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End of Treatment Outcomes for Patients with Anxiety Disorders

Since opening my practice in 2009, I have evaluated 14 patients who presented with a primary diagnosis of an anxiety disorder. All former patients who attended at least one treatment session with me following their evaluation were included in this sample (n = 9). Those who are currently still in treatment with me were not included in this sample. Please bear in mind that the results described below are specific to my practice and my patients, and should not be generalized to other therapists or other patient populations.

The sample described includes nine female patients who ranged in age from 10 to 42 years old (median age = 22). The patients’ primary diagnoses were Panic Disorder (n = 3), Anxiety Disorder Not Otherwise Specified (n = 2), Acute Stress Disorder (n = 2), Hypochondriasis (n = 1), and Generalized Anxiety Disorder (n = 1). One-third of the patients (n = 3) had a comorbid diagnosis: one had Social Anxiety Disorder, one had Major Depressive Disorder, and one had Depressive Disorder Not Otherwise Specified.

Duration of treatment ranged from one month to 11 months, with a mean duration of 5.6 months. Number of sessions attended ranged from 1 session to 18 sessions, with a mean of 10 sessions.

The primary treatment model used was individual Cognitive Behavioral Therapy (CBT). The children in this sample (n = 2) each had a high degree of family involvement, with a parent participating in part of each session. All of the college-aged patients in this sample (n = 3) were treated individually but had some degree of family involvement, with a parent participating in at least one session over the course of treatment. Amongst the adult patients in this sample (n = 4), half had no family involvement and half had some family involvement, with a loved one attending one session over the course of treatment.

None of the patients in this sample had a history of psychiatric hospitalizations before beginning treatment with me, and none of them needed to be hospitalized while in treatment with me. Forty-four percent (n = 4) of these patients took psychotropic medication during treatment. Approximately 56% of patients (n = 5) paid a reduced rate for my services based on their financial situation, and the remaining 44% (n = 4) paid my full rate.

For the purposes of this study, “full remission” was defined as complete absence of anxiety disorder symptoms in the past two weeks, along with good social, occupational, and academic functioning. “Significant progress” was defined having substantially less severe and less frequent anxiety symptoms compared to intake, along with significant improvement in social, occupational, and academic functioning. “Some progress” was defined as having somewhat less severe and frequent anxiety symptoms compared to intake, along with fair social, occupational, and academic functioning.

Forty-four percent (n = 4) of the patients in this sample completed treatment. The remaining 56% (n = 5) quit treatment prematurely. Seventy-five percent of the patients who completed treatment (n = 3) achieved full remission, and the remaining 25% (n = 1) made significant progress.

Patients who quit treatment prematurely attended an average of 12 sessions before quitting. Amongst patients who quit treatment prematurely, 80% (n = 4) had made significant progress at the time of the last session they attended, and the remaining 20% (n = 1) had made some progress. Importantly, the only individual who did not make significant progress quit treatment after attending only an evaluation and one treatment session.

In sum, patients with anxiety disorders responded very well to treatment in a relatively short period of time. All patients who attended more than two sessions experienced substantial improvement in anxiety symptoms as well as significant improvement in functioning, even if they did not complete a full course of treatment.

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Correlates of Treatment Outcome for Patients With Mood Disorders

In my last blog post, I described end-of treatment outcomes for patients with mood disorders. Here, I will elaborate on factors that were correlated with treatment outcome for these patients. Please be advised that these results are specific to my practice and my patients, and should not necessarily be generalized to other clinicians or populations.

Diagnosis
Type of mood disorder diagnosis was strongly correlated with treatment outcome. Patients with Depressive Disorder NOS (DDNOS; n = 3) fared best. Two-thirds of these patients (n = 2) completed treatment and achieved full remission. The remaining one-third (n = 1) attended treatment for two months and made significant progress before quitting prematurely.

Patients with Mood Disorder NOS (MDNOS; n = 4) had varying outcomes. Half of them (n = 2) completed treatment; of these, one achieved full remission and the other made significant progress. Of the remaining MDNOS patients, one quit prematurely after making some progress and the other regressed and was referred to a higher level of care.

Both of the patients in this sample with Dysthymic Disorder also had a diagnosis of Major Depressive Disorder (MDD). For statistical purposes, I am subsuming these individuals under the category of MDD, as that is the more severe of the two diagnoses. Patients with Major Depressive Disorder (MDD; n = 11) had varying outcomes. Eighteen percent (n = 2) completed treatment and achieved full remission; 9% (n = 1) quit treatment after making significant progress; 45% (n = 5) either quit treatment or moved away after making some progress; and 27% (n = 3) were referred to other providers.

The presence of both dysthymic disorder and MDD (n = 2) did not have a consistent impact on treatment outcome – one of these individuals completed treatment and achieved full remission, while the other regressed and was referred to a higher level of care.

None of the patients with bipolar disorder (n = 3) completed treatment or achieved full remission. However, one of the patients with bipolar disorder remained in treatment for over a year and made significant progress, but was eventually referred to another treatment provider to address other treatment needs.

Comorbidity
Presence of a co-morbid diagnosis was a negative prognostic factor. Only 18% (n = 2) of the patients with comorbid disorders completed treatment, and only 9% (n = 1) achieved full remission, while the remaining 9% (n = 1) made significant progress. In contrast, 40% (n = 4) of patients without a comorbid diagnosis completed treatment, and all of these patients achieved full remission.

Medication
Patients who did not take psychiatric medication during treatment with me were more likely to make progress in treatment and more likely to achieve remission than those who took psychiatric medication. All of the patients who did not take medication (n = 8) made at least some progress in treatment. In contrast, 30% of those who took medication either made no progress (n = 2) or regressed (n = 2) during treatment. Half of the patients who did not take medication (n = 4) achieved remission by the end of treatment, compared to 8% (n = 1) of those who took medication.

My hypothesis is that patients who took medication had poorer outcomes not because their medication didn’t work or made them worse, but rather because taking medication is confounded with severity of mood disorder and with comorbidity. In other words, those with more severe mood disorders and/or comorbid conditions were more likely to require medication in order to function, whereas those with mild to moderate mood disorders were less likely to need medication.

Age and Family Involvement
Younger age was a significant predictor of treatment completion. Patients who completed treatment ranged in age from 16 – 29, with an average age of 19.7. Those who did not complete treatment ranged in age from 12 – 59, with an average age of 28.6.

Being under 18 years old was a protective factor. None of the adolescents under 18 quit treatment prematurely. Of the 6 adolescents in this sample, 50% (n = 3) completed treatment and attained full remission, 33% (n = 2) were referred to other treatment settings after a year or more of treatment with me due to other needs, and the remaining 16% (n = 1) engaged in treatment as a 17-year-old and made some progress, but quit shortly after his 18th birthday. I suspect that the high level of parental involvement that I require for adolescent patients is the primary reason why they are likely to remain in treatment and have positive outcomes. In addition, younger patients tend to have shorter duration of illness compared to adult patients, and early intervention is also predictive of positive outcome.

