Treating eating-disorder patients in a managed care environment. Contemporary American issues and Canadian response

Strategies for Creating Multidisciplinary Community Care Teams to Address Barriers to Providing Family Based Treatment of Eating Disorders

Eating disorders, especially anorexia nervosa, are complex and devastating illnesses. Although eating disorders have a high mortality rate and are relatively common, there are many barriers for those seeking treatment. Provider training and education, weight bias among health care providers, geographical and language barriers, and a lack of options because of insurance restrictions prevent many families from receiving appropriate care, especially in smaller or rural communities. In those areas, providers are left to piece together treatment using a small number of other providers from different disciplines who have a willingness to work with this population. Outpatient family based treatment is an evidenced-based treatment of anorexia nervosa and relies on a multidisciplinary approach to care. Community-based care teams can be an effective way to treat those with eating disorders seeking family based treatment. There are several strategies for building collaborative teams that can provide comprehensive and accessible care to those with few options. [Pediatr Ann. 2024;53(1):e22-e27.].

Day hospital program for anorexia nervosa in children and adolescents: Assessment, management and specific focus on early onset anorexia nervosa

INTRODUCTION

The French day hospital program specialized in eating disorders (ED) opened in January 2018. Our study presents preliminary data on clinical profiles of patients with anorexia nervosa (AN). We describe more specifically clinical characteristics of patients with early onset AN and according to their therapeutics orientations. Then, we compare the weight gain of patients managed only in day-patient (DP) treatment with those managed initially inpatient (IP) treatment and relays in DP.

METHODS

Ninety-two patients with AN, aged between 8 and 18 years, were evaluated with several questionnaires (EDI-2, EDE-Q, BSQ, EDS-R, CDI, STAI-Y, VSP-A, EPN-13).

RESULTS

Patients with early onset AN, n = 23 (25.3%), presented more restrictive behaviors, less marked dietary symptomatology, a lower degree of clinical perfectionism and a less marked feeling of ineffectiveness than adolescent patients with AN. Regarding the choice of hospitalization modality (DP alone or IP-DP), the only difference highlighted was the severity of patient undernutrition. Among the patients who were treated (IP-DP n = 27 vs DP alone n = 25), the weight evolution after one month and at discharge was favorable for both groups.

CONCLUSION

These preliminary data suggest the effectiveness of DP in the care of AN in children and adolescents.

Blind versus open weighing from an eating disorder patient perspective

BACKGROUND

Weighing is a key component in the treatment of eating disorders. Most treatment protocols advocate for open weighing, however, many clinicians choose to use blind weighing, especially during the early phase of treatment. Despite considerable debate about this issue in the literature, there is no empirical evidence supporting the superiority of one weighing approach over the other. In addition, little is known about patients' perspectives of open and blind weighing and which weighing practice they view as more acceptable and/or beneficial for their treatment.

METHODS

Semi-structured qualitative interviews were conducted with 41 women with a current or past diagnosis of Anorexia or Bulimia Nervosa: 26 were undergoing specialist inpatient treatment (n = 13 being blind weighed; n = 13 being open weighed) and 15 were community members who have recovered from an eating disorder. Interviews were audiotaped, transcribed verbatim and analysed thematically using framework methods. Participant demographics, clinical characteristics, weighing anxiety and weight concerns were also assessed.

RESULTS

Qualitative analyses yielded five themes: (1) therapy engagement and progress; (2) Control and tolerance of weight uncertainty; (3) treatment team relationships and autonomy; (4) life outside of treatment; and (5) weighing practice preferences and rationale. Participants stated that blind weighing decreased anxiety and eating disorder psychopathology (e.g., weight preoccupation) and increased treatment responsivity. For many, relinquishing control over their weight facilitated body trust and was a necessary step towards recovery. Participants found that not knowing their exact weight helped challenge their overconcern with weight. Lack of support post-discharge was identified as a major difficulty of blind weighing. Overall, the majority of participants preferred blind weighing, particularly at the early, acute stage of treatment, whereas open weighing was viewed as more suitable at later stages of recovery. Quantitative analyses found current blind-weighed patients felt significantly less anxiety around being weighed and had greater tolerance of weight uncertainty than current open-weighed patients.

