy is differentially grounded in theories and differentially implemented in approaches. Specifically, outcome-oriented treatments tend to consider motivation a prerequisite for treatment and emphasize transparency and up-front consent; process-oriented treatments tend to consider motivation a treatment aspect and give less emphasis to transparency and consent.

Psychological treatments for bulimia nervosa and binging

BACKGROUND

A specific manual-based form of cognitive behavioural therapy (CBT) has been developed for the treatment of bulimia nervosa (CBT-BN) and other common related syndromes such as binge eating disorder. Other psychotherapies and modifications of CBT are also used.

OBJECTIVES

To evaluate the efficacy of CBT, CBT-BN and other psychotherapies in the treatment of adults with bulimia nervosa or related syndromes of recurrent binge eating.

SEARCH STRATEGY

Handsearch of The International Journal of Eating Disorders since first issue; database searches of MEDLINE, EXTRAMED, EMBASE, PsycInfo, CURRENT CONTENTS, LILACS, SCISEARCH, CENTRAL and the The Cochrane Collaboration Depression, Anxiety & Neurosis Controlled Trials Register; citation list searching and personal approaches to authors were used. Search date June 2007.

SELECTION CRITERIA

Randomised controlled trials of psychotherapy for adults with bulimia nervosa, binge eating disorder and/or eating disorder not otherwise specified (EDNOS) of a bulimic type which applied a standardised outcome methodology and had less than 50% drop-out rate.

DATA COLLECTION AND ANALYSIS

Data were analysed using the Review Manager software program. Relative risks were calculated for binary outcome data. Standardised mean differences were calculated for continuous variable outcome data. A random effects model was applied.

MAIN RESULTS

48 studies (n = 3054 participants) were included. The review supported the efficacy of CBT and particularly CBT-BN in the treatment of people with bulimia nervosa and also (but less strongly due to the small number of trials) related eating disorder syndromes.Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals were promising. Exposure and Response Prevention did not enhance the efficacy of CBT.Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders.

AUTHORS' CONCLUSIONS

There is a small body of evidence for the efficacy of CBT in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small. More and larger trials are needed, particularly for binge eating disorder and other EDNOS syndromes. There is a need to develop more efficacious therapies for those with both a weight and an eating disorder.

Predictors of early change in bulimia nervosa after a brief psychoeducational therapy

We aimed to examine baseline predictors of treatment response in bulimic patients. 241 seeking-treatment females with bulimia nervosa completed an exhaustive assessment and were referred to a six-session psychoeducational group. Regression analyses of treatment response were performed. Childhood obesity, lower frequency of eating symptomatology, lower body mass index, older age, and lower family's and patient's concern about the disorder were predictors of poor abstinence. Suicidal ideation, alcohol abuse, higher maximum BMI, higher novelty seeking and lower baseline purging frequency predicted dropouts. Predictors of early symptom changes and dropouts were similar to those identified in longer CBT interventions.

Self-image and treatment drop-out in eating disorders

INTRODUCTION

Drop-out from treatment is a serious problem in eating disorders which remains poorly understood. The present study investigated whether self-image and interpersonal theory could help to explain why eating disorder patients drop out of treatment.

METHOD

Intake data on eating disorder patients who terminated treatment prematurely (N=54) were compared with patients who had completed treatment (N=54) and those who were still in treatment after 12 months (N=54). Self-image was assessed using the structural analysis of social behaviour (SASB), and comparisons were made on demographic and clinical variables.

RESULTS

Patients who dropped out had initially presented with less negative self-image and fewer psychological problems compared with remainers. Low levels of SASB self-blame discriminated drop-outs from completers and remainers and significantly predicted treatment drop-out.

DISCUSSION

Drop-out in eating disorders appears to be a complex phenomenon, not necessarily as pathological as often assumed. There may be important differences in the treatment goals of drop-outs and therapists; patients who drop out may be choosing to disengage at a time when symptom improvement creates space for closer examination of interpersonal issues.

Control expectancies as predictors of psychotherapy outcome: a systematic review

PURPOSE

Patient expectancies are known as a common factor contributing to psychotherapy outcome. Among expectancies, specific control expectancies (such as the perceived responsibility for change) can be considered of special clinical interest because of their connection with the engagement of patients in therapy. Attempts to study control beliefs in relation to psychotherapy outcome have been made by the locus of control research but received less attention in recent years. Based on findings from the expectancies literature (also including outcome and patient role expectancies), this systematic review proposes ways to reactivate the promising field of control expectancies in the psychotherapy context.