For patients over 18, family involvement often included spouses and significant others instead of parents, based on the patient’s living situation and relationship status. Sixty percent (n = 9) of the patients over 18 in this sample had no family involvement whatsoever, 27% (n = 4) had a low level of family involvement, and 13% (n = 2) had a moderate level of family involvement. None of the patients over 18 had a high level of family involvement.

Importantly, amongst the adults in this sample, family involvement was not necessary in order to make progress in treatment or attain remission. None of the adults who attained full remission (n = 2) had family members involved in their treatment. Likewise, 67% (n = 2) of the adults who made significant progress in treatment had a low level of family involvement and 33% (n = 1) had no family involvement at all.

None of the patients over age 30 (n = 5) completed treatment. I hypothesize that there are several reasons for this: 1.) Older patients had a longer duration of illness, which means that their illness was more entrenched and more difficult to treat; 2.) The majority of these patients (80%; n = 4) had no family support at all; 3.) All of these older patients paid reduced rates for my services, which indicates that they were of lower socio-economic status, and which may suggest that they value my services less than those who pay full price; 4.) I saw all of these patients during my post-doctoral year, when I was less experienced and not yet fully licensed. Therefore, it is reasonable to assume that the quality of my services was somewhat lower back then than it is now that I am fully licensed and more experienced; and 5.) I prefer working with child and adolescent patients and find that I tend to be more effective with them. For these reasons, particularly #5, I no longer treat adult patients beyond their mid-twenties.

Gender
Average duration of treatment was comparable for males and females (6.8 months vs 7.4 months, respectively). Rates of remission were similar between males and females. Twenty percent (n = 1) of males completed treatment and achieved remission, compared with 25% (n = 4) of females. However, amongst those who did not achieve remission, females were more likely to make significant progress than males. Twenty-five percent (n = 4) of females made significant progress, compared with none of the males.

Hospitalization
Hospitalization during treatment with me predicted regression in treatment. Of the patients who were hospitalized during treatment with me, 67% (n = 2) had regressed by the end of their treatment with me. In contrast, none of the patients who were not hospitalized during treatment had regressed as of their final session with me.

I hypothesize that patients who remained out of the hospital during treatment with me were responding well to treatment, which would explain why they were more likely to achieve remission or at least make significant progress. In contrast, being hospitalized during treatment may have been an indication that the patient was not responding well to treatment, which explains why they were likely regressed as of their last session with me.

Surprisingly, history of hospitalization before entering treatment with me was not related to outcome. Of the 8 patients who had been hospitalized previously, 25% (n = 2) achieved remission, 25% (n = 2) made significant progress, 38% (n = 3) made some progress, and only 12% (n = 1) regressed in treatment with me. These percentages are comparable to those of the 13 patients who had not been hospitalized before beginning treatment with me: 23% (n = 3) achieved remission, 15% (n = 2) made significant progress, 38% (n = 5) made some progress, 15% made no progress, and 8% (n = 1) regressed.

I would have suspected that history of hospitalization would be confounded with illness severity, and therefore would predict poor treatment outcome. However, it is possible that the individuals who had been hospitalized before entering treatment with me had not been given appropriate outpatient treatment, hence the escalation of illness need for hospitalization. Perhaps these patients were able to benefit from their treatment with me, and it is possible that, in some cases, hospitalization could have been avoided if they had received effective outpatient treatment sooner.

Attendance at Therapy Sessions
Attendance at therapy sessions was correlated with treatment retention as well as treatment outcome. Sixty-seven percent (n = 4) of those who completed treatment attended all of their appointments, while the remaining 33% (n = 2) had only one missed appointment. Eighty percent of patients who attained full remission (n = 4) had perfect attendance in therapy; the remaining 20% (n = 1) missed only one appointment. None of the patients who missed more than one appointment completed treatment or achieved full remission.

I suspect this relates to the old adage: “You get out of it what you put into it.” A patient who frequently misses appointments probably places little value on their mental health, which may explain why they tended to drop out of treatment prematurely. Those who were diligent about their treatment prioritized their mental health and worked hard in therapy. Those who were conscientious and responsible about attendance were, most likely, conscientious and responsible about completing therapy homework, taking their medication consistently, and making positive life choices in general. Thus, it is natural that these individuals had better treatment outcomes.

Fee for Services
Payment of full fee for services was a predictor of treatment completion and achieving full remission. Sixty-seven percent of patients (n = 2) who paid my full rate completed treatment, compared with only 22% of patients (n = 4) who paid a reduced rate. Given that so few patients in this sample paid my full rate (n = 3), it is difficult to draw any conclusions about how these individuals differ from those who pay a lower rate.

However, in my practice, the correlation between payment of full services and better treatment outcome has been consistent across diagnoses, regardless of the number of clients in the sample. As I have noted in recent posts, individuals who pay lower fees are, by definition, of lower socio-economic status (SES). These individuals may have more financial stressors than those of higher SES, and may have other life obstacles in general (limited access to healthcare, transportation difficulties, unemployment, single parent families) which interfered with their ability to progress in treatment.

In addition, those who pay reduced rates were much more likely than those who pay full rate to no-show for sessions or to cancel at the last minute. This finding suggests to me that, on average, individuals who paid reduced fees placed less personal value on their sessions, had less respect for my time, did not prioritize their recovery, and/or were generally irresponsible, compared with individuals who paid full rate.

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End of Treatment Outcomes for Patients with Mood Disorders

Since opening my practice in 2009, I have evaluated 30 patients with mood disorders. Former patients who attended at least one treatment session with me following their evaluation were included in this sample. Patients who are currently in treatment with me were not included in this sample. As you read, please bear in mind that these data are specific to my practice and my patients, and should not be generalized to other therapists or other patient populations.

The 21 patients in this sample had a range of different mood disorder diagnoses. The most common diagnosis was Major Depressive Disorder (43%; n = 9). Other mood disorder diagnoses included Mood Disorder Not Otherwise Specified (19%; n = 4), Depressive Disorder Not Otherwise Specified (14%; n = 3), Bipolar Disorder (14%; n = 3), and Dysthymia (10%; n = 2). Approximately one quarter of the sample (24%) was male.

Patients ranged in age from 12 to 59, with a median age of 21. Most of these patients had been suffering from their mood disorder for years before beginning treatment with me, and most had received some sort of psychological or psychiatric treatment in the past. Duration of illness prior to intake ranged from 1 month to 35 years, with an average duration of 8.4 years. These figures reflect the length of time since symptoms began, which is usually substantially earlier than diagnosis.

Many mood disorders, such as Major Depressive Disorder and Bipolar Disorder, tend to be episodic, characterized by periods of remission and periods of relapse. Thus, the “duration of illness prior to treatment” figures reflect the total length of time from the onset of first symptoms to the initial session with me. Many patients had periods of mild or absent symptoms and good functioning in between mood disorder episodes.

Most of the patients in this sample had relatively severe forms of mood disorders. Thirty-eight percent of them (n = 8) had been hospitalized for a suicide attempt, suicidal gesture, or related psychiatric issue prior to beginning treatment with me, and many of these individuals had been hospitalized multiple times. Fourteen percent of patients (n = 3) had to be hospitalized during the course of their treatment with me.

