Rehospitalization and “Revolving Door” in Anorexia Nervosa: Are There Any Predictors of Time to Readmission?

Abstract

Objective: Anorexia nervosa (AN) is a severe psychiatric illness with multifactorial etiology and unsatisfactory treatment outcomes. Hospitalization is required for a substantial number of patients, and readmission (RA) commonly occurs. Some individuals need multiple hospitalizations sometimes over a short amount of time, thus, delineating the “revolving door” (RD) phenomenon. However, very little is known about readmissions and their frequency in AN. Therefore, we aimed to longitudinally investigate readmissions in AN in order to: (a) characterize patients with AN who need readmission (i.e., RA-AN), sometimes rapidly (RD-AN); (b) ascertain differences between RA-AN and non-RA-AN groups during baseline hospitalization; (c) investigate as to whether clinical or psychometric parameters worsened on RA; and (d) analyze predictors of time-to-readmission in AN.Methods: A total of 170 inpatients with AN were enrolled at their baseline hospitalization; all their subsequent rehospitalizations were recorded with a longitudinal design by which each patient has been observed for 3 years. Patients were classified as RD-AN if requiring a readmission <12 months since last discharge. Clinical characteristics were measured upon admission and discharge for each hospitalization, and at all time points, patients completed questionnaires assessing eating and general psychopathology, and body shape concerns.Results: Sixty-seven patients (39.4%) needed at least one readmission and 62 (92.5% of RA-AN) reported RD. Compared with non-RA-AN, those with RA-AN were younger, reported a shorter duration of illness, and were more frequently diagnosed with AN-BP. Also, greater severity of anxious and depressive symptoms and body shape concerns emerged in the RA-AN group. The outcome of baseline hospitalization did not differ between groups, and only depressive symptoms worsened at readmission. Shorter duration of AN and low weight gain during baseline hospitalization predicted early readmission but did not survive statistical control. In contrast, high scores on drive for thinness upon baseline hospital entry robustly predicted a shorter time to readmission even after statistical control.Discussion: Individuals with AN who require readmission do so over a short period notwithstanding a positive treatment outcome during their baseline hospitalization. Shorter time-to-readmission can be predicted mostly in case of marked drive for thinness and poor weight gain at baseline hospital admission.

Body Mass Index Specifiers in Anorexia Nervosa: Anything below the “Extreme”?

“…Further studies adding a clinician-based evaluation could clarify this issue. Similarly, the EDI-2 data did not help define severity in our sample; although drive for thinness has been proposed as a reliable marker of severity [10,26], it failed to discriminate those in the VE-AN or E-AN group. In contrast, it is noteworthy that dissatisfaction for body image has not been measured in the past, thus our data are difficult to compare; however, patients' marked emaciation could contribute to explain the lower levels of dissatisfaction for body image concerns reported by those with VE-AN and E-AN when compared to patients with NE-AN.…”

“…It should be highlighted that length of stay had an impact on hospitalization trajectory; after statistical control for this parameter, EDI-2 drive for thinness, trait anxiety, body image concerns, and quality of life resulted as not significantly improved upon discharge suggesting how the latter measures tend to need a longer timeframe to improve. Earlier research suggested drive for thinness as more relevant for framing severity in AN [26], thus it is reasonable that more time can be required to improve such a criticalalso with respect to outcome [10]-measure. Moreover, patients' anxiety is a hallmark of AN even after recovery [29], and earlier research from our group showed that several components of body image are at play during hospitalization [30], therefore duration of hospital stay can influence the outcome concerning these measures.…”

“…Details of the treatment can be found elsewhere [10]. Treatment is delivered following the requirements and specificities needed when dealing with patients with AN who need inpatient treatment, therefore the clinical team is multidisciplinary and individualized treatment plans are provided.…”

“…However, groups with different BMI specifiers did not differ in comorbidity (anxiety, mood, substance use disorders) and distress [9]. Nevertheless, it is well-known that an intensification of treatment is needed when patients' BMI is low or decreases rapidly; as a result, a substantial proportion of patients require hospitalization in a very malnutrition-related acute phase of their illness [10]. Therefore, research on outpatients may not apply to the inpatient setting.…”

“…This broad heterogeneity highlights the need to garner further evidence on this topic, suggesting that the extreme specifier could be investigated more. In fact, it is questionable that the degree of severity can change from mild to extreme due to one point of BMI; however, the extreme category is broad, eventually encompassing several points of BMI (e.g., [9][10][11][12][13][14][15]. Therefore, the extreme specifier applies equally to people who are in a life-threatening condition, unable to handle everyday activities [12] and patients in a much less severe clinical condition, without functional impairments.…”