A Novel Inpatient CBT Program for Adolescents

While inpatient treatment for anorexia nervosa (AN) often successfully restores body weight, too many patients have relapses after discharge from the treatment unit. The risk of malnutrition and weight loss is higher among teens than adults, and if weight restoration is unsuccessful, lasting complications may occur.

Dr. Richard Delle Grave and colleagues at Villa Garda Hospital, Garda, Italy, and Warneford Hospital, Oxford University, Oxford, UK, sought to reduce the relapse rate by modifying their conventional inpatient treatment program (Front Psychiatry. 2014; February 12). The team replaced the traditional approach with one based on “enhanced” cognitive behavioral therapy (CBT-E). The enhanced CBT approach is designed to address some of the key mechanisms that help maintain eating disorders, such as restricting intake and promoting underweight, life events and mood, and overvaluing shape and weight.

A 13-week program for adolescents

The new approach was used in 27 adolescent patients 13 to 17 years of age who had severe AN. The teens were treated over 20 weeks (13 weeks in an inpatient setting and 7 weeks while enrolled in a day treatment program). The patients were assessed before and after treatment, and then 6 and 12 months later. CBT-E for eating disorders was “adapted to make it suitable both for an inpatient setting and for adolescents.” The authors described the treatment as CBT-E “immersion” because the CBT-E program is designed to operate around the clock. Rather than focusing on eating and weight gain, the treatment is designed to enhance the patient’s sense of control over his or her eating and life. The young patients undergo individual sessions with a trained clinical psychologist twice a week during the first 4 weeks and once a week afterward. More intensive support of eating is provided until patients achieve a body mass index (BMI) of 18.5 kg/m². CBT-E based group sessions are held 4 times a week and focus on core issues such as dietary restraint. Group physical exercise sessions are held twice a week to help the patients restore muscle mass and improve overall fitness.

Two more elements of the inpatient program include a CBT-E-based family module that includes 6 sessions with the psychologist and 2 with a CBT-E trained dietitian that are designed to help families plan meals at home. Parents also become involved early in treatment: during the first week of therapy, parents attend a private session where the psychologist and family assess the family environment, and parents are educated about their child’s eating disorder and elements that may be maintaining the disorder. The remaining 5 sessions focus on family communication, crisis management, and modification of the home environment. Weekly group sessions address adolescent topics such as identity, autonomy, social skills, and coping with puberty.

The authors believe that three particular strategies may help reduce relapse risk. First, the inpatient unit is “open,” so patients are exposed to stimuli that may provoke the return of eating disorder psychopathology. Second, possible triggers for relapse are identified and addressed in the individual CBT-E sessions. Finally, the parents and significant others work to develop a more positive and stress-free home environment.

Was the program successful?

Treatment was well accepted by the patients and they responded well to it. The authors reported that only 1 patient of the 27 in the study did not complete the program. The 26 who did complete treatment gained a substantial amount of weight—the mean weight gain from admission to discharge was 11.7 kg. Twenty-five teens (96.2%) achieved a BMI greater than 18.5. The mean global EDE score decreased by 1.7, and 38.5% of the patients had “minimal residual eating disorder psychopathology,” defined as a global EDE scoreless than 1 standard deviation above community norms.

Follow-up at 6 and 12 months

Follow-up data were available for 81 and 85% of participants are 6 and 12 months. Twenty-two, or nearly 85%, received some outpatient treatment after discharge. Overall, the changes in BMI and eating disorders cognitions made while the teens were inpatients were well maintained at 6-month and 1-year follow-ups. The authors speculate that the good outcome could be traced to several factors. First, CBT-E may have addressed key mechanisms that maintain eating disorder psychopathology, including inclusion of parents and the open nature of the unit. According to the authors, future refinements of the CBT-E approach may include more focused forms of inpatient CBT-E that can address key elements that may interfere with outpatient CBT-E. Dr. Delle Grave and colleagues suggest that after brief inpatient treatment with this focus, that outpatient CBT-E could then successfully be resumed.