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Updated Summary of Treatment Outcomes

Since opening my private practice in 2009, I have been privileged to work with over 300 individuals and families, providing consultation, evaluations, and treatment for a variety of mental health conditions.  I believe in being transparent and straightforward about the services I provide and why I provide them.  Individuals who are seeking mental health services for themselves or for their children have a right to know what treatment with a particular provider will actually be like, how long it will last, what outcomes they can expect, and what factors contribute to a more or less favorable outcome.

To this end, I collect detailed information on my patients’ treatment outcomes and publish the results on my blog.  Here is an updated summary of treatment outcomes for the disorders I most commonly treat.  For more detailed information on the types of treatment provided and treatment outcomes in my practice for each of these disorders, click on the category heading.

Treatment Outcomes for Anorexia Nervosa

  • 50% of patients who entered treatment with me completed a full course of treatment with me. 26% dropped out of treatment prematurely.  22% were referred to other providers who could better meet their needs.  3% moved to other geographic locations during treatment.
  • 97% of patients who completed treatment achieved full remission. The remaining 3% achieved physical remission.
  • The majority of patients who completed treatment did so in a time frame of somewhere between 7 months and 2 years.
  • A full course of treatment required, on average, 27 sessions over the course of 17 months.
  • Patients with co-morbid conditions, such as anxiety disorders or depression, required more sessions, on average, than those without co-morbid conditions.
  • All patients who completed treatment achieved 100% full weight restoration, as indicated by a return to their pre-AN percentile patterns of growth for height and weight.
  • Average time to achieve weight restoration was 3.6 months.
  • Patients who recovered with individual therapy took longer, on average, to achieve weight restoration than those who recovered through Family-Based Treatment (FBT).
  • Patients receiving FBT were almost twice as likely to recover as those receiving individual therapy.
  • Patients receiving individual therapy were almost twice as likely as those receiving FBT to drop out of treatment prematurely.
  • Individuals with restrictive Anorexia Nervosa were twice as likely to achieve full remission as those with binge-purge Anorexia Nervosa.
  • For treatment drop-outs, there was a significant correlation between length of time spent in treatment and progress made. All treatment dropouts who were in treatment with me for at least 2 months had made significant progress towards treatment goals at the time of drop-out.  Patients who dropped out of treatment after one month or less had not made any progress at the time of drop-out.

 

Treatment Outcomes for Bulimia Nervosa

  • Over half of patients with bulimia nervosa (54%) discontinued treatment prematurely after making significant progress towards treatment goals, but prior to achieving full remission.  15% percent of patients were referred to other treatment providers or types of treatment that could better meet their needs, after making little or no progress in treatment with me. 8% of patients moved to other geographic locations and were thus referred to providers near their new homes.  23% of patients completed a full course of treatment with me.
  • Of those who completed a full course of treatment, 100% achieved full remission from their eating disorder.
  • A full course of treatment required, on average, 13 sessions over the course of 5 months.
  • Patients who took Prozac during treatment were more likely to achieve full remission than those who did not take medication.
  • Patients with a prior history of Anorexia Nervosa were less likely to recover from Bulimia than those who did not have a prior history of Anorexia Nervosa.
  • The presence of a comorbid diagnosis was not related to likelihood of achieving full remission from Bulimia.
  • Level of family involvement in treatment was not related to the likelihood of achieving full remission. This finding is in stark contrast to my outcomes for Anorexia Nervosa, in which family involvement was strongly correlated with positive treatment outcome.

Treatment Outcomes for Mood Disorders

  • Only 18% of patients who presented with a primary diagnosis of a mood disorder completed a full course of treatment with me. 50% discontinued treatment prematurely for unknown reasons, 15% moved to other geographic locations, and 18% were referred to other providers who could better meet their needs.
  • Of those who completed a full course of treatment with me, 83% achieved full remission from their mood disorder and the remaining 17% made significant progress towards their treatment goals.
  • Length of time to complete treatment varied dramatically (from 1 month to 3 years) based on individual needs, symptom severity, and progress. On average, a full course of treatment required 23 sessions over the course of 16 months.
  • High levels of family involvement predicted treatment completion and full recovery for adolescent patients but not for adult patients.
  • Patients who were self-referred were more likely to complete treatment and achieve full remission than those who were referred by another professional.
  • Predictors of less favorable treatment outcomes included hospitalization during treatment and taking psychotropic medication during treatment, most likely because these variables are markers for more severe forms of mental illness.
  • The following variables did NOT predict treatment outcome: age at intake, gender, ethnicity, duration of illness, diagnosis (type of mood disorder), presence of co-morbid diagnoses, rate paid for services, type of treatment received with me, or history of hospitalization prior to starting treatment.

