Remuda Ranch

Length of Stay and Eating Disorder Treatment

Course of Treatment for Eating Disorders

Effective treatment of eating disorder patients involves more than acute medical stabilization. According to the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Eating Disorders (2000), eating disorder treatment is most effective when it includes multi-disciplinary teams working with cognitive-behavioral, skills-oriented, family systems, and holistic approaches across a full continuum of care.

Eating disorders have the highest mortality rate of any psychiatric disorder, ranging between 5-15% for patients with anorexia and 1-2% for those with bulimia (e.g., Casper & Jabine, 1996; Eckert, Halmi, Marchi, Grove, & Crosby, 1995; Steinhausen & Seidel, 1993). Half of patients with eating disorders have the potential for imminent and serious self-harm (Theander, 1992) and those with anorexia are 57 times more likely to commit suicide than the expected rate for women in the same age/racial groupings (Herzog, Keel, Dorer, Franko, Eddy, & Charat, 2002).

Specialized, rather than general, treatment is imperative for successful outcome (American Psychiatric Association, 2000). The cognitions and environmental triggers that elicit eating disorder behaviors often arise from complex developmental and psychosocial disruptions, often overdetermined (Fairburn & Brownell, 2002). The intense focus of the eating disorder functions as a form of emotion regulation, distracting patients from difficult emotions and thoughts related to trauma, relationship problems, maturational deficits, and identity issues (McCabe & Marcus, 2002)..The patient must therefore cease the destructive behaviors first in order to acknowledge and experience the troubling emotions and thoughts for which the eating disorder is being used to cope. Only after cessation of eating disorder behaviors can patients begin developing ego-strength, healthy identity apart from the eating disorder, constructive coping mechanisms, appropriate emotion regulation skills, and obtain benefit from cognitive-behavioral therapies.. As such, a cessation of active eating disorder behaviors is only the beginning of treatment. Unless a range of new skills is established, the patient will revert to eating disorder behaviors in order to cope with difficult emotions and thoughts. Repetitive relapses, multiple acute hospitalizations, and a protracted course of outpatient treatment are therefore common with eating disorder patients. The cost of multi-year outpatient treatment alone may approach $100,000 (National Association of Anorexia Nervosa and Associated Disorders, 1999), with additional costs for multiple acute hospitalizations. Clearly, this approach to treatment is not the most cost-effective.

Most patients are able to decrease or cease bingeing, purging, and restricting behaviors rather quickly in a highly structured milieu that is monitored 24 hours a day. For several reasons, however, this is generally not an indication of their ability to maintain recovery outside of the restrictive environment. First, patients with eating disorders often evidence high performance and people-pleasing behaviors and may therefore appear, at least superficially, to be making rapid progress. Second, patients are unable to maintain recovery because the inability to engage in ineffective eating disorder behaviors usually causes intense anxiety. Patient’s emotional and cognitive changes lag behind the pace of acute stabilization and symptom decrease. Although the patient may be able to refrain from eating disorder or other ineffective behaviors with continual supervision, intervention, and support, without the requisite cognitive and emotional development the patient is likely to relapse into the perceived comfort of the eating disorder when structure is decreased. Relapse rates for eating disorders are accordingly quite high, ranging from 35% to 44% within roughly one year of treatment (Carter et al., 2004; Halmi et al., 2003).

Some patients have a long history of eating disorder thoughts and ineffective behaviors, and their eating disorders are complicated by co-occurring factors including depression, obsessive-compulsive traits, PTSD, Axis II, and a range of anxiety disorders (Blinder, Cumella, & Sanathara, 2004). Given the longevity and complexity of such cases, to expect that cognitive changes, mood regulation, and actual behaviors can be effectively treated in a short time frame is unrealistic. For success to occur, cognitive re-structuring must take place to reduce irrational fears, body image distortions, obsessive thought processes, trauma, and other issues related to the identity and perceived control provided by the eating disorder.

Often, the severity of an eating disorder and ingrained thought patterns prevent patients from embracing recovery despite a high level of motivation. Distorted eating disorder thoughts and obsessions generally have become so pervasive that patients are unable to overcome them without sustained intervention and support. To discharge such patients prematurely may serve to treat the outward symptoms of the disorder but not the complex psychiatric and psychological issues involved. If a patient is discharged too early based on a superficial display of program compliance and reverts to eating disorder behaviors, progress and emotional development are hindered, the patient is much more likely to relapse (Vandereycken, 2003) and to have a chronic, deteriorating course of illness (Zipfel, Lowe, Reas, Deter, & Herzog, 2000).

