Predictors of Treatment Acceptance and Completion in Anorexia Nervosa: Implications for Future Study Designs

Department of Psychiatry, Weill Medical College of Cornell University, White Plains, NY 10605, USA.
Archives of General Psychiatry (Impact Factor: 14.48). 08/2005; 62(7):776-81. DOI: 10.1001/archpsyc.62.7.776
Source: PubMed


There have been very few randomized controlled treatment studies of anorexia nervosa.
To evaluate factors leading to nonacceptance and noncompletion of treatment for 2 specific therapies and their combination in the treatment of anorexia nervosa.
Randomized prospective study.
Weill-Cornell Medical Center, White Plains, NY; University of Minnesota, Minneapolis; and Stanford University, Stanford, Calif. Patients One hundred twenty-two patients meeting DSM-IV criteria for anorexia nervosa.
Treatment with cognitive-behavioral therapy, fluoxetine hydrochloride, or their combination for 1 year.
Dropout rate and acceptance of treatment (defined as staying in treatment at least 5 weeks).
Of the 122 randomized cases, 21 (17%) were withdrawn; the overall dropout rate was 46% (56/122) in the remaining patients. Treatment acceptance occurred in 89 (73%) of the 122 randomized cases. Of the 41 assigned to medication alone, acceptance occurred in 23 (56%). In the other 2 groups, acceptance rate was differentiated by high and low obsessive preoccupation scores (rates of 91% and 60%, respectively). The only predictor of treatment completion was high self-esteem, which was associated with a 51% rate of treatment acceptance.
Acceptance of treatment and relatively high dropout rates pose a major problem for research in the treatment of anorexia nervosa. Differing characteristics predict dropout rates and acceptance, which need to be carefully studied before comparative treatment trials are conducted.

