In this Swedish study, most adolescents improved without need for inpatient care.
Reprinted from Eating Disorders Review
May/June Volume 27, Number 3
Some adolescent girls with anorexia nervosa (AN) or restrictive eating disorders not otherwise specified (EDNOSr) can be successfully treated as outpatients in a family-based setting, without the need for hospitalization, according to the outcome of a Swedish study (Upsala J Med Sci. 2016. 121:50).
Dr. Agneta Rosling and her colleagues studied the one-year outcomes and analyzed predictors of outcome among a cohort of168 female patients (29 with AN and 112 with restrictive-type EDNOS), 141 of whom were followed for one year after starting treatment in 1991.
In Sweden, all services for child and adolescent psychiatry services are tax-supported and thus free for patients. Patients are immediately accepted for assessment, following inquiries by parents or referral from school health services. At the Uppsala University Eating Disorders Unit, care is provided by a multidisciplinary team and largely follows American Psychiatric Association recommendations. However, inpatient care is only available in emergency situations and not for weight restoration.
The outpatient program
The first step (weeks 1 to 3) focuses solely on halting weight loss. At the first assessment, parents are advised about their role and how to re-establish normal meals served on a fixed schedule. Patients usually do not attend school, and exercise is not allowed until normal eating patterns have been re-established. Parents and teens attend separate counseling sessions, and the patients are invited to participate in psychoeducational groups.
The second step (weeks 6 to 8) begins once the patient is eating normal meals. At this point, the goal is to restore weight at a rate of 0.5 to 1 kg (1.1 to 2.2 lb) per week.
The third step begins when the patient has regained a substantial amount of weight and gradually begins attending school once more. This step may take several months, and may still include family meal support.
The final step begins only when eating, attending school, and reassuming daily routines are being “reliably maintained,” according to the authors. Cognitive behavioral therapy (CBT) using a “transdiagnostic” approach to prevent relapse may be added at this point. Hospitalization and pharmacologic treatment (usually with selective serotonin reuptake inhibitors, or SSRIs) are used only in severe cases. For example, the teen may be hospitalized if she is at imminent risk for arrhythmias and/or when she refuses to eat or drink. In such cases, cardiac monitoring and nasogastric intubation may be needed.
168 adolescent participants
At the initial assessment,The 168 teenaged girls were diagnosed with AN (n=31) or EDNOSr (n=137). The girls diagnosed with AN had ED symptoms for about 9 months (range: 1-32 months), while those with EDNOSr had symptoms for about 12 months (range: 1-42 months). Follow-up data were available for 141 of the 168.
At the one-year follow-up point, 73% had been outpatients for the entire year. Among those with AN, 6/29 (21%) were free of an ED. Of those with EDNOS, 48% were free of an ED. Roughly 40% received medication, and 5% were hospitalized. Overall, the majority showed improvement in weight.
These results support the value of extensive outpatient treatment, particularly for those with EDNOS.