CONCLUSIONS

This study provided in-depth patient insights into open versus blind weighing practices. The next step for future research will be to supplement these insights with treatment outcomes gained from randomised controlled trials comparing the two weighing practices.

Stopping the "revolving door": "Zeida Laderech," a unique rehabilitation house for young adults with severe and enduring eating disorders

A failure to maintain improvement achieved during acute treatment, followed by a "revolving door syndrome," is a common phenomenon in eating disorders (EDs). As a result, many patients develop a chronic course that is difficult to treat. To target these difficulties, we established a novel rehabilitation treatment model in Israel for patients with severe and enduring EDs, based on the "recovery theory" in mental health treatment. This paper describes the process of conceiving this model and specifies the components of this rehabilitation house, "Zeida Laderech" (Provisions for the Journey), that aims to provide a home-like environment, while assisting in developing a healthy and balanced lifestyle. Finally, the model is discussed in light of other residential programs established in the world. With the hope to improve the overall prognosis of individuals with EDs, it is suggested that the similar programs and ongoing innovation will continue to emerge internationally.

Eating Disorders in the Adolescent Population:

Adolescents become vulnerable to developing eating disorders as they mature. Very little is known about the prevalence, etiology, assessment, treatment, and outcome of eating disorders among adolescents. In general, research on eating disorders continues to be plagued with design flaws. Future studies need to be prospective research based on larger, more diverse samples of adolescents that represent all developmental stages of adolescence. Consistent diagnostic criteria and definitions of treatment interventions and outcomes also need to be employed. In addition, research should address the identification of protective and risk factors that predict who will actually develop an eating disorder.

Treatment of Adolescents with Anorexia Nervosa

Research on the treatment of adolescents with anorexia nervosa is limited but shows that effective strategies employ a multidisciplinary team approach. Most patients receive medical attention when there is an acute medical or psychiatric emergency after losing a significant amount of weight and there is a need for nutritional and metabolic stabilization. Medical and nutritional stabilization are the first courses of treatment, followed by psychological stabilization. Initial treatment settings are dependent on the severity of symptoms and can range from inpatient to partial hospitalization or from day treatment to outpatient clinics. Physical activity and weight gain must be gradually accomplished. Effective treatment includes a variety of psychotherapeutic approaches (individuals and family therapy). Psychopharmacotherapy is generally unreliable in the treatment of anorexia nervosa and should be targeted to specific symptoms or complications. Prevention programs have been shown to have limited success.

Weight gain in an eating disorders day program

BACKGROUND

Day treatment programs have increasingly become an important level of care in the medical and psychiatric management of patients with eating disorders, yet there is little in the literature describing the weight gain patterns of patients in these programs.

METHODS

Weight gain accomplished by 198 patients admitted to a day program over a 2-year period was studied. Weight gain was analyzed by demographic, diagnostic and program-related variables and was compared for weekdays and weekends.

RESULTS

The mean length of stay was 2.6 weeks and patients gained a mean of 2.1 pounds (0.95 kg) in the program. Approximately one-quarter of patients lost weight, one-quarter gained 0 to <2 pounds (0.9 kg), one-quarter gained 2-4 pounds (0.9-1.8 kg), and one-quarter gained more than 4 pounds (1.8 kg). Weight gain was greater in those with a diagnosis of anorexia nervosa or eating disorder not otherwise specified (compared to bulimia nervosa), a longer time in the program, and a lower body mass index on admission. Patients gained more on weekdays, while in the program, than on weekends, when they were home.

CONCLUSIONS

The data showed that most patients accomplished modest weight gains during a relatively short stay in an eating disorders day program, demonstrating what can be expected for this level of care in the current healthcare environment.

Effects of reducing the frequency and duration criteria for binge eating on lifetime prevalence of bulimia nervosa and binge eating disorder: implications for DSM-5

OBJECTIVE

We assessed the impact of reducing the binge eating frequency and duration thresholds on the diagnostic criteria for bulimia nervosa (BN) and binge eating disorder (BED).

