1. The Treatment of Chronic Eating Disorders: Predictors of Outcomes Megan I. Jones, Krista E. Brown, Josie Geller, Suja Srikameswaran, & Erin C. Dunn St. Paul’s Hospital, The University of British Columbia Introduction Summary of Results Method Objective References The Quest Program Treatment Outcome Please address correspondence to: Megan I. Jones E-mail: mjones@providencehealth.bc.ca Individuals with chronic eating disorders are a challenging group to treat, as evidenced by high rates of treatment refusal, drop-out, and relapse (Pike, 1998). Despite the widespread use of inpatient treatments for individuals with chronic eating disorders, little is known about the efficacy of these treatments (Vandereycken, 2003). Predictors of outcome, such as early discharge from program, are also unknown (Halmi, Agras, Crow, Mitchell, Wilson, et al., 2005). Previous research has shown that patients at St. Paul’s Hospital who enroll in intensive residential treatment with non-individualized symptom-reduction expectations have high baseline readiness for change. In this group, readiness for change (specifically, restriction precontemplation, or the extent to which clients want to restrict dietary intake) predicts dropout, symptom change, and relapse (Geller, Drab-Hudson, Whisenhunt, & Srikameswaran, 2004). Predictors of early discharge for individuals with chronic eating disorders, who are less ready for change and who typically receive individualized inpatient symptom reduction treatments, are unknown. The purpose of this research is to evaluate the efficacy of a voluntary individualized inpatient treatment program for individuals with chronic eating disorders and to identify patient characteristics that are associated with early discharge. The St. Paul’s Hospital Eating Disorders Program (EDP) provides tertiary care treatment to individuals with eating disorders in British Columbia, Canada. The EDP offers a menu of inpatient and outpatient treatment options that are tailored to patient readiness and motivation for change. Quest is an intensive inpatient treatment designed for individuals with persistent and unrelenting eating disorders. Quest has two phases: The inpatient phase addresses symptom reduction and the outpatient phase focuses on maintenance and integration of change. In both phases of Quest, group, individual, and family interventions address the function of the eating disorder, readiness for change and alternative ways of coping. Unlike other intensive treatments at the EDP that require high motivation for change prior to admission, Quest accepts individuals with varying degrees of readiness for change. As such, treatment goals are tailored to individual need, resulting in variable length of stay and pace of recovery. Prior to admission, Quest patients engage in pre-care sessions that address readiness and motivation for change. In these addition, they experiment with symptom reduction and collaboratively develop and agree upon treatment goals and non-negotiables. This research focuses on the inpatient phase of Quest. Early discharge occurs if the patient is no longer wanting or able to make changes and/or adhere to the treatment non-negotiables that they established in pre-care. High treatment retention in Quest may have resulted from the use of collaborative pre-care interventions that targeted symptom reduction and readiness and motivation for change prior to admission to the inpatient program. Flexibility regarding pace of recovery (i.e., Quest patients were not required to meet group-based/standardized expectations for change) may also have influenced patients’ ability to complete inpatient treatment. Although previous research has shown that restriction precontemplation predicts outcome in a non-individualized residential treatment, readiness did not predict early discharge for individuals enrolled in Quest. Early discharge from Quest was associated with more severe eating disorder and psychiatric symptoms. This suggests that for programs tailored to individuals who have high ambivalence about normalizing eating, other factors, such as global distress, may be more important in determining patients’ capacity to engage in treatment. These findings suggest that global symptom severity may be important to consider in determining when individuals are most likely to benefit from programs like Quest. Despite a lengthy duration of illness, individuals who participated in Quest experienced significant improvements in overall functioning. It is not known whether these favourable outcomes are representative of other programs providing inpatient treatment to individuals with chronic eating disorders. Follow-up data collection