Treatment Outcomes for Anxiety Disorders

  • Half of patients who entered treatment for anxiety disorders completed a full course of treatment with me.
  • Of those who completed a full course of treatment, 88% achieved full recovery and the remaining 12% made significant progress towards their treatment goals.
  • Length of time required to complete a full course of treatment varied dramatically from 1 month to 19 months, with a median treatment duration of 3 months.
  • Of those who discontinued treatment prematurely, 63% had made significant progress towards their treatment goals as of their final session with me, and the remaining 37% had made some progress.
  • Predictors of positive treatment outcome included high levels of family involvement in treatment, younger age at intake, shorter duration of illness, being self-referred to my practice, paying full rate for services, and having good attendance at therapy sessions.
  • Predictors of less favorable treatment outcome included presence of a comorbid diagnosis, taking psychotropic medication during treatment with me, and being referred to my practice by a psychiatrist.

General Conclusions

  • Across diagnostic categories, less than half of patients who enter treatment with me complete a full course of treatment with me.
  • I tend to set the bar high for my patients, striving to engage them and help them continue to progress until they reach full remission.
  • Many individuals and families decide to discontinue treatment after making significant progress towards treatment goals, but prior to achieving full remission.
  • I hope that those who discontinue treatment after making significant progress, but prior to achieving full remission, continue to move forward and eventually achieve full remission with the support of their families and/or with other professional supports.  My primary goal in working with families is to empower the parents to help their child.  My goal is to become obsolete for that particular family.   For this reason, when a family reaches a point where the parents are confident that “We’ve got it from here!” and my involvement is no longer necessary, then I have done my job well.    Therefore, dropping out of treatment prematurely, after making significant progress in treatment, may not necessarily be a negative thing.
  • Across all diagnostic categories, patients who complete a full course of treatment with me do very well in recovery. The vast majority achieve full remission from their illness.

 

 

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Weight Gain Predicts Psychological Improvement in Anorexia Nervosa

A recent study published in the journal Behavior Research and Therapy demonstrated that weight gain was a significant predictor of improved psychological functioning in adolescents undergoing treatment for anorexia nervosa (AN). In other words, adolescents who gained more weight during treatment did better mentally than those who gained less weight. This study also showed that weight gain early in the course of treatment had a greater impact on psychological recovery than weight gain later in the course of treatment.

This finding is extremely relevant not only to clinicians who treat adolescent AN, but also to the adolescent patients themselves and their families. The process of re-feeding and restoring weight often feels agonizing for patients and may cause tremendous stress to caregivers. Psychological recovery lags behind physical recovery, so patients often feel worse before they start to feel better. This study provides objective evidence that it is in the patient’s best interest – both physically and psychologically – to eat more and gain weight as soon as possible after diagnosis.

Weight gain is an essential component of treatment for patients with AN. The knowledge that full nutrition is necessary to repair the physical damage caused by AN – including weakened heart, low blood pressure, hypothermia, osteoporosis, stress fractures, lanugo, amenorrhea, infertility, and risk of premature death – helps many patients and families to persevere through the difficult days of re-feeding. Now, patients and families can hold onto hope that weight restoration will bring about psychological improvement as well. This study provides families with direct scientific evidence that gaining weight gives their loved one a greater chance of recovering mentally, emerging from the fog of depression, and reclaiming a meaningful life free from food and weight preoccupation.

Patients in this study were randomly assigned to receive either Family-Based Treatment (FBT) or Adolescent Focused Treatment (AFT). The authors of this study found that weight gain predicted psychological recovery regardless of the type of treatment (FBT vs. AFT) the patient received. This finding may be especially relevant to clinicians who treat adolescent AN using individual therapy. A common criticism of FBT (usually made by clinicians who reject FBT without really understanding it) is that it focuses on weight gain at the expense of the adolescent’s psychological wellbeing. This study clearly demonstrates that weight gain and improved psychological functioning are not mutually exclusive. On the contrary, weight gain and improved psychological functioning are strongly correlated!

It is clear that FBT supports the adolescent’s psychological wellbeing indirectly by promoting regular nutrition and steady weight gain, which help to repair the brain damage caused by malnutrition. I would also argue that FBT has a direct impact on the adolescent’s psychological wellbeing by externalizing the illness, removing any sense of self-blame the adolescent may have, supporting her emotionally, and relieving her of the burden of fighting this deadly illness alone.

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Sleep and Mood Disorders: Implications for Mental Health Care

Getting enough sleep is important for everyone. Well-rested bodies and brains are healthier, more resilient, and more energetic. For those with depression and other mood disorders, getting plenty of sleep must be a priority. In fact, research has demonstrated that people with insomnia are ten times more likely to develop depression than those who get sufficient sleep. Further, new research has shown that sleep disturbances can trigger psychiatric illnesses in those who are vulnerable.