METHOD

We estimated the lifetime population prevalence of BN and BED in 13,295 female twins from the Swedish Twin study of Adults: Genes and Environment employing a range of frequency and duration thresholds. External validation (risk to cotwin) was used to investigate empirical evidence for an optimal binge eating frequency threshold.

RESULTS

The lifetime prevalence estimates of BN and BED increased linearly as the frequency criterion decreased. As the required duration increased, the prevalence of BED decreased slightly. Discontinuity in cotwin risk was observed in BN between at least four times per month and at least five times per month. This model could not be fit for BED.

DISCUSSION

The proposed changes to the DSM-5 binge eating frequency and duration criteria would allow for better detection of binge eating pathology without resulting in a markedly higher lifetime prevalence of BN or BED.

The outcome of Japanese anorexia nervosa patients treated with an inpatient therapy in an internal medicine unit

OBJECTIVE

To investigate the outcome of Japanese anorexia nervosa (AN) patients who were treated with the standard Japanese inpatient therapy.

METHOD

Of the 88 female AN patients treated with our inpatient therapy between January 1997 and December 2002, 67 (76.1%) who agreed to cooperate in this study were assessed by the Global Clinical Score (GCS) at admission and follow-up, 6.3±1.8 years after discharge. Their clinical characteristics at admission and discharge were also examined.

RESULTS

Four (6.0%) patients had died before follow-up. BMI was significantly increased during inpatient therapy. At follow-up, excellent, much improved, symptomatic, and poor outcomes on GCS were 57.1%, 14.3%, 14.3% and 14.3%, respectively. Younger age at admission and larger BMI at discharge were significantly associated with a better outcome.

DISCUSSION

This study shows the potential for the use of this method for the treatment of AN patients in countries without specialized eating disorder units.

An innovative short-term, intensive, family-based treatment for adolescent anorexia nervosa: case series

OBJECTIVE

In order to improve the dissemination of new expert-based treatments for adolescents with anorexia nervosa, we have developed an innovative 1-week intensive family-based evaluation and treatment programme. Ages of the adolescents in the programme ranged from 10 to 18 years (mean = 15.0, SD = 2.1). We report the outcomes of the first 19 cases.

METHOD

Data were obtained from a retrospective chart review and a follow-up of cases at 52 to 738 days (mean = 278.4, SD = 193.8) post-treatment. The primary outcome measure was ideal body weight (IBW) percentage.

RESULTS

At admission, the duration of illness ranged from less than 1 to 8 years (mean 2.1, SD = 1.7). Admission IBW ranged from 69.3 to 99.1% (mean = 84.3%, SD = 8.7). Follow-up IBW ranged from 84.4 to 134.6% (mean = 99.3%, SD = 11.8). All but one patient reported a sustained gain in weight post-treatment (mean = 15.0, SD = 14.5).

DISCUSSION

These data provide further support for the notion that short-term family-based therapy may be useful for weight restoration and maintenance in some adolescents with anorexia nervosa.

Service providers' perceptions of the strengths and prospective improvements in UK eating disorder services: findings from a Royal College survey

AIMS AND METHODS

This study aims to explore perceptions of eating disorder service strengths and to develop a clearer picture of improvements clinicians would like to see occur in the services they lead. A survey designed by the Royal College of Psychiatrists' Section of Eating Disorders was completed by 83 lead clinicians in both public and private sector services in the UK and Eire. Content analysis was performed, and common themes were identified.

RESULTS

Five main strengths of a service were identified as follows: quality of treatment (n = 36), staff skills (n = 21), continuity of care (n = 15), family involvement (n = 12) and accessibility and availability (n = 11). These themes also arose when clinicians evaluated areas they wished to develop and improve.

CONCLUSIONS

Service providers' views were congruent with each other, NICE guidelines and quality standards as proposed by the Royal College. Although clinicians feel that their service fulfils many practice guidelines, there remains areas in which adherence is felt to be lacking.

