BRIEF REPORT

Does Family-Based Treatment Reduce the Need for

Hospitalization in Adolescent Anorexia Nervosa?

James Lock, MD, PhD1* ABSTRACT

Objective: We examined the timing and
W. Stewart Agras, MD1 number of days of hospitalization during
S.W. Bryson, MS1 the course of treatment, hospitalization
effects on outcome, and predictors and
Harry Brandt, MD2 moderators of the use of hospitalization
Katherine A. Halmi, MD3 in adolescents with anorexia nervosa
Walter Kaye, MD4 (AN).
Denise Wilfley, PhD5 Method: Data used in this study were
Blake Woodside, MD6 collected from 158 adolescents (ages 12
to 18 years of age) who met DSM-IVTR
Sarah Pajarito, MS1 criteria for AN (exclusive of the amenor-
Booil Jo, PhD1 rhea criteria) randomized to receive
either Family Based Treatment (FBT) or
Systemic Family Therapy (SyFT) in a 7 site
study.
for improvements in percent weight
change for both treatment groups
(t(1)52.6, p 5 0.011). Co-morbid psycho-
pathology predicted early hospital use in
both treatments. Higher levels of eating
related obsessions and depression mod-
erated hospitalization rates suggesting
that FBT reduces early hospitalization
rates compared to SyFT for these
subgroups.
Discussion: These data support and
extend findings from previous studies by
identifying patterns of hospital use, and
predictors and moderators of treatment
effect for early hospitalization use in ado-
lescent AN. VC 2016 Wiley Periodicals, Inc.

Results: The trajectory of hospital day Keywords: anorexia nervosa; hospi-

use is similar in the first 5 weeks irrespec- talization; adolescents; family
tive of treatment allocation. However, therapy
days of hospitalization continued to
increase throughout SyFT but leveled off (Int J Eat Disord 2016; 00:000-000)
in FBT after 5 weeks of treatment. Early
hospitalization was a negative predictor

Introduction ing weight gain in the short-term, long term

benefits have not been demonstrated.2 Two studies
The cost of treatment for adolescent anorexia nerv- suggest that Family Based Treatment (FBT) is a
osa (AN) is relatively high for a psychiatric disorder; specific form of family therapy that reduces the use
the main cause of this high cost being the use of of hospitalization in adolescent AN. Lock et al.3
hospitalization.1 Although a number of studies sug- found that significantly fewer adolescents who
gest that inpatient treatment is effective at promot- were treated with FBT were hospitalized than those
who received individual therapy. Similarly Agras
Accepted 21 February 2016 et al. found participants who received FBT gained
Trial registration: clinicaltrials.gov. identifier NCT 00610753 weight significantly more quickly early in treat-
Supported by 1U01 MH076290, MH 076254, MH 076251, MH ment and used fewer hospital days than those who
076255, MH 076252 from National Institute of Mental Health.
*Correspondence to: J. Lock, Department of Behavioral Sciences,
received Systemic Family Therapy (SyFT).4 The
Stanford University, School of Medicine, 401 Quarry Road, purpose of the current exploratory study is to shed
Stanford, CA. E-mail: jimlock@stanford.edu
1
further light on hospitalization use by adolescent
Department of Psychiatry and Behavioral Sciences, Stanford
University
AN patients during treatment by examining the
2
Sheppard Pratt Health System, 6501 N Charles St, Towson, MD process of hospitalization in the above study4 that
21204
3
compared FBT to SyST to describe patterns of hos-
Department of Psychiatry, Weill Medical College, Cornell
University, Westchester Division. 21 Bloomingdale Rd. White
pital use, hospital effects on outcome, and predic-
Plains, NY 10605 tors and moderators of hospitalization.
4
Department of Psychiatry, University of San Diego, 9500
Gilman Dr, La Jolla, CA 92093
5
Department of Psychiatry, Washington University, 4940
Childrens Pl, St Louis, MO 63110
6
Method
Department of Psychiatry, University of Toronto, 1001 Queen
Street W. Toronto, ON M6J 1H4 The study was conducted between September 2005 and
Published online 00 Month 2016 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/eat.22536 April 2012 and involved a randomized parallel compari-
VC 2016 Wiley Periodicals, Inc. son of FBT and SyFT. The study was approved by the

