Combining day treatment and outpatient treatment for eating disorders: findings from a naturalistic setting

Abstract

Background

Day treatment programs for individuals with eating disorders (ED) have been the subject of research and are promoted as an alternative to inpatient treatment due to their therapeutic and economic advantages, but have not regularly been implemented in regular care.

Purpose

We investigated the long-term effectiveness of a transdiagnostic combined eating disorder treatment program which consisted of an 8-week day treatment phase followed by an average of 19 sessions of outpatient treatment over an average of 39 weeks in a naturalistic setting.

Methods

We accepted 148 patients with different diagnoses of eating disorders into our combined treatment program. We assessed weight, behavioral eating disorder symptoms and eating disorder related cognitions and attitudes at the beginning and the end of the day treatment phase and after 6, 12 and 26 months.

Results

Over the course of the 8-week day treatment phase, patients with initial binge eating, purging and/or fasting behavior reduced these symptoms by 91%, 90% and, 86%. Patients who were underweight at baseline gained on average 1.05 BMI points (d = 0.76). In addition, eating disorder related cognitions and attitudes of all patients significantly improved with large effect sizes (d = 1.12). On average, all improvements remained stable during the follow-up period.

Conclusions

Our findings add to the existing studies on day treatment and support previously found encouraging effects of treatment programs that combine day treatment and consecutive outpatient treatment for eating disorders.

Level of evidence

Level III, longitudinal cohort study.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

References

  1. 1.

    Hay P, Chinn D, Forbes D et al (2014) Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry 48:977–1008. https://doi.org/10.1177/0004867414555814

    Article  PubMed  Google Scholar 

  2. 2.

    National Guideline Alliance (2017) National institute for health and care excellence: clinical guidelines. In: Eating disorders: recognition and treatment. National Institute for Health and Care Excellence, London

    Google Scholar 

  3. 3.

    American Psychiatric Association (2006) Practice guidelines for the treatment of patients with eating disorders. APA

  4. 4.

    Herpertz S, Herpertz-Dahlmann B, Fichter M et al (2011) S3-Leitlinie Diagnostik und Behandlung der Essstörungen. Springer, Berlin

    Google Scholar 

  5. 5.

    Fairburn CG (2005) Evidence-based treatment of anorexia nervosa. Int J Eat Disord 37(Suppl):S26–S30. https://doi.org/10.1002/eat.20112 (discussion S41–22)

    Article  PubMed  Google Scholar 

  6. 6.

    Watson HJ, Bulik CM (2013) Update on the treatment of anorexia nervosa: review of clinical trials, practice guidelines and emerging interventions. Psychol Med 43:2477–2500. https://doi.org/10.1017/S0033291712002620

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Madden S, Hay P, Touyz S (2015) Systematic review of evidence for different treatment settings in anorexia nervosa. World J Psychiatry 5:147–153. https://doi.org/10.5498/wjp.v5.i1.147

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Dalle Grave R, Ricca V, Todesco T (2001) The stepped-care approach in anorexia nervosa and bulimia nervosa: progress and problems. Eating and weight disorders. EWD 6:81–89

    CAS  PubMed  Google Scholar 

  9. 9.

    Herpertz-Dahlmann B, Schwarte R, Krei M et al (2014) Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa (ANDI): a multicentre, randomised, open-label, non-inferiority trial. Lancet 383:1222–1229. https://doi.org/10.1016/S0140-6736(13)62411-3

    Article  PubMed  Google Scholar 

  10. 10.

    Treat TA, Mccabe EB, Gaskill JA et al (2008) Treatment of anorexia nervosa in a specialty care continuum. Int J Eat Disord 41:564–572. https://doi.org/10.1002/eat.20571

    Article  PubMed  Google Scholar 

  11. 11.

    Birchall H, Palmer RL, Waine J et al (2002) Intensive day programme treatment for severe anorexia nervosa—the Leicester experience. Psychiatr Bull 26:334–336. https://doi.org/10.1192/pb.26.9.334

    Article  Google Scholar 

  12. 12.

    Piran N, Kaplan A, Kerr A et al. (1989) A day hospital program for anorexia-nervosa and bulimia. Int J Eat Disord 8:511–521. https://doi.org/10.1002/1098-108x(198909)8:5%3C511::Aid-Eat2260080503%3E3.0.Co;2-1

    Article  Google Scholar 

  13. 13.

