The Villa Garda treatment is feasible and promising for patients with severe and persistent anorexia nervosa

The Villa Garda treatment is feasible and promising for patients with severe and persistent anorexia nervosa

When persists anorexia nervosa (AN) for more than seven years it has defined as serious and persistent (IF-AN). Various studies have found that patients with SE-AN have a poor quality of life, increased risk of developing serious medical comorbidities, (osteoporosis, cardiovascular abnormalities and brain structural changes) associated with a reduced life expectancy. In addition, due to high levels of disability that affects their ability to work, often a significant burden for their families, health professionals and the welfare state.

The on the an outcome studies have shown that the long duration of the disorder before treatment is a poor prognostic factor. This is why the American insurance companies often refuse to fund the treatment of patients with SE-AN and the United Kingdom offer to these patients only a general psychiatric treatment or any kind of care.

Recently it has been also proposed a new treatment paradigm for patients with SE-AN shifting the objectives of the intervention by a model of care based on healing, which is promoted weight recovery, one aimed at improving the rate of retention in treatment and quality of life, to minimize the damage and prevent further experiences of failure.

In partial support of this approach are the findings of a recent randomized controlled trial comparing two psychological treatments adapted for patients with SE-AN which aimed to improve the quality of life but not to promote weight recovery : cognitive behavioral therapy (CBT-SE) and clinical management support specialist (SSCM-SE). A 6-month follow-up, despite the small increase in body mass index (BMI), patients treated with CBT-SE obtained lower values ??to the global score dell'Eating

Disorder Examination (EDE) and increased availability to heal than those taking the SSCM-SE. In addition, both treatments were associated with a low drop-out rate (15%).

However, there are strong reasons to indicate that pessimism about prospects for recovery of patients with SE-AN is not entirely justified, and it is premature to abandon treatment models based on healing for this subgroup of patients.

First, the majority of randomized controlled trials on the effectiveness of treatments based on the healing did not include patients with SE-AN and, therefore, we have no data on how they respond to treatment  evidence-based , such as cognitive-behavioral therapy improved (CBT-E) or therapy based on the family (FBT). In addition, some case reports have reported that patients with AN many years may benefit from additional treatment and in some of them, reach a full recovery.

In light of these encouraging results, it was performed at the Nutritional Rehabilitation Unit of the Nursing Home Villa Garda a study that compared the short- and long-term outcomes of patients with SE-AN and with less duration of the disturbance (NSE -AN) treated with a hospital rehabilitation program based on CBT-E and oriented to healing.

Sixty-six adult patients aged 18 and suffering from AN 65 were recruited from patients consecutively admitted. The BMI and all'EDE scores and the Brief Symptom Inventory (BSI) were recorded on admission, at the end of the treatment, at 6 and 12 months of follow-up. For the assessment of ' outcomes  have been used three measures:

Good BMI Outcome : BMI = 18.5 kg / m 2
Full Response : BMI of = 18.5 kg / m 2  and overall score all'EDE <1.74
Definition of gravity of AN according to the DSM-5: mild (BMI = 17), moderate (BMI 16 - 16,99), severe (BMI 15 - 15,99), extreme (BMI <15)

Thirty-two patients (48.5%) were classified as SE-AN (ie duration of the disturbances> 7 years), and 34 (51.5%) as the NSE-AN. Compared to patients with SE-AN, those classified as NSE-AN were aged significantly lower and lower frequency of misuse of laxatives.

Fifty-six participants (84.8%) completed the treatment, while 10 (15.2%) left the program before the end of the 20 weeks of treatment provided, with no difference between the groups and SE NSE-AN-AN. During treatment, both groups showed a similar and large increase of BMI and a significant improvement in the specific and general psychopathology.

From discharge to 6 months of follow-up there was little deterioration that stops between 6 and 12 months (see Figure). In addition, a 12-month follow-up, both groups showed similar rates of  Good Outcome BMI  (44.0% and 40.7%, respectively) and  Full Response  (32.0% and 33.3%, respectively ).

As for the severity indicators, the percentage of patients in the NSE-AN group of extreme gravity has dropped from 55.9% at baseline to 12% at 12 months of follow-up, and similar declines were also observed in the group SE-AN (46.9% vs 11.1%) (See Table).

The Villa Garda treatment is feasible and promising for patients with severe and persistent anorexia nervosa

Figure 1.   Estimated Means of body mass index (BMI), and global scores dell'Eating Disorder Examination (EDE) and the Brief Symptom Inventory (BSI) at each point of time in patients with anorexia nervosa not serious and persistent and ( NSE-AN) and persistent serious and persistent anorexia nervosa (AN-SE). Estimates are obtained using mixed effects models

Table .  Good BMI outcome ,  full response  and the current level of gravity to any time in patients co anorexia nervosa not serious and persistent (NSE-AN) and severe and persistent anorexia (IF-AN). Data are shown as frequency and percentage.

The study produced three major results. The first concerns the acceptability of patients admitted and treated with CBT-E. Over 80% of eligible patients agreed to undertake the processing and 85% completed it, with no significant differences between the groups and NSE SE-AN-AN, despite the objective of normalizing weight had been explained before recovery.

The second result is that both groups have achieved a substantial increase in BMI, and significant improvements in the specific and general psychopathology, with CBT-E hospital. At the end of the treatment, most patients who completed the course of treatment has reached a  Good Outcome BMI  and over 40% met the criteria for  Full Response .

These positive results are evident even at 12-month follow-up, when over 40% of both groups maintained a  Good Outcome BMI  and more than 30% a  Full Response.  Finally, the data show that between baseline and 12 months of follow-up, the majority of patients has gone from one extreme severity to one mild.

The third and most important result of the study is that there are no significant differences between the two groups in the short and long term outcomes. Although it has been observed a disparity in the BMI change curves, indicating that compared to patients with NSE-AN, those with SE-AN have had a more rapid initial improvement of the BMI, a more stable maintenance up to 6 months of follow up, and decreased slightly faster follow-up of 12 months, there is no significant difference in BMI scores at various times.

The study's findings have several clinical implications. First, the data show that the duration of AN in patients who are motivated to change does not seem to influence the results of a hospital intensive treatment based on a model of healing. This suggests that it is not yet time to give up heal patients with SE-AN.

Clinicians should always keep in mind that patients who do not reach the normal weight are intended to develop medical complications and psychological damage of increasing severity that inevitably compromise their quality of life. For this reason it is recommended that the audition therapists always to engage patients with SE-AN in treatments aimed at normalizing weight and remission of psychopathology, before concluding that you can not benefit from the recovery-oriented treatment.

The programs cha are meant to minimize damage and improve the quality of life, de-emphasizing weight recovery, they should only be considered for patients with AN who have not had any success in ambulatory and hospital treatments well-conducted and / or with those who have a persistent lack of motivation to change, regardless of the duration of their disorder.

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