International Journal of Eating Disorders 00:00 0000 2016 1

LOCK ET AL.
Institutional Review Board at each site. After describing
the study to the participating families, written informed
consent was obtained from the parents and an assent
from the adolescent. Details describing this studys pro-
tocol and primary outcomes are available elsewhere.4
For this study we examined the hospitalization data for
each of the participants together with relevant baseline
data. Medical and psychiatric hospitalization admission
and discharge decisions were made by clinicians blind to
the treatment randomization of participants. Medical
hospitalizations, the main type utilized in this study,
were based on guidelines by the Society of Adolescent
Medicine for the inpatient treatment of adolescents with
anorexia nervosa.5
Measures
The following measures were used in this study:
1. Hospital days for individuals and by treatment includ-
ing both medical and psychiatric hospitalizations.
2. Timing (by weeks of treatment) of hospital usage. Hos-
pitalizations were divided into early (during the first 5-
weeks of treatment) and late (after 5-weeks of treat-
ment) based on examination of the data.
3. Weight defined as percent mean body weight for age,
height and gender using CDC norms.6
4. Attrition was defined as either dropping out of treat-
ment or the study.
Other secondary outcome measures used were the
Eating Disorder Examination (EDE),7 Yale-Brown-
Cornell-Eating Disorder Scale (YBC-ED),8 Rosenberg
Self-Esteem Scale (RSE),9 Beck Depression Inventory
(BDI),10 Child-YaleBrown Obsessive Compulsive Scale
(CY-BOCS),11 Kiddie-Schedule for Affective Disorders
and Schizophrenia KSADS),12 Multidimensional Perfec-
tions Scale (MPS)13 as described in the original article.
For purposes of this study only baseline measures were
used as potential predictors or moderators of
hospitalization.
Statistical Analysis
Because the hospital data were not normally distrib-
uted, nonparametric statistics were used as appropriate.
Analyses were conducted in line with the intent-to-treat
principle. The timing of hospitalization and use of hospi-
tal days between the two treatments was investigated by
plotting the variables and examining the effects on hos-
pitalization by treatment group. We also examined the
effect of hospitalization on dropout from treatment and
on clinical outcome. In addition, we examined all base-
line variables as potential moderators of treatment
assignment effect on early hospitalization in line with
the McArthur approach.14 We used logistic regression
2 International Journal of Eating Disorders 00:00 0000 2016
analysis for our investigation of moderators and non-
specific predictors of early hospitalization. In this explor-
atory analysis we relaxed the significance level
(alpha5.10) to allow detection of potential moderators in
this relatively small sample.15
Results
Participants
Data used in this study were collected from 158
(78 in FBT, 80 in SyFT) adolescents (ages 12 to 18
years of age) who met DSM-IVTR criteria for AN
(exclusive of the amenorrhea criteria). The mean
age of participants was 15.3 (1.8) years, 89.2% were
female, the average duration of AN was 13.5 (13.9)
months. Full details of participant characteristics
and the study protocol are available elsewhere.4 As
reported in the original article there were no differ-
ences between groups for any demographic or
baseline variable. There were also no statistically
significant differences between treatments for per-
cent ideal body weight, eating disorder symptoms,
or comorbid psychiatric disorders at either end of
treatment or 1 year follow-up.
Pattern of Hospitalization Use
Figure 1 illustrates two distinct patterns of hos-
pital use during treatment based on treatment
assignment (FBT 5 12; SyFT 5 15). Most hospital-
izations (73%) occurred in the first 5 weeks of treat-
ment (early hospitalization). The median number
in days for those hospitalized early for FBT was 7
(Interquartile Range 5 20) compared with 23 for
SyFT (Interquartile Range 5 21), Mann-Whitney
U 5 28.5, p 5 0.018. While hospitalizations contin-
ued throughout treatment in SyFT, there were few
later hospitalizations (after 5 weeks of treatment)
for FBT. For FBT 2 patients (16.6% of early hospital-
izations) were rehospitalized after the first 5-weeks
of treatment and for SyFT 6 patients (40%) were
rehospitalized, accounting for a total of 6 rehospi-
talizations for FBT and 13 for SyFT because of mul-
tiple hospitalizations per patient. The total number
of hospital days used in SyFT was 655 and 369 in
FBT. As noted previously the median number
of days per hospitalization was 21.0 for SyFT and
8.3 for FBT, Mann-Whitney U 5 51.0, p 5 0.02.4
Although not statistically significant, weight gain
differed between groups during the first 4-weeks of
treatment for those hospitalized early (9.0 lbs for
FBT and 0.2 lbs for SyFT).
 HOSPITALIZATION IN ADOLESCENT ANOREXIA NERVOSA