METHODS

The PsychInfo and PubMed databases were searched with the keywords 'expectancies', 'expectations', 'locus of control', and 'role expectancies'; these terms were cross-referenced with the terms 'patient', 'client', 'psychotherapy', 'treatment', and 'outcome'. A total of 35 studies published in the last 25 years and focusing on the relationship between patient expectancies and psychotherapy outcome were identified and included in this review.

RESULTS

The review of the literature shows a modest direct relationship between specific expectancies and clinical improvement. Studies focusing on the association between global expectancies and outcome led to rather inconsistent findings.

CONCLUSIONS

The study of control expectancies in psychotherapy has been neglected in the past years probably due to mixed results. The main reasons for inconsistency can be found in the scarcity of specific assessment measures for treatment expectancies as well as in the limited knowledge about process variables in the past. Implications for future control expectancies research are discussed, and a new rating scale is proposed as a possible tool for measuring control expectancies in the specific context of psychotherapy.

Perceived responsibility for change as an outcome predictor in cognitive-behavioural group therapy

PURPOSE

The study of control beliefs in psychotherapy research has been neglected in the past years. Based on the evidence that some patients do not benefit enough from therapy because of inadequate expectancies regarding the responsibility and the mechanisms of therapeutic change, assessing control beliefs specific to the psychotherapy context and linking them to therapy outcome can help highlighting this specific aspect and reactivating a neglected field of clinical research.

METHOD

Using a new validated instrument (Questionnaire on Control Expectancies in Psychotherapy, TBK), this study investigated whether and how perceived responsibility for change predicts favourable response to group cognitive-behavioural therapy in a sample of 49 outpatients with social anxiety disorder (SAD). Patient engagement and therapy-related self-efficacy were assessed as possible process variables.

RESULTS

Among therapy-related control beliefs, low powerful others expectancies (towards the therapist) were found to be the strongest predictor for clinical improvement at follow-up. At a process level, analyses of mediation showed that powerful others expectancies predicted therapy engagement, which then influenced the degree of clinical improvement on social anxiety levels and global symptoms. The association between therapy-specific internality and outcome was confirmed for social anxiety at follow-up and was partially mediated by therapy-related self-efficacy.

CONCLUSIONS

Findings confirm that therapy-related control beliefs predict psychotherapy process (patient engagement and therapy-specific self-efficacy) and outcome in cognitive-behavioural group therapy for SAD. Implications for clinicians and for future research are discussed.

The use of multiple purging methods as an indicator of eating disorder severity

OBJECTIVE

Previous studies indicate a distinction between those who use one versus multiple methods of purging, but these studies have not controlled for differences in purging frequency. The current study examined whether purging frequency or the use of multiple purging (MP) methods provides more information about eating disorder severity.

METHOD

Existing data were reanalyzed to examine associations between facets of purging and psychological measures among women with bulimia nervosa, purging disorder, and controls. Analyses compared the use of MP methods and purging frequency as indicators of eating pathology.

RESULTS

MP methods demonstrated associations with greater eating disorder severity; purging frequency was associated with increased binge frequency and general psychopathology.

CONCLUSION

The presence of MP methods provides more information about eating disorder severity than purging frequency, which seems to be a marker of related psychopathology.

Drop-out rate in eating disorders: could it be a function of patient-therapist relationship?

OBJECTIVE

The factors influencing drop-out in eating disorders (ED) are still unclear. The aim of the present study was to determine whether compliance is strongly related to the patient-therapist relationship.

MATERIALS AND METHODS

During 14 months all new patients affected by EDs referring to our Specialist Service Center, were assessed and followed up, they underwent EAT 40, EDI II, and computerized case history for ED. Moreover, we collected data from therapist using the GCI scale, and we recorded as the patient perceived his weight (PPW).

RESULTS

We found that out of the 100 patients enrolled, 53 withdraw and when probability was predicted according to a digit model, it was not influenced by EDI-II subscales, age, sex, education, EAT-40 score, duration of the disorder and diagnosis while it significantly decreased when GCI scores increased and decreased when the PPW was altered.

CONCLUSION

These results seem to confirm that some psychological factors related to patient-therapist relationship can play a key role for a stable and continuous therapeutic program.

Motivation to change in recent onset and long-standing bulimia nervosa: are there differences?

REASON FOR THE STUDY: Little is known about how motivation to change evolves over the course of an eating disorder. The present study compared 'stage of change' and motivation, confidence and readiness to change in two groups of patients with bulimia nervosa (BN), adolescents with a short duration of illness and adults with a long duration of illness.

METHOD

Patients completed the Severity of eating disorder symptomatology scale, Hospital Anxiety and Depression Scale and measures of stage of change and motivation, readiness and confidence to change their bulimic symptomatology at pre-treatment.

