Comments about the article “Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa (ANDI): a multicentre, randomized, open-label, non-inferiority trial”

Authors: Riccardo Dalle Grave, Simona Calugi, Marwan El Ghoch

Department of Eating and Weight Disorders, Villa Garda Hospital. Via Montebaldo, 89, 37016 Garda (Vr), Italy, rdalleg@tin.it, si.calugi@gmail.com, marwan1979@hotmail.com

Source: Herpertz-Dahlmann B, Schwarte R, Krei M, Egberts K, Warnke A, Wewetzer C, Pfeiffer E, Fleischhaker C, Scherag A, Holtkamp K, Hagenah U, Buhren K, Konrad K, Schmidt U, Schade-Brittinger C, Timmesfeld N, Dempfle A. Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa (ANDI): a multicentre, randomised, open-label, non-inferiority trial. Lancet. 2014.

We read with interest the paper by Herpertz-Dahlmann et al., recently published in the Lancet,1 concluding that inpatient treatment and day treatment have similar effects in adolescents with anorexia nervosa (AN). However, before it is widely accepted that day treatment may be a less costly alternative to inpatient treatment for such patients, which could have a significant impact on their management, it is vital that the aforementioned study is interpreted in its appropriate context.

Indeed, the mean percentile of patients’ BMI at discharge, 17.2, suggests that the inpatient treatment in question failed to produce complete weight restoration in a subgroup of patients. As complete weight restoration is a fundamental goal of inpatient treatment, being associated with better outcome, at least in adults,2 this suggests that the inpatient treatment arm was suboptimal, and therefore less than ideal for comparative purposes. Likewise, the mean BMI percentile reported at 12-month follow-up fell to as low as 16.7, and only 23% of patients had a BMI ≥20th percentile. This contrasts starkly with the results of a recent study on adolescents with AN in whom inpatient treatment produced a BMI percentile of 34.2 at discharge and 29.9 at 12-month follow-up (67% of patients had a BMI ≥20th percentile).3

Although comparison of treatments in samples not paired for key clinical variables and administered in countries with different health systems is problematic, the question of how well the less intensive (day) treatment would fare if compared with a more successful inpatient strategy still remains.

References

  1. Herpertz-Dahlmann B, Schwarte R, Krei M, Egberts K, Warnke A, Wewetzer C, Pfeiffer E, Fleischhaker C, Scherag A, Holtkamp K, Hagenah U, Buhren K, Konrad K, Schmidt U, Schade-Brittinger C, Timmesfeld N, Dempfle A. Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa (ANDI): a multicentre, randomised, open-label, non-inferiority trial. Lancet. 2014.
  2. Kaplan AS, Walsh BT, Olmsted M, et al. The slippery slope: prediction of successful weight maintenance in anorexia nervosa. Psychol Med 2009; 39: 1037-45.
  3. Dalle Grave R, Calugi S, El Ghoch M, Conti M,  Fairburn C.G. Inpatient cognitive behaviour therapy for adolescents with anorexia nervosa: immediate and longer-term effects. Front Psychiatry, 2014. doi: 10.3389/fpsyt.2014.00014.