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Toronto General Hospital Stepped Care Program for Eating Disorders Jacqueline C. Carter, PhD and

Toronto General Hospital Stepped Care Program for Eating Disorders Jacqueline C. Carter, PhD and Marion P. Olmsted, PhD Toronto General Hospital and University of Toronto. Stepped Care Model. Sequencing model Least most intensive, costly

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Toronto General Hospital Stepped Care Program for Eating Disorders Jacqueline C. Carter, PhD and

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  1. Toronto General Hospital Stepped Care Program for Eating Disorders Jacqueline C. Carter, PhD and Marion P. Olmsted, PhD Toronto General Hospital and University of Toronto

  2. Stepped Care Model • Sequencing model • Least most intensive, costly • Treatment focuses on the attitudes, beliefs and behaviours related to the eating disorder (e.g., food restriction, binge eating, purging)

  3. Toronto General Hospital Stepped CareEating Disorder Program Unguided Self-help Follow-up Interview TEC TEC TEC TEC Transition Program TEC = Treatment Evaluation Coordinator

  4. Waiting ListUnguided Self-help (Step 0) • may be a useful means of accelerating the treatment process by providing psychoeducation in written form • may help to increase perceived support and decreasing isolation • may help prepare patients for more intensive treatments • in some cases, may reduce the need for further treatment

  5. METHOD • 85 females meeting DSM-IV criteria for BN • following initial assessment, randomly assigned to one of 3 experimental conditions for eight weeks: • specific self-help • non-specific self-help • waiting list control

  6. Experimental Conditions • Specific self-help • based on the CB approach to BN • focuses directly on specific symptoms of BN • Non-specific self-help • focused on developing assertiveness skills • does not address specific symptoms of BN • designed to control for “non-specific” factors • Waiting list control • no self-help manual

  7. Response %

  8. Toronto General Hospital Stepped Care ProgramAssessment Unguided Self-help Follow-up Interview TEC TEC TEC TEC Transition Program TEC = Treatment Evaluation Coordinator

  9. Assessment and Coordination Initial Consultation • Clinical history • Eating disorder diagnosis • Co-morbidity • Treatment recommendations Treatment and Evaluation Coordinator (TEC) • Clinical and research assessment • In between each treatment component • Negotiates next “step” • Coordinates patient’s movement through system

  10. Stepped Care ProgramTEC Assessments • weight and frequency of binge eating, vomiting, laxative misuse, restriction • physical and psychological side-effects • occupational/vocational adjustment • social support • readiness to change and personal treatment goals

  11. Toronto General Hospital Stepped Care ProgramOutpatient Symptom Interruption Unguided Self-help Follow-up Interview TEC TEC TEC TEC Transition Program TEC = Treatment Evaluation Coordinator

  12. Outpatient Symptom Interruption Step 1 Psychoeducation Group • 6 weekly group lectures • information and CB strategies • Group members not introduced • No limit on group size • No expectation of behavioral change

  13. Outpatient Symptom Interruption Step 2 Symptom Interruption Group • 10 weekly group sessions • First 3 weeks motivational work • CBT focus on behavioural change • Limit of 12 group members

  14. Toronto General Hospital Stepped Care ProgramIntensive Symptom Interruption Unguided Self-help Follow-up Interview TEC TEC TEC TEC Transition Program TEC = Treatment Evaluation Coordinator

  15. Intense Symptom InterruptionStep 3 Day Hospital Program • 4-5 days weekly, 7-8 hours per day • 6-8 week stay for normalized eating • up to 14 week stay for weight gain • Supervised meals and group therapy • Capacity of 12 patients OR

  16. Intense Symptom InterruptionStep 3 Inpatient Program • 7 days weekly, specialized programming 5 days weekly • No limit on length of stay • Supervised meals and group therapy • 10 beds

  17. Transition Program Step 4 Track 1 - Follow-up Care • 4 group therapy sessions weekly • Up to 12 week stay • Lunch and group therapy • Available immediately following day hospital or inpatient treatment • Variable group size • Goal is maintenance of change

  18. Transition Program Step 5 Relapse Prevention Group OR Contemplation Group • 1 group session weekly • Up to 24 week stay • Available immediately following Track 1

  19. Stepped Care ModelTreatment Planning Issues • Match type of treatment to patient characteristics - treatment history - weight - symptom frequency - medical complications - comorbidity - practical considerations

