Table 52.
Inpatient and day treatment in combination for children and adolescents with anorexia nervosa
| Certainty assessment | Impact | Certainty | Importance | ||||||
|---|---|---|---|---|---|---|---|---|---|
| № of studies | Study design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | |||
| Weight Change (assessed with: Change in weight during treatment) | |||||||||
| 5 | Case Control and Case Series | very serious a | not serious | not serious | not serious | none | 265 patients over 5 studies, all with AN. All studies treated patients as inpatients and then transferred to day treatment once medically stable. Details regarding the number of hours/days spent in day treatment not completely reported. Mean LOS were 3.9 months, 15.1 weeks and 7.9 weeks. Patients gained weight as described by BMI in 3 studies where BMI increase from 12.1 (SD1.1) to 18.6 (SD 0.42) in one study, 15.7 (SD1.2) to 18.0 (SD 1.0) in the second study and 15.19 (+/− 1.54) to 17.56 (+/− 1.07) in the third study. The second study also reported weight as %TGW which rose from 77.6% at admission to inpt to 88.5% at end of day treatment. In 2 studies weight change was described using BMI centiles and weight rose from a mean BMI centile of 2.7 (+/− 4.2) to 34.2 (+/− 15.7) in one study and 1.6 (+/− 5.1) to 49.4 (+/− 3.9) in the second study. 5/40 patients eligible for one study left treatment AMA and were not included in analysis. |
⨁◯◯◯ VERY LOW |
CRITICAL |
| Eating Disorder Inventory - 2 Score at discharge (assessed with: Rating Scale) | |||||||||
| 1 | Case Series | very serious a,b | not serious | not serious | not serious | none | 35 patients completed inpt, day treatment and measures. Mean LOS 15.1 weeks. Change in ED1–2 total, drive for thinness and body dissatisfaction not significantly different between admission and discharge. |
⨁◯◯◯ VERY LOW |
IMPORTANT |
| Anorexia Nervosa Stages of Change Questionnaire (assessed with: Rating Scale) | |||||||||
| 1 | Case Series | very serious a,c | not serious | not serious | serious d | all plausible residual confounding would reduce the demonstrated effect | 35 patients completed ANSOCQ at admission and d/c (ie after 15.1 weeks of inpatient + day treatment). Overall score increased a mean of 21.7 points which would signify moving from contemplation to preparation phases. Overall 29.4% (up from 0% at admission) of patients were classified as in “maintenance phase” and 26.5% (up from 15% at admission) in “action phase” at time of discharge. |
⨁◯◯◯ VERY LOW |
IMPORTANT |
| Overall Outcome (assessed with: Rating combining weight + compensatory symptoms) | |||||||||
| 1 | Case series | very serious a,e | not serious | not serious | not serious | all plausible residual confounding would reduce the demonstrated effect | One study which included 71 patients who completed 7.9 weeks of combined inpatient and DTP (33 days inpatient and 22 days DTP). At end of DTP 35.2% were deemed to have an excellent outcome (> 90% ideal BMI, maintaining weight and no use of compensatory symptoms in last week of program), 26.8% were deemed good outcome (85–90% ideal BMI, maintaining weight and no use of compensatory symptoms in last week of treatment), 14.1% deemed below average outcome (80–85% ideal BMI and maintaining weight OR > 85% ideal BMI, but losing 0.15–0.45 kg/week with no compensatory symptoms in the last week of treatment) and 23.9% were deemed to have a poor outcome (either < 80% ideal BMI OR < 85% ideal BMI and losing > 0.15 kg/week OR readmitted to inpatient unit OR use of compensatory symptoms in the last week of treatment). |
⨁◯◯◯ VERY LOW |
IMPORTANT |
| Eating Disorder Symptomatology (assessed with: Pre-post EDE-Q) | |||||||||
| 1 | Case series | very serious a | not serious | not serious | serious d | none | One study, including n = 26 adolescents. Patients received 13 weeks of inpatient treatment based on CBT-E model followed by 7 weeks of DTP. EDE scores decreased significantly pre-post for global and all subscales other than Shape Concern. Global EDE at admission 3.7 (+/− 1.3) to d/c 2.0 (+/− 1.1), % of patients with Global EDE < 1 SD above the community mean at admission 2% (+/− 7.7) and at d/c 10% (+/− 38.5). Dietary restraint at admission 4.1 (+/− 1.2) and at d/c 1.1 (+/− 1.0), Eating Concern (3.3 (+/− 1.4) and at d/c 1.5 (+/− 1.4), Shape Concern (3.8 (+/− 1.8) and at d/c 3.2 (+/− 1.4), Weight Concern at admission 3.5 (+/− 1.9) and at d/c 2.3 (+/− 1.4). |
⨁◯◯◯ VERY LOW |
IMPORTANT |
| Change in Frequency of Eating Disorder Symptoms (assessed with: Pre-post ED symptom frequency) | |||||||||
| 1 | Case series | very serious a | not serious | not serious | serious d | none | One study, including n = 26 adolescents. Patients received 13 weeks of inpatient treatment based on CBT-E model followed by 7 weeks of DTP. Binge eating was present in 8 patients (30%) at admission and only 2 patients (7.7%) at discharge. Median frequency of bingeing in previous 28 days was 17 (range 2–148) at admission and 8 (range 1–15) at discharge. Purging by vomiting was present at admission for 10 patients (28.5%) and at d/c for 4 patients (15.1%). Frequency of vomiting in previous 28 days was 25 (range 1–196) at admission and 10.5 (range 0–30) at dscharge. Laxative misuse was present for 3 patients at admission and none at discharge. Frequency of laxative abuse in previous 28 days was 1 (range 1–20) at admission and nil at d/c. |
⨁◯◯◯ VERY LOW |
CRITICAL |
Explanations
aObservational study with no comparison/control
bSelf-rating scale (EDI-2)
cSelf-rating scale (ANSOCQ)
dLower end of confidence interval overlaps with score that would signify no change
eInformation on compensatory symptoms was taken only from clinician notes
Bibliography:
Case control - El Ghoch 2015 [250], Strober 2006 [248]
Case series - Delle Grave 2014 [249], Hillen 2015 [251], Treat 2008 [200]