Therapy Amount and Outcome of Inpatient Psychodynamic Treatment of Eating Disorders in Germany: Data From a Multicenter Study

[Therapeutic Effort in Inpatient or Day Patient Treatments and Therapy Success in Patients with Depressive Disorders]

Several therapeutic treatments like individual psychotherapy, group therapy, creative therapies and talks with the nursing staff are components in an inpatient psychosomatic (psychotherapeutic) treatment or a psychosomatic day hospital treatment. In Germany, these therapies have to be documented by the administration with so called OPS-Codes. These codes are reported to the Institute for Reimbursement in Hospitals (InEK). With the data of the INDDEP-study it should be investigated how the therapies of 7 hospitals and 8 day-hospitals compare to each other. In addition, it should be studied, if the amount of the documented therapies is connected to the outcome in these hospitals. In the INDDEP-study, data of patients with major depression were assessed at 4 measurement points (admission, discharge, 3 months and 12 months follow up). In addition, the OPS codes of the treatments were documented. The results show that it is possible to get a rough estimation of the psychotherapeutic doses by the OPS-codes. The results show significant differences between the hospitals in terms of the intensity and professional group composition of the treatments. This result is confirmed for in-patient and day hospital treatments. Correlation analyses showed no significant correlation between the total amount of therapy and the improvement in depressive symptoms. It is assumed that there are moderating variables (patient-, therapy and process-related) which moderate the relation between doses and outcome. This should be identified in further studies.

The therapeutic process in psychological treatments for eating disorders: a systematic review

OBJECTIVE

For eating disorders, a vast number of investigations have demonstrated the efficacy of psychological treatments. However, evidence supporting the impact of therapeutic process aspects on outcome (i.e., process-outcome research) has not been disentangled.

METHOD

Using the Generic Model of Psychotherapy (GMP) to organize various process aspects, a systematic literature search was conducted on psychological treatment studies for anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified.

RESULTS

Improved outcomes resulted for family-based treatment compared to individual treatment, for individual compared to group treatment, booster sessions, and positive patient expectations (GMP contract aspect); for nutritional counseling and exercising but not exposure with response prevention as adjunct interventions (therapeutic operations); for highly motivated patients and, to a lesser extent, for therapeutic alliance (therapeutic bond); as well as for rapid response and longer overall treatment duration (temporal patterns). Regarding other GMP aspects, studies on self-relatedness were completely lacking and in-session impacts were rarely investigated.

DISCUSSION

As most studies assessed only a limited number of process aspects, the ability to draw conclusions about their overall impact regarding outcome is rather limited. Therefore, future process-outcome research is needed beyond investigations of treatment efficacy for eating disorders.

Comparison of specialist and nonspecialist care pathways for adolescents with anorexia nervosa and related eating disorders

OBJECTIVE

To explore the role of specialist outpatient eating disorders services and investigate how direct access to these affects rates of referral, admissions for inpatient treatment, and continuity of care.

METHOD

Services beyond primary care in Greater London retrospectively identified adolescents who presented with an eating disorder over a 2-year period. Data concerning service use were collected from clinical casenotes.

RESULTS

In areas where specialist outpatient services were available, 2-3 times more cases were identified than in areas without such services. Where initial outpatient treatment was in specialist rather than nonspecialist services, there was a significantly lower rate of admission for inpatient treatment and considerably higher consistency of care.

DISCUSSION

Developing specialist outpatient services with direct access from primary care is likely to lead to improvements in treatment and reduce overall costs.

Introduction of DRG-based reimbursement in inpatient psychosomatics--an examination of cost homogeneity and cost predictors in the treatment of patients with eating disorders

OBJECTIVE

Various western countries are focusing on the introduction of reimbursement based on diagnosis-related groups (DRG) in inpatient mental health. The aim of this study was to analyze if psychosomatic inpatients treated for eating disorders could be reimbursed by a common per diem rate.