This sample was ethnically diverse, comprised of 43% White Hispanic, 43% White Non-Hispanic, 10% multi-racial, and 4% Black Hispanic. The majority of patients in this sample (86%; n = 18) paid a reduced fee for my services; only 14% (n = 3) paid my full rate. Thus, most of these patients were of lower socio-economic status and/or were college students responsible for supporting themselves.

Approximately half of the sample (52%; n = 11) had a comorbid psychiatric disorder. The most common comorbid diagnoses were Anxiety Disorder Not Otherwise Specified (14%; n = 3) and Eating Disorder Not Otherwise Specified (14%; n = 3).

The patients in this sample received various types of treatment, depending on their age and symptoms. Nearly half of the patients in this sample (48%; n = 10) received Cognitive-Behavioral Therapy (CBT). Patients whose illnesses were characterized by impulsivity and self-harm received a Dialectical Behavior Therapy (DBT) skills-based approach (38%; n = 8). Patients with milder symptoms and social difficulties received supportive counseling focused on self-care and interpersonal relationships (14%; n = 3). Sixty-two percent of patients (n = 13) were also seeing a psychiatrist and taking psychotropic medication during their treatment with me.

The level of family involvement in a patient’s treatment varied based upon his or her age, symptoms, and preferences as well as logistics. In this sample, 43% (n = 9) of patients had no family involvement, 19% (n = 4) had a low level of family involvement, 19% (n = 4) had a moderate level of family involvement, and 19% (n = 4) had a high level of family involvement.

I require the parents of all patients under 18 to be fully informed and actively involved in their child’s treatment. Therefore, all patients under 18 in this sample had moderate to high degrees of family involvement in treatment. This means that the patient’s parents participated fully in the evaluation and treatment planning, and participated in a portion of most therapy sessions (e.g., the last 10 minutes of each session) for the purposes of providing feedback, setting goals, and evaluating progress. These parents also had regular access to me via phone and email for the purpose of sharing information about their child and asking questions. For patients over age 18, family members were involved as appropriate, as needed, and as requested by the patient. For example, many college-aged patients had parents involved in their treatment, particularly when it came to issues of psychiatric consultation and hospitalization.

Patients in this sample attended between 1 and 96 sessions, with a mean of 19 sessions. Duration of treatment ranged from 1 month and 39 months, with a mean duration of 7 months. In other words, the typical mood disorder patient attended 19 sessions over the course of 7 months.

Twenty-nine percent of patients (n = 6) completed treatment and 38% (n = 8) quit treatment prematurely. I referred twenty-four percent of patients (n = 5) to other treatment providers who could better meet their needs, and 9% of patients (n = 2) moved to other geographic locations during their treatment and were referred to other providers near their new homes.

Patients who completed treatment attended between 1 and 96 sessions, with an average of 23 sessions. Duration of treatment for those who completed treatment ranged from 1 to 39 months, with an average duration of 11 months. Thus, it typically took approximately 23 sessions over the course of 11 months to complete treatment.

Each patient was given an end-of-treatment rating which describes their state as of their final session with me, regardless of the reason why treatment ended.

• Patients were classified as being in “full remission” if they had not experienced any symptoms of their mood disorder within the past two weeks, and their social / occupational / academic functioning were good.

• Patients were classified as having made “significant progress” if their mood disorder symptoms over the past two weeks were substantially less severe, less frequent, and less intense than at intake, but were still occurring, and their social / occupational / academic functioning were relatively good.

• Patients were classified as having made “some progress” if their symptoms over the past two weeks were somewhat less severe and less frequent than at intake, and if their social / occupational / academic functioning were fair.

• Patients were classified as having made “no progress” if the frequency, intensity, and duration of symptoms had not improved since intake, and social / occupational / academic functioning had not improved since intake.

• Patients were classified as “regressed” if their symptoms over the past two weeks were more severe or more frequent than at intake and their social / occupational / academic functioning had declined since intake.

Of the patients who completed treatment, 83% (n = 5) achieved full remission from their mood disorder and 17% (n = 1) made significant progress. Of the patients who quit treatment prematurely, 25% (n = 2) had made significant progress by their last session with me, 63% (n = 5) had made some progress, and 12% (n = 1) had made no progress. Among the patients whom I referred to other providers, 40% (n = 2) regressed during their treatment with me, 20% (n = 1) made no progress (n = 1), 20% (n = 1) made some progress, and 20% (n = 1) made significant progress.

In my next post, I will discuss factors that are correlated with treatment completion and good outcome in these mood disorder patients.

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A Comparison of Treatment Outcomes: AN, BN, and EDNOS

My previous posts described treatment outcomes and correlates of my patients with various eating disorder diagnoses, including Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Specified (EDNOS). Some findings were similar across diagnostic groups:

• The vast majority of patients with any diagnosis who completed treatment achieved full remission.

• The attrition rate, overall, was high.

• Family-Based Treatment (FBT) was associated with treatment retention, meaning that patients who participated in FBT were less likely to discontinue treatment prematurely than those receiving individual therapy.

• Patients who paid a reduced rate for services were much less likely to complete treatment and much less likely to achieve remission than those who paid full rate.

• Hospitalization during treatment with me was not related to treatment completion or treatment outcome, regardless of diagnosis.

• History of intensive eating disorder treatment (e.g., residential treatment, day treatment) was related to treatment non-completion and poorer outcome for patients across diagnoses.

Quite surprisingly, the differences among the diagnostic groups outnumbered the similarities:

• Patients with AN who completed treatment attended more sessions, over a longer period of time, than patients with BN or EDNOS. Completing treatment for AN involved an average of 28 sessions over 17 months, whereas completing treatment for BN or EDNOS involved an average of 15 sessions over 10 months.

• Type of treatment had a significant impact on outcome for patients with AN but not for patients with BN or EDNOS. All AN patients who achieved remission did so through FBT. However, patients with BN and EDNOS achieved remission through various means, including individual therapy with no family involvement, individual therapy with family involvement, and FBT.

• Younger age at intake and shorter duration of illness predicted treatment completion and remission for patients with AN. However, neither age nor duration of illness affected treatment outcome for patients with BN or EDNOS.

• All “treatment non-completers” with AN (those who quit prematurely, moved away, or were referred to other treatment settings) discontinued treatment within the first six months. In contrast, a number of “treatment non-completers” with BN or EDNOS remained in treatment for more than a year.

• Among patients with AN, those who completed treatment attended significantly more sessions than those who did not (28 sessions vs. 8 sessions) and remained in treatment for a much longer time than those who did not (17 months vs. 3 months). In contrast, for patients with BN and EDNOS, treatment completers and non-completers both remained in treatment for an average of 10 months, and treatment non-completers actually averaged more sessions than treatment completers (20 sessions vs. 15 sessions). Thus, it appears that for BN and ENDOS, treatment completers did not remain in treatment longer, but rather reached remission more quickly.

• Caucasians with AN were slightly more likely than Hispanics with AN to complete treatment and achieve remission. In contrast, Hispanics with BN or EDNOS were significantly more likely than Caucasians with these diagnoses to complete treatment and achieve remission.

• The presence of a comborbid disorder was not related to treatment completion or treatment outcome for patients with AN. However, the presence of a comorbid disorder was a significant predictor of treatment dropout and poorer outcome for patients with BN and EDNOS.

