Description of the condition
Eating disorders are a group of diagnoses defined by severe disturbances in eating behaviour. They include anorexia nervosa, bulimia nervosa, binge eating disorder and other specified or unspecified eating disorder (APA 2013; WHO 1992). Anorexia nervosa is an eating disorder with features of weight loss or failure to gain weight. This leads to a weight that is less than 85% of that expected for height and age, an intense fear of gaining weight, a distorted body image and loss of at least three consecutive menstrual cycles. Bulimia nervosa, by definition, is a disorder of normal or above normal weight characterised by binge eating and extreme weight control methods to compensate for the binge eating. Recurrent binge eating is defined as eating unusually large amounts of food over which there is a sense of loss of control. The compensatory extreme weight-control behaviours may take the form of self induced vomiting with or without laxative or diuretic use (purging), or fasting with or without intense exercise (the non-purging form of bulimia nervosa). In addition to disordered eating behaviours, people with bulimia nervosa also have specific eating disorder psychopathology whereby their self view or self evaluation is unduly influenced by concerns about their weight, shape, body image or a combination of these. Other eating disorders may share the body image, shape and weight concerns of those people with anorexia nervosa or bulimia nervosa, or share the disordered eating or weight control behaviours, or share a combination of these. People with binge eating disorder have regular binge eating behaviour but do not have regular extreme weight control behaviours. Other specified eating disorders include atypical anorexia nervosa (where the person's weight is in or above the normal range); bulimia nervosa or binge eating disorder of low frequency or limited duration or low frequency and limited duration; purging disorder and night eating syndrome. Finally, unspecified feeding or eating disorder is a heterogeneous category where patients do not meet criteria for an eating disorder but have a clinical eating or feeding disorder syndrome. It most usually comprises people with disordered eating behaviours with or without body image disturbance characteristic of the better-defined disorders. This review will not address feeding disorders such as 'avoidant restrictive food intake disorder', which are categorised with eating disorders in the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic scheme (APA 2013; WHO 1992).
Eating disorders are common (Hoek 2003; Hudson 2007), and increasing (Lucas 1991; Hay 2008). One national US survey found that lifetime prevalence estimates of DSM-IV anorexia nervosa, bulimia nervosa and binge eating disorder were 0.9%, 1.5% and 3.5%, respectively among women, and 0.3%, 0.5% and 2.0%, respectively among men (Hudson 2007). In Australia between 1995 and 2005, there was a two-fold increase in the point prevalence of eating disorder behaviours in the general community (Hay 2008).
Description of the intervention
Treatments for eating disorders have been developed for outpatient, inpatient and partial hospitalisation (the latter is also known as day hospital care). Clinical practice guidelines vary on recommendations, but there is some consensus that inpatient care is most often needed for people with anorexia nervosa (NICE 2004; RANZCP 2004). Bulimia nervosa and other eating disorders seldom require an admission unless there are medical complications, for example, hypokalaemia (reduced levels of potassium in the blood) or high suicide intent (NICE 2004; RANZCP 2004; APA 2006). Inpatient programmes are usually multidisciplinary (where treatment providers include psychologists or psychiatrists (or both), dieticians, nurses and other allied healthcare specialists) and involve a programme of nutritional counselling and supervised meals, combined with individual and group psychotherapy and medical care (La Puma 2009). Partial hospitalisation is similar to inpatient programmes with regards to multidisciplinary care, intensity of therapy, the capacity for regular supervision of meals and the direct provision of meals (Thornton 2009). However, there is no overnight stay with partial hospitalisation. In contrast, outpatient care does not provide regular meal supervision. In outpatient care, therapy is also usually less frequent (e.g. occurring one or two times a week) and care is less likely to include therapists of multiple disciplines. Indeed, in an outpatient programme, care may be delivered by a single therapist of one discipline (e.g. a psychologist). We present an overview of the different components of care across treatment settings in Table 1.
