Reprinted from Eating Disorders Review
May/June 2000 Volume 11, Number 3
©2000 Gürze Books
Teens with anorexia nervosa are hospitalized for a number of reasons, including life-threatening illness, family and professional concern, and resistance to intervention. In the short term, hospitalization makes it possible to complete physical evaluation and monitoring, reestablish adequate caloric intake, and relieve family and professional anxiety. However, until recently little was known about the long-term effects of hospitalization on adolescents.
According to a team at the University of Liverpool, for some patients the gains achieved in the hospital are reversed over time (Br J Psychiatry 2000; 176:138). These researchers measured a range of presenting variables for 75 teens with DSM-III-R anorexia nervosa being treated at a regional adolescent center. The teens were then reevaluated 2 to 7 years after hospitalization and their outcome was rated.
Looking at outcome
At follow-up, 2 of the 75 girls had died. Of the remaining 73 patients, 21 who had inpatient treatment had a significantly worse outcome than those who were never admitted to the hospital. (Of course, the hospitalized group was likely to have been more ill in the first place.) The outcome was rated as good if the girl had maintained weight above 85% of normal, if menstruation had resumed, and if social functioning was satisfactory. A poor outcome was assigned if the girl still had an eating disorder and in all cases where weight was maintained below 85% of normal levels.
Deaths due to anorexia nervosa are said to exceed those of any other adolescent psychiatric disorder, including depression, and there is a lethal outcome in up to 15% of cases (Herzog et al, 1992). Further, only about half of younger patients can be expected to make a full recovery. In this study, 34 patients (45.3%) had a good outcome, 23 (30.7%) had an intermediate outcome, and 15 (20%) had a poor outcome. Data were incomplete for 3 patients (4%).
The researchers found a clear association between the severity of the condition when the patient first presented for treatment and its medium-to-long-term outcome. The more underweight the patient, particularly when she was below 70% of expected weight, and the lower the score on the Morgan-Russell Global Assessment Score (MRGAS), the worse the outcome. Age, length of illness, and presence of purging were not significantly associated with outcome.
Those treated as inpatients had a notably poorer outcome, but, again, they may represent a sicker group to start with. Weight restoration alone did not guarantee a good outcome; in fact, weight gain alone was a poor predictor of outcome.
How patients see hospitalization
According to the authors, not all patients view hospitalization negatively. In fact, patients find being hospitalized helpful or supportive, particularly when attention is given to the psychological aspects of the disorder.
The understanding and care of the professional staff sometimes exceed that experienced outside the hospital. In addition, the peer group and educational setting within the adolescent unit is perceived as a safe environment, far from the stresses of life in the outside world. In such a situation, discharge from the hospital may require tremendous adjustment, particularly in resuming responsibilities and obligations relating to eating. Discharge can also be viewed as a significant loss of support.
Authors advise considering the impact on outcome
The authors urge clinicians to consider the likely positive impact of a period of hospitalization on outcome of the condition. Some of the costs of hospitalization, beyond the actual cost for treatment, include disruption of education and family life. The decision to hospitalize may also send an unrealistic message to the patient and her family that anorexia nervosa is a condition that can be overcome by professionals “doing something” to the patient rather than supporting him or her in the patient’s own decision to change behaviors and attitudes.