MAIN FINDINGS

Short- and long duration groups did not differ in illness severity, comorbidity, stage of change, motivation, readiness, and confidence to change. There were, however, some differences between groups in terms of the relationship between motivational measures, illness severity, duration and comorbidity.

CONCLUSIONS

There seem to be more similarities than differences between adolescents with short duration of illness and those with well-established BN in terms of their motivation to change.

How does dialectical behavior therapy facilitate treatment retention among individuals with comorbid borderline personality disorder and substance use disorders?

For individuals presenting with comorbid borderline personality disorder (BPD) and substance use disorders (SUD), rates of treatment dropout from combined mental health and substance abuse treatment centers approach 80%, rendering dropout the rule rather than the exception. Several studies indicate that utilizing a more comprehensive treatment such as Dialectical Behavior Therapy (DBT) may be useful for client retention; however, given the scope and effort required to conduct this treatment, it may be more practical to determine which specific components within DBT are useful in retaining clients in substance use treatment. Thus, the purpose of the current paper is first to determine what exact deficits underlie treatment dropout among the BPD-SUD comorbidity. Second, we review and evaluate effectiveness of DBT retention-enhancing strategies by assembling work from other samples and literatures that also tests retention-enhancing strategies discussed in DBT. As a last step, the paper will conclude with a discussion on methodological limitations and potential future directions in this line of research.

Factors affecting dropout in outpatient eating disorder treatment

OBJECTIVE

To evaluate the incidence and effects of factors potentially influencing eating disordered patients' dropping out of outpatient cognitive-behavioural therapy (CBT).

METHOD

Sixty-seven (64 female, 3 male) patients with eating disorders participated in the study. All patients followed a multidisciplinary team approach for a median period of 9 months. Several factors potentially affecting dropout were retrospectively assessed prior to treatment.

RESULTS

The dropout rate was significantly higher in patients with purging anorexia nervosa (AN) compared to those with restrictive AN, bulimia nervosa and eating disorder not otherwise specified (33% vs. 27%, 25% or 21%, respectively, p<0.05). Among several factors influencing dropout, there was a significant association of patient low cooperativeness, purging episodes, restrictive eating, use of several weight control practices and psychiatric co-morbidity in patients who dropped out compared to completers (all p<0.05).

CONCLUSIONS

In outpatient eating disorder treatment, non-compliance and premature interruption of therapy are affected primarily by factors which are related to patients' attitude and behaviour. These factors should be carefully addressed in patients with eating disorders to improve outcome.

Reasons for non-participation in follow-up research on eating disorders

OBJECTIVE

Lack of participation in follow-ups is thought to be a serious bias in outcome research on eating disorders; however, little systematic knowledge exists about the problem. The present study aimed to delineate non-participation in long-term follow-up research, and explore the reasons for non-participation.

METHOD

Eating disorder patients (N=840) entering a naturalistic, longitudinal multi-centre study were divided into participators (N=508) and non-participators (N=332) in 36-month follow-ups. Non-participators were further classified as either active (i.e. refused participation or failed to attend scheduled appointments) or passive non-participators (i.e. could not be traced).

RESULTS

Active non-participators exhibited significantly lower levels of general and eating disorder psychopathology at intake compared to participators, while passive non-participators reported higher levels of hostility.

DISCUSSION

Systematic exploration of non-participation in longitudinal research can help to mitigate the problem of indistinct results due to missing data. Barriers to successful longitudinal research and how to overcome non-participation at endpoint are discussed.

Impact of interactive school-based media literacy lessons for reducing internalization of media ideals in young adolescent girls and boys

OBJECTIVE

The primary objective of the current study was to examine the efficacy of single media literacy lessons in reducing media internalization in young adolescents.

METHOD

Eleven classes of 237 students (100 girls and 137 boys; mean age = 13.79 years, SD = .42) randomly received 1 of 6 lessons. Eating disorder risk factors were assessed at baseline, and the Sociocultural Attitudes Towards Appearance Questionnaire-3 (SATAQ-3) was used to assess media internalization postintervention.

RESULTS

At postintervention, boys had significantly lower SATAQ-3 scores on 4 of the 5 subscales (effect sizes = .42-.71), whereas girls had significantly lower scores on 1 subscale (effect size = .54). Higher baseline levels of dietary restraint, magazines bought/read, and perceived sociocultural pressure predicted smaller reductions in boys' scores, whereas depression predicted smaller reductions in girls' scores.

CONCLUSION

The current study provides support that boys be included in eating disorder prevention programs and that media literacy may represent a promising prevention approach.