|Inpatient||Partial or day hospital||Outpatient|
|Anorexia nervosa||Multidisciplinary medical, nursing, dietetic (re-feeding) and psychological care1||Multidisciplinary medical, nursing, dietetic (re-feeding) and psychological care||Multidisciplinary medical, nursing, dietetic (re-feeding) and psychological care or psychological care incorporating re-feeding and other elements delivered variably|
|Bulimia nervosa||Multidisciplinary medical, nursing, dietetic and psychological care||Multidisciplinary medical, nursing, dietetic and psychological care||May be multidisciplinary but is most usually individual psychotherapy with limited medical care of complications from purging|
|Binge eating disorder||Multidisciplinary medical, nursing, dietetic and psychological care||Multidisciplinary medical, nursing, dietetic and psychological care||May be multidisciplinary but is most usually individual psychotherapy with dietetic care for those with obesity|
|Other eating disorders||Multidisciplinary medical, nursing, dietetic and psychological care||Multidisciplinary medical, nursing, dietetic and psychological care||Multidisciplinary medical, nursing, dietetic and psychological care or psychological care and other elements delivered variably|
There is no one psychotherapeutic approach that is applied consistently in outpatient care worldwide, although cognitive behavioural therapy has the best evidence base for bulimia nervosa (NICE 2004; Hay 2009). In adolescents and children, a family-based approach is regarded as the first line in treatment (NICE 2004). It is superior to 'treatment as usual' but there is insufficient evidence for any single form of family therapy (Fisher 2010). Derivations of the Maudsley model (as described in Le Grange 2005 and in Rhodes 2009) have gained ascendancy worldwide.
Medical care comprises physician and nursing management of physical aspects of eating disorders. This includes re-feeding but also management of osteopenia and other effects from starvation. A comprehensive account of medical management is provided in the text by Birmingham and Treasure (Birmingham 2010). Medications for physical or psychological co-morbidities are seldom used as a stand-alone treatment but will often be used in either inpatient or outpatient settings. Evaluations of the relative efficacy of medications in eating disorders are also found in Flament 2012 and Hay 2012. These reviews reported that the evidence of efficacy of drug treatments is mostly weak or moderate with generally low recovery rates. However, there was support for the use of antidepressants, particularly high-dose fluoxetine in bulimia nervosa, and anticonvulsants (topiramate) for binge-eating disorder. Attrition rates were usually higher than for psychotherapies and combined treatments in bulimia nervosa and binge eating disorder had better outcomes than either approach alone. Low-dose antipsychotic medication was considered to be possibly clinically useful as adjunct treatment of anxiety in anorexia nervosa but more trials were needed.
Further details of psychological approaches in treatment may be found in complementary Cochrane reviews of family therapy (Fisher 2010), and individual outpatient psychotherapies for anorexia nervosa (Hay 2003), and other eating disorders (Hay 2009). There are also three Cochrane reviews of antidepressant medication use, one in bulimia nervosa (Bacaltchuk 2003), one in anorexia nervosa (Claudino 2006), and one of combination medication and psychotherapies in bulimia nervosa (Hay 2001).
However, while there is a growing evidence base for treatments (albeit still sparse in anorexia nervosa (Lock 2009)), many people with eating disorders do not access treatment. In particular, up to half of people with anorexia nervosa may never present for treatment (Keski-Rahkonen 2007), and attrition in anorexia nervosa treatment trials can be unacceptably high with reasons for dropout difficult to identify (Halmi 2005). Stigma and perceived fear of hospitalisation may well contribute to underutilisation of services. Where trials have compared inpatient versus outpatient care, preference for the outpatient care (Freeman 1992) and higher attrition in the inpatient care have been found (Gowers 2007). In addition, there is concern from professional bodies as, for example, expressed in position statements by the Australian and New Zealand Academy for Eating Disorders that inpatient care may be being underutilised, undervalued, or both, leading to a reduction in services (www.anzaed.org.au/uploads/7/3/9/2/7392147/positionstatementinpatient.pdf). While many jurisdictions are not now providing inpatient services, lack of evidence hampers the ability to argue for these.
