The goal: getting ahead of relapse.

Relapse is common following treatment for AN, and new methods to prevent this are needed. A group in the Netherlands has developed a new program designed to prevent AN relapse, the Guideline Relapse Prevention Anorexia Nervosa (GRP) (BMC Psychiatry. 2016; 16:316).

Tamara Berends and colleagues at Altrecht Eating Disorders Rintveld, the Netherlands, designed a cohort follow-up study of 83 patients successfully treated for AN. The study group included inpatients and outpatients 12 years of age and older who met DSM-IV criteria for a diagnosis of AN or of eating disorder not otherwise specified (EDNOS) that had been “clinically referred to as AN.”

Treatment at the study site addressed three major areas: (1) eating habits, body weight, and body image; (2) psychological aspects of function, such as self-esteem, perfectionism, and trauma; and (3) social functioning. All patients who started the relapse prevention program had completed previous outpatient treatment. Patients were only eligible for the relapse prevention program when remission was reached. Full relapse was defined as a body mass index (BMI, kg/m²) less than 18.5 for adults and SD BMI <-1 for younger patients.

Program content and goals

The primary aim of the GRP program was to enhance cooperation between the professional, the patient, and her relatives, to gain better understanding of each patient’s process of relapse, including triggers and early warning signs. The cooperating parties then formulate actions that they can take in the face of a new and impending relapse. This information is then summarized in a “Relapse Prevention Plan” so that appropriate action can be taken when early warning signs point to relapse.

Once the prevention plan is developed, the aftercare program starts, and continues for at least 18 months. In a series of aftercare visits, the patient, therapist, and family monitor and discuss the patient’s status. Dr. Berends and colleagues described two very common scenarios. In the first, the patient is stable, and thus the focus of the visits is on maintaining stability by promoting good physical health and optimal personal and social function. Real or possible stressful life events in the near future are discussed and anticipated. In the second scenario, the patient has one or more early warning signs of impending relapse. When this happens, the main focus during the aftercare visits is getting a thorough understanding of the actual triggers of relapse and how to deal with these to promote recovery.

The frequency of visits depends on the patient’s condition and the need for treatment and care. Stable patients generally come to the center for a visit 4 to 6 months after initial recovery. If the patient is less stable, visits are planned every 2 months. Working together, patient and therapist can decide whether a longer aftercare period is needed when the patient is vulnerable to relapse. Follow-up lasts for 5 years.

What an aftercare visit looks like

The typical 45-minute visit is attended by the patient and her family. At each visit, there is a weigh-in and the patient’s overall physical condition is evaluated. Two main topics are always on the agenda: psychosocial and social functioning, including discussion of school, friends, sports, and overall moods; and the presence of AN symptoms, such as anorectic cognitions, return of abnormal eating habits or excessive exercise. At the end of each visit, a new appointment is made for the next visit.

How effective was the aftercare program?

Full relapse occurred in 11% of the participants and partial relapse in 19%. Of those who did relapse, about a fifth recovered again during follow-up. Patients were most vulnerable to relapse between months 4 and 16. As intended by the program, contact in case of relapse often occurred within a week.

These results argue for the use of a relapse prevention plan at the end of treatment, together with interval monitoring. Taking this step may be one way to significantly contribute to lowering reduction rates of relapse for AN patients.