Does personalized feedback improve the outcome of cognitive-behavioural guided self-care in bulimia nervosa? A preliminary randomized controlled trial

OBJECTIVES

Feedback has long been a part of psychosocial and health behaviour interventions and with the advent of computerised assessment and treatment tools, is gaining greater importance. The aim of the present study was to evaluate the addition of personalized feedback to a guided cognitive-behavioural (CBT) self-help programme for patients with bulimia nervosa.

DESIGN

Randomised-controlled trial.

METHOD

61 patients with DSM-IV bulimia nervosa or eating disorder not otherwise specified (EDNOS) were randomly allocated to receive 14 sessions of cognitive behavioural guided self-care with or without added personalised feedback on current physical and psychological status, risk and problems, and variables facilitating or hindering change. Feedback to patients was delivered in a number of ways: (a) personalised letters after assessment and at the end of treatment, (b) a specially designed feedback form administered half-way through treatment, (c) computerised feedback about bulimic and other symptoms, such as anxiety, depression and interpersonal functioning repeated at intervals throughout treatment and follow-up.

RESULTS

Outcome was assessed using patient-rated measures of bulimic symptoms at the end of treatment and at 6-month follow-up. The data were analysed using maximum likelihood methods of assess group differences at the follow-up. Added feedback did not have an effect on take-up or drop-out from treatment. However, it improved outcome by reducing self-induced vomiting and dietary restriction more effectively.

CONCLUSIONS

The findings lend support to the notion that the addition of repeated personalised feedback improves outcome from guided CBT self-help treatment and deserves further study.

Unilateral treatment exit: a failure of retention or a failure of treatment fit?

This article highlights perceived weaknesses in the current understanding of unilateral client exit from alcohol and other drug psychosocial treatment. It is argued that unilateral client exit is typically interpreted as a "failure of retention" when it could equally be interpreted as a "failure of treatment fit"; that is, the failure to deliver treatment optimally suited to actual client attendance. The results from an exploratory study conducted within a failure of treatment fit framework are presented. This study explored the possibility that short-term outpatient alcohol and other drug (AOD) treatment attendance may be an intentional service use strategy and that short-term attendees may exit AOD treatment as satisfied, successful, consumers. Standardized questionnaires were administered to clients (n = 109) starting a new treatment episode between June-August 2003 at admission and two-months post admission. Questionnaires explored the accuracy of client estimates of future appointment attendance, the reasons for short-term service exit, the satisfaction and outcome ratings of short-term clients, and the extent to which these compared with their longer-term peers. Findings suggest short-term treatment attendance is not an intentional service use strategy. However, despite attending fewer appointments than intended, most short-term participants reported significant levels of service satisfaction and problem improvement, and at a level comparable with their longer term peers. Problem-improvement was endorsed as the number one reason for short-term service exit. Implications for treatment delivery are discussed in light of these findings.

Exposure utilization and completion of cognitive behavioral therapy for PTSD in a "real world" clinical practice

This study assessed rates of imaginal exposure therapy (ET) utilization and completion of cognitive behavioral therapy (CBT) for posttraumatic stress disorder (PTSD) in a clinical setting and examined variables associated with CBT completion. Using a clinical definition, the completion rate of CBT was markedly lower than rates reported in randomized trials. CBT completion was inversely related to severity of overall pretreatment measures of PTSD, avoidance, hyperarousal, depression, impaired social functioning, and borderline personality disorder. Regression yielded avoidance and depression as unique predictors of completion. Most dropouts occurred before starting imaginal ET, although initiating ET was associated with greater likelihood of completion. Results highlight methodological differences between research and practice notions of treatment completion and the need for further study of variables influencing CBT completion in practice settings.

Travel distance and attrition in outpatient eating disorders treatment

OBJECTIVE

The purpose of this study was to investigate the impact of the distance patients had to travel for treatment on attendance patterns and treatment attrition.

METHOD

Contact information, clinical records, and/or appointment records of 209 adult patients presenting to an outpatient eating disorder treatment center over a specific period of time were reviewed. Information was obtained on demographics, diagnosis, number of appointments attended, cancelled, and failed, and termination status. Patients were classified as treatment completers or dropouts and compared on demographic, diagnostic, attendance, and distance to treatment site variables.

RESULTS

Treatment completer and dropout groups did not differ significantly on demographic variables, with the exception of employed patients being more likely to drop out of treatment. Although not statistically significant, patients diagnosed with bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS) were more likely to drop out of treatment prematurely. Surprisingly, distance traveled to the treatment site was not significantly different between groups and did not appear to significantly impact attendance patterns.

CONCLUSION

Results of this archival investigation were unexpected and likely limited by the design. Results can be useful in understanding motivational factors inherent in noncompliance and premature termination of treatment. A prospective study including fine-grained analysis of variables associated with eating disorder treatment attrition is indicated.