    Lammers MW, Exterkate CC, De Jong CA (2007) A Dutch day treatment program for anorexia and bulimia nervosa in comparison with internationally described programs. Eur Eat Disord Rev 15:98–111. https://doi.org/10.1002/erv.767

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Thornton C, Beumont P, Touyz S (2002) The Australian experience of day programs for patients with eating disorders. Int J Eat Disord 32:1–10. https://doi.org/10.1002/eat.10059

    Article  PubMed  Google Scholar 

  15. 15.

    Peake KJ, Limbert C, Whitehead L (2005) An evaluation of the Oxford adult eating disorders service between 1994 and 2002. Eur Eat Disord Rev 13:427–435. https://doi.org/10.1002/erv.627

    Article  Google Scholar 

  16. 16.

    Dancyger I, Fornari V, Schneider M et al (2003) Adolescents and eating disorders: an examination of a day treatment program. Eat Weight Disord 8:242–248

    CAS  Article  Google Scholar 

  17. 17.

    Abbate-Daga G, Gramaglia C, Preda S et al (2009) Day hospital programmes for eating disorders: a review of the similarities, differences and goals. Eat Weight Disord 14:e31–e41

    CAS  Article  Google Scholar 

  18. 18.

    Friedman K, Ramirez AL, Murray SB et al (2016) A narrative review of outcome studies for residential and partial hospital-based treatment of eating disorders. Eur Eat Disord Rev 24:263–276. https://doi.org/10.1002/erv.2449

    Article  PubMed  Google Scholar 

  19. 19.

    Olmsted MP, Mcfarlane T, Trottier K et al (2013) Efficacy and intensity of day hospital treatment for eating disorders. Psychother Res 23:277–286. https://doi.org/10.1080/10503307.2012.721937

    Article  PubMed  Google Scholar 

  20. 20.

    Abbate-Daga G, Marzola E, De-Bacco C et al (2015) Day hospital treatment for anorexia nervosa: a 12-month follow-up study. Eur Eat Disord Rev 23:390–398. https://doi.org/10.1002/erv.2369

    Article  PubMed  Google Scholar 

  21. 21.

    Brown TA, Cusack A, Anderson LK et al (2018) Efficacy of a partial hospital programme for adults with eating disorders. Eur Eat Disord Rev 26:241–252. https://doi.org/10.1002/erv.2589

    Article  PubMed  Google Scholar 

  22. 22.

    Fittig E, Jacobi C, Backmund H et al (2008) Effectiveness of day hospital treatment for anorexia nervosa and bulimia nervosa. Eur Eat Disord Rev 16:341–351. https://doi.org/10.1002/erv.883

    Article  PubMed  Google Scholar 

  23. 23.

    Goldstein M, Peters L, Baillie A et al (2011) The effectiveness of a day program for the treatment of adolescent anorexia nervosa. Int J Eat Disord 44:29–38. https://doi.org/10.1002/eat.20789

    Article  PubMed  Google Scholar 

  24. 24.

    Willinge AC, Touyz SW, Thornton C (2010) An evaluation of the effectiveness and short-term stability of an innovative Australian day patient programme for eating disorders. Eur Eat Disord Rev 18:220–233. https://doi.org/10.1002/erv.997

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Hoste RR (2015) Incorporating family-based therapy principles into a partial hospitalization programme for adolescents with anorexia nervosa: challenges and considerations. J Fam Therapy 37:41–60. https://doi.org/10.1111/1467-6427.12055

    Article  Google Scholar 

  26. 26.

    Henderson K, Buchholz A, Obeid N et al (2014) A family-based eating disorder day treatment program for youth: examining the clinical and statistical significance of short-term treatment outcomes. Eat Disord 22:1–18. https://doi.org/10.1080/10640266.2014.857512

    Article  PubMed  Google Scholar 

  27. 27.

    Girz L, Robinson AL, Foroughe M et al (2013) Adapting family-based therapy to a day hospital programme for adolescents with eating disorders: preliminary outcomes and trajectories of change. J Fam Therapy 35:102–120. https://doi.org/10.1111/j.1467-6427.2012.00618.x

    Article  Google Scholar 

  28. 28.

    Ornstein RM, Essayli JH, Nicely TA et al (2017) Treatment of avoidant/restrictive food intake disorder in a cohort of young patients in a partial hospitalization program for eating disorders. Int J Eat Disord 50:1067–1074. https://doi.org/10.1002/eat.22737

    Article  PubMed  Google Scholar 

  29. 29.