Sleep is every bit as important as medication and therapy in the treatment of mood disorders. For this reason, I make a point of discussing and monitoring sleep patterns with my patients, and I integrate sleep hygiene into their treatment plans.

A recent study financed by the National Institute of Mental Health and published in The New York Times found that a psychological treatment called CBT-I (Cognitive-Behavioral Therapy for Insomnia) doubled the effectiveness of antidepressant medication in the treatment of depression.

This was not surprising to me. I was trained in CBT in graduate school and I have seen cognitive-behavioral techniques work wonders in many of my patients. But the implications of this study, and the fact that the results have made it into the popular media, are quite significant.

One of the most disturbing and unfortunate trends in mental health care in recent years has been the overuse of psychotropic medication and the corresponding underuse of behavioral and psychological interventions. This trend is especially bothersome to me because I am keenly aware – thanks to my training and experience as a psychologist – that certain evidence-based psychological treatments are as effective, if not more effective, than medication for treating certain illnesses.

Unfortunately, most people outside the field of psychology don’t know this. Americans are bombarded daily with advertisements for psychotropic medication on television, online, and in print. It’s only natural, then, that consumers who are suffering from depression or anxiety would request medications from their doctors, even when they have a problem that can be successfully treated by other means.

Don’t get me wrong – I am by no means anti-medication. I am thankful that we have effective, relatively safe medications on the market now that can help people effectively manage serious illnesses which were once disabling. Indeed, psychotropic medication can be extremely helpful – even life-saving – for many people. My concern is that psychotropic medications are prescribed too frequently to people who may not need them, often without the necessary monitoring, and often without the corresponding psychological and behavioral interventions that have been proven effective.

As a psychologist who practices said psychological and behavioral interventions, rather than a psychiatrist who prescribes said medications, am I biased? Well, obviously. I believe in what I do and I chose this profession for a reason. But still.

My hope is that, with articles such as this one, the general public will learn that evidence-based psychological treatments exist which can reduce their suffering and improve their quality of life. I would like people to be fully informed about their options when it comes to mental health treatment. I look forward to the day when people experiencing psychiatric symptoms routinely ask their primary care physicians for referrals to psychologists who practice evidence-based treatments, rather than, or in addition to, asking for prescriptions.

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Columbia University Teen Bulimia Study: Participants Needed

There’s a lot of exciting research being conducted on patients with eating disorders. The results of these studies may help us gain a better understanding of these illnesses and, ultimately, develop more effective treatments.

Here is one study which offers teenage participants free treatment for bulimia nervosa in exchange for participating:

Columbia Center for Eating Disorders Offers No Cost Treatment To Teens with Bulimia Nervosa

Researchers at Columbia University Medical Center are interested in learning about the development of Bulimia Nervosa. We are looking for 10 more girls (12 to 17 years) who binge eat and purge to participate in the study. They can receive inpatient or outpatient treatment at no cost. Monetary compensation (up to $900) is also available. Please call the clinic (212-543-5739) and visit the study website for more details: http://teenbulimiastudy.org/

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Summary of Treatment Outcomes

My blog posts from June through November 2013 have been devoted to describing my patients’ treatment outcomes. I’ve been advised that my recent posts have been too data-heavy and too detailed, but hey – that’s how I roll. I like to be thorough, meticulous, and transparent. Prospective patients and their families deserve to have access to this information. But for those who prefer brevity, I’ve summarized my treatment outcomes below. Click on the headings in bold for details.

    Outcomes for Patients with Anorexia Nervosa


Fifty-seven percent of my former patients with Anorexia Nervosa (AN) completed treatment. Of the “treatment completers,” 94% reached full remission and the remaining 6% reached physical remission. Patients required, on average, 28 sessions over the course of 17 months to complete treatment.

Forty-three percent of my former patients with AN did not complete treatment with me. Of the “treatment non-completers,” 23% were referred to other treatment settings which could better meet their needs; 15% moved to other geographic locations during treatment and thus were referred for treatment near their new homes; and the remaining 62% dropped out of treatment prematurely.

    Outcomes for Patients with Bulimia Nervosa and Eating Disorder Not Otherwise Specified


Thirty-three percent of my former patients with Bulimia Nervosa (BN) and Eating Disorder Not Otherwise Specified (EDNOS) completed treatment. One-hundred percent of those who completed treatment reached full remission. On average, patients took 15 sessions over the course of 10 months to complete treatment. Amongst patients with BN, 44% made significant progress prior to discontinuing treatment prematurely. For patients with EDNOS, 17% made significant progress prior to discontinuing treatment prematurely.