  20. Stepped Care ModelTreatment Planning Issues (continued) • Address expectations, motivation and readiness to change • Defining non-response - lack of symptom frequency change - lack of weight gain - program non-compliance • Effect of non-response on subsequent response to treatment - prepare and motivate - demoralize

  21. Number of Treatment Components Attended(n = 652) 1 Treatment 2 Treatments 3 Treatments 6 Treatments 5 Treatments 4 Treatments

  22. Disposition Following Psychoeducation Group for 467 Eating Disordered Patients Drop-outs No more tx N = 73 (16%) Completers No more tx N = 124 (26%) Psychoeducation N =467 Symptom Interruption N = 152 (33%) Day Hospital or Inpatient Unit N = 98 (21%) Other N=20 (4%)

  23. Disposition Following Symptom Interruption for 155 Eating Disordered Patients Drop-outs No more tx N = 36 (23%) Completers No more tx N = 78 (50%) Symptom Interruption Group N=155 Psychoeducation Day Hospital or Inpatients N = 25 (17%) Other N = 16 (10%)

  24. Disposition Following Day Hospital for 229 Eating Disordered Patients Drop-outs - No more tx N =33 (14%) Day Hospital 1st admissions N =229 Completers - No more tx N = 46 (20%) TransitionProgram N = 129 (56%) Any Outpatient Group N =11 (5%) Day Hospital re-admission N =10 (4%)

  25. Disposition Following Inpatient Program for 103 AN Patients Drop-outs - No more tx N =24 (23%) Inpatient admissions N =103 Completers - No more tx N = 13 (13%) Transition Program N = 24 (23%) Day Hospital N =5 (5%) Inpatient re-admission N =31 (30%)

  26. Outcome Criteria for Binge Eating and Vomiting Abstinent 0 episodes per 28 days Subthreshold1-7 episodes per28 days Threshold > 8 episodes per 28 days

  27. Psychoeducation GroupBingeing Outcome for 142 Threshold Bingers Abstinent Subthreshold Threshold

  28. Psychoeducation GroupVomiting Outcome for 125 Threshold Vomiters Abstinent Subthreshold Threshold

  29. Symptom Interruption GroupBingeing Outcome for 29 Threshold Bingers Abstinent Subthreshold Threshold

  30. Symptom Interruption GroupVomiting Outcome for 19 Threshold Vomiters Subthreshold Abstinent Threshold

  31. Day Hospital ProgramBingeing Outcome for 79 Threshold Bingers Abstinent Threshold Subthreshold

  32. Day Hospital ProgramVomiting Outcome for 74 Threshold Vomiters Abstinent Subthreshold Threshold

  33. Inpatient Program Bingeing/Purging Outcome for 32 AN-B/P Patients Subthreshold Abstinent Threshold

  34. Outcome Criteria for Weight Weight RestoredBMI > 20.0 Good 18.5 < BMI < 20.0 Moderate BMI < 18.5 AND wt gain > 3.0 kg PoorBMI < 18.5 AND wt gain < 3.0 kg

  35. Psychoeducation GroupWeight Outcome for 65 AN Patients Weight Restored Good Moderate Poor

  36. Symptom Interruption GroupWeight Outcome for 8 AN Patients Good Poor

  37. Day Hospital ProgramWeight Outcome for 42 AN Patients Weight Restored Poor Good Moderate

  38. Inpatient ProgramWeight Outcome for 103 AN Patients Weight Restored Poor Good

  39. Toronto General Hospital Stepped Care ProgramFollow-up Assessment Unguided Self-help Follow-up Interview TEC TEC TEC TEC Transition Program TEC = Treatment Evaluation Coordinator

  40. Follow-up Outcome for 57 Weight-Restored AN Patients Method • median length of follow-up = 15.7 months • participation rate = 51/57 = 89% • weight, EDE interview and self-report questionnaires Definition of relapse • 3 consecutive months BMI < 17.5

  41. RATE AND TIMING OF RELAPSE (88%) (mean time to relapse) (70%) (55%) (N=51)

  42. RATE AND TIMING OF RELAPSE (N=51)

  43. Advantages of the Stepped Care Model • cost-effective to offer “just enough” treatment • built-in opportunities to review patient goals, progress and treatment plan • treatments are well-specified and protocol-driven • easy accountability: each component can be evaluated and revised or dropped

  44. Difficulties with the Stepped Care Model • lack of response to individual patient needs • lack of empirical evidence • less applicable to AN - medical complications - difficult to identify early non-responder • patients might become demoralized by treatment failure

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