Effects of Early Hospitalization on Outcomes
There was no effect of early hospitalization
on treatment attrition or later hospitalization dur-
ing the treatment period. However, early hospitali-
zation was a negative predictor (see Table 1) for
the percent weight change for both treatment
groups.
Participant Characteristics Predictive of Early
Hospitalization
In line with our original article,10 we examined
16 baseline variables as potential moderators of
treatment effect on early hospitalization. None of
these variables were identified as moderators using
our a priori significance level of alpha 5 0.05 (two-
tailed), but six variables were found to be nonspe-
cific predictors of early hospitalization (see Table 1
for descriptive data). That is, regardless of the treat-
ment assignment status (i.e., FBT vs. SyFT), partici-
pants with lower baseline scores on the BDI, YBC-
ED. MPI, or RSE and lower baseline rates of com-
pensatory behavior and comorbidity were less
likely to be hospitalized. Given the possibility of
FIGURE 1 Cumulative hospital days over time and by treatment.
FBT (family-based treatment) SyFT (systemic family therapy). [Color fig-
ure can be viewed in the online issue, which is available at wileyonli-
nelibrary.com.]
Type 2 error in the moderator analysis in this small
sample, we relaxed the Type 1 error rate (i.e.,
change the alpha from 0.05 to 0.10). In this explora-
tory analysis, we identified two potential modera-
tors of treatment effect: baseline BDI (p 5 0.094)
and YBC-ED (p 5 0.078). The YBC-ED score has
been previously identified as a moderator of treat-
ment effect in studies of FBT on recovery rates.3,16
If these moderators were confirmed in a larger
sample of hospitalized patients, this would suggest
that FBT decreases early hospitalization specifically
for individuals with higher baseline BDI and YBC-
ED scores.
Discussion
The current study extends findings from previous
studies related to FBT effects on hospitalization by
illustrating the difference in timing of hospitaliza-
tion with FBT compared to SyST (see Fig. 1). When
hospitalization occurs in FBT, it occurs early then
levels off; whereas in SyFT hospitalization rates not
only occur early but continue to increase through-
out treatment. These differences in hospitalization
patterns are likely the result of greater weight gain
early in FBT4 compared to SyFT. Early weight gain
during the first 5 weeks of treatment is protective
of later hospitalization because it decreases vulner-
ability to medical instability. Regardless of treat-
ment allocation, hospitalization during treatment
was predicted by the presence of obsessive-
compulsive symptoms related to eating (i.e., YBC-
ED), lower self-esteem, higher perfectionism,
depressive symptoms, and greater psychiatric co-
morbidity. Because the importance of identifying
moderators of treatment effect is high15 and the
rarity of even moderately large samples of adoles-
cents with AN in treatment studies, we relaxed our
significance level to alpha 5 0.10 in a highly explor-
atory hypothesis generating analysis. This yielded
two potential moderators: YBC-ED and BDI.

TABLE 1. Predictors of early hospitalization

Early Hospitalization (n 5 25) (means No Early Hospitalization (N 5 133)
Variable and standard deviations) (means and standard deviations) Significance
1
Percentage weight change at end of 86.14 (10.94 91.15 (7.92) (t 52.6, p 5 0.011)
treatment
Beck Depression Inventory 22.16 (10.17) 13.36 (8.07) (p 5 0.001)
Yale-Brown-Cornell eating disorder 14.48 (8.30) 10.95 (8.07) p20.021
score at baseline
Frequency of compensatory behaviors 16% (64%) 54% (41%) (p 5 0.024)
at baseline
Percent co-morbid disorders at 17% (68%) 36 (27%) (p 5 0.003)
baseline
Multidimensional Perfectionism scale 110.4 (22.06) 100.25 (19.85) (p 5 0.009)
Rosenberg Self-Esteem Scale at 27.16 (6.20) 22.7 (6.00) (p 5 0.007)
baseline