• History of hospitalization for an eating disorder or related psychiatric issue was related to poorer outcome for patients with BN and EDNOS, but not for patients with AN.

• Taking psychotropic medication during treatment was related to treatment completion and positive outcome for patients with AN but not for patients with BN or EDNOS.

Please bear in mind that these findings are specific to my practice and my patients, and are not intended to be generalized to other treatment settings or other patients.

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Correlates of Treatment Outcome for Patients with BN & EDNOS

My previous post described the treatment outcomes of my 21 former patients with diagnoses of Bulimia Nervosa (BN) or Eating Disorder Not Otherwise Specified (EDNOS). Treatment was very successful for these patients, with 100% of those who completed treatment (n = 7) achieving full remission. However, the attrition rate was very high, with two-thirds of patients (n = 14) discontinuing treatment prematurely for various reasons. Nineteen percent (n = 4) of patients were referred to other providers or treatment settings because I was unable to meet their needs, 5% (n = 1) moved to another geographic area, and 43% (n = 9) quit before finishing treatment.

Given that treatment completion always led to full remission, attrition appears to be the biggest challenge for this population. Therefore, my post will focus on the differences between those who completed treatment and therefore achieved full remission (aka “treatment completers”) versus those who did not (“treatment non-completers”).

Neither age at intake nor duration of illness before intake predicted treatment outcome. Both treatment completers and treatment non-completers averaged approximately 19 years old at intake, with an average duration of illness of 4.5 years.

Patients who completed treatment and achieved full remission did so through a variety of treatment modalities: 43% (n = 3) received individual therapy with no family involvement, 29% (n = 2) received Family-Based Treatment (FBT), 14% (n = 1) received individual therapy with a high level of family involvement, and 14% (n = 1) received individual therapy with moderate family involvement.

Patients receiving FBT (n = 7) were significantly less likely than those receiving individual therapy to quit treatment prematurely. Only 14% of patients receiving FBT (n = 1) quit treatment prematurely. I referred 43% of them (n = 3) to other treatment settings due to my inability to help them progress in treatment. Twenty-nine percent (n = 2) completed treatment with me and 14% (n = 1) moved to another geographic area and continued her treatment there.

Of the 14 patients who received individual therapy, 57% (n = 8) quit treatment prematurely. The remainder of patients either completed treatment and achieved full remission (36%; n = 5) or were referred to other treatment settings (7%; n = 1).

Interestingly, treatment completers did not differ from treatment non-completers on duration of treatment or on number of sessions attended. For treatment completers, duration of treatment ranged from 1-38 months, with an average duration of 10 months. For treatment non-completers, duration of treatment ranged from 1-28 months, with an average duration of 10 months. Treatment completers attended an average of 15 sessions, while treatment non-completers attended an average of 20 sessions. Thus, it appears that treatment completers did not necessarily remain in treatment longer, but rather reached remission more quickly. Anecdotally, I recall that a number of patients who quit treatment prematurely actually did quite well in their first 6-9 months of treatment and nearly reached remission, but then began to regress, got discouraged, and quit.

Rates of treatment completion and treatment outcome differed based on diagnosis. Amongst patients with BN, 22% (n = 2) completed treatment and achieved full remission, while 44% (n = 4) made significant progress prior to discontinuing treatment. For patients with EDNOS, 42% completed treatment and achieved full remission, while 17% (n = 2) made significant progress prior to discontinuing treatment.

Prior history of untreated Anorexia Nervosa (AN) was associated with treatment dropout and poor outcome. Only 18% (n = 2) of those with a prior history of AN completed their BN/EDNOS treatment with me, and both of those patients had been successfully treated for AN years before. None of the patients with a prior history of untreated AN completed their treatment with me.

Patients with a co-morbid disorder were much less likely to complete treatment. While two-thirds of patients in this sample (n = 14) had a co-morbid disorder, only 29% of them (n = 4) completed treatment and achieved remission.

Taking psychotropic medication during treatment was not related to treatment completion. Thirty-six percent of those who took medication during treatment (n = 4) completed treatment and achieved full remission, compared with 30% (n = 3) of those who did not take medication during treatment.

This sample of patients was 71% Caucasian (n = 15), 24% Hispanic (n = 5), and 5% multi-racial (n = 1). Hispanic patients were much more likely to complete treatment and achieve remission than Caucasian patients. Eighty percent (n = 4) of Hispanic patients in this sample completed treatment and achieved remission, compared with only 20% (n = 3) of Caucasian patients.

I work on a sliding fee scale, offering reduced rates based on patient’s ability to pay. Those who paid my full rate were more likely to complete treatment and achieve remission compared with those who paid a reduced rate. Forty-six percent of those who paid my full rate completed treatment (n = 6), compared with 25% of those who paid a reduced rate (n = 2).

Individuals with a history of intensive eating disorder treatment were less likely to complete treatment than those without such a history. Amongst treatment non-completers, 50% (n = 7) had been hospitalized for their eating disorder or a related psychiatric issue, 21% (n = 3) had a history of residential treatment, and 21% had been in partial hospitalization, day treatment, or intensive outpatient programs. Amongst treatment completers, 29% (n = 2) had a prior history of hospitalization, 14% (n = 1) had a history of residential treatment, and none had a history of partial hospitalization, day treatment, or intensive outpatient treatment. The need for hospitalization during treatment with me was not related to treatment completion or treatment outcome.

In sum, the only variables that were related to treatment completion and remission were diagnosis of EDNOS and payment of my full fee for services. The following variables were associated with treatment non-completion: presence of a comorbid diagnosis, history of untreated AN, and prior history of intensive eating disorder treatment. Surprisingly, neither age at intake, duration of illness before intake, type of treatment received, number of sessions attended, duration of treatment, nor need for hospitalization during treatment were related to treatment completion.

These findings are specific to my practice and my patients, and are not intended to be generalized to other clinicians or other populations.

My next post will explore similarities and differences in treatment outcome among patients with AN, BN, and EDNOS.

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End of Treatment Outcomes for Patients with Bulimia Nervosa & EDNOS

Since I opened my practice in 2009, I have evaluated 10 patients with a diagnosis of Bulimia Nervosa (BN) and 16 patients with a diagnosis of Eating Disorder Not Otherwise Specified (EDNOS). All patients with a diagnosis of BN or EDNOS who attended an evaluation and at least one treatment session with me, and who are no longer in treatment with me, were included in this sample. Patients I evaluated who did not attend any treatment sessions with me were not included in this sample. Patients who are currently in treatment with me were not included in this sample either. Thus, the sample I will be describing includes a total of 21 patients: 12 with EDNOS and 9 with BN.

As you continue to read, bear in mind that these results are specific to my practice and my patients. These data should not be generalized to other clinicians or other patients.

All patients in this sample were female. Age at intake ranged from 14 – 28, with an average age of 19. Two thirds of the patients (n = 14) had a comorbid disorder, with the most common being Major Depressive Disorder. Sixty-two percent of patients (n = 13) paid my full rate for services, while 38% (n = 8) paid a reduced rate.

