Premature Termination of Treatment for AN Patients

Two distinct groups emerged
in a study in the UK.

It’s not unusual for 50% or more of patients with anorexia nervosa (AN) to drop out of treatment before they reach their target weights. Dr. Richard Sly and colleagues recently found key differences between adult patients who prematurely discharged themselves from treatment and patients who were prematurely discharged by clinical staff (Int J Eat Disord 2014; 47:40). The authors suggest that adult patients with longer histories of illness are more likely to discharge themselves from treatment and thus should be offered additional support, which may help them complete treatment.

Causes for termination of treatment

Staff-initiated discharge may result when the clinical team feels the patient is not working within the alliance of the boundaries of the treatment program; for example, a patient may deliberately stop gaining weight, engage in self-harm, or abuse substances such as alcohol while in treatment.   Patients who discharge themselves may do so when weight gain rises and motivation decreases.

The study group consisted of successive new admissions at four specialist eating disorders treatment centers in the United Kingdom. The study group had a confirmed diagnosis of AN according to DSM-IV guidelines, a body mass index on admission of <17.5 kg/m², and an ability to complete a number of self-report questionnaires. One hundred and nine patients met the inclusion criteria and 90 agreed to participate in the study. The majority were white, female, and had a mean age of 27.7 years, and had been admitted to the hospital with a mean BMI of 14.16. The majority (88.9%) had been treated previously and had a mean duration of illness of 11.2 years and had been treated 4 times before the latest admission.

The authors found significant differences between patients who had terminated treatment and those for whom staff members had terminated treatment. For example, the survival curve for those who terminated their own treatment was 133 days, compared with 360 days for those whose treatment was terminated by staff members. After 60 days of treatment, 72.2% of those in the self-termination group had left, while just 12.0% of staff-initiated terminations had occurred at that point in time. Those who dropped out on their own left treatment with less overall weight change, and increased their weight by about 1.5 BMI points, compared to 3 BMI points among those terminated by staff. BMIs were lower for those who left treatment on their own (mean BMI: 15.59) compared with those who were terminated by staff (BMI: 17.45).

Those who terminated their own treatment also left treatment earlier than those among the staff-terminated group (mean: 43 days vs. 140 days, respectively). Older patients were more likely to discharge themselves from treatment than be discharged by the clinical staff, and were more likely to have received previous treatment for AN. Those who dropped out of treatment were also more likely to begin gaining weight at a quicker pace than were those patients discharged by the staff and also were more likely to report having lower motivation to recover. The timing of discharge was also significantly quicker for those who dropped out of treatment. There was a definite drawback to leaving treatment earlier because these patients had worse outcomes and had higher levels of risk for the future than did those who were discharged by the clinical tram.

One unexpected finding was that not all forms of premature termination of treatment posed a high risk for patients. Patients who were discharged by staff had similar outcomes to those who completed treatment as originally planned.

Helping patients with long-term AN stay in treatment

The authors suggest that patients with longer histories of AN could benefit if they were identified at admission and offered additional support to stay in treatment. For example, these individuals could be offered more realistic and achievable treatment goals, such as a brief admission for medical stabilization, followed by discharge into an outpatient care setting. Such an approach might help prevent the sense of failure that may be internalized after a patient chooses to leave treatment. Also, patients who gain weight quickly and subsequently have lower motivation could be offered increased support through post-meal supervision groups or with an increase in individual sessions.