Managing Eating Disorders in the Natural Environment: Intensive vs. Limited Programs

Article excerpt

Abstract: Objective: To evaluate stratified management of care for eating disorders in community services using a personalized program (2-20 hours weekly) delivered in a therapeutic center by a multidisciplinary team, or in the patients' natural environment by clinical mentors. Method: Sixty females with anorexia nervosa and 63 with bulimia nervosa attended the program voluntarily. Symptoms and global outcome were assessed using the Anorexic Outcome Scale. Results: At termination of treatment, 66% of the anorexies and 78% of the bulimics were in fully recovered or good condition. At four-year follow-up, 68% of the treated anorexic patients and 73% of the treated bulimic patients were categorized as fully recovered or in good condition. The improvement in social functioning and occupation status was greater among subjects treated in the extensive, compared with limited, programs. All patients who completed the program had regular occupations. Conclusions: The proposed treatment model addresses the heterogeneous needs of patients with eating disorders and, at the same time, allows them to stay in the community. It can serve as an alternative to hospitalization whenever patients are able and willing to cooperate with their treatment, and their medical condition allows for ambulatory treatment.

Introduction

There is a growing awareness of the need to treat patients suffering from mental disorders in the community, rather than in psychiatric wards. In this way, the patients can maintain social and vocational roles, and generalize new skills that are learned in treatment within their home environment (1, 2). Moreover, community-based facilities might prevent the adverse effects frequently associated with long and repeated hospitalizations. Major advantages of an intensive outpatient program are the flexibility to design and alter individual treatment and the leverage to help patients move back and forth between programs, as needed, creating a beneficial continuity of care. The 2004 evidence-based guidelines from the National Institute for Clinical Excellence (NICE) recommend treating eating disorders with a comprehensive approach. These guidelines state that wherever possible, patients should be managed on an outpatient basis with psychological treatment provided by a service that is competent in giving that treatment and assessing the physical risk of people with eating disorders (3). However, the availability of public intensive services that address the particular needs of patients with eating disorders in community-based programs is low (4, 5). The need for costand time-efficient applications of ambulatory treatment, combined with uncertainty over outcome for inpatient treatments, increases the importance of developing innovative facilities.

We present here a description of an Israeli, community-based continuum of care with an innovative outreach facility. It provides the intensity often sought in hospitalization, structured eating situations, and active treatment interventions, while allowing the individual to live at home and continue to attend school or work. Such services address the necessity for aftercare programs to manage the patients general medical and psychiatric problems and to prevent relapse while also addressing the need for social and occupational rehabilitation.

Program principles

* Personalization and modulation of treatment. Treatment is personalized and modularized to meet the particular needs of each patient. It is based on a conceptualization of the specific factors that contributed to each individual's pathological eating concerns and habits. Most sessions are during afternoons and evenings to encourage those patients who manage to keep a job or attend school to continue to do so. Treatment is tailored around those activities.

* Location in the community. Treatment is located in the community and takes place at the center house, the patient's house or workplace. …