Giving Patients a Choice May Reduce Early Drop-Out

One of the challenges of treating patients with eating disorders is that some leave treatment early. Dropping out of treatment is usually seen as a sign of noncompliance, or resistance, or as a failure of treatment. But, what would happen if patients were given the choice of staying in treatment or of dropping out? According to results of a recent study, giving patients such a choice early on can reduce drop-out from treatment (Eur Eat Disorders Rev 2009; 1:177).

Drs. Walter Vandereycken and Maarten Vansteenkiste of Catholic University and Ghent University, Leuven, Belgium, designed a study to see if changing the admission strategy at their specialized inpatient treatment unit might decrease the percentage of patients who leave treatment early. The researchers used a quasi-experimental research approach to compare the outcomes of 87 patients treated until 2000 (“old strategy”) with 87 patients treated from 2001 on (“new strategy”).

The old strategy

Under the old strategy, the family (parents or spouse) are asked to endorse treatment decisions and to use various ways to convince patients to stay in treatment, including using medical arguments and psychological pressure, with direct or indirect guilt-inducing messages (such as, ‘an untreated eating disorder will undermine your further development’ or ‘it will be a burden on your family’). If patients run away or refuse to return to the hospital after a weekend at home, the family brings them back to the hospital. If patients continued to be uncooperative, the adult patients and parents of minors sign a form stating that they accept full responsibility for this ‘discharge against medical advice.’

The new strategy

Before entering the hospital, all patients are seen by a staff member for a brief interview. If inpatient treatment is being considered, a short visit is made to the treatment unit, and a brief explanation of the treatment program is given. The patient then is invited to come in for an introductory week (a minimum commitment is made for 5 days, Monday to Friday, with the explicit promise that she or he will be free to leave the hospital, even if the family would prefer the patient stays. If, however, the individual’s medical condition is serious, she will be transferred to the internal medicine department of a general hospital nearby.

The family receives a packet of information explaining the key components of the treatment approach, and is asked to avoid any battles around the patient’s decision. When the first week is over, the patient’s decision is fully respected. If she decides to seek no further help, no attempts are undertaken to change her mind. If she opts for outpatient treatment, the team assists her in finding a specialist in her area. If, on the other hand, she decides to stay, she enters into a “motivation program,” which includes psycho-education and exploratory group sessions.

As long as her physical health is not endangered, the patient is free to eat or not, to lose weight or not, and the treatment team does not monitor use of vomiting or taking laxatives. The whole point is to convey to the patient that it is her responsibility to take care of her health, and the decision to enter inpatient treatment is hers alone. If she cannot accept the basic guidelines of the treatment program, or if she is too ambivalent at the end of the fourth week, discharge follows, with the proviso that she can always come back when “she is ready.”

Each case of non-negotiated termination of treatment, unilaterally decided by either the staff or the patient, was considered a “drop-out.” The authors also differentiated between patients who were “early” drop-outs or those who stopped treatment within 1 month after admission, and “later” drop-outs, those who left treatment 2 or 3 months after admission. For anorexia nervosa (AN) patients, the authors calculated the evolution of body mass index (BMI) every 4 weeks from admission (baseline) to discharge.

Results

Drop-out information was obtained for 171 of 174 patients with eating disorders. Giving patients a choice about treatment significantly reduced drop-out, at least during the first weeks of inpatient treatment. After this, the diffrences between the groups lessened. Across both types of treatment, 40 patients (21.4%) prematurely terminated treatment: 10 patients (5.8%) dropped out before the end of the first month; 21 (12.3%) before the end of the second month; 30 (17.5%) before the end of the third month, and 33 (19.3%) before the end of the fourth month. No significant differences were found between both strategies and later drop-out and weight change among AN patients.

The authors noted that one limitation of the study was that the comparison was limited to the short-term outcome, and that longer-term studies would be helpful.