ترک درمان بستری نوجوان و جوان برای بی اشتهایی عصبی

We examined factors predictive of dropout from inpatient treatment for anorexia nervosa (AN) among adolescents in a prospective study of 359 consecutive hospitalizations for AN (DSM-IV). Patients were assessed at admission (clinical, socio-demographic, and psychological data). Multivariate analyses were performed. Drop-out (i.e. leaving hospital before the target weight is achieved) occurred in 24% (n=86) of hospitalizations; in 42.3% (n=30) of the cases, dropout was initiated by the treatment team and in 58.6% (n=41) by the patients and/or their parents. 18.6% (16/86) occurred during the first half of the inpatient program. Frequency of drop-out was significantly higher when the patient was living with only one parent, had been hospitalized previously, had a lower BMI at admission and was over 18 at admission. These elements should draw the attention of the clinician, so that he/she can prepare hospitalization with patients presenting lower admission BMI, particularly by motivational interventions for a better therapeutic alliance, and by the deployment of intensive accompaniment of single parents. Further studies aiming to replicate these results, and including the evaluation of other clinical dimensions such as impulsivity and other personality traits, are needed to elucidate this important topic.

Patients with the most severe forms of anorexia nervosa (AN) often require hospitalization because of malnutrition, the chronic course of their illness, or their psychological state (American Psychiatric Association, 2006). However, a significant percentage of patients with AN do not successfully complete inpatient treatment. Reported drop-out rates range from 20.2% (Surgenor et al., 2004) to 57.6% (Vanderheiken and Pierloot, 1983). Dropping out from inpatient treatment for AN also appears to have a negative impact on the successful long-term treatment overall. More specifically, leaving the hospital before the care program is complete (i.e. target weight achieved) predicts poorer outcome, with an increased risk of relapse within the first year (Baran et al., 1995, Strober et al., 1997 and Carter et al., 2004). Furthermore, patients who have dropped out from inpatient care display more eating disorder symptoms in follow-up (Baran et al., 1995) and a more chronic and severe course of illness. In addition it has been shown that compliance is a major factor among treatment-resistant eating-disordered in-patients, and facilitates recovery and successful treatment (Towell et al., 2001). Very few studies have examined pre-admission factors predictive of drop-out (see Wallier and Fassino for a comprehensive review (Wallier et al., 2009; Fassino et al., 2009)). Socio-demographic, psychological and other clinical factors have been associated with drop-out, although only a small number of predictors have been identified in more than one study. In multivariate analysis, only a few factors have emerged as predictive of drop-out: lower Body Mass Index (BMI) among adults at admission (Surgenor et al., 2004), higher BMI among adolescents at admission (Godart et al., 2005), low desired BMI at admission (Huas et al., 2010), binge eating/purging AN subtype (Surgenor et al., 2004), the absence of comorbid depression (Zeeck et al., 2005), later age at onset, factors related to the eating disorder (weight concerns, restraint, maturity fears, number of symptoms at admission, general psychopathology, eating behavior symptoms) (Kahn and Pike, 2001, Woodside et al., 2004, Surgenor et al., 2004 and Huas et al., 2010), having one or more children (Huas et al., 2010), and low educational status (Huas et al., 2010). Although these studies have unearthed a certain number of predictors of drop-out, they have all focused on samples mostly in an adult age range. We have already published preliminary results in a letter concerning both pre-admission and pre-hospitalization factors in an adolescent population (Godart et al., 2005). We postulated that the reasons why adolescents drop out from care may be different from those for adults, and that this requires further study: the treatment programs and clinical characteristics of these two patient populations are somewhat different. For example, the family environment of adolescent patients, and the parents in particular, has an important role in the success of the treatment (Lock et al., 2006 and Pereira et al., 2006). In addition, non-adult patients are under the legal care of their parents, and hospitalization is possible only with parental approval. Little research has examined these topics. An understanding of the factors associated with adolescents dropping out of care would theoretically make it possible to develop strategies to reduce drop-out rates and improve treatment success rates for the most severe cases of adolescent AN (i.e. needing inpatient treatment), this being a predictive factor for a better long-term outcome (Steinhausen, 2002). Therefore the purpose of this study was to examine factors related to drop-out from inpatient treatment in a large sample of adolescent inpatients with AN. More specifically, this research explored the factors cited above that have been shown to predict drop-out in adult populations, as well as some further elements that we hypothesized could be linked to drop-out (socio-demographic features of parents and patients, and clinical characteristics that describe the severity of patient condition).

Our findings suggest that adolescents who prematurely terminate inpatient treatment for AN (i.e. drop-outs) and those who complete it differ with respect to four predictive variables in multivariate analysis, which should be brought to the attention of the clinician: past history of hospitalization, lower BMI, legal status at admission (major or minor) and living with only one parent. The first three elements should draw the attention of the clinician so that he/she can prepare the way for the hospitalization of these subjects by means of motivational interviews aiming for a better therapeutic alliance and reduced likelihood of drop-out. The fourth element (living with a single parent) should lead to the deployment of an intensive accompaniment of parents, to reduce conflict and inform and support them in this situation so that they in turn can help their child to comply with treatment. Further studies aiming to replicate these results, and including the evaluation of other clinical dimensions such as impulsivity and other personality traits, are needed to elucidate this important topic. These studies should also differentiate dropout initiated by the team and by the families.