For the purpose of calculating duration of illness, the onset of illness was defined as the period of time in which the patient began engaging in behavioral symptoms of eating disorders (e.g., restricting, bingeing, compulsive exercise, purging) as reported by the patient and/or parents. This is an important point to clarify, as symptoms of the illness typically begin long before a diagnosis is made. Length of illness before intake varied considerably, ranging from 6 months to 15 years, with an average of 4.5 years.

Over half of the patients in this sample (n = 11) had a prior history of Anorexia Nervosa (AN). Some of them had been diagnosed with and treated for AN, while others met criteria for AN at one point but were not treated until their illness morphed into BN or EDNOS.

The patients in this sample with EDNOS (n = 12) presented with a range of different symptoms. Half of the patients (n = 6) struggled with some combination of restricting, bingeing, and purging. One quarter of patients (n = 3) presented primarily with binge eating. Seventeen percent (n = 2) had Type I diabetes and withheld insulin (known as “diabulimia”). Eight percent (n = 1) presented with body image distress associated with a history of AN.

Ninety percent of these patients (n = 19) had a history of some type of psychological treatment prior to meeting with me. The majority had been in individual therapy for their eating disorder at some point. Forty-three percent of the sample (n = 9) had been hospitalized for their eating disorder or for a related psychiatric issue prior to beginning treatment with me. Nineteen percent (n = 4) had a history of residential eating disorders treatment and 24% (n = 5) had a history of partial hospitalization, day treatment, or intensive outpatient treatment.

One-third of the patients in this sample (n = 7) were treated with Family-Based Treatment (FBT). The remaining two-thirds (n = 14) were treated with individual Cognitive-Behavioral Therapy (CBT), with varying degrees of family involvement. Of the individual therapy patients, 21% (n = 3) had a high level of family involvement, meaning that a family member participated in part of each session, shared information and impressions frequently, was kept apprised of weekly goals and progress, and maintained regular phone and email contact with me. Twenty-nine percent of individual therapy patients (n = 4) had a moderate level of family involvement, meaning that a family member participated in some sessions and had occasional phone and email contact with me. Seven percent of individual therapy patients (n = 1) had a low level of family involvement, meaning that a family member attended one or two sessions, and 43% of individual therapy patients (n = 6) had no family involvement whatsoever.

Parents were the most common family members involved in the patient’s treatment. However, some patients had boyfriends, husbands, stepparents, grandparents, siblings, aunts, and uncles involved depending on their living situation and individual circumstances. Whenever family members were involved with treatment, the focus was on providing them with psycho-education about eating disorders and enlisting them as sources of practical and emotional support for the patient at home. Family members were coached in providing meal support and in assisting their loved one in refraining from eating disorder behaviors such as bingeing and purging.

For patients who received individual therapy, my approach was primarily cognitive-behavioral (CBT). In addition, many patients were taught Dialectical Behavior Therapy (DBT) skills such as distress tolerance and emotion regulation, as well as Acceptance and Commitment Therapy (ACT) principles such as thought defusion and values-based living.

Patients in this sample attended between 2 and 54 sessions, with an average of 18 sessions. Duration of treatment with me ranged from 1 month to 38 months, with a mean of duration of 10 months. Slightly more than half of the patients (n = 11) took psychotropic medication while in treatment with me. Three patients had to be hospitalized over the course of their treatment with me.

All patients were assigned an end-of-treatment status describing how they had progressed as of their final session with me. Outcomes were defined as follows:

1. Patient must meet ALL of the following criteria to be classified as in full remission:
a.) Patient gets regular menstrual periods.
b.) Patient is medically healthy, with good vital signs and blood work.
c.) Patient is completely abstinent from eating disorder behaviors, including restricting, binge/purge behaviors, laxatives, and diet pills.
d.) Patient eats regular, balanced meals most of the time or always, as reported by patient and parent (when applicable)
e.) No more than mild preoccupation with food, weight, body image, or fear of weight gain

2. Patient is classified as in physical remission if she meets criteria a, b, c, and d under full remission, but does not meet criteria e under full remission. Essentially, a patient in physical remission is physically well and free of eating disorder behaviors, but continues to be very distressed with her body image and/or preoccupied with thoughts about food and weight.

3. Patient is classified as having made significant progress if:
a.) Patient has made significant improvement in dietary habits (e.g., eats regular, balanced meals and snacks) as reported by patient and parents (when applicable)
b.) Patient is medically healthy, with good vital signs and blood work
c.) Frequency of eating disorder behaviors (e.g., restricting, bingeing, purging) has been reduced to once per week or less.

4. Patient is classified as having made some progress if:
a.) Patient has improved dietary habits somewhat since intake, but needs more improvement
b.) Patient has reduced the frequency of eating disorder behaviors (e.g., restricting, bingeing, purging) since intake, but still engages in these behaviors more than once per week.

5. Patient is classified as having made no progress if she has not improved dietary habits and/or has not reduced the frequency of eating disorder behaviors.

6. Patient is classified as regressed if she meets ANY of the following criteria:
a.) Dietary intake has declined since intake (e.g., more skipped meals, less variety, less nutritional balance)
b.) Frequency of binge/purge behaviors has increased since intake
c.) Patient has become medically unstable

Thirty-three percent of patients (n = 7) completed treatment, 43% (n = 9) quit treatment prematurely, 19% (n = 4) were referred to other providers or treatment settings because I was unable to meet their needs, and 5% (n = 1) moved to another geographic area during treatment.

One-hundred percent of the patients who completed treatment (n = 7) reached full remission. For those who completed treatment, known henceforth as “treatment completers,” duration of treatment ranged from one month to 38 months, with an average duration of 10 months. Number of sessions attended for treatment completers ranged from 3 – 45, with an average of 15 sessions. In other words, the typical patient with BN or EDNOS who completed treatment achieved full remission in 15 sessions over the course of 10 months.

Unfortunately, the attrition rate was very high, so these treatment completers comprised only one-third of the full sample. Of the 14 patients who discontinued prematurely, 43% (n = 6) made significant progress, another 43% (n = 6) made some progress, 7% (n = 1) made no progress, and 7% regressed (n = 1).

My next post will involve a detailed examination of the differences between patients who completed treatment and reached full remission versus those who discontinued treatment prematurely and did not reach full remission.

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Correlates of Treatment Outcome for Patients with Anorexia Nervosa

In my last blog post, I described the end-of-treatment outcomes of my former patients (N = 30) with Anorexia Nervosa (AN). In sum, 57% of patients completed treatment (n=17) and 43% of patients (n = 13) did not complete treatment. The former group is referred to as “treatment completers” and the latter as “treatment non-completers.”

As expected, end-of-treatment results differed dramatically between the two groups. By the end of treatment, 94% percent of treatment completers had achieved full remission and 6% (n = 1) had achieved physical remission. In contrast, none of the treatment non-completers achieved remission, although 46% of them made significant progress (n = 6).

Bear in mind that I set the bar very high for my patients in terms of defining remission. In most published studies of AN treatment outcome, the patients whom I categorized as having made significant progress would be categorized as “recovered” or “in remission.” If I used the (completely inadequate) definitions of remission that other studies have used, a full 77% of my sample would have completed treatment and made a full recovery. But I digress.