Remuda’s Mission and Goals

Remuda offers a full continuum of care for eating disorder patients and is therefore able to find the appropriate intensity and duration of intervention needed for patients based on individualized assessments. Above all, Remuda has long specialized in treating the most severe and complex eating disorder cases. Remuda has aimed to develop a treatment program that meets all of the American Psychiatric Association’s (2000) guidelines for treating eating disorders as well as offers the range of treatments with scientific evidence for efficacy with this population (Fairburn & Brownell, 2002). The intention of the Remuda program is to dramatically improve eating disorder treatment success over the average expectation of 50-75% for other treatment programs; to enable patients to escape the financially costly and medically tragic revolving door of multiple acute stabilizations and relapses; and to virtually eliminate mortality from this disease. Remuda’s extensive treatment outcome research confirms its success in achieving these goals (Cumella, 2001a; Cumella, 2001b), with a one-year post-discharge success rate of 92%, an inpatient readmission rate only ¼ that of other treatment programs (Davis, 2003), a relapse rate perhaps only 1/5 as high as other treatments (Carter et al., 2004; Halmi et al., 2003), and a mortality rate of less than 1/10 the expectation in the field (Richards, Baldwin, Frost, Clark-Sly, Berrett, & Hardman, 2000).

Remuda’s mission includes:

• provision of a full continuum of specialized treatment exclusively dedicated to the care of individuals suffering from eating disorders and related problems
• safe, non-institutional environments
• cost-effective interventions
• a consistent philosophy of individualized treatment
• family involvement to change environmental patterns that cause relapse and sustain eating disorders
• educational programs designed to meet the full range of treatment needs

To accomplish this mission, Remuda has developed a program that includes:

• broad ranges of evidence-based therapeutic activities
• a coordinated system across the continuum of care
• individualized interventions designed to bring about continuing lifestyle change
• challenging therapeutic environments
• a staff committed to meeting clients’ medical, nutritional, psychological, educational, and spiritual needs
• ongoing relationships with eating disorder specialists around the country to coordinate seamless care transitions

For the provision of such treatment, each patient is assessed and treated by a team of professionals, including psychiatric and primary care providers, psychologists, registered dietitians, Master’s prepared therapists, and registered nurses.

The objective of treatment is to establish a foundation for recovery instead of mere crisis stabilization for patients with severe eating disorders. Length of stay issues were considered when developing program components capable of delivering the range of treatments needed to accomplish this objective. Remuda’s estimated length of stay has been established over the course of time based on Remuda’s experience as the largest eating disorder inpatient treatment center in North America and its treatment of nearly 6,000 eating disorder inpatients. Individualized lengths of stay are assigned based on norms developed for the patient populations and diagnostic profiles that we have served and post-discharge assessments of recovery success (Cumella, 2001a; Cumella, 2001b). If a patient does better than expected or assimilates more slowly compared to our norm, the discharge date is flexible. However, until the patient is thoroughly assessed and engaged in treatment, we progress with the norm as our standard.

The length of stay is estimated in all patients based on the severity and history of their eating disorder behaviors and symptoms. The appropriateness of the projected length of stay is evaluated throughout the patient’s stay by the Treatment Team. The estimated length of stay is generally established based on the minimum expected number of days necessary for a positive outcome; however, patients determined to be no longer in need of the intensive level of care may be discharged or transferred at an earlier date. Remuda’s team, invested in real and lasting outcomes, relies on the results of ongoing objective assessments, scientific studies, and best practices to make these length of stay determinations (e.g., Commerford et al., 1997).

We encourage the comparison of our treatment outcomes with those of other programs. We are confident that our method of providing a multi-modal program and comprehensive treatment that addresses all aspects of the eating disorder is not only in the best interest of the patient, but is actually the most cost-effective in the long-term due to the decreased need for multiple admissions, repeat acute medical stabilization, and protracted outpatient care. Many insurance companies that were initially resistant to Remuda’s program now recommend Remuda to their clients due to the positive outcomes experienced by previously treated patients within their network and their less than satisfactory experiences with other treatment programs. Although Remuda’s intensive treatment program necessitates a longer length of stay than some other programs offer, the investment proves to be cost effective and humane in the intermediate and longer terms.

