premature termination of treatment in an inpatient eating disorder programme

European Eating Disorders Review
Eur. Eat. Disorders Rev. 15, 275–282 (2007)
Premature Termination ofTreatment in an Inpatient EatingDisorder Programme

* Correspondence to: Christopher M. Perlmdies Coordinator, Homewood Health CentreGuelph, Ontario, Canada N1E 6K9.E-mail: [email protected] candidate.zPhD candidate.

Copyright # 2006 John Wiley & Sons, Ltd a

Published online 10 October 2006 in Wiley In

Philip C. Masson1,2y, Christopher M. Perlman1,3,4*,z,Stuart A. Ross1 and April L. Gates11Homewood Health Centre, Guelph, Ontario, Canada2University of Guelph, Guelph, Ontario, Canada3University of Waterloo, Waterloo, Ontario, Canada4Homewood Research Institute, Guelph, Ontario, Canada

This retrospective studywas conducted to explore rates, timing andpredictors of two forms of premature termination of treatment(PTT) in an inpatient eating disorders programme: patient dropout(DO) and administrative discharge (AD). A chart review was con-ducted to obtain demographic, Eating Disorder Inventory-2 (EDI-2), and Resident Assessment Instrument-Mental Health (RAI-MH)data for 186 patients being treated for bulimia nervosa (BN),anorexia nervosa (AN), or eating disorder not otherwise specified(EDNOS). Overall, of the 37.6% of patients who terminated treat-ment prematurely, 22.1% of patients dropped out, and 15.5% ofpatients were administratively discharged. Time at which dis-charge occurred was found to be associated with the type ofpremature termination. The presence of DSM-IV Axis-I comorbid-ity was found to be the only factor associated with an increasedrisk of being administratively discharged. No factors were predic-tive of patients dropping out of treatment. The findings supportthe notion that AD and patient DO are different events that mayhave different factors influencing their rates and timing. Implica-tions for future research and programme planning are discussed.Copyright # 2006 John Wiley & Sons, Ltd and Eating DisordersAssociation.

Keywords: treatment dropout; premature termination; treatment compliance; treatment outcomes;eating disorders

INTRODUCTION

Individuals with eating disorders are at anincreased risk of suicide and life-threatening

an, Outcome Stu-, 150 Delhi Street,

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terScience (www.inte

medical complications making the availability ofeffective treatment programmes essential (Favaro &Santonastaso, 1997; Rome & Ammerman, 2003;Sullivan, 1995). Rates of premature termination oftreatment (PTT) for patients receiving treatment forbulimia nervosa (BN) and anorexia nervosa (AN)have been estimated to be as high as 30% and 50%,respectively (Mahon, 2000). PTT has been found tobe associated with lower social functioning and moresevere mental health symptomology (Killaspy,Banerjee, King, & Lloyd, 2000) as well as higher

Association.

rscience.wiley.com) DOI: 10.1002/erv.762

276 P. C. Masson et al.

rates of rehospitalisation (Baran, Weltzin, & Kaye,1995).

A number of recent studies have emergedexamining factors that may predict and, possibly,prevent PTT in treatment programmes for patientswith eating disorders (Fassino, Abbate-Daga, Piero,Leombruni, & Rovera, 2003; Franzen, Backmund, &Gerlinghoff, 2004; Surgenor, Maguire, & Beumont,2004; Woodside, Carter, & Blackmore, 2004; Zeeck,Hartmann, Buchholz, & Herzog, 2005). However,results tend to vary and replication studies are rare.In fact, only two known studies of PTT in eatingdisorder treatment programmes have been repli-cated (Mahon, Bradley, Harvey, Winston, & Palmer,2001; Zeeck et al., 2005). Studies that have attemptedto examine similar factors have yielded conflictingresults (Mahon et al., 2001). For example, thepresence of maturity fears (Fassino et al., 2003;Woodside et al., 2004) and age at admission(Mahon, Winston, Palmer, & Harvey, 2001; Fassino,Abbate-Daga, Piero, & Rovera, 2002), have beenfound to be both associated and not associatedwith PTT. A firmer consensus on factors con-tributing to PTT is needed in order to attempt todecrease the occurrence of this potentially negativeoutcome.