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    • "Anorexia nervosa (AN) in adults is one of the most difficult psychiatric disorders to treat and study (Fairburn et al., 2013; Halmi et al., 2005) because of its high risk of death or disability and poor motivation for change (Arcelus, Mitchell, Wales, & Nielsen, 2011; Treasure, Claudino, & Zucker, 2010). Psychological therapies are the first-line treatment, yet outcomes are poor, dropout is high, and the evidence base is limited (Dejong, Broadbent , & Schmidt, 2012; Watson & Bulik, 2013). "
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    ABSTRACT: Anorexia nervosa (AN) in adults has poor outcomes, and treatment evidence is limited. This study evaluated the efficacy and acceptability of a novel, targeted psychological therapy for AN (Maudsley Model of Anorexia Nervosa Treatment for Adults; MANTRA) compared with Specialist Supportive Clinical Management (SSCM). One hundred forty-two outpatients with broadly defined AN (body mass index [BMI] ≤ 18.5 kg/m2) were randomly allocated to receive 20 to 30 weekly sessions (depending on clinical severity) plus add-ons (4 follow-up sessions, optional sessions with dietician and with carers) of MANTRA (n = 72) or SSCM (n = 70). Assessments were administered blind to treatment condition at baseline, 6 months, and 12 months after randomization. The primary outcome was BMI at 12 months. Secondary outcomes included eating disorders symptomatology, other psychopathology, neuro-cognitive and social cognition, and acceptability. Additional service utilization was also assessed. Outcomes were analyzed using linear mixed models. Both treatments resulted in significant improvements in BMI and reductions in eating disorders symptomatology, distress levels, and clinical impairment over time, with no statistically significant difference between groups at either 6 or 12 months. Improvements in neuro-cognitive and social-cognitive measures over time were less consistent. One SSCM patient died. Compared with SSCM, MANTRA patients rated their treatment as significantly more acceptable and credible at 12 months. There was no significant difference between groups in additional service consumption. Both treatments appear to have value as first-line outpatient interventions for patients with broadly defined AN. Longer term outcomes remain to be evaluated. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
    Full-text · Article · May 2015 · Journal of Consulting and Clinical Psychology
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    • "This study aimed to first to investigate associations between health related quality of life, stage of change and other previously found factors such as illness sub-type and treatment attrition in women with SE-AN, and the second aim was to explore the strength of association between adaptive function and stage of change and other more established predictors of attrition. In this study, as in Halmi et al. [28] there were few factors associated with treatment dropout; one of which was however not previously reported namely, poor eating disorder quality of life. The previously consistently identified factor of AN-purging subtype [1-3] was as well associated with treatment attrition in this study. "
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    ABSTRACT: Attrition is common in the treatment of anorexia nervosa and its causes are complex and incompletely understood. In particular, its relationship with adaptive function and motivational stage of change has been little studied. This study aimed to (1) investigate and (2) compare the strength of associations between adaptive function, stage of change and other previously found factors such as illness sub-type and treatment attrition in women with severe and enduring anorexia nervosa (SE-AN). Participants were 63 adult women with SE-AN of at least 7 years duration who were enrolled in a multi-site randomized controlled trial conducted from July 2007 through June 2011. Treatment comprised 30 outpatient visits over 8 months of either Cognitive Behaviour Therapy for Anorexia Nervosa (CBT-AN) or Specialist Supportive Clinical Management (SSCM) both of which were modified for severe and enduring illness. Assessments were done at baseline, end of treatment, and 6 and 12 month post treatment follow-up. Demographic variables, duration of illness, specific and generic health related quality of life (QoL), eating disorder (ED) and mood disorder symptoms, social adjustment, body mass index (BMI), and motivation for change were assessed with interview and self-report questionnaires. Treatment attrition was defined as leaving therapy after either premature termination according to trial protocol or self-instigated discharge. Binary logistic regression was used to investigate relative strength of associations. Those who did not complete treatment were significantly more likely to have the purging sub-type of anorexia nervosa and poorer ED related QoL. There were no significant differences between attrition and which therapy was received, educational level, and global ED psychopathology, stage of change, BMI, social adjustment, duration of illness or level of depression. The strongest predictors on multivariable analysis were ED QoL and AN-purging subtype. This study supported previous findings of associations between attrition and purging subtype. Furthermore, we found associations between a potentially important cycle of attrition, and poorer EDQoL, which has not been previously reported. Contrary to expectations we did not find an association with BMI, severity of ED symptoms, low level of motivation to change ED features, or level of education.
    Full-text · Article · Mar 2014 · BMC Psychiatry
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    • "These symptoms of emotional instability, irritability and loss of concentration make it more difficult for the patient to engage in meaningful psychotherapy that results in behavior change. Severity of core eating disorder psychopathology usually predicts greater resistance to treatment in anorexia nervosa patients [3]. "
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    ABSTRACT: Treatment resistance is an omnipresent frustration in eating disorders. Attempts to identify the features of this resistance and subsequently develop novel treatments have had modest effects. This selective review examines treatment resistant features expressed in core eating disorder psychopathology, comorbidities and biological features. Novel treatments addressing resistance are discussed.Description: The core eating disorder psychopathology of anorexia nervosa becomes a coping mechanism likely via vulnerable neurobiological features and conditioned learning to deal with life events. Thus it is reinforcing and ego syntonic resulting in resistance to treatment. The severity of core features such as preoccupations with body image, weight, eating and exercising predicts greater resistance to treatment. Bulimia nervosa patients are less resistant to treatment with treatment failure related to greater body image concerns, impulsivity, depression, severe diet restriction and poor social adjustment. For those with binge eating disorder overweight in childhood and high emotional eating predicts treatment resistance. There is suggestive data that a diagnosis of an anxiety disorder and severe perfectionism may confer treatment resistance in anorexia nervosa and substance use disorders or personality disorders with impulse control problems may produce resistance to treatment in bulimia nervosa. Traits such as perfectionism, cognitive inflexibility and negative affect with likely genetic influences may also affect treatment resistance. Pharmacotherapy and novel therapies have been developed to address treatment resistance. Atypical antipsychotic drugs have shown some effect in treatment resistant anorexia nervosa and topiramate and high doses of SSRIs are helpful for treatment of resistant binge eating disorder patients. There are insufficient randomized controlled trials to evaluate the novel psychotherapies which are primarily based on the core psychopathological features of the eating disorders. Treatment resistance in eating disorders is usually predicted by the severity of the core eating disorder psychopathology which develops from an interaction between environmental risk factors with genetic traits and a vulnerable neurobiology. Future investigations of the biological features and neurocircuitry of the core eating disorders psychopathology and behaviors may provide information for more successful treatment interventions.
    Full-text · Article · Nov 2013 · BMC Psychiatry
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