How the intervention might work
There is consensus that therapy in eating disorders includes dietetic, medical, nursing and psychological care. In anorexia nervosa, multidisciplinary care is expected (NICE 2004). This is in order to be able to provide the level of expertise in medical or physical care, individual or group psychotherapy, and re-feeding that is needed. Medical or physical care may be administered by a paediatrician, general practitioner or adult physician; individual and group therapy from a psychologist, psychiatrist or other therapist; and re-feeding from a dietician (Steinhausen 2002; Zipfel 2000).
Inpatient and partial hospitalisation have the benefit of being able to provide care for extended periods (6 to 24 hours a day). Notably, meals can be directly supervised and staff can respond quickly to psychiatric or physical emergencies (such as re-feeding syndrome) (Treasure 2005; La Puma 2009). However, outpatient care is argued to be both more effective and efficient in terms of therapy time and cost. Fairburn has described a comprehensive outpatient approach in his treatment manual for underweight, normal or overweight patients with eating disorders (Fairburn 2008). Such treatment is usually conducted where inpatient care for medical or psychiatric crises (e.g. hypokalaemia due to vomiting or active suicidal ideation) is available. Admissions are for brief periods sufficient for stabilisation prior to resumption of outpatient care.
It is thought that outpatient care preserves the patient's sense of autonomy and is perceived as collaborative. Thus, there is increased patient acceptability, and less risk of further psychological harm to a patient's already fragile self esteem. It may also be associated with less stigma, and the maintenance of usual social and work (including educational) activities.
Partial hospitalisation has the advantages of increased intensity of care (and supported or supervised meals) found in inpatient services. It also has an argued increased preservation of personal autonomy and life activities that are associated with outpatient care. However, it has higher fiscal cost than outpatient care.
Why it is important to do this review
Eating disorders have high social, medical and fiscal costs (Crow 2003). For example, in Australia they are the 12th leading cause of mental health hospitalisation expenses (Mathers 1999). It is agreed that the more intensive care of a hospital admission is mandatory where there is high medical or psychiatric risk (APA 2006; NICE 2004; RANZCP 2004). However, its advantage where patients may be 'safely' cared for as an outpatient is unproven. Outpatient care is also preferred by most people and has perceived advantages. These include being more collaborative in approach, with reduced associated stigma, maintenance of work/education and social relationships, and fiscal savings. An admission necessarily will lead to loss of usual social contacts and interruption to work or education. Cost savings associated with avoiding hospitalisation or reducing hospital stay, or both, to that needed for medical stabilisation alone could be very large. For example, one UK study found that outpatient care costs approximately 10% the cost of inpatient care (Katzman 2000).
However, there are few studies into the role of treatment settings in mental health and these are largely confined to anorexia nervosa. Previous systematic reviews have found results from studies of anorexia nervosa to be contradictory (Lock 2009; Meads 1999; Meads 2001). While some studies have found higher discharge weights to be associated with better long-term weight outcomes (Barren 1995; Gross 2000; Zipfel 2000), a more recent trial linked hospital admissions with poor weight outcomes (Gowers 2000). One very early trial also reported similar weight outcomes from in and out patient management (Crisp 1991). In addition, although hospitalisation is effective in the short-term, one 20-year retrospective study found it was not predictive of long-term recovery (Zipfel 2000).
The aim of this review is to investigate whether or not there is demonstrable benefit to inpatient compared with outpatient or day patient care in eating disorders, beyond that which is essential for treating acute medical and psychiatric emergencies. This review will extend the work of previous systematic reviews in anorexia nervosa (Meads 1999; Meads 2001; Lock 2009, and further strengthen the portfolio of Cochrane reviews in anorexia nervosa and other eating disorders (Hay 2001; Hay 2003; Bacaltchuk 2003; Pratt 2002; Perkins 2006; Claudino 2006; Hay 2009; Fisher 2010).