There are also varying definitions and termsused to describe PTT. The term dropout (DO) hasbeen used to describe the unilateral ending ofregular treatment by a patient (Mahon, 2000) andthe term administrative discharge (AD) has beenused to refer to patients who are discharged bythe treatment team (Britt, Kinsely, Dawson, &Schnoll, 1995; Goldberg & Leibenluft, 1989). Thereis little agreement as to whether patients whoDO or are administratively discharged fromtreatment should be examined as two differentpatient groups. Patients who were administra-tively discharged have been found to have higherrates of comorbid personality disorders (Zeeck &Herzog, 2000) and psychological symptoms(Zeeck et al., 2005) compared to patients whodropped out or completed treatment. However,the largest difference between these groupshas been proposed to be the timing at whichthe decision to end treatment develops in thetreatment team and patient (Woodside et al.,2004).

The overall goal of this study is to examinewhether patients who DO of an eating disordertreatment programme are distinct from patientswho are administratively discharged. In achievingthis goal there are two main objectives. First, thisstudy will re-examine factors identified in prior

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders A

literature as possibly relating to DO and AD. It ishypothesised that patients who PTT may presentwith more complex psychological issues includinghigher rates of anxiety, comorbid psychiatricdiagnoses, eating disorder-related cognitions, andprior psychiatric admissions. The inability of thetreatment programme to adequately addressthese more complex issues may lead to PTT. Thelimited research suggests patients who are admin-istratively discharged may have higher rates ofthese psychological issues compared to patientswho DO of treatment. Second, this study willexamine the rates, timing, and predictors ofdropping out of treatment and being administra-tively discharged. Due to the wide variety ofpossible reasons for patient DO and the relativelylimited number of reasons for AD as it ishypothesised that the timing (during a patient’sstay in programme) that AD occurs will differ fromdropping out of treatment.

METHOD

Participants

Retrospective chart reviews were conducted for allpatients consecutively admitted to an inpatientEating Disorder Program (EDP) between January2003 and December 2004. A total of 186 patientswere identified. Forty-two per cent were diag-nosed with AN, 41.4% with BN, and 16.6% witheating disorder not otherwise specified (EDNOS).Participants had been suffering from eatingdisorder symptoms for an average of 8.9 years(SD¼ 7.5). The mean age at admission was 26.5years (SD¼ 9.4) and 93% (n¼ 173) were women.Most patients had their high school diploma(20%), some college or university education(29%), or an undergraduate degree (19%). Patientstended to be single (66.7%, n¼ 114), while 24.0%(n¼ 41) were married, 2.3% (n¼ 4) were engagedin a significant relationship with another person,and 7.1% (n¼ 13) were separated/divorced. Allparticipants had a length of stay (LOS) of at least 1day within the programme (mean¼ 57.8 days,SD¼ 31.6).

Programme Description

The EDP at Homewood Health Centre in Guelph,Ontario, Canada accepts individuals 16 years of ageand older, who are medically stable, and have aDSM-IV Axis-I diagnosis of AN, BN or EDNOS (at

ssociation. Eur. Eat. Disorders Rev. 15, 275–282 (2007)

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Premature Termination in Eating Disorders 277

the time of this study this did not includepatients with binge eating disorder). All patientsadmitted to the programme are referred by otherclinicians and thus, independent of the outcome, aredischarged back to their referral source in order tomaintain continuity of care and safety of the patient.

The EDP is based on a cognitive behaviouralapproach incorporating psychodynamic, and psychoeducational treatment options including body-imageand body-esteem group, horticulture, expressiveart, family and recreation therapy and nutritionaleducation. The EDP is designed to develop self-responsibility, healthy coping mechanisms, andleisure activities within patients while providingintensive therapy. LOS for patients with BN istypically 7–9 weeks and a minimum of 12 weeks forpatients with AN with an additional 1–2 weeks formaintenance for all patients.

Measures

Resident Assessment Instrument-Mental HealthAll patients were assessed with the Resident

Assessment Instrument-Mental Health (RAI-MH)within the first 72 hours of admission by clinicalstaff of the EDP. The RAI-MH (Hirdes et al., 1999) isnow mandated for use in all designated inpatientpsychiatric beds in Ontario. Information obtainedfrom the RAI-MH included demographic infor-mation (marital status and education), the number oflifetime psychiatric admissions prior to the currentadmission, and the presence of three indicators ofanxiety (anxious complaints, obsessive thoughtsand compulsive behaviour observed in the first3 days of admission). Inter-rater reliability of theRAI-MH in psychiatric inpatient settings is wellestablished with most items showing at least 70%agreement between raters (Hirdes et al., 2002).

