Study compares differences between inpatient and day treatment of bulimia nervosa

A German study published in the fifth issue of Psychotherapy and Psychosomatics compares the differences between inpatient and day treatment of bulimia nervosa. The Authors reported in detail on the design and 3-month outcome in a previous article and present the results of the 12-month follow-up in this letter. Fifty-five of 204 patients screened at an outpatient clinic fulfilled the inclusion criteria, gave informed consent and could be randomized. Twenty-one percent were lost before admission.

Finally, 22 patients could be treated in the day clinic and 21 in the inpatient group. The treatments represent common multimodal inpatient and day clinic programs in Germany, integrating psychodynamic, cognitive-behavioral and systemic components. Medication (selective serotonin reuptake inhibitor) was given when needed. Treatment length was about 12 weeks of inpatient or day clinic treatment, with some flexibility.

Before treatment, at discharge as well as at 3- and 12-month follow-up, eating behavior and general psychopathology was assessed by the EDI-2, the expert rating form of the SIAB-EX and the SCL-90-R. Diagnoses were given according to SCID I+II. At 12-month follow-up, treatment since discharge, life events and medication were documented. Differences between groups were tested by T tests, analysis of variance and X² statistics (all tests two-sided). Change effects were tested by ANOVA for repeated measurement.

At the end of the investigation, the Authors found a statistically significant difference in the improvement of bulimic symptoms with an advantage for the day clinic program (p<0.002; intention to treat: exact F = 4.99, df = 1,41, p<0.03). This result was stable when controlling for medication or intensity of psychotherapy after discharge. One third (5 of 15) of the patients that were treated as inpatients deteriorated compared to 1 patient from the day clinic group (1 of 21; Fisher's exact test: p<0.005).

 The Authors found highly significant interactions between setting and frequency ratings of binges (p<0.0008), also after controlling for medication and outpatient psychotherapy sessions. Day clinic patients showed a significantly higher reduction in the number of binges. This was not the case for purging behavior (p<0.999). Using the criteria of full and partial remission, the investigators found no statistically significant difference between settings: 1 year after inpatient treatment, 9 of 15 patients still fulfilled all criteria of the disorder, 3 had a partial remission and 3 patients were in full remission. There were missing data on 6 further cases. One year after day clinic treatment, 10 of 22 patients were still fully symptomatic, 6 in partial remission and 6 in full remission (all tests nonsignificant). There was no significant change in general psychopathology after treatment and no significant difference between the 2 groups (time x setting¸p<0.970; intention to treat: p<0.546).

Results of the study give first evidence of a superiority of day clinic treatment over inpatient treatment in a small sample of bulimic patients. The advantage of day clinic treatment could be shown concerning the course of bulimic symptoms after discharge, but there was no differential impact on general psychic disturbance or purging behavior. The higher impact on bulimic symptoms was found in patient self-ratings (EDI-2) focusing on bulimic cognitions (scale 'bulimia') as well as in an expert rating of binge frequency (SIAB-EX) evaluating eating behavior. The assessment of remission status could not detect this difference, probably due to the severity of patient's initial disturbance (for example, a reduction from 10 binges per day to 2 binges per week would not lead to a change in remission status).