METHODS

Inclusion criteria for patient selection (n=256) were (1) a main diagnosis of anorexia nervosa (AN), bulimia nervosa (BN) or eating disorder-related obesity (OB), (2) minimum length of hospital stay of 2 days, (3) and treatment at Charité Universitaetsmedizin Berlin, Germany during the years 2006-2009. Cost calculation was executed from the hospital's perspective, mainly using micro-costing. Generalized linear models with Gamma error distribution and log link function were estimated with per diem costs as dependent variable, clinical and patient variables as well as treatment year as independent variables.

RESULTS

Mean costs/case for AN amounted to 5,251€, 95% CI [4407-6095], for BN to 3,265€, 95% CI [2921-3610] and for OB to 3,722€, 95% CI [4407-6095]. Mean costs/day over all patients amounted to 208€, 95% CI [198-218]. The diagnosis AN predicted higher costs in comparison to OB (p=.0009). A co-morbid personality disorder (p=.0442), every one-unit increase in BMI in OB patients (p=.0256), every one-unit decrease in BMI in AN patients (p=.0002) and every additional life year in BN patients (p=.0455) predicted increased costs.

CONCLUSION

We see a need for refinements to take into account considerable variations in treatment costs between patients with eating disorders due to diagnosis, BMI, co-morbid personality disorder and age.

Stability of long-term outcome in bulimia nervosa: a 3-year follow-up

We report on the 3-year course and outcome of patients with bulimia nervosa (BN), initially treated in an inpatient or day clinic setting. Patients were assessed by structured interviews (Structured Clinical Interview for DSM Disorders I and II and Structured Interview for Anorexia and Bulimia Nervosa) and questionnaires (Eating Disorder Inventory-2, Symptom Checklist-90-R, and Social Adjustment Scale) at time points of admission, discharge, and 3-month, 12-month and 36-month follow-ups. Data of 83.7% of the 43 patients were available. After 3 years, about one third of patients showed complete remission, one third showed partial remission, and one third still fulfilled all the criteria of BN. Most changes occurred during hospitalization. Remission status showed substantial fluctuation over time, with little correlation between time points of assessment (discharge and 3-month, 12-month, and 36-month follow-ups). A cluster analysis revealed four patterns of longitudinal symptom change. Day clinic and inpatient treatment are overall effective. Longitudinal and repeated assessments are necessary to validly measure outcome in BN.

[Effectiveness of inpatient psychodynamic psychotherapy: a follow-up study]

OBJECTIVES

This study investigates the stability of symptomatic and interpersonal changes after inpatient psychodynamic psychotherapy.

METHODS

437 patients were assessed 3 to 5 years after discharge with the Symptom Checklist (SCL-90-R), the Inventory of Interpersonal Problems (IIP), global assessment of effectiveness and utilization of posttreatment psychotherapy. The therapist's perspective was evaluated by the Impairment Severity Score (BSS), the Global Assessment of Functioning Scale (GAF), and the Clinical Global Impressions (CGI).

RESULTS

Patients improved in all SCL-90-R scales significantly. The Global Severity Index (GSI) effect size was 0.81 posttreatment and 0.82 at follow-up. All IIP scales improved significantly; effect size of IIP total score was 0.40 at posttreatment and 0.60 at follow-up. There were substantial gains in BSS,GAF, and CGI. 84% of the patients were in psychotherapy after dismissal.

DISCUSSION

Posttreatment results were in accordance with comparable studies. The results are stable on a symptomatic level and improve further on an interpersonal level.

Estimating dose-response effects in psychological treatment trials: the role of instrumental variables

We present a relatively non-technical and practically orientated review of statistical methods that can be used to estimate dose-response relationships in randomised controlled psychotherapy trials in which participants fail to attend all of the planned sessions of therapy. Here we are investigating the effects on treatment outcome of the number of sessions attended when the latter is possibly subject to hidden selection effects (hidden confounding). The aim is to estimate the parameters of a structural mean model (SMM) using randomisation, and possibly randomisation by covariate interactions, as instrumental variables. We describe, compare and illustrate the equivalence of the use of a simple G-estimation algorithm and two two-stage least squares procedures that are traditionally used in economics.

[Comparison of inpatient and day clinic treatment of anorexia nervosa]

OBJECTIVES

Explorative comparison of short term outcomes of day clinic and inpatient treatment for anorexia nervosa.