Brokering authenticity: Borderline personality disorder and the ethics of care in an American eating disorder clinic

This paper examines the moral work of a controversial psychiatric diagnosis--Borderline Personality Disorder--in an American eating disorder treatment center in the era of managed mental health care. Based on fieldwork at this clinic spanning more than 6 years, I consider how clinicians invoke aspects of Borderline Personality Disorder in everyday conversation, in a practice I call "borderline talk." I argue that borderline talk emerges in response to being caught between contradictory models of the subject entailed in managed care and psychodynamic discourses. Specifically, borderline talk enables clinicians to endorse a formulation of the subject that, although considered pathological, provides them with a clear path of ethical action in otherwise ethically ambiguous situations. These kinds of everyday ethical negotiations percolate throughout the American health care system and are key mechanisms through which notions of economic expediency become entangled with concepts of the healthy subject. As clinicians struggle out a course of action between competing ethical imperatives, they also struggle out the workability--and failures--of various articulations of the subject within contemporary American cultural ideologies of health and pathology.

Eating disorder not otherwise specified: the view from a tertiary care treatment center

OBJECTIVE

This study sought to characterize a large number of adult outpatients diagnosed with eating disorder not otherwise specified (EDNOS).

METHOD

The sample consisted of 1,449 patients who were classified as anorexia nervosa (AN), bulimia nervosa (BN), or assigned to one of six EDNOS categories. Eating disorder groups were compared on demographic features, symptom frequencies, and psychological functioning.

RESULTS

Forty percent of the sample was categorized as EDNOS. A subgroup of purging only patients closely resembled the BN purging subtype. Although EDNOS subthreshold BN patients reported less psychopathology than full syndrome BN they, nevertheless, displayed clinical levels of disturbance. Patients who binge-eat once a week demonstrate a profile of psychological functioning similar to those who binge eat twice a week.

CONCLUSION

Consistent with previous research, in this sample there were subgroups embedded in the EDNOS category that both share similarities with and differ from full syndrome BN.

Inpatients with eating disorders: demographic, diagnostic, and service characteristics from a nationwide pediatric sample

OBJECTIVE

This study describes the demographic and clinical characteristics of youth hospitalized with an eating disorder, using the Pediatric Health Information System (PHIS) database.

METHOD

Descriptive and inferential statistics were used to examine and compare PHIS inpatients (N = 1,713) with a primary discharge diagnosis of anorexia, bulimia, or eating disorder, not otherwise specified.

RESULTS

Of pediatric inpatients with eating disorders, 92% were female and 78% were non-Hispanic white. Their mean age was 15.3 years; 71% had anorexia; 68% had one or more comorbid psychiatric disorders; 53% stayed on a psychiatric unit; the mean length of stay was 15.7 days. Private insurance paid for 55% of hospital stays. Patients without private insurance were more likely than patients with private insurance to be Black or Hispanic and to have comorbid psychiatric diagnoses.

CONCLUSION

This study provides new information that can be used by hospitals to anticipate developmental and treatment needs of future inpatients with eating disorders.

Hospitalization of children and adolescents for eating disorders in the State of New York

PURPOSE

To examine hospitalization patterns, length of stay, cost and insurance status for children and adolescents with Eating Disorders.

METHODS

A cross-sectional study was conducted of patients with eating disorders aged 9 to 17 years, discharged from hospitals in the State of New York in 1995. All patients discharged in the state were registered by the State Planning and Research Collaborative System (SPARCS). A subset was identified based on coding by the International Classification of Diseases (ICD) for Anorexia Nervosa, Bulimia and Eating Disturbance Not Otherwise Specified. The Statistical Analysis System (SAS) was used for data analysis. The variables selected were gender, ethnicity, insurance status and length of stay.

