Inpatient vs. Outpatient Treatment for Adolescents with AN

Patients and parents preferred outpatient programs, which also produced better long-term results.

Inpatient psychiatric treatment has been identified as the gold standard for treating adolescent patients with anorexia nervosa (AN), but thus far this approach has neither been more successful or cost-effective than outpatient treatment. In fact, most forms of intervention have not been well researched.

Dr. S. G. Gowers and other British researchers recently reported the results of a large population-based randomized controlled trial of the three most common treatments available in the United Kingdom for adolescent patients with AN. The Treatment Outcome for Child and Adolescent Anorexia Nervosa (TOuCAN) trial compared the merits of inpatient psychiatric treatment and two forms of outpatient management, Community Generic Child and Adolescent Mental Health Services (CAMHS) and a specialist multimodal multidisciplinary program developed just for the study (Health Technology Assessment 2010; 14:7).

The aim of this study was to determine if at 1, 2 and 5 years young people treated in specialist inpatient and outpatient services would have any advantages over those who used general outpatient treatment programs. In addition, the study sought to evaluate if inpatient management had any advantages over outpatient treatment and to examine the cost-effectiveness and the satisfaction of patients and physicians with each type of treatment.

The randomized controlled study was conducted among 215 young patients between 12 and 18 years of age presenting with AN at CAMHS. Inclusion criteria included food restriction plus or minus compensatory behaviors, weight below 85% of that expected based on age and height, intense fear of gaining weight or undue influence of weight or shape on self-evaluation, and primary or secondary amenorrhea of at least 3 months in females or menstruation only while on oral contraceptives. Those with severe chronic comorbid physical conditions that affected digestion or metabolism were excluded. Thirty-five centers in northwest England participated.

Study participants were randomized to either treatment as usual within community generic mental health centers; treatment consisting of individual cognitive behavior therapy, dietary advice, parental counseling and feedback on self-report measures; or to inpatient treatment within one of four specialist but not exclusively inpatient units. Outpatient treatment spanned at least 6 months; the length of inpatient treatment was at the service’s discretion, with outpatient follow-up for a minimum of 6 months.

What the study results showed

Of the 167 young persons randomized to either inpatient or outpatient treatment, 67% adhered to the allocated treatment; adherence was lower in groups assigned to inpatient management. Each subject was followed up at 1 and 2 years (the main outcome point), and the main outcome measure was completed by 94% at 2 years (only 47% at 5 years). At each time point, there was significant improvement in all groups: 19% achieved a good outcome at 1 year, 33% at 2 years, and 64% at the 5-year point.

Patients who received inpatient treatment had poor results; among these were patients who failed to progress with outpatient treatment and who were transferred for inpatient treatment due to clinical symptoms. Generalist treatment was slightly more expensive over the first 2 years, largely because greater numbers of patients were subsequently admitted to hospital after the treatment phase. The cost-effectiveness analysis showed that specialist outpatient services were incrementally more cost-effective.

And, how satisfied were patients with treatment? Overall, young people were twice as likely to express positive views of outpatient treatment. Parents were also much more satisfied with outpatient treatment, and five times as many expressed positive than negative views of treatment. Parents were consistently more satisfied than were young patients with each type of treatment but both parents and young people were more satisfied with specialist than with general treatments—this was largely due to their confidence in “expertise” and their ability to form a good relationship with an individual therapist, in either an inpatient or an outpatient setting.

Some implications for health care

On the basis of their findings, the authors recommend that for moderately to severely ill adolescents with AN, outpatient services delivered by experienced expert professionals, and supported by medical management of physical complications as required, offer the most cost-effective approach to treatment. In contrast, lengthy psychiatric inpatient treatment does little to add to positive outcomes and is not cost-effective. Treatment by specialists with experience and expertise in managing AN is preferable, owing to its cost-effectiveness and higher levels of satisfaction among both patients and physicians. When young people with AN are managed in community health centers, a consultation and advice link with a specialist service may enable the treatment team to contain the anxiety and reduce the number of unnecessary hospitalizations.

The researchers also feel that further research is needed to help clarify the positive and negative aspects of inpatient care. Physical and psychological risk, parental anxiety and social and educational withdrawal by adolescents often result in inpatient admissions. This is often a logical step because of the availability of intensive psychological therapies, general support, and refeeding and respite from the external world. While satisfaction is generally good, particularly among parents, research outcomes are disappointing. This may suggest that adverse effects are under-recognized, according to the authors.