Anorexia has a higher risk of mortality than any other psychiatric disorder, says Angela Guarda, director of the Johns Hopkins Eating Disorders Program. Yet, in an era of increasing accountability within health care, outcomes research on intensive treatment of anorexia nervosa has been “surprisingly absent.”
“Few programs publish outcomes and if they do, there’s often more marketing than evidence-based data, making it hard for families, patients or referral sources to judge a program’s effectiveness,” says Guarda. With many private, for-profit residential treatment programs marketing directly to consumers, “We feel that it’s very important for families and patients to know what questions to ask of programs, such as, What is the rate of weight gain for anorexia?; What percentage of patients reach a normal weight prior to discharge?; and How do they do six months to a year after treatment?”
In an article published in the International Journal of Eating Disorders, Guarda and colleagues at Columbia University, the University of Pittsburgh and Weill Cornell Medical College called for more consistent, transparent outcomes data from eating disorder treatment programs. At a minimum, Guarda says, programs should freely share basic, de-identified information about their patients’ age and illness severity, diagnosis, and body mass index at admission—as well as weight restoration outcomes for patients with anorexia nervosa, so potential patients and their families can make informed decisions. Ideally, the programs should also include results from follow-up assessments three to six months after discharge.
“In a hospital setting, the cost per day is going to be higher than many freestanding residential programs. But in the Johns Hopkins program, with our emphasis on faster weight restoration and over 70 percent of our patients reaching a normal weight before leaving, the advantages are both clinical as well as economic.”
Guarda’s team found that among patients who argued that they did not need intensive treatment and were admitted under pressure from family or friends, more than 40 percent reported that within two weeks, they had changed their minds and felt treatment was helpful.
The Johns Hopkins program uses peer support from patients further along in treatment to help those newly admitted to change their eating habits. While many programs negotiate individual diet plans and calorie levels with patients, Johns Hopkins has patients follow a food plan with choices but also uniform calorie increases. This approach has been shown to safely achieve weight gain of at least 4 pounds each week—about twice the national average—while helping patients diversify their food choices and learn to eat balanced meals. “A standardized meal protocol like ours helps patients change their behavior, complete meals and practice healthy eating skills,” Guarda says.
Guarda is upfront about Johns Hopkins’ treatment protocol. Treatment for anorexia nervosa is uncomfortable, she says—patients are ambivalent about changing driven and habitual eating and weight control behaviors. “Yet changing behavior and gaining weight are the essential first steps needed for recovery,” Guarda says.
The multidisciplinary team in the Johns Hopkins Eating Disorders Program also treats concurrent medical and psychiatric illnesses and severe complications of eating disorders.
Most patients transition from inpatient to the partial hospitalization program, Guarda says, where focus shifts to relapse prevention skills training. Patients practice eating meals independently across different social settings “and work with the clinical team to plan their transition home and return to a full life.”