RESULTS

In one year there were 352 hospitalizations, 312 females (88.6%) and 40 males (11.4%); 279 Caucasians (79.3%), 35 African Americans (9.9%), and 38 Other (10.8%); commercial insurance 246 (69.9%), Medicaid 68 (19.3%), other 38 (10.8%). The diagnostic categories were Anorexia Nervosa 242, Bulimia 59, and Eating Disturbance Not Otherwise Specified 63 (reflecting dual diagnosis in 13). Mean length of stay was 18.43 days, the median was 7 days. The cost per stay ranged between 341.78 dollars and 148,471 dollars; with a median of 3817 dollars and a mean of 10,019 dollars. Length of stay was not influenced by gender, age, or ethnicity; only payor status, availability of insurance, was dominant.

CONCLUSIONS

This is the first statewide report on hospitalization of children and adolescents for eating disorders. The mean cost in 1995 exceeded 10,000 dollars. A correlation was found between length of stay and insurance status. Hospitalizations for eating disorder have a significant public health impact, calling for the formulation of fair and rational strategies to optimize care.

Residential treatment for eating disorders

OBJECTIVE

The current study describes residential treatment for eating disorders in the United States.

METHOD

A national study involving 22 residential eating disorder treatment programs was conducted using a survey to determine treatment program descriptions and trends. Data from 19 respondents, representing 86% of all residential treatment programs in the United States, were examined.

RESULTS

Residential treatment options for individuals with anorexia nervosa and bulimia nervosa are becoming increasingly more common. A wide variety of techniques and methods are employed in the treatment of individuals with eating disorders in residential treatment programs. The average length of stay in treatment was 83 days, with an average cost per day of 956 US dollars.

CONCLUSION

The residential treatment of individuals with eating disorders is a growing, variable, and largely unregulated enterprise. Future research is needed to focus on quantifying treatment program effectiveness in the residential treatment of individuals with eating disorders.

Short-term outcome of psychiatric inpatients with anorexia nervosa in the current care environment

OBJECTIVE

The current study describes the short-term outcome of 61 inpatients with anorexia nervosa (AN), utilizing a standardized protocol that could be completed by most patients within the typical length of stay (LOS) in an academic medical center in our geographic area.

METHOD

Patients were placed on disorder-specific and medication clinical pathways and completed questionnaires at admission and discharge. Diagnostic, historical, demographic, and treatment-related information was obtained.

RESULTS

Treatment was sufficient to resolve acute medical problems, initiate refeeding, and interrupt compensatory behaviors, but continued intensive treatment will be critical to full recovery. Patients were discharged at an average of 85% of ideal body weight (IBW). Twenty patients were discharged against medical advice (AMA). Clinical and demographic variables poorly predicted AMA status.

DISCUSSION

Attainable inpatient treatment goals in our care environment appear to be > or = 80% IBW at discharge, resolution of acute medical problems, and interruption of compensatory behaviors. Future research should examine whether shorter LOS increases readmission rates or long-term costs.

An international collaborative database: its use in predicting length of stay for inpatient treatment of anorexia nervosa

OBJECTIVE

We describe the establishment of an Australasian multisite research database for inpatient treatment of anorexia nervosa (AN). Using this database, the second aim of this study is to investigate the extent to which length of stay (LOS) in participating facilities could be predicted at admission from patient, clinical, and site variables.

METHOD

Standardized demographic and clinical data were collated for 213 admission episodes involving 154 participants over a 20 month period from five Australian and one New Zealand specialist treatment centres.

RESULTS

While nine variables significantly predicted LOS on univariate analysis, linear regression determined that only body mass index, and having had 2-3 previous admissions made significant independent contributions to LOS.

DISCUSSION

Multisite databases offer a viable means by which to conduct clinical research, particularly in regard to low prevalence disorders such as AN. Their additional advantage is that of involving front-line practitioners recruiting participants more likely to be representative of cases seen across treatment centres. At just under a fifth of the total variance predicted by the best-fit model, LOS in hospital remains an aspect of AN treatment difficult to predict, and future studies need to explore variables other than the obvious demographic or clinical issues at admission. The clinical and planning implications are discussed.