These data clearly demonstrate that my approach to treating AN is effective. Patients with AN who have completed treatment with me always achieved physical remission and almost always achieved psychological and behavioral remission as well.

The 43% attrition rate is disheartening, given that patients are likely to achieve remission if they remain in treatment long enough. Attrition is a major problem in AN treatment in general, and in AN treatment for adults in particular. The validity of most AN treatment outcome studies is compromised by the high rates of attrition. It is not surprising that many adults discontinue AN treatment prematurely, given that treatment is very difficult, anxiety provoking, and lengthy.

This raises the question of what is “long enough” in terms of AN treatment? In my opinion, “long enough” is as long as it takes to bring the patient to full remission, which varies considerably based on individual differences. Among the treatment completers, the length of time to full remission ranged from 2 months to 4 years, with a mean of 17 months. The number of sessions attended by treatment completers ranged from 3 – 82, with a mean of 28 sessions. There were a handful of the young patients who achieved full remission in 12 sessions or less, although this was not the norm.

The rates of treatment completion versus non-completion in my sample beg the question of how these two groups differed. What was it that made treatment completers stick it out until the end, while the treatment non-completers either quit or regressed to the point that they required more intensive treatment? Cause and effect cannot be determined from this type of study. However, a careful examination of the similarities and differences between treatment completers and non-completers may yield useful information and hypotheses which can be tested in future studies.

The patients who completed treatment and reached remission differed in several important ways from those who discontinued treatment prematurely.

Variables That Had a Significant Impact on Treatment Outcome:

1.) Type of Treatment

In my practice, all children and adolescents under age 18 with AN receive FBT (Family-Based Treatment, also known as the Maudsley Method). Some adolescents also receive individual therapy as an adjunct to FBT after weight restoration. Some children and adolescents transition to individual therapy with me after FBT is complete; this may be the case for those who have comorbid disorders or other ongoing issues. Patients over 18 with AN are strongly encouraged to do FBT whenever appropriate, although it is not always possible for logistical reasons, and some young adults are staunchly opposed to it. In my sample, 66.7% of patients (n = 20) received FBT alone, 16.7% (n = 5) received FBT plus individual therapy, and 16.7% (n = 5) received individual therapy alone.

In my sample, all of the patients who received individual therapy alone were 20 or older. Six of the 11 young adults in my sample (n = 55%) participated in FBT, either alone or in conjunction with individual therapy. All of the patients under age 18 received FBT, and two of these patients also received individual therapy.

One-hundred percent of treatment completers (n = 17) received FBT, either by itself (n = 15) or in conjunction with individual therapy (n = 2). In other words, all patients who achieved remission did so through FBT. One-hundred percent of the patients who did individual therapy alone (n = 5) ended treatment prematurely, either because they moved (n = 2), they quit (n = 2), or I referred them to a higher level of care (n = 1). In other words, individual therapy by itself never resulted in treatment completion or remission.

2.) Subtype of AN

This sample contained 5 patients with the Binge-Purge subtype of AN (AN – BP) and 25 patients with the Restricting subtype of AN (AN – R). One-hundred percent of treatment completers had a diagnosis of AN-R. None of the AN-BP patients completed treatment.

Among the AN-BP patients, 2 were referred to higher levels of care after regressing during treatment with me. One patient moved to another state after making some progress in treatment with me. Two patients quit treatment prematurely after making significant progress with me.

The patients in my sample with AN-BP were more likely to have a history of impulsivity, self-injury, and suicidal gestures compared to those with AN-R. I hypothesize that this cluster of symptoms made these patients more difficult for me to treat effectively as an outpatient solo practitioner, and more likely to benefit from a more structured, comprehensive treatment approach such as day treatment or residential treatment.

3.) Age

On average, those who completed treatment and achieved remission were significantly younger at intake than those who did not complete treatment (p <.01). Treatment completers ranged in age from 10 – 24 at intake, with a median age of 14. Treatment non-completers ranged in age from 10 – 37, with a median age of 20. However, it is important to note that there was a broad range of ages in both groups, with some young adults achieving full remission and some children and adolescents discontinuing treatment prematurely. 4.) Fee Paid for Services I believe that neither finances nor insurance issues should prevent people from accessing high-quality healthcare services. Therefore, I do not participate on any insurance panels. I am flexible with my fees and I work on a sliding scale based on a patient's ability to pay. If a family’s financial status changes during the course of treatment, I will change my fee for them accordingly. I work with many patients for very low hourly fees. Thus, I can only assume that the patients who discontinued treatment prematurely did not do so for financial reasons. Among the patients in this AN sample, 87% (n = 26) paid my full fee and 13% (n = 4) paid a reduced rate. The rate of reduced-pay patients in this sample is significantly lower than in my other diagnostic groups. I hypothesize that this may be due to the fact that the majority of patients in this sample received family-based treatment and had at least one parent who was a working professional, or who at least was employed full-time. In contrast, many of my patients with other diagnoses were college students supporting themselves, who were therefore eligible for a low fee. In this sample of AN patients, those who paid a reduced rate were significantly less likely to complete treatment compared to those who paid a full rate. Only 25% of reduced fee patients (n = 1) completed treatment, versus 62% of full fee patients (n = 16). It is unclear why reduced rate patients were less likely to complete treatment. However, the reduced rate patients differed from the full rate patients in several important ways. First, and most obviously, they had lower incomes, and likely dealt with the host of stressors that accompany being of lower socio-economic status. Second, they were all over the age of 18, which statistically reduces their likelihood of full recovery. Third, they were more likely to receive individual therapy than the full-rate patients. All of the low-rate patients received individual therapy, either alone (n = 2) or in combination with FBT (n = 2). Observing my patients with other diagnoses, I have noticed that those who pay full rate are much more likely to attend all of their sessions and to complete treatment, whereas those who pay lower rates are more likely to cancel sessions, no-show for sessions, and drop out prematurely. While I’m sure that the reasons for these differences are complex, I can’t help but wonder if people who pay more for something tend to value it more and take it more seriously. Variables That Had a Minor Impact on Treatment Outcome:

1.) Length of illness before intake.

Among treatment completers, length of illness before intake ranged from 3 months to 13 years (mean = 27 months). Amongst treatment non-completers, length of illness before intake ranged from 3 months to 21 years (mean = 67 months). However, this difference was not statistically significant (t = 1.63; p = 0.11).

2.) Use of Medication During Treatment

Individuals who took psychotropic medication during treatment with me were somewhat more likely to complete treatment and achieve remission. Fifty-nine percent of treatment completers (n = 10) took medication during treatment, compared with 38% of treatment non-completers (n = 5).

3.) Ethnicity

This sample of 30 patients was comprised of 60% White Non-Hispanic individuals (n = 18) and 40% White Hispanic Individuals (n = 12). These percentages are roughly similar to the ethnic makeup of Coral Gables, Florida, the Miami Suburb in which my office is located. The treatment completers group was comprised of 71% White Non-Hispanic individuals (n = 12) and 29% White Hispanic individuals (n = 5). The treatment non-completers group included 46% White Non-Hispanics (n = 6) and 54% White Hispanics (n = 7). Therefore, White Non-Hispanics were slightly more likely to complete treatment and achieve full recovery than White Hispanics.