Eating disorder inventory-2All patients also completed the Eating Disorder

Inventory-2 (EDI-2; Garner, 1991) within the first5 days of admission. The EDI-2 subscales of interestin the present study were: (a) Maturity fears(Cronbach’s alpha¼ 0.83), (b) Ineffectiveness (Cron-bach’s alpha¼ 0.90), (c) Drive for thinness (Cron-bach’s alpha¼ 0.83) and (d) Impulse regulation(Cronbach’s alpha¼ 0.77; Garner, 1991).

Diagnostic assessmentPatients are assessed on an individual basis by the

entire treatment team during their first week in the


EDP. Although patients come into the programmewith a tentative diagnosis, the final diagnosis isarrived at by the entire team which uses self-developed questionnaires, the EDI-2 and thePersonality Assessment Inventory (Morey, 1991).This diagnosis was used as the official diagnosis forthe present study.

Assessment of Premature Termination

Patients were considered to have dropped out ifthere was documentation in their charts indicatingthat they decided unilaterally to leave the pro-gramme without the recommendation or approvalof the clinical team. AD was considered to haveoccurred if the patient’s chart indicated that, dueto continued noncompliance with a mutuallyagreed upon treatment contract or failure toengage with the programme, the treatment teamasked the patient to take their discharge from theprogramme.

Statistical Analyses

Descriptive statistics for patients who droppedout, were administratively discharged, or com-pleted the programme were compared using Chi-square analyses (categorical variables) and one-wayanalysis of variance (ANOVA; continuous vari-ables). Alpha was set at 0.05 for all analyses and alltests were two-tailed.

To examine the rate, timing and predictors of DOand AD, competing risks Kaplan–Meier survivalanalyses were executed using SAS version 9.0.Competing risks analyses were used to predict thehazard rate for DO and AD simultaneously(Corning & Malofeeva, 2004; Singer & Willett,2003). For the DO model, all individuals who eithercompleted the programme or were AD werecensored. For the AD model, all individualswho either DO or completed the programme werecensored. The time variable of interest was thenumber of days the patient was admitted withinthe programme. Mantel–Cox log rank tests wereused to examine the survival functions and hazardfunctions of categorical variables. Cox proportionalhazards regression were used to examine the effectof continuous variables on the hazard functions andto determine hazard ratios for all significantpredictors.


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Table 1. Characteristics for patients who completed, dropped out, and were administratively discharged fromtreatment

Dependant variable Complete(n¼ 113)

Dropout(n¼ 40)

Administrativedischarge (n¼ 28)

df F p

Mean (SD) Mean (SD) Mean (SD)

Age at admission 27.1 (9.0) 26.6 (10.6) 23.9 (8.6) 2, N¼ 178 1.31 n.s.EDI-2

Maturity fears 5.1 (5.3) 5.6 (6.8) 8.1 (7.9) 2, N¼ 166 F¼ 2.37 n.s.Ineffectiveness 13.3 (7.6) 14.2 (9.0) 15.4 (9.5) 2, N¼ 166 F¼ 0.74 n.s.Drive for thinness 14.7 (6.0) 14.2 (6.5) 14.6 (6.8) 2, N¼ 166 F¼ 0.08 n.s.Impulse regulation 5.8 (5.2) 6.6 (4.6) 7.8 (6.0) 2, N¼ 166 F¼ 1.47 n.s.

