Discussion
anxiety, weight gain, psychiatric, comorbid disorder, AN, reduction, depressive symptoms
REMISSION, PATHOLOGY
Few empirical data examine the implementation of guideline-oriented CBT for EDs and associated outcomes in routine clinical care. In the present study, findings for full-time treatment (e.g., hospitalization) were contrasted with findings for ambulatory treatment. Across settings, patient characteristics and treatment intensity were quite heterogeneous. Due to these differences, direct comparisons of treatment outcomes between settings are not indicated and results should not be interpreted as superiority of one treatment setting over another. Generally, the present study showed that a substantial number of patients with AN and BN displayed symptomatic improvements on several indicators of mental health within three months of treatment admission, although recovery rates remained quite low.Among women with AN receiving full-time treatment, substantial improvements were observed in body weight, depressive symptoms, symptoms of anxiety, and somatic symptoms, while improvements in ED pathology were moderate. It should be noted that, particularly for this group, the range of the number of psychotherapeutic sessions received was remarkably broad, indicating strong variations in treatment intensity. Results showed that, for women with AN, reduction in ED pathology was directly related to the number of psychotherapeutic sessions received, while weight gain was associated with higher AN severity (i.e., more severe underweight). Although nearly one fifth of patients with AN was considered partially remitted after three months of full-time treatment, the recovery rate (i.e., full remission of symptoms) was very low (3.1%). In line with this, a multi-centre study of short-term outcomes of inpatient treatment (e.g. hospitalization) similarly reported large increases in BMI and improvements in physical health, but the majority of patients remained in an underweight BMI range and continued to display clinical levels of ED symptoms at discharge [For women with BN receiving full-time treatment, large improvements in self-reported ED pathology and somatic symptoms were observed as well as moderate improvements in depressive symptoms and symptoms of anxiety. In line with this, research indicates that nearly half of patients with severe BN showed clinically significant symptom changes after hospitalization [Several differences between the full-time setting and the ambulatory setting are noteworthy. First, as expected, patient characteristics differed between settings. Patients with AN receiving full-time treatment were younger, had a lower BMI, and more often a severe or extreme form of AN compared to ambulatory AN patients. Patients with BN receiving full-time treatment more often reported the use of psychopharmateucis, were more often diagnosed with a comorbid disorder, and more often displayed an extreme form of BN compared to ambulatory BN patients. These findings indicate that ED severity and psychiatric comorbidity are somewhat more severe among patients who voluntarily admitted to full-time treatment compared to ambulatory treatment. Yet, it is noteworthy that approximately half of all full-time AN patients displayed a mild or moderate severity form (average BMI of full-time AN patients was 16.7). This finding indicates that, in clinical practice, hospitalization of patients with AN often occurs for reasons other than very low body weight (i.e., severe form of AN).Furthermore, treatment intensity differed largely between settings as well as treatment institutions. Full-time patients with AN received on average 65 psychotherapeutic sessions within three months after admission and full-time patients with BN received on average 38 psychotherapeutic sessions. It should be noted, that the range of the number of sessions differed largely, especially among AN patients. In this context, it should be noted that one treatment institution adminstered a highly intensive AN treatment program (including 2–5 individual sessions per day plus daily group sessions, resulting in an average of 130 psychotherapeutic sessions for AN patients in this treatment institution), thereby strongly increasing the average number of psychotherapeutic sessions for full-time AN patients in the present study. In line with this, previous studies have already noted a large variability in treatment programs and outcomes [The present study has several limtations. First of all, generalizability of the present findings may be limited by several factors including small sample size of subgroups, specific sample characteristics of study participants, or specific characteristics of cooperating treatment institutions. It should be acknowledged that both patients and institutions do not represent the general population. Furthermore, the present study only examined a few potential covariates. It is possible that additional patient or treatment characteristics may be associated with treatment setting as well as symptom course. In addition, the present study does not include a control group. Therefore, it cannot disentangle symptomatic improvements attributable to the treatment and naturally occurring fluctuations in symptoms. Furthermore, the short-term outcomes reported in the present study should be distinguished from long-term outcomes. As treatments may still be ongoing, remission rates after treatment termination will probably be higher. Therefore, comparisons to the remission rates of clinical trials, which typically report remission rates after treatment termination, are not feasible. Finally, it should be noted that the response rate of therapists, who provided information regarding treatment characteristics, was relatively low (67%). The strengths of the present study include the application of a thorough diagnostical procedure and well-validated measures among ED patients in nine different treatment facilities in Germany and Switzerland. It is one of the few studies evaluating outcomes of guideline-oriented ED treatment in routine clinical care.In conclusion, the present study showed considerable symptomatic improvements among patients with AN and BN in routine clinical care. Among women with AN, full-time treatment was associated with substantial improvements in body weight, ED pathology, depressive symptoms, symptoms of anxiety, and somatic symptoms. Among women with BN, full-time treatment and ambulatory treatment were associated with considerable improvements on all measured variables, but with different treatment dosages. Results also show that full recovery of EDs is typically not achieved within three months of treatment initiation and requires prolonged treatment duration, even after initial symptomatic improvements during intensive hospitalization. Generally, results also show that treatment intensity and treatment outcomes are quite diverse, indicating the possibility for increasing effectiveness in the treatment of EDs in routine clinical care.