4.) History of intensive eating disorder treatment.

History of residential, day treatment, or intensive outpatient treatment had a minor impact on treatment outcome. Twelve percent of treatment completers (n = 2) and 23% of treatment non-completers (n = 3) had a history of residential eating disorders treatment prior to beginning treatment with me. Twenty-four percent of treatment completers (n = 4) and 31% of treatment non-completers had a history of partial hospitalization, day treatment, or intensive outpatient eating disorder treatment.

Variables that Had No Impact on Treatment Outcome:

1.) Comorbid disorders

The presence of comorbid disorders did not differ significantly between the two groups. Fifty-three percent of treatment completers (n = 9) had a comorbid diagnosis, as did 46% of treatment non-completers.

2.) Gender.

Given that only 7% of the sample was male (n = 2), I cannot draw any conclusions about gender differences in treatment response. Incidentally, both of the males in my sample achieved full recovery.

3.) Hospitalization before treatment.

Being hospitalized for AN or a related psychiatric issue prior to beginning treatment with me did not have a significant impact on treatment outcome. Thirty-five percent of treatment completers (n = 6) had been hospitalized at least one prior to beginning treatment with me, as had 31% percent of treatment non-completers (n = 4).

4.) Hospitalization during treatment.

The need for hospitalization during the course of treatment with me did not have a significant impact on treatment outcome. Eighteen percent of treatment completers (n = 3) needed to be hospitalized during the course of their treatment, compared with 15% (n = 2) of treatment non-completers.

These data, taken together, suggest that a patient with AN-R who enters treatment with me and receives FBT is very likely to achieve full remission within 28 sessions over the course of 17 months, regardless of gender, comorbid diagnosis, or history of hospitalization. A patient under age 18 has a greater likelihood of achieving full remission, although a patient over 18 is also likely to achieve full remission, provided that he or she is treated with FBT.

Please bear in mind that these results are specific to my practice and my patients. These data are not intended to be generalized to other clinicians or other patient populations.

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End of Treatment Outcomes for Patients with Anorexia Nervosa

Since opening my practice in 2009, I have evaluated 49 patients with primary diagnoses of Anorexia Nervosa (AN). All patients who attended an evaluation and at least one treatment session with me, and who are no longer in treatment with me, were included in this sample. In addition, there were several patients who have completed their treatment but have elected to see me two or three times per year for check-ins; these patients were included in this sample as well. Patients who are currently in treatment with me were not included. Patients who saw me for an evaluation and / or consultation only, but did not attend any treatment sessions, were not included either. Thirty patients met criteria for inclusion in this sample. The remaining 19 did not meet criteria, either because they saw me for evaluation and consultation only or because they are currently in treatment with me.

Please bear in mind that this is not a randomized, controlled study. The results I am posting are specific to my practice and my patients. They are not intended to be generalized to other clinicians or other patients. While many of my patients are referred to me by their pediatrician or psychiatrist, the majority of my patients are self-selecting. That is, their families researched their treatment options on their and chose to work with me for a specific reason. The self-selecting nature of many of these families also limits the generalizability of the results.

The sample described in this post contains 30 patients. These patients ranged in age from 10 – 37 (median age = 15). Eighty-three percent of these patients (n = 25) met criteria for restricting subtype (AN-R) and the remaining 17% (n = 5) met criteria for binge-purge subtype (AN-BP). Half of these patients (n = 15) had a co-morbid diagnosis, with the most common being Major Depressive Disorder and Depressive Disorder Not Otherwise Specified. Fifty-three percent of patients (n = 16) took some type of psychotropic medication during their treatment with me.

The patients varied widely in terms of length of illness and severity of symptoms. Duration of illness before intake ranged from 3 months to 21 years (median duration = 19 months). Importantly, these figures reflect the duration since the onset of illness, which is typically longer (and often much longer) than the duration since diagnosis. For the purpose of calculating duration of illness, onset of illness was defined as the period of time in which patient began engaging in behavioral symptoms of AN (e.g., restricting, compulsive exercise, purging) as reported by the patient and/or parents.

The majority of these patients arrived at my office with some history of treatment. Seventy percent of patients (n = 21) had already received some type of treatment before beginning therapy with me. As expected, most of those who were new to treatment had a much shorter duration of illness. One-third of patients (n = 10) had been hospitalized for their eating disorder or a related psychiatric issue (e.g., suicide attempt) prior to their evaluation with me. Seventeen percent of the patients (n = 5) had previously been in residential treatment and 27% (n = 8) had previously been in partial hospitalization, day treatment, or intensive outpatient treatment eating disorder treatment.

Duration of treatment with me ranged from one week to 48 months (median duration of treatment = 11 months). Number of treatment sessions with me ranged from 1 – 82. For those whose treatment lasted 18 months or longer, the duration of treatment can be explained by either a relapse after a period of remission or continued treatment to address a comorbid condition, such as anxiety or depression. Seventeen percent of patients (n = 5) had to be hospitalized during their treatment with me.

Prior to reporting end-of-treatment outcomes, it is important to clarify how I defined outcomes. I created the following definitions, each with specific criteria, in order to categorize patient outcomes:

1. Patient must meet ALL of the following criteria to be classified as in full remission:
a.) Patient is 100% weight-restored. Target weights were calculated based on patient’s individual historic growth chart and parent input. Patients under age 20 were expected to return to their historic percentiles for height, weight, and BMI. For patients age 20 and up, target weights were calculated based on the patient’s height, body build, weight history, menstrual history, and parental input (when available).
b.) Patient has started or resumed menstrual periods (for females ages 14 +).
c.) Patient is medically healthy.
d.) Complete abstinence from binge/purge behaviors, laxatives, and diet pills.
e.) Patient eats regular, balanced meals most of the time or always , as reported by patient and parent (when applicable)
f.) For children under 18 – child eats independently in an age-appropriate way most of the time or all of the time. For patients ages 18 and up, patient is able to eat independently while maintaining his/her weight.
g.) No more than mild preoccupation with food, weight, body image, or fear of weight gain

2. Patient is classified as in physical remission if he/she meets criteria a, b, c, d, and e under full remission, but does not meet criteria f or g under full remission. Essentially, a patient in physical remission is physically well and free of eating disorder behaviors, but cannot eat well independently, and/or continues to be preoccupied with thoughts about food, weight, and body image.

3. Patient is classified as having made significant progress if:
a.) Patient has made significant improvement in dietary habits (e.g., eats regular, balanced meals and snacks and has expanded the variety of foods he/she eats) as reported by patient and parents (when applicable)
b.) Patient has restored some weight and is at least 90% of ideal body weight (as defined in criterion a under full remission)
c.) Patient is medically healthy
d.) If patient has a history of bingeing, purging, laxatives, or diet pills, the frequency of these behaviors has been reduced to once per week or less.