% (n) % (n) % (n) df x2 pEating disorder type

Anorexia 16.8 (19) 15.0 (6) 17.9 (5) 4, N¼ 181 1.74 n.s.Bulimia 43.4 (49) 35.0 (14) 46.4 (13)EDNOS 39.8 (45) 50.0 (20) 35.7 (10)

Comorbid diagnosisDepression 15.0 (17) 12.5 (5) 25.0 (7) 2, N¼ 181 2.13 n.s.OCD 1.8 (2) 10.0 (4) 7.1 (2) 2, N¼ 181 5.32 n.s.PTSD 15.0 (17) 14.3 (5) 12.5 (4) 2, N¼ 181 0.15 n.s.Any Axis-I disorder 39.8 (45) 35.0 (14) 67.9 (19) 2, N¼ 181 8.56 0.01

Prior psychiatric admissionsNone 52.7 (58) 57.1 (20) 52.0 (13) 6, N¼ 170 5.77 n.s.1–3 35.4 (39) 25.7 (9) 20.0 (5)4–5 6.4 (7) 8.6 (3) 16.0 (4)6 or more 5.4 (6) 8.6 (3) 12.0 (3)

Anxiety indicatorsAnxious complaints 10.0 (11) 20.0 (7) 12.0 (3) 2, N¼ 170 0.29 n.s.Obsessive thoughts 27.3 (30) 42.9 (15) 32.0 (8) 2, N¼ 170 0.22 n.s.Compulsive behaviour 10.1 (11) 11.4 (4) 24.0 (6) 2, N¼ 169 0.16 n.s.

Note: Sample sizes vary based on missing data. SD¼ Standard Deviation, df¼degrees of freedom, F¼ F value for one-way ANOVA,x2¼Chi-square value, p¼probability.


RESULTS

Analyses of Patient Characteristics

Table 1 shows Chi-square and one-way ANOVAresults comparing a number of patient character-istics among the DO patients, AD patients andprogramme completers. The only significant differ-ence was found for the presence of a comorbidpsychiatric condition, x2 (2, N¼ 181)¼ 8.07, p¼0.018. While programme completers (40%) had ahigher proportion of comorbid conditions than theDO group (35%), the largest difference was foundfor the AD group. Of these patients, 67.9% had anAxis-I comorbid condition.

Rates, Timing and Predictors of PrematureTermination

Sixty-two per cent of patients (n¼ 113) completedthe programme, 22.1% (n¼ 40) DO and 15.5%


(n¼ 28) were AD. The average LOS for patientswho completed the programme was 73.4 days (SD¼25.6). For the DO group, the average LOS was32.5 days (SD¼ 25.3), while the average LOS was32.2 days (SD¼ 19.6) for AD group.

Figure 1 illustrates the survival curve for the DOpatient group. A steady decline in the proportion ofpatients remaining in the programme can be seen asLOS increases up to Day 90. The probability ofpatient DO was greatest at 15, 55 and 75 days. ForAD, Figure 2 shows the proportion of patientsremaining in the programme declines less steadilyand levels off at approximately Day 60. Theprobability of AD is highest between 30 and45 days into the programme.

The presence of comorbidity was found to besignificantly related to AD (Mantel–Cox, x2¼ 6.97,df¼ 1, p¼ 0.008). The risk of AD is 2.77 times greaterfor patients with a comorbidity compared topatients without comorbidity. For patients who


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Figure 1. Baseline survival distribution function and hazard function of patients who dropped out of treatment


DO, the effect of comorbidity was not significant(Hazard Ratio¼ 0.79, n.s.).

DISCUSSION

The purpose of this study was to examine the rates,timing and predictors of dropping out of atreatment programme for eating disorders com-pared to being administratively discharged. Thepercentage of patients who PTT was considerable(38%) but consistent with rates reported elsewhere(Zeeck et al., 2005; Zeeck & Herzog, 2000). Further,consistent with previous findings, slightly more(7%) patients DO of treatment compared to the percent who were AD.

The timing for AD and DO were found to differ.While the risk of being AD was highest at the earlymid-point of treatment (approximately 40 days), therisk of patient DO was widely distributed at thebeginning (15 days), middle (55 days) and end(75 days) of treatment. Given the structure of


participation in the EDP the findings regarding thetiming for AD suggest difficulties may have arosefor these patients early on in treatment. Patients signa contract at the beginning of treatment stating theywill not engage in eating disorder behaviour (e.g.excessive exercise), the use of drugs or alcohol, orself-harm. Patients are given several opportunitiesto adjust to these guidelines. If continued breachesoccur, the patient has not engaged with theprogramme, and team interventions with thepatient are unsuccessful, AD is likely to occur.Patients are most often administratively dischargeddue to a patient’s engagement in eating disorderbehaviour followed by drug use or continued self-harm. A small proportion of patients are dischargeddue to unwillingness to co-operate and engage intherapy. Thus, the design of the programme and theconcentration of AD around Day 40 suggests thatthe majority of patients who were administrativelydischarged may have developed programme com-pliance issues within several weeks of admission.The moderate risk of AD found near the very


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Figure 2. Baseline survival distribution function and hazard function of patients who were administrativelydischarged from treatment


beginning may be indicative of patients being seenas unfit for the programme by the treatment team inthe first week/assessment-phase of the programme.