    Ornstein RM, Lane-Loney SE, Hollenbeak CS (2012) Clinical outcomes of a novel, family-centered partial hospitalization program for young patients with eating disorders. Eat Weight Disord 17:e170–e177

    CAS  Article  Google Scholar 

  30. 30.

    Crino N, Djokvucic I (2010) Cohesion to the group and its association with attendance and early treatment response in an adult day-hospital program for eating disorders: a preliminary clinical investigation. Clin Psychol 14:54–61. https://doi.org/10.1080/13284207.2010.500308

    Article  Google Scholar 

  31. 31.

    Exterkate CC, Vriesendorp PF, De Jong CA (2009) Body attitudes in patients with eating disorders at presentation and completion of intensive outpatient day treatment. Eat Behav 10:16–21. https://doi.org/10.1016/j.eatbeh.2008.10.002

    Article  PubMed  Google Scholar 

  32. 32.

    Schaffner AD, Buchanan LP (2008) Integrating evidence-based treatments with individual needs in an outpatient facility for eating disorders. Eat Disord 16:378–392. https://doi.org/10.1080/10640260802370549

    Article  PubMed  Google Scholar 

  33. 33.

    Jones A, Bamford B, Ford H et al (2007) How important are motivation and initial Body Mass Index for outcome in day therapy services for eating disorders? Eur Eat Disord Rev 15:283–289. https://doi.org/10.1002/erv.736

    Article  PubMed  Google Scholar 

  34. 34.

    Manara F, Manara A, Todisco P (2005) Correlation between psychometric and biological parameters in anorexic and bulimic patients during and after an intensive day hospital treatment. Eat Weight Disord 10:236–244

    CAS  Article  Google Scholar 

  35. 35.

    Ben-Porath DD, Wisniewski L, Warren M (2010) Outcomes of a day treatment program for eating disorders using clinical and statistical significance. J Contemp Psychother 40:115–123. https://doi.org/10.1007/s10879-009-9125-5

    Article  Google Scholar 

  36. 36.

    Zeeck A, Herzog T, Hartmann A (2004) Day clinic or inpatient care for severe bulimia nervosa? Eur Eat Disord Rev 12:79–86. https://doi.org/10.1002/erv.535

    Article  Google Scholar 

  37. 37.

    Gerlinghoff M, Backmund H, Franzen U (1998) Evaluation of a day treatment programme for eating disorders. Eur Eat Disord Rev 6:96–106. https://doi.org/10.1002/(Sici)1099-0968(199806)6:2%3C96::Aid-Erv236%3E3.0.Co;2-P

    Article  Google Scholar 

  38. 38.

    Zeeck A, Weber S, Sandholz A et al (2011) Stability of long-term outcome in bulimia nervosa: a 3-year follow-up. J Clin Psychol 67:318–327. https://doi.org/10.1002/jclp.20766

    Article  PubMed  Google Scholar 

  39. 39.

    Zipfel S, Reas DL, Thornton C et al (2002) Day hospitalization programs for eating disorders: a systematic review of the literature. Int J Eat Disord 31:105–117. https://doi.org/10.1002/eat.10009

    Article  PubMed  Google Scholar 

  40. 40.

    Birchall H, Palmer RL, Waine J et al (2018) Intensive day programme treatment for severe anorexia nervosa—the Leicester experience. Psychiatr Bull 26:334–336. https://doi.org/10.1192/pb.26.9.334

    Article  Google Scholar 

  41. 41.

    Williamson DA, Thaw JM, Varnado-Sullivan PJ (2001) Cost-effectiveness analysis of a hospital-based cognitive-behavioral treatment program for eating disorders. Behav Ther 32:459–477 doi. https://doi.org/10.1016/S0005-7894(01)80031-9

    Article  Google Scholar 

  42. 42.

    Goddard E, Hibbs R, Raenker S et al (2013) A multi-centre cohort study of short term outcomes of hospital treatment for anorexia nervosa in the UK. BMC Psychiatry 13:287. https://doi.org/10.1186/1471-244X-13-287

    Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Kong S (2005) Day treatment programme for patients with eating disorders: randomized controlled trial. J Adv Nurs 51:5–14. https://doi.org/10.1111/j.1365-2648.2005.03454.x

    Article  PubMed  Google Scholar 

  44. 44.