The place of inpatient care in the treatment of anorexia nervosa: questions to be answered

BACKGROUND

The chance that an anorexia nervosa patient will be hospitalized depends more on circumstantial rather than on scientifically based factors. Although there is a lot of information on the treatment of anorexia nervosa patients in a residential setting, answers to questions relating to the "when," "where," and "how" of treatment are subjective. There is no clinical consensus and the paucity of controlled research is hampering the development of an evidence-based practice.

RESULTS

Increasing economic restraints through managed care policies limit the length of inpatient treatment, which leads to early discharge at a lower body weight, which leads to a higher likelihood of readmissions, which leads to increasing costs.

DISCUSSION

We will highlight important issues in the ongoing debate between economic demands and clinical challenges. Our goal is to stimulate critical reflections and systematic research.

Adolescents and eating disorders: an examination of a day treatment program

OBJECTIVE

In this study, we report on our day treatment program (DTP) for adolescents and young adults with eating disorders (EDs).

METHOD

Data for the 82 female patients in DTP were examined, compared across ED diagnosis and by age (adolescents vs. young adults). At admission, patients completed the Eating Disorder Inventory-2 (EDI-2) and the Beck Depression Inventory (BDI) and the Family Adaptability and Cohesion Evaluation Scale- II (FACES-II).

RESULTS

Forty-nine percent of patients successfully completed the day program and 13% required hospitalization following day treatment. Overall, there were no significant differences between the adolescents and adults at discharge of the day program.

DISCUSSION

With shortened inpatient (IP) hospitalizations, DTPs can provide the long-term care required by many adolescent patients for psychological and physical recovery. This may be particularly important for the development of children and adolescents.

Trends in eating disorder symptomatology in an outpatient clinic: 1988-1998

Eating disorders treatment has been altered by changes in the health care system. In addition, there has been a major emphasis on prevention in recent years. Yet, there are few investigations of the effects of these changes on the severity of patients' symptomatology at intake. This study examined differences in symptoms among women who presented to an outpatient clinic between 1988 and 1998. Patients were divided into Cohort 1 (1988-1992) and Cohort 2 (1993-1998). Patients with anorexia nervosa (AN) in Cohort 2 had significantly lower body mass indices (BMIs) at intake. Moreover, a greater number of patients with AN in Cohort 2 had BMIs<or=15, suggesting severe malnourishment. Cohort 2 patients with bulimia nervosa obtained higher scores on the Interpersonal Distrust, Interoceptive Awareness, and Maturity Fears subscales of the Eating Disorder Inventory. There were no cohort differences in eating disorder duration, exercising, laxative or diuretic use, or self-induced vomiting. These results provide some evidence that the severity of eating symptomatology has increased in recent years.

A health service perspective on anorexia nervosa

This article reviews anorexia nervosa from a health services perspective. From such a perspective, costs of care, changes in insurance types, lack of empirically supported treatments, and involvement of legislative and judicial processes are discussed. Based on this review, processes for designing optimal insurance strategies are outlined, needs for treatment, service, and prevention development suggested, and the need for systematic evaluation of effective treatments identified.

American Academy of Pediatrics. Committee on Adolescence. Identifying and treating eating disorders

Pediatricians are called on to become involved in the identification and management of eating disorders in several settings and at several critical points in the illness. In the primary care pediatrician's practice, early detection, initial evaluation, and ongoing management can play a significant role in preventing the illness from progressing to a more severe or chronic state. In the subspecialty setting, management of medical complications, provision of nutritional rehabilitation, and coordination with the psychosocial and psychiatric aspects of care are often handled by pediatricians, especially those who have experience or expertise in the care of adolescents with eating disorders. In hospital and day program settings, pediatricians are involved in program development, determining appropriate admission and discharge criteria, and provision and coordination of care. Lastly, primary care pediatricians need to be involved at local, state, and national levels in preventive efforts and in providing advocacy for patients and families. The roles of pediatricians in the management of eating disorders in the pediatric practice, subspecialty, hospital, day program, and community settings are reviewed in this statement.