is currently underway to determine longer term Quest outcomes. Procedure Study participants (N = 43) completed measures of readiness and motivation, eating disorder symptomatology, psychiatric distress, and quality of life at baseline and post-inpatient treatment. Participants All participants had previously received specialized inpatient and outpatient treatment for their eating disorder DSM-IV diagnostic breakdown was as follows: AN-B/P: 12.8 % AN-R: 23.1 % BN: 15.4 % EDNOS * : 46.2 % * 15.8 % of the EDNOS group met all but one of the diagnostic criteria for AN Age = 32.13 (9.50) years Socioeconomic status = 2.35 (1.28) indicating upper middle class (Hollingshead, 1979) Body Mass Index = 18.35 (3.84) Duration of eating disorder = 16.71 (9.53) years Length of inpatient stay = 14.67 (5.13) weeks Readiness for change (Restriction Precontemplation) = 59.07 (28.79) Note: Restriction Preontemplation at intake for patients admitted to the EDP’s intensive residential program = 49.44 (28.43) Measures Readiness and Motivation Interview (RMI; Geller & Drab, 1999; Geller, Cockell, & Drab, 2001). A symptom specific interview measure of readiness and motivation for change in the eating disorders. Quality of Life Inventory (QOLI; Frisch, 1994). A questionnaire measure of life satisfaction. Eating Disorders Inventory-2 (EDI-2; Garner, 1991). A questionnaire measure of eating disorder symptomatology. Brief Symptom Inventory (BSI; Derogatis & Spencer, 1982). A questionnaire measure of psychiatric symptom severity. Derogatis, L. R. & Spencer, P. M. (1982). The brief symptom inventory (BSI): Administration, scoring, and procedures manual. Towson, MD: Clinical Psychometric Research. Frisch, M. B. (1994). Quality of life inventory (QOLI): Manual and treatment guide. Minneapolis, MN: National Computer Systems. Garner, D. (1991). Eating disorder inventory-2: Professional manual. Odessa, FL: Psychological Assessment Resources. Geller, J. & Drab, D. (1999). The Readiness and Motivation Interview: A symptom- specific measure of readiness to change in the Eating Disorders. European Eating Disorders Review, 7, 259-278. Halmi, K.A., Agras, W.S., Crow, S., Mitchell, J., Wilson, T.G., Bryson, S.W., & Kraemer, H.C. (2005). Predictors of treatment acceptance and completion in anorexia nervosa. Archives of General Psychiatry, 62, 776-781. Hollingshead, A.B. (1979). Four Factor Index of Social Status. New Haven, CN: privately printed. Pike, K. (1998). Long-term course of anorexia nervosa: Response, relapse, remission, and recovery. Clinical Psychology Review, 18, 447-475. Vandereycken, W. (2003). The place of inpatient care in the treatment of anorexia nervosa: Questions to be answered. International Journal of Eating Disorders, 34, 409-422. Eating Disorder Symptoms Psychiatric Symptoms Early Discharge Note: There were significant improvements in eating disorder symptoms over time: EDI-2 Drive for thinness (p <.001), Body Dissatisfaction (p <.05), Bulimia (p <.001), and total score (p <.001). Note: Scores represent percentiles relative to female inpatient norms. There were significant improvements in psychiatric symptoms over time: BSI Depression (p <.01), Anxiety (p <.05), and Global Severity Index (p <.01). Note: There were significant improvements in quality of life over time: QOLI (p <.05). Note: Higher scores indicate lower readiness for change. There were significant improvements in RMI restriction precontemplation ( p <.01). Readiness for change Body Mass Index Note: There were significant improvements in BMI (p <.001) over time for individuals who were underweight at baseline. Note: EDI-2 Drive for Thinness (p <.01), and Bulimia (p <.05) scores were significantly higher at baseline for the early discharge group. Seven individuals (16%) were discharged early from inpatient treatment. In 3 cases (43%) the patient and care provider came to a mutual decision regarding discharge, in 3 cases (43%) the patient decided to leave, and in one case (14%) the patient was asked to leave. Eating Disorder Symptoms Psychiatric Symptoms Note: Scores represent percentiles relative to female inpatient norms. BSI Global Severity Index (p <.05) scores were significantly higher at baseline for the early discharge group. Quality of Life Conclusions Overall, treatment retention in the inpatient phase of the Quest program was high. Only 16% did not complete treatment. Individuals who did not complete inpatient treatment had more severe eating disorder and psychiatric symptoms at baseline than did those who completed treatment. Treatment completers reported significant improvements in readiness for change, quality of life, and eating disorder and psychiatric symptomatology.