    World Health Organization (1992) The ICD-10 Classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. World Health Organization, Geneva

    Google Scholar 

  45. 45.

    Hilbert A, Tuschen-Caffier B (2006) Eating disorder examination: deutschsprachige Übersetzung. Verlag für Psychotherapie., Münster

    Google Scholar 

  46. 46.

    Berg KC, Peterson CB, Frazier P et al (2012) Psychometric evaluation of the eating disorder examination and eating disorder examination-questionnaire: a systematic review of the literature. Int J Eat Disord 45:428–438. https://doi.org/10.1002/eat.20931

    Article  PubMed  Google Scholar 

  47. 47.

    Hilbert A, Tuschen-Caffier B, Karwautz A et al (2007) Eating disorder examination-questionnaire. Evaluation der deutschsprachigen Übersetzung. Diagnostica 53:144–154. https://doi.org/10.1026/0012-1924.53.3.144

    Article  Google Scholar 

  48. 48.

    Franke GH (2000) BSI: Brief Symptom Inventory von L. R. Derogatis—Kurzform der SCL-90-R. Deutsche Version. Manual. Beltz Test, Göttingen

    Google Scholar 

  49. 49.

    Derogatis LR, Savitz KL (1999) The SCL-90-R, brief symptom inventory, and matching clinical rating scales. In: The use of psychological testing for treatment planning and outcomes assessment, 2nd edn. Lawrence Erlbaum Associates Publishers, Mahwah, pp 679–724

    Google Scholar 

  50. 50.

    Ferring D, Filipp S-H (1996) Messung des Selbstwertgefühls: Befunde zu Reliabilität, Validität und Stabilität der Rosenberg-Skala. Diagnostica 42:284–292

    Google Scholar 

  51. 51.

    Rosenberg MJ (1965) Society and the adolescent self-image. Princeton University Press, Princeton

    Google Scholar 

  52. 52.

    Jacobi C, Thiel A, Paul T (2008) Kognitive Verhaltenstherapie bei Anorexia und Bulimia nervosa. Beltz, Weinheim

    Google Scholar 

  53. 53.

    Fairburn CG, Cooper Z, Shafran R (2003) Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment. Behav Res Ther 41:509–528. https://doi.org/10.1016/S0005-7967(02)00088-8

    Article  PubMed  Google Scholar 

  54. 54.

    Chakraborty H, Gu H (2009) A mixed model approach for intent-to-treat analysis in longitudinal clinical trials with missing values. RTI Int Res Triangle Park. https://doi.org/10.3768/rtipress.2009.mr.0009.0903

    Article  Google Scholar 

  55. 55.

    Rabe-Hesketh S, Skrondal A (2012) Multilevel and longitudinal modeling using stata, volumes I and II. Stata Press, College Station

    Google Scholar 

  56. 56.

    Statacorp (2013) Stata statistical software: release 13. StataCorp LP, College Station

    Google Scholar 

  57. 57.

    Cohen J (1988) Statistical power analysis for the behavioral sciences. Erlbaum, Hillsdale

    Google Scholar 

  58. 58.

    Feingold A (2013) A regression framework for effect size assessments in longitudinal modeling of group differences. Rev Gen Psychol 17:111–121. https://doi.org/10.1037/a0030048

    Article  PubMed  Google Scholar 

  59. 59.

    Kazis LE, Anderson JJ, Meenan RF (1989) Effect sizes for interpreting changes in health status. Med Care 27:S178–S189

    CAS  Article  Google Scholar 

  60. 60.

    Leonhart R (2004) Estimating effect sizes in clinical trials. Rehabilitation (Stuttg) 43:241–246. https://doi.org/10.1055/s-2004-828293

    CAS  Article  Google Scholar 

  61. 61.

    Höfler M (2004) Statistik in der Epidemiologie psychischer Störungen. Springer, Heidelberg

    Google Scholar 

  62. 62.

    Bardone-Cone AM, Harney MB, Maldonado CR et al (2010) Defining recovery from an eating disorder: conceptualization, validation, and examination of psychosocial functioning and psychiatric comorbidity. Behav Res Ther 48:194–202. https://doi.org/10.1016/j.brat.2009.11.001

    Article  PubMed  Google Scholar 

  63. 63.

    Brauhardt A, De Zwaan M, Hilbert A (2014) The therapeutic process in psychological treatments for eating disorders: a systematic review. Int J Eat Disord 47:565–584. https://doi.org/10.1002/eat.22287

    Article  PubMed  Google Scholar 

  64. 64.