International Journal of Eating Disorders 00:00 0000 2016 3

LOCK ET AL.
Importantly, higher scores on the YBC-ED has
been found to moderate clinical outcome (i.e.,
recovery) in other studies of adolescent AN.3,16
These exploratory findings are potentially impor-
tant in developing hypotheses to be tested in future
confirmatory studies.
There are significant limitations to the findings
of this study. The sample size of hospitalized par-
ticipants is relatively small and data were collected
from hospital charts, discharge letters, and self-
reports rather than from a systematic data base.
The sample used in the moderator analysis is likely
too small to rule out Type 2 error and therefore
there may be moderators which were not able to
be identified in this sample despite relaxing the sig-
nificance level (Type 1 error rate) for this analysis.
The results should be considered primarily applica-
ble to settings that use similar medical criteria for
hospitalization as those used in this study. None-
theless, health planners looking to contain costs
while providing an effective treatment for adoles-
cents with AN should consider supporting the
training and implementation of FBT for this
population.
References
1. Striegel-Moore R, Leslie D, Petrill SA, Garvin V, Rosenheck RA. One-year use
and cost of inpatient and outpatient services among female and male
patients with an eating disorder: Evidence from a national database of
health insurance claims. Int J Eat Disord 2000;27:381389.
2. Gowers S, Clark A, Roberts C, Griffiths A, Edwards V, Bryan C, et al. Clinical
effectiveness of treatments for anorexia nervosa in adolescents. Br J Psy-
chiatr 2007;191:427435.
4 International Journal of Eating Disorders 00:00 0000 2016
3. Lock J, Le Grange D, Agras WS, Moye A, Bryson S, Jo BA. randomized clinical
trial comparing family based treatment to adolescent focused individual
therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry 2010;67:
10251032.
4. Agras W, Lock J, Brandt H, Bryson S, Dodge E, Halmi K, et al. Comparison of
2 family therapies for adolescent anorexia nervosa: A randomized parallel
trial. JAMA Psychiatry 2014;72:12791286.
5. Golden N, Katzman D, Kreipe R, Stevens S, Sawyer S, Rees J, et al. Eating dis-
orders in adolescents: Position paper of the Society for Adolescent Medici-
ne:Medical Indications for Hospitalization in an Adolescent with an Eating
Disorder. J Adolesc Health 2003;33:496503.
6. Le Grange D, Doyle P, Swanson S, Ludwig K, Glunz C, Kreipe R. Calculation
of expected body weight in adolescents with eating disorders. Pediatrics
2012;129:e438e446.
7. Cooper Z, Fairburn CG. The Eating Disorder Examination: A semi-structured
interview for the assessment of the specific psychopathology of eating disor-
ders. Int J Eat Disord 1987;6:18.
8. Mazure S, Halmi CA, Einhorn A. The Yale-Brown-Cornell Eating Disorder
Scale: A new scale to asses eating disorder symptomatology. Int J Eat Disord
1995;18:237245.
9. Rosenberg M. Conceiving the Self. New York: Basic Books; 1979.
10. Beck AT. Beck Depression Inventory. San Antonio, TX: The Psychological Cor-
poration; 1987.
11. Freeman J, Flessner C, Garcia A. The Childrens Yale Brown Obsessive Com-
pulsive Scale: Reliability, and validity for use among 5 to 8 year olds with
obessive compulsive disorder. J Abnorm Psychol 2011;39:877883.
12. Orvaschel H, Puig-Antich J, Chambers W, Tabrizi M, Johnson R. Retrospective
assessment of pre-pubertal major depression with the Kiddie-SADS-E. J Am
Acad Child Adolesc Psychiatry 1982;21:392
13. Frost R, Marten P, Lahart C, Rosenblate R. The dimensions of perfectionism.
Cognit Ther Res 1990;14:449468.
14. Kraemer H, Wilson GT, Fairburn CG, Agras WS. Mediators and moderators of
treatment effects in randomized clinical trials. Arch Gen Psychiatry 2002;59:
877884.
15. Kraemer H. Discovering, comparing, and combining moderators of treat-
ment on outcome after randomized clinical trials: A parametric approach.
Stat Med 2013;32:19641973.
16. Lock J, Agras WS, Bryson S, Kraemer H. A comparison of short- and long-
term family therapy for adolescent anorexia nervosa. J Am Acad Child Ado-
lesc Psychiatry 2005;44:632639.