Integrated Enhanced Cognitive Behavioural (I-CBTE) therapy significantly improves effectiveness of inpatient treatment of anorexia nervosa in real life settings

Abstract

Inpatient treatment of anorexia nervosa (AN) often results in poor outcomes. To address this, the Oxford service has adapted the multistep enhanced cognitive behavioural (CBTE) treatment model, first developed in Italy, to an NHS setting. Aim: to evaluate short- and long-term outcomes of Integrated CBTE (I-CBTE) with alternative treatment models in routine clinical practice. Methods This is a longitudinal cohort study, involving all adults with AN admitted from a geographical area in England covering a total population of 3.5 million between 2017-2020 using routinely collected data. We compared treatment as usual (TAU) with the Oxford model, which included: 1. short term planned admission with partial weight restoration; 2. I-CBTE (weight restoration defined as BMI 20, combined with 7 weeks day treatment followed by outpatient CBTE); 3. standalone inpatient CBTE. Primary outcome measures (min. 1 year after discharge from hospital) were defined as: 1. good outcome: BMI>19.5 and no binge purging behaviour; 2. poor outcome: BMI<19.5 and/or binge purging; 3. readmission; or 4. deceased. Secondary outcomes were BMI on admission and discharge, and length of stay. Results 212 patients were admitted to 15 specialist units in the UK depending on availability: 120 to Oxford and 92 elsewhere. The mean age: 28.9 (18-60) years, mean BMI: 14.4. There were no significant differences in baseline parameters between patients admitted to different units. Mean discharge BMI was >19.0 in the CBTE groups, 16.0 in the short admission and 17.0 in the TAU groups. At one year follow up, 70% of patients receiving I-CBTE maintained good outcomes, in contrast with <5% TAU or planned short admissions. Readmission rates were 14.3% vs ~60% (χ2=0.0000). Standalone CBTE had intermediate outcomes. The main predictor of good long-term outcome was I-CBTE. Conclusions Our main finding is that in a real-life setting, I-CBTE has superior short- and long-term outcomes as compared with alternative inpatient treatment models. This was achievable regardless of age, and BMI on admission. Dissemination of I-CBTE across the care pathway has the potential to transform outcomes of inpatient treatment for this high-risk patient population and reduce personal and societal costs.