    Fichter MM, Leibl K, Rief W et al (1991) Fluoxetine versus placebo: a double-blind study with bulimic inpatients undergoing intensive psychotherapy. Pharmacopsychiatry 24:1–7. https://doi.org/10.1055/s-2007-1014424

    CAS  Article  PubMed  Google Scholar 

  65. 65.

    Zeeck A, Weber S, Sandholz A et al (2009) Inpatient versus day clinic treatment for bulimia nervosa: a randomized trial. Psychother Psychosom 78:152–160. https://doi.org/10.1159/000206869

    Article  PubMed  Google Scholar 

  66. 66.

    Kordy H, Kramer B, Palmer RL et al (2002) Remission, recovery, relapse, and recurrence in eating disorders: conceptualization and illustration of a validation strategy. J Clin Psychol 58:833–846. https://doi.org/10.1002/jclp.2013

    Article  PubMed  Google Scholar 

  67. 67.

    Willer MG, Thuras P, Crow SJ (2005) Implications of the changing use of hospitalization to treat anorexia nervosa. Am J Psychiatry 162:2374–2376. https://doi.org/10.1176/appi.ajp.162.12.2374

    Article  PubMed  Google Scholar 

  68. 68.

    Hartmann A, Weber S, Herpertz S et al (2011) Psychological treatment for anorexia nervosa: a meta-analysis of standardized mean change. Psychother Psychosom 80:216–226. https://doi.org/10.1159/000322360

    Article  PubMed  Google Scholar 

  69. 69.

    Zipfel S, Wild B, Gross G et al (2014) Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial. Lancet 383:127–137. https://doi.org/10.1016/S0140-6736(13)61746-8

    Article  PubMed  Google Scholar 

  70. 70.

    Fairburn CG, Cooper Z, Doll HA et al (2009) Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up. Am J Psychiatry 166:311–319. https://doi.org/10.1176/appi.ajp.2008.08040608

    Article  PubMed  Google Scholar 

  71. 71.

    Rienecke RD (2018) Treatment dropout in a family-based partial hospitalization program for eating disorders. Eat Weight Disord. https://doi.org/10.1007/s40519-018-0543-9

    Article  PubMed  Google Scholar 

  72. 72.

    Dalle Grave R, Bohn K, Hawker DM et al (2008) Inpatient, day patient and two forms of outpatient CBT-E. In: Fairburn CG (ed) Cognitive behavior therapy and eating disorders. Guilford Press, New York, pp 231–244

    Google Scholar 

  73. 73.

    Masson PC, Perlman CM, Ross SA et al (2007) Premature termination of treatment in an inpatient eating disorder programme. Eur Eat Disord Rev 15:275–282. https://doi.org/10.1002/erv.762

    Article  PubMed  Google Scholar 

  74. 74.

    Wallier J, Vibert S, Berthoz S et al (2009) Dropout from inpatient treatment for anorexia nervosa: critical review of the literature. Int J Eat Disord 42:636–647. https://doi.org/10.1002/eat.20609

    Article  PubMed  Google Scholar 

  75. 75.

    Dejong H, Broadbent H, Schmidt U (2012) A systematic review of dropout from treatment in outpatients with anorexia nervosa. Int J Eat Disord 45:635–647. https://doi.org/10.1002/eat.20956

    Article  PubMed  Google Scholar 

  76. 76.

    Mccabe RE, Mcfarlane T, Polivy J et al (2001) Eating disorders, dieting, and the accuracy of self-reported weight. Int J Eat Disord 29:59–64

    CAS  Article  Google Scholar 

Download references

Acknowledgements

Katrin Schuster, Susann Theuring, Katja Hergesell, Jana Kullmann, Annett Joerss (staff therapists). Eike Fittig, Peter Musiat (data management).

Author information

Affiliations

Authors

Corresponding author

Correspondence to Ina Beintner.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures followed were in accordance with the ethical standards (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Beintner, I., Hütter, K., Gramatke, K. et al. Combining day treatment and outpatient treatment for eating disorders: findings from a naturalistic setting. Eat Weight Disord 25, 519–530 (2020). https://doi.org/10.1007/s40519-019-00643-6

Download citation

Keywords

  • Eating disorders
  • Day treatment
  • Naturalistic study