METHODS

N = 13 consecutively admitted day clinic patients (anorexia nervosa; DSM IV) were matched with N = 13 inpatients (variables: age, duration of illness, gender, admission weight, subtype of anorexia nervosa). Results at discharge were compared using defined outcome criteria as well as scores of the SCL-90-R and EDI-2.

RESULTS

After inpatient treatment significantly more patients showed a good outcome (predefined criteria). Effect sizes also pointed to a superiority of inpatient treatment.

CONCLUSIONS

In the initial phase of therapy the structured and holding environment of an inpatient unit may be favourable for severely underweight anorexic patients. The interpretation of these results is limited due to the small sample size.

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.

A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods

OBJECTIVE

Propensity score (PS) analyses attempt to control for confounding in nonexperimental studies by adjusting for the likelihood that a given patient is exposed. Such analyses have been proposed to address confounding by indication, but there is little empirical evidence that they achieve better control than conventional multivariate outcome modeling.

STUDY DESIGN AND METHODS

Using PubMed and Science Citation Index, we assessed the use of propensity scores over time and critically evaluated studies published through 2003.

RESULTS

Use of propensity scores increased from a total of 8 reports before 1998 to 71 in 2003. Most of the 177 published studies abstracted assessed medications (N=60) or surgical interventions (N=51), mainly in cardiology and cardiac surgery (N=90). Whether PS methods or conventional outcome models were used to control for confounding had little effect on results in those studies in which such comparison was possible. Only 9 of 69 studies (13%) had an effect estimate that differed by more than 20% from that obtained with a conventional outcome model in all PS analyses presented.

CONCLUSIONS

Publication of results based on propensity score methods has increased dramatically, but there is little evidence that these methods yield substantially different estimates compared with conventional multivariable methods.

Versorgungsforschung in der psychosozialen Medizin

The following article presents aspects of the field of psychosocial medicine in Germany from the perspective of health services research. First, the tasks and topics of health services research are listed. The identification and appropriate treatment of people with mental disorders is one of the core themes of psychosocial health care; therefore, a brief overview of research results on the epidemiology of mental disorders is first presented. The primary focus of this article is then to provide a description and analysis of the structures of psychosocial care in inpatient and outpatient settings. Research findings concerning treatment processes and the result of these processes are additionally presented. The findings show that there is still a considerable lack of research results regarding the treatment of patients with mental disorders, as is also the case in other health care areas. An important empirical basis for rationally founded treatment planning in this area is thus lacking.

Principles for modeling propensity scores in medical research: a systematic literature review

PURPOSE

To document which established criteria for logistic regression modeling researchers consider when using propensity scores in observational studies.

METHODS

We performed a systematic review searching Medline and Science Citation to identify observational studies published in 2001 that addressed clinical questions using propensity score methods to adjust for treatment assignment. We abstracted aspects of propensity score model development (e.g. variable selection criteria, continuous variables included in correct functional form, interaction inclusion criteria), model discrimination and goodness of fit for 47 studies meeting inclusion criteria.

RESULTS

We found few studies reporting on the propensity score model development or evaluation of model fit.

CONCLUSIONS

Reporting of aspects related to propensity score model development is limited and raises questions about the value of these principles in developing propensity scores from which unbiased treatment effects are estimated.

Psychotherapy in a day clinic: results of a 1.5 year follow-up

OBJECTIVE

In a prospective, naturalistic 1.5 year follow-up study of N= 114 consecutively admitted day clinic patients efficacy of the program and predictors of outcome are evaluated.

METHODS

Patients had severe neurotic disturbances and personality disorders. Interviews and questionnaires (SCL-90-R, EDI) were used for evaluation at admission, discharge and follow-up.

RESULTS

From 79.8% of the patients information could be obtained. In the main diagnostic categories between 30 to 50% of the patients showed complete remissions at follow-up. Patients at least kept improvements at follow-up. The rating of the "transition phase" after discharge was predictive for outcome. The group of patients that rated this phase as difficult showed higher levels of psychopathology at admission.

CONCLUSIONS

It is possible to treat severely disturbed patients in a psychotherapeutic day clinic with good and lasting effects. A more disturbed group of patients needs special help to cope with the transition into the outpatient situation.