Children and adolescents with eating disorders: the state of the art

BACKGROUND

Eating disorders in children and adolescents remain a serious cause of morbidity and mortality in children, adolescents, and young adults. The working knowledge of pathophysiology, recognition, and management of eating disorders continues to evolve as research in this field continues.

OBJECTIVES

This article builds on previous background and position papers outlining issues relevant to the care of the adolescent patient with an eating disorder.

METHODS

The eating disorder special interest group from the Society for Adolescent Medicine recognized the need to update the state of the art published guidelines for the care of the adolescent patient with an eating disorder. This article was a multidisciplinary, group effort to summarize the current knowledge of best practice in the field.

RESULTS

This article summarizes newer findings on pathogenesis and etiology, prevention and screening, risk factors, nutritional issues, care from the primary care clinician's perspective, appropriate use of a multidisciplinary team, and issues of managed care and reimbursement.

CONCLUSIONS

Primary prevention combined with early recognition and treatment helps decrease morbidity and mortality in adolescents with eating disorders.

Indicações para internação hospitalar completa ou parcial

Este artigo discute as indicações para tratamento hospitalar total e parcial em transtornos alimentares. A literatura básica sobre o tema é revisada, explicando tipos e locais de tratamento e guias terapêuticos para abordagem de pacientes nestas condições.

Inpatient and partial hospital treatment for adolescent eating disorders

The eating disorders are complex illnesses that tend to have a chronic relapsing course with severe morbidity and high mortality rates. Outcome seems to be best when the disorders are recognized early, brought to treatment quickly, the family is involved, and the first episode of care results in full return and maintenance of weight and menstruation. Adolescents who reach the point of needing hospitalization should be treated aggressively. In this article the authors have tried to outline some key treatment principles not just for the hospital stay, but elements that should be carried throughout the entire program of recovery for adolescents with eating disorders: from medical evaluation, through inpatient stay, partial hospitalization, intensive outpatient program, and follow-up outpatient therapy. Recent reductions in insurance authorizations and decreased lengths of stay in the psychiatric hospital make the already difficult challenge of recovery from AN and BN even more daunting. Despite these difficulties, we are still able to get a high proportion of youths better and eventually fully recovered.

Eating disorders and health insurance understanding and overcoming obstacles to treatment

Eating disorders are complex in cause and course, with biomedical, psychiatric, and psychosocial components. To maximize the likelihood of recovery, patients require skillful and coordinated care from various health care professionals, including medical professionals, mental health professionals, and nutritionists. All too often, at some point in treatment, clinicians discover that their patients' health insurance status has been compromised or that further treatment is denied because of maximization of mental health benefits. It is important for patients, families, and health care professionals to understand the health insurance issues that are involved in the treatment of eating disorders and learn strategies that may help to overcome the obstacles that these issues present.

Short-term group CBT versus psycho-education on an inpatient eating disorder unit

The purpose of the current study was to compare, on an inpatient eating disorder unit, short-term cognitive behavior group therapy with a psycho-education group.

Changing patterns of hospitalization in eating disorder patients

OBJECTIVE

This study investigated the changing patterns of hospitalization of eating disorder patients over the past 15 years.

METHOD

The records of 1,185 eating disorder patients between 1984 and 1998 were examined on several variables.

RESULTS

Over the 15 years, the number of first admissions increased from 20 to 182. There was a concomitant decrease in length of stay from 149.5 days in 1984 to 23.7 days in 1998. Readmissions increased markedly from 0% during the first year to 27% of total admissions in 1998. The discharge weight of anorectic patients significantly decreased from a body mass index (BMI) of 19.3 in 1984 to 17.7 in 1998. These changes were particularly salient in the past 3 years, concurrent with a dramatic rise in managed care cases.

CONCLUSIONS

Over the past 15 years, eating disorder hospital treatment has metamorphozed from long-term treatment of a disorder to stabilization of acute episodes. For some patients, this change has been deleterious and not cost effective.