The wider distribution of timing for DO may bethe result of issues internal or external to the EDP, orboth. Issues that may occur in a patient’s personallife (e.g. death of friend or family) as well as thepatient’s struggle with treatment for their eatingdisorder may influence their decision to leave treat-ment prematurely. While it is difficult to predict thetiming as to when these events may occur,qualitative research may be helpful in determiningthe specific factors that influence patients’ decisionsto DO from treatment.

Of the variables hypothesised to be associatedwith PTT, only the presence of any Axis-I comor-bidity was found to be a significant predictor of AD.These findings suggest that while eating disordertype or symptom severity may not influence PTT,psychological complexity does influence PTT,particularly AD. This finding further supports theeffect of comorbidity on AD, but not DO, found


previously (Surgenor et al., 2004; Zeeck & Herzog,2000). Future research needs to examine the natureof the relationship between comorbidity and AD.For instance, patients may be more susceptible toAD if they have a specific type of secondarydiagnosis (e.g. obsessive compulsive disorder).Thus far, low sample sizes may have limited theability to detect these specific effects.

The influence of comorbidity on PTT may be dueto how EDPs address comorbid conditions duringthe course of treatment. At the present time theHomewood EDP treatment team works to identifyand perform early interventions which may includebrief counselling, education, consultation withother psychiatric programmes and pharmacother-apy. However, clinicians are cautious when usingpharmacotherapy and are careful not to prescribemedications known to lead to weight gain, a factorthat may affect patients’ adherence to treatment.Following such early interventions, patients areencouraged to seek more intensive treatment fortheir comorbid condition following treatment in the


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EDP. While it is hoped that these steps will improvetreatment functioning of patients with comorbidconditions, the findings from this study suggest thatthis EDP needs to consider new ways to assist thesepatients. Patients may benefit from more intensivecounselling aimed at treating comorbid conditions.Also, it is recommended that clinicians carefullyexamine how a patient’s comorbidity interacts withtheir eating disorder. This may allow the clinicianinsight into difficulties that may arise due to thecomorbid condition when the patient attempts tocontrol their eating disorder behaviour (Kaplan &Garfinkel, 1999).

Although this study did use a moderately largesample size, the sample sizes for the two groups(AD and DO) were relatively small. This could haveincreased the risk of type II error. The retrospectivedesign also limited the amount and type ofinformation available for analysis. For instance,specific information about the circumstances sur-rounding a PTT would have been beneficial tounderstanding whether the termination was in factdue to a common factor experienced by manypatients or whether there was a broad array ofinfluences. This design also allowed for the ability toexamine only patient variables—a limitation inmany studies on PTT (Mahon, 2000). The examin-ation of specific programme characteristics in futureresearch may further the understanding of howprogrammes can effectively reduce PTT.

The results of the present study support theexamination of treatment DO and AD as twoseparate dimensions of PTT. It seems clear that thereare different factors that influence each of thesenegative outcomes. In addition to studies aimed atreplicating and further expanding upon theseresults, exploratory qualitative studies need to beconducted examining patient and clinician pers-pectives on these negative treatment outcomes.Knowing the extent to which and how patients whocomplete, DO and are administratively dischargedfrom treatment will increase the accuracy andmeaningfulness of future PTT findings and hope-fully the success of future interventions attemptingto prevent these unfortunate outcomes.

ACKNOWLEDGEMENTS

We thank all the staff at Clinical Information Ser-vices at the Homewood Health Centre for theirassistance in data collection. We also thank MaryWilson for her helpful editing suggestions and Neil


Patterson for his graphics assistance while prepar-ing this paper.

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premature termination of treatment in an inpatient eating disorder programme

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