For more information on Remuda Programs for Eating Disorders, please call 1-800-445-1900.

References

American Psychiatric Association (2000). Practice guideline for the treatment of patients with eating disorders (revision). American Journal of Psychiatry, Suppl., 157, 1-39.

Blinder, B.J., Cumella, E.J., & Sanathara, V. (2004). Psychiatric comorbidities of female inpatients with eating disorders. American Journal of Psychiatry, in press.

Carter, J.C., Blackmore, E., Sutandar-Pinnock, K., & Woodside, D.B. (2004). Relapse in anorexia nervosa: A survival analysis. Psychological Medicine, 34, 671-679.

Casper, R.C., & Jabine, L.N. (1996). An eight year follow-up: Outcome from adolescent compared to adult onset anorexia nervosa. Journal of Youth and Adolescence, 25, 499-518.

Commerford, M.C., Licinio, J., & Halmi, K.A. (1997). Guidelines for discharging eating disorder inpatients. Eating Disorders: The Journal of Treatment and Prevention, 5, 69-74.

Cumella, E.J. (2001a). Treatment outcome reports: Rio adult intensive center. Wickenburg, AZ: Remuda Ranch Center for Anorexia and Bulimia, Inc.

Cumella, E.J. (2001b). Treatment outcome reports: Del Sol adolescent intensive center. Wickenburg, AZ: Remuda Ranch Center for Anorexia and Bulimia, Inc.

Davis, W.N. (Summer 2003). Treatment outcome research and the Renfrew Center. The Renfrew Center Foundation Perspective, 14-16.

Eckert, E.D., Halmi, K.A., Marchi, P., Grove, W., & Crosby, R. (1995). Ten year follow-up of anorexia nervosa: Clinical course and outcome. Psychological Medicine, 25, 143-156.

Fairburn, C.G. & Brownell, K.D. (2002). Eating disorders and obesity: A comprehensive handbook. New York: The Guilford Press.

Halmi, K.A., Agras, W.S., Mitchell, J., Wilson, G.T., Crow, S., Bryson, S.W., & Kraemer, H. (2003). Relapse predictors of patients with bulimia nervosa who achieve abstinence through cognitive behavioral therapy. Archives of General Psychiatry, 59, 1105-1109.

Herzog, D.B., Keel, P.K., Dorer, D.J., Franko, D.L., Eddy, K.T., & Charat, V.E. (2002). Predictors of mortality in eating disorders. Paper presented at the Academy for Eating Disorders International Conference on Eating Disorders, Boston, MA, April 25-28, 2002.

McCabe, E.B. & Marcus, M.D. (2002). Is dialectical behavior therapy useful in the management of anorexia nervosa? Eating Disorders: The Journal of Treatment and Prevention, 10, 335-337.

National Association of Anorexia Nervosa and Associated Disorders (1999). Statistical Fact Sheet. National Association Anorexia Nervosa and Associated Disorders.

Richards, P.S., Baldwin, B.M., Frost, H.A., Clark-Sly, J.B., Berrett, M.E., & Hardman, R.K. (2000). What works for treating eating disorders? Conclusion of 28 outcome reviews. Eating Disorders: The Journal of Treatment and Prevention, 8,189-206

Steinhausen, H.C., & Boyadjieva, S. (1996). The outcome of adolescent anorexia nervosa: Findings from Berlin and Sofia. Journal of Youth and Adolescence, 25, 473-482.

Steinhausen, H.C., & Seidel, R. (1993). Outcome in adolescent eating disorders. International Journal of Eating Disorders, 14, 487-496.

Theander, S. (1992). Chronicity in anorexia nervosa: Results from the Swedish long-term follow-up study. In W. Herzog, H.C. Deter, & W. Vandereycken (Eds.), The course of eating disorders: Long term follow up studies of anorexia nervosa and bulimia nervosa (pp. 214-227). Berlin: Springer.

Vandereycken, W. (2003). The place of inpatient care in the treatment of anorexia nervosa: Questions to be answered. International Journal of Eating Disorders, 34, 409-422.

Zipfel, S., Reas, D.L., Thornton, C., Olmsted, M.P., Williamson, D.A., Gerlinghoff, M., Herzog, W., & Beamont, P.J. (2002). Day hospitalization programs for eating disorders: A systematic review of the literature. International Journal of Eating Disorders, 31, 105-117.