Epidemiology and mortality of eating disorders

Although considerable progress has been made over the past 2 decades in the field of eating-disorder epidemiology, there is room for improvement. Eating disorder diagnoses for children, need assessment, prospective longitudinal studies, studies of natural cause, treatment dose-effect studies, and bias are all areas that need careful consideration. Clinicians should consider establishing a Cochrane database for eating disorders. The mortality studies reviewed in this article are dominated by small, sparse, unbalanced data sets, and publication bias and bias caused by loss to follow-up limits the validity of the reported findings. Some methodologic advice is given in the hope that some of the more obvious pitfalls can be avoided in future research.

Matching patient variables to treatment intensity. The continuum of care

This article has reviewed what is currently known regarding the relationship between specific patient variables and treatment response in AN, BN, and BED. Matching patient variables to treatment intensity remains an important and fruitful area for future research. There is a need for established guidelines for clinicians regarding the choice of the appropriateness of treatment settings and type of interventions delivered in those settings. These guidelines should be evidence based, with clear clinical indicators for each of the recognized eating disorders and their subclinical variants.

Hypophosphatemia secondary to oral refeeding in anorexia nervosa

OBJECTIVE

Hypophosphatemia is a well-known complication of the refeeding syndrome in severe cases of anorexia nervosa, described mostly as a result of refeeding with total parenteral nutrition. Few cases have been reported secondary to either nasogastric or oral refeeding.

METHOD

The authors present three cases in which hypophosphatemia developed secondary to oral refeeding in severe anorexia nervosa.

RESULTS

All 3 patients developed significant hypophosphatemia, to a low of 0.9 mg/dl in two cases and a low of 1. 7 mg/dl in the third. The first patient received close to 3,000 calories per day, along with intravenous fluids, in the hospital; the other 2 patients ate large amounts for several days at home. Caloric restriction and replenishment with phosphorous resulted in a rapid return of phosphorous values to normal levels.

DISCUSSION

Those who treat severely malnourished patients with eating disorders, whether as inpatients or outpatients, need to be vigilant for the development of the refeeding syndrome, even in patients receiving oral refeeding alone.

One-year use and cost of inpatient and outpatient services among female and male patients with an eating disorder: evidence from a national database of health insurance claims

OBJECTIVE

This study examined rates and cost of inpatient and outpatient treatment among 1,932 patients with an eating disorder.

METHOD

One-year (1995) data were available through MarketScan, a national insurance database containing claims for 1,902,041 male patients and 2,005,760 female patients.

RESULTS

Female patients (n = 1,756, 0.14% of all females) were significantly more likely to have been treated for an eating disorder than male patients (n = 176, 0.016% of all males), and females received more days of treatment than males. Outpatient treatment was the norm, regardless of gender or type of eating disorder. Average number of days (inpatient or outpatient) was less than the minimum recommended by standards of care. Age-adjusted costs for the treatment of anorexia nervosa and bulimia nervosa were comparable to the cost of treatment for schizophrenia.

DISCUSSION

The utilization data are discussed in terms of barriers to care and treatment guidelines for eating disorders.

Anorexia nervosa and bulimia nervosa in children and adolescents: a review of the past 10 years

OBJECTIVE

To critically review the research in juvenile anorexia nervosa and bulimia nervosa over the past 10 years and highlight recent advances in normal development as it pertains to these disorders and their diagnosis, prevention, and treatment.

METHOD

Computerized search methods were combined with manual searches of the literature. A detailed review of the most salient articles is provided. Preference was given to studies involving children and adolescents that approached the subject from a developmental perspective.

RESULTS

The information from these studies is presented in a developmental framework. Research in eating disorders has progressed, but definitive longitudinal data are still absent from the literature. Research specific to treatment of child and adolescent eating disorders remains rare.

CONCLUSIONS

Data approaching eating disorders from a developmental perspective are available in only a few studies. Research is needed addressing normative data on the development of eating behavior and specific risk and resilience factors for pathology in specific developmental periods. Especially lacking are studies regarding the continuities and discontinuities of eating disturbances across the life span. Best documented are epidemiological studies of prevalence and incidence, long-term outcome in anorexia nervosa, and short-term treatment response in bulimia.