Design
Cohort study of patients successfully treated for AN included in a relapse prevention program for AN, with a follow-up of 18 months.
Participants and setting
The following inclusion criteria were applied: in- and outpatients, age 12 years and older, meeting the diagnostic criteria of the DSM-IV [19] for AN or EDNOS clinically referred to as AN (for example women meeting all criteria for AN, except that the individual has menses. In 33 cases the diagnosis was determined according to the DSM-IV criteria and ascertained by eating disorder experts (all psychiatrists), supported by questions from the EDE (Eating Disorder Examination) [20, 21]. In 50 cases the actual EDE interview was administered to confirm the eating disorder diagnosis that was determined by the psychiatrist in accordance with the DSM-IV criteria.
Participants had successfully completed their treatment, were weight restored with a normal (SD) BMI based on their age and height. For inclusion it was further required that they had drawn up a relapse prevention plan (RPP) at the end of their treatment.
Ninety-six patients were eligible to participate in the after-care program between 2009 and 2012, where the Guideline Relapse Prevention Anorexia Nervosa (GRP) was implemented. Thirteen participants did not meet the inclusion criteria: seven participants did not have a complete RPP, two patients were re-admitted for treatment during the drafting of the RPP, two participants refused to participate in the after-care program after making a RPP, one patient moved abroad before starting the after-care program, and one patient was admitted to a closed ward during this study due to severe comorbidity (severe depression with a risk of suicide). The remaining 83 participants were included in the analyses.
The study was carried out in a specialized treatment center for eating disorders in the Netherlands, Altrecht Eating Disorders Rintveld. The treatment provided in this specialized setting is based on the state-of-the-art evidence- and practice-based knowledge as described in three guidelines: The Dutch Multidisciplinary Guideline Eating Disorders [15], the NICE guidelines Eating Disorders [16] and the American Psychiatric Association Practice Guideline: Treatment of Patients with Eating Disorders [17]. Treatment focuses on three areas: (1) eating habits, body weight, and body image; (2) psychological aspects of functioning, such as self-esteem, perfectionism, and traumas; and (3) social functioning within the family system and in society. In our center, patients are basically treated on an outpatient basis, and only admitted for short periods at a time, followed by outpatient treatment. All patients who started the relapse prevention program received prior outpatient treatment. Only when remission was reached during outpatient treatment were patients eligible for participation in the aftercare program. Comorbidity is managed either in the center itself or by co-treatment in a different specialized center.
Definition of relapse
In the present study the primary outcome was the occurrence of relapse. The distinction was made between full and partial relapse. A full relapse was defined as: BMI <18.5 for adults and SD BMI < -1 for adolescents, together with full recurrence of the core diagnostic symptoms of AN according to DSM-IV criteria, in the first instance assessed by the professional, and next confirmed in a multidisciplinary consensus meeting. In case of confirmation, this formed an indication for renewed treatment. Partial relapse was defined as the re-occurrence of one or more core diagnostic symptoms of AN, after a previous positive response to treatment. As a response to the re-occurrence of symptoms, a temporary intensification of the after-care program for a period up to three months was needed to achieve full recovery again. If a longer intensification of the program was needed the relapse was classified as a full relapse.
The guideline relapse prevention anorexia nervosa (GRP)
The primary aim of the guideline is that the professional, patient and her relatives work closely together to gain a better understanding of the patient’s individual process of relapse. Triggers and early warning signs that preceded previous relapses are identified and elaborated for the individual patient, and actions are formulated that can be performed in the event of a new impending relapse. All this information is summarized in a Relapse Prevention Plan (RPP). The essence of the relapse prevention strategy is to ensure that appropriate action is taken as early as possible when early warning signs of relapse occur.
The guideline is made up of three parts: (a) a theoretic framework for relapse and relapse prevention, developed on the basis of both the literature and practical experience of experts and patients, leading to conclusions and recommendations for clinical practice; (b) a practical manual for the professional; and (c) a workbook for patients.
For a complete description of the application of the GRP, see the case report by Berends, van Meijel & van Elburg [22]. The GRP is freely accessible via the internet.
Drawing up a fully fledged relapse prevention plan requires approximately six meetings of patient, relatives and the professional. Practical experience with the application of the GRP showed that individual sessions should last approximately 45 min and should preferably be scheduled every other week. After each session, the patient receives homework assignments, to be carried out either individually or together with relatives.
After a RPP is drawn-up, the aftercare-program starts. This is a low-frequent individual program and has a minimum duration of 18 months. During the aftercare-visits the condition of the patient is thoroughly monitored and discussed. Two scenarios can occur during these visits: 1) The patient is stable, in which case the focus is on maintaining this stable condition by promoting good physical health and optimal personal and social functioning. Actual or possible stressful life events in the near future are discussed and anticipated on. 2) The patient shows one or more early signs of impending relapse, in which case the main focus during the visit is on obtaining a thorough understanding of the actual triggers of relapse, and how to deal with these in order to promote recovery. In this context specific arrangements are made and actions are planned, based on the content of the previously established relapse prevention plan (RPP).
The frequency of the aftercare visits depends on the patient’s condition and the need for treatment and care. For example, patients who are stable will come for a visit after four to six months. If the patient is less stable the visits can be planned every two months. The patient and the professional can decide to extend the aftercare period after 18 months in case of prolonged vulnerability to relapse, with a maximum of five years.
The visits last 45 min and are attended by both the patient and her relatives. At each visit the patient is weighed and her condition is evaluated. During the visit, two main topics are discussed, i.e., psychological and social functioning (school, friends, sports, overall moods, etc.) and the presence of AN-symptoms (anorectic cognitions, abnormal eating habits, excessive exercise pattern et cetera). Based on this information, the RPP is updated if necessary. At the end of the visit a new appointment is made for the next visit. The patient’s record contains the following details of each visit: weight, possible stage of relapse, and the arrangements made during the visit.
Between the formal visits, a patient or her relatives can contact the professional at any time in case of need for help.
Data collection
Data were collected on:
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1.
Demographic and clinical characteristics: age, age of onset, severity of the eating disorder, treatment duration, duration of the eating disorder, BMI, in- or outpatient treatment, number of sessions in the aftercare program, subtype of AN (restrictive type (ANR) or binge/purging type (ANBP)), and comorbidity (as ascertained by psychiatrists at the start of treatment and confirmed in a consensus meeting by the clinical team).
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2.
Data concerning full and partial relapse: weight, stage of relapse, and the agreements made during the visit.
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When a participant had a full relapse the indication for renewed treatment was documented.
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When a participant had a partial relapse the stage of relapse was documented, as well as the intensification of the aftercare-visits. When a participant crossed the three-month duration of partial relapse, it was registered as a full relapse.
Data-analysis
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1.
Kaplan-Meier survival analysis was used to analyze the rate and timing of full relapse.
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2.
Demographic and clinical characteristics between the group of patients with either full or partial relapse, and the group of patients with no relapse are presented with percentages and means.
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3.
In order to identify significant predictors of relapse, Cox regression was used to assess the predictive value of demographic and clinical characteristics with respect to relapse. First, the variables were tested univariate, after which predictors with a p-value < .10 were entered in a multivariate Cox regression model. SPSS for Windows (version 21.0) was used to perform all statistical procedures.