Removing Treatment Obstacles

Reprinted from Eating Disorders Review
November/December 2009 Volume 20, Number 6
©2009 Gürze Books

The course a patient with an eating disorder travels between diagnosis and discharge may contain unnecessary obstacles that interfere with successful treatment, according to a group of British eating disorders specialists. Dr. Glenn Waller and colleagues have developed a series of recommendations to improve patient care and compliance (Psychiatr Bull R Coll Psychiatr 2009; 33:26).

Dr. Waller and his co-workers evaluated eating disorder services in two highly specialized adult eating disorder services in South London. Each service had a patient-centered model of care, offered a range of treatments, and served patients 18 years of age or older. The duration of treatment for inpatients and day patients was determined individually and transitions were arranged according to individual clinical criteria, such as weight stability and ability to travel for day-patient treatment. Most patients with bulimia nervosa had about 20 treatment sessions, while those with anorexia nervosa had 40 treatment sessions. During the two-year study, 1887 referrals were made to the two services87.1% came from the immediate area and 12.9% from outside the area. Of this group, 1134 were assessed

How patients fared

The largest group (546, or 34.5%) selected outpatient treatment. A few entered the more intensive forms of day-care treatment and inpatient care (119, or 7.5%). In a number of cases, the referral was found to be inappropriatefor example, the patient did not have an eating disorder or could not be referred because he or she lived out of the area and was refused treatment (379 patients, or 23.9%). Other patients failed to attend their assessment sessions (260 patients, or 16.4%). Another group of 180 persons were not suitable for treatment in the local eating disorders service because of psychoses or substance abuse, or they had moved from the area. No patient was refused treatment on the basis of the severity of the eating disorder. In 56 cases (3.5%), the person was assessed and found to be a candidate for treatment, but refused it. Over the course of the study, six patients (0.053% of the initial group of 1134 patients) died.

Of the 213 patients who were offered outpatient treatment, which included face-to-face therapy or guided self-help therapy, 28 (13%) failed to participate and 93 (44%) failed to finish treatment. Thus, only 92 (43%) completed outpatient treatment. As for more intensive treatment, of 97 persons who entered an inpatient or day patient program and reached an end-point, 13 (13%) failed to participate and 37 (38%) failed to complete their treatment. Thus, only 8 of the 97 patients completed either stand-alone day-patient programs (n=7) or day-patient programs following inpatient admission (n=1).

Suggestions for improving compliance and care

The authors identified a number of changes that they feel would have improved patients compliance and care. Starting with clearer guidelines for referring physicians, including determining which patients are suitable for care and what information should be provided, the authors made these recommendations:

Direct telephone contact with patients to negotiate potential appointment dates and times is likely to be more effective than is sending appointment letters.

Patients often prefer to have information about proposed treatment and the appointment provided to them in written form.

Once a patient had attended the assessment session, motivational techniques enhanced the likelihood that the patient would make his or her own recovery a priority.

When appropriate, it can be valuable to engage a patients caregivers in the assessment and treatment, to provide the patient support between appointments.

Once treatment is begun, patients are more likely to be motivated to stay in treatment if they are given information about the clear-cut benefits of treatment.

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