    Outcomes for Patients with Mood Disorders


Twenty-nine percent of patients my former patients with primary diagnoses of mood disorders completed treatment. Of the patients who completed treatment, 83% achieved full remission and the remaining 17% made significant progress. On average, patients took approximately 23 sessions over the course of 11 months to complete treatment.

Thirty-eight percent of mood disorder patients quit treatment prematurely, 24% were referred to other treatment providers who could better meet their needs, and 9% moved to other geographic locations during their treatment and were referred for treatment near their new homes.

    Outcomes for Patients with Anxiety Disorders


All of my former patients with primary diagnoses of anxiety disorders 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. Patients with anxiety disorders attended an average of 10 sessions over the course of 6 months.

Amongst those who completed a full course of treatment, 75% achieved full remission and the remaining 25% made significant progress.

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Pride and Prejudice

“It is never too late to give up your prejudices…No way of thinking or doing, however ancient, can be trusted without proof. What everybody echoes or in silence passes by as true today may turn out to be falsehood tomorrow, mere smoke of opinion.”

– Henry David Thoreau, Walden

Last weekend, I attended the annual National Eating Disorders Association conference in New York City. It was a fantastic conference and an exhilarating experience, a whirlwind of thinking and conversing and listening and networking.

That said, I attended a few lectures that made me cringe and perhaps set the field back a few years. One well-known psychologist and author stated in her lecture that there’s a false dichotomy between research and practice, because all clinicians are, ipso facto, researchers. She went on to explain to the clinicians in the room that that if you work with eating disorder patients and you contemplate eating disorder issues, then you are a researcher.

I think, therefore I am…a researcher?

And therein lies the rub. Working with eating disorder patients and thinking about them does not make you a researcher anymore than watching MSNBC and contemplating the mid-term election makes you a political scientist.

Historically, a major problem within the field of eating disorders is that etiological theories were formed, and treatment approaches created, based upon clinicians’ casual observation and reflection. Hilde Bruch, MD, who wrote the highly influential book The Golden Cage (1978), based her theories on her observation and treatment of the anorexic patients in her practice. Bruch concluded that anorexia nervosa occurs almost exclusively in upper-class white families (because those were the families, residing in her primarily Caucasian neighborhood, who could afford to enter treatment with her), that dysfunctional patterns of family interaction are key in the etiology of anorexia nervosa (because she observed strained and tense relationships between her severely ill patients and their worried parents) and that anorexia represents a misguided attempt at forming an identity and asserting some control over an otherwise uncontrollable life (based upon the self-reports of malnourished patients suffering from a brain disease).

This book was immensely popular amongst clinicians and the general public, as it was the first book to attempt to explain anorexia nervosa, and these theories became professional dogma. Bruch’s ideas spread like wildfire, and it would be many years before scientific research would be published to counter her claims. And to this day, more than three decades later, many clinicians, anorexics, and their families still hold these beliefs.

We are, in general, resistant to change. People have a very hard time letting go of long-held beliefs, which may explain why societal change tends to happen incrementally over generations. Many clinicians have so much pride in the work they have done in the past, and so much prejudice against new ideas which are diametrically opposed to their own, that they vigorously defend the theories they have held forever even when all reliable evidence points to the contrary. They seek to assimilate new information into their preexisting beliefs (for example, a racist person may boast about having one black friend, claiming that his buddy is “not like most black people”) rather than abandoning their old beliefs once it becomes clear that they are flawed. To quote the 17th century philosopher John Locke: “New opinions are always suspected, and usually opposed, without any other reason but because they are not already common.”

It is essential, therefore, that the most recent scientific research on the etiology and effective treatment of eating disorders is featured prominently and unapologetically at local, national, and global events aimed professionals, patients, and families in the eating disorder world. The new message cannot be muted or diluted with antiquated theories or treatments under the politically-correct assumption that all ideas are equally valid. As it is, big-name wealthy treatment centers get the most publicity, most likely because of their massive donations to eating disorder organizations who feature them prominently in exhibit halls at conferences. People are so easily swayed by catch phrases and neat giveaways and glossy brochures featuring impossibly happy eating disordered teenagers riding horses and finger painting. But these centers do not necessarily offer the most effective treatments. If we want our field to make progress, if we truly want to save more lives and rescue more sufferers from the agony of this illness, money cannot trump science.

One of the most promising statements I heard all weekend was this, from a psychologist who is the director of an eating disorders treatment program:

“It is no longer acceptable, in 2010, for clinicians to practice a certain way simply because they have been practicing that way for years.”

My friend Carrie Arnold and I gave a standing ovation to that one and clapped until our hands hurt.

We invite you to join us in doing the same.