4. Patient is classified as having made some progress if:
a.) Patient has improved dietary habits since intake, but needs more improvement
b.) Patient has restored some weight but remains more than 10% below target weight (as defined in criterion a under physical remission).
c.) Patient is a female age 14 or older but is not menstruating
d.) If patient has a history of bingeing, purging, laxatives, or diet pills, he/she has reduced the frequency of these behaviors since intake but still engages in them more than once per week.

5. Patient is classified as having made no progress if he/she has not improved dietary habits, has not restored any weight, and/or has not reduced the frequency of bingeing or compensatory behaviors.

6. Patient is classified as regressed if he/she meets ANY of the following criteria:
a.) Patient has lost weight since starting treatment
b.) Patient has been eating less since intake (in terms of frequency, quantity, and variety)
c.) Frequency of bingeing or compensatory behaviors has increased since intake
d.) Patient has become medically unstable

Fifty-seven percent of patients (n = 17) completed treatment and will be referred to as “treatment completers.” Treatment completers ranged in age from 10 – 24 at intake, with a median age of 14. Duration of treatment for treatment completers ranged from 2 months to 48 months (median duration = 15.5 months).

Ninety-four percent of treatment completers (n = 16) met criteria for full remission at end of treatment. The remaining 6% (n = 1) met criteria for physical remission at end of treatment. For the treatment completers, weight restoration was achieved in an average of 3 months (range = 1 – 7 months). Two of the treatment completers were fully weight-restored (though not in full remission) at the start of treatment with me, having already been in eating disorder treatment elsewhere.

Forty-three percent of patients (n = 13) did not complete treatment and will be referred to as “treatment non-completers.” Treatment non-completers ranged in age from 10 – 37, with a median age of 20. Duration of treatment for the non-completers ranged from one week to six months (median duration = 3 months). Of the treatment non-completers, I referred 23% (n = 3) to other providers because they required something I could not provide (e.g., residential treatment) or my treatment approach was not helping them. Fifteen percent of non-completers (n = 2) moved to other parts of the country during their treatment and thus were referred to other providers near their new homes. Sixty-two percent of treatment non-completers (n = 8) dropped out of treatment prematurely.

Of the treatment non-completers, 46% (n = 6) had made significant progress by their last session with me. Fifteen percent had made some progress, 23% (n = 3) had made no progress, and 15% (n = 2) had regressed.

Stay tuned for my next blog post, in which I will examine and interpret the differences between treatment completers and treatment non-completers.

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A Preview of My Treatment Outcome Data

As a scientist-practitioner, I am well aware that therapists aren’t always good at judging their patients’ outcomes. That’s why I love statistics. Numbers offer an objective, quantitative view. Numbers paint a clear picture that words cannot.

I believe strongly in evidence-based treatment. I also believe in therapist transparency – that is, that therapists should explain to patients and their families what interventions they are using, why they are using them, and what evidence is behind them.

For these reasons, I have chosen to collect data on my own patients and measure their response to treatment. I want prospective patients and their families to have access to these data to assist them in choosing a clinician. After four years in private practice, I have finally seen enough patients to collect treatment outcome data with a decent-sized sample. I am compiling these data for the purpose of improving the quality of my own practice. The results of my patients’ treatment outcomes are not intended to be used to generalize to other populations.

Since opening my practice in 2009, I have evaluated 138 patients. Eighty-nine percent (n = 123) of these patients were female and (n = 15) 11% were male. They ranged in age from 7-64, with a median age of 18 and a modal age of 15. The majority of patients were between the ages of 10 and 25.

The patients’ primary diagnoses were as follows:
• 54% (n = 75) had eating disorders, including anorexia nervosa, bulimia nervosa, and EDNOS
• 22% (n = 30) had mood disorders, such as major depressive disorder or bipolar disorder
• 10% (n = 14) had anxiety disorders, such as OCD or social anxiety disorder
• 8% (n = 11) did not meet criteria for any psychiatric disorder, but rather came to me for help with a specific problem, such as coping with parents’ divorce or stress management.
• 6% (n = 8) had an assortment of other primary diagnoses, including borderline personality disorder, adjustment disorder, or body dysmorphic disorder.

I work on a sliding scale based on the patient’s ability to pay. Sixty-three percent (n = 87) paid my full rate and 37% (N = 51) paid a reduced rate due to their financial circumstances (e.g., unemployment, low income, single parent supporting children alone, or college student paying for his/her own treatment). I saw 16% of these patients (n = 22) for evaluation and/or consultation only. The remaining 84% (n = 116) attended at least one treatment session with me.

All former patients who attended at least one treatment session with me are included in this sample. In addition, four patients who have completed their treatment but have opted to continue seeing me two or three times per year for “check-ups” were included as well. Patients who are currently in treatment with me were not included.

Over the next few weeks, I will be blogging about the end-of-treatment outcomes of my former patients, categorized by primary diagnosis. I am also in the process of conducting a follow-up study, and I hope to publish those data by the end of the summer. All data will be reported in aggregate form so that no individual patients will be identifiable.

Randomized controlled trials (RCTs) are the gold standard in treatment outcome research. However, other types of studies can be quite useful as well. My study tells a different story from the RCTs – the story of clinical practice in the “real world,” with all of the freedoms and confounds that come with it. While I do use evidence-based treatments such as Family-Based Treatment (FBT) and Cognitive Behavioral Therapy (CBT), I frequently make modifications to the manualized form of treatment based on the needs of the individual patient and family.

In addition, rather than fitting all patients into a 10-session or 20-session protocol, the length of treatment varied based on individual needs. Essentially, patients could stay in treatment until they were completely well. Insurance constraints were not an issue, as I don’t participate on insurance panels, and finances were not a deterrent from completing treatment, as I am very flexible with my sliding scale.

So what do treatment outcomes look like in the real world? You’ll have to keep reading my blog to find out!

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Book Review: Food to Eat

There are a number of books that I recommend to the parents of every eating disorder patient I see. When it comes to books for eating disorder sufferers themselves, however, I am much more cautious. Many of the books that are directed at sufferers, while well-intentioned, can be triggering for some patients.

Now all of that has changed. I have finally found a book that I would wholeheartedly recommend to any adult eating disorder patient at any stage of recovery: Food to Eat. I have never read anything quite like this before. Food to Eat, authored by dietician Lori Lieberman and recovering eating disorder patient Cate Sangster, combines practical nutritional advice with quick, easy-to-prepare recipes. The most unique part of Food to Eat is that the pages of recipes and nutritional advice are peppered with dialogue between Lori and Cate. A virtual cognitive restructuring exercise, this dialogue counteracts common eating disorder thoughts with empathic, scientifically-grounded information about nutrition and behavior change.

Food to Eat can be particularly helpful for young adults with eating disorder histories who are transitioning into independent living situations which require them to prepare their own food for the first time. In addition, I would recommend Food to Eat for an adult of any age who is pursuing recovery and wants to develop a certain level of comfort in preparing and eating a variety of foods. Finally, I would recommend Food to Eat for caregivers of eating disorder patients who are responsible for preparing and serving food to the patient, as this book provides unique insight into what the patient is likely thinking when a given recipe is presented.

Full nutrition is the most crucial ingredient of eating disorder recovery. Food to Eat provides a recipe for success in overcoming the cognitive as well as nutritional challenges of eating disorders.