Lectures 17 18 Treatment modalities these are individual or group patient treatments o Inpatient in treatment setting always o Residential o Outpatient Day like a job with the hours Bi weekly weekly monthly Partial day Evening Inpatient and Residential Treatment o Very resource intensive very costly Average cost for 1 month of patient treatment in US is 30 000 Average duration of residential treatment in US is 83 days with average cost of 956 day or an average total cost of 79 348 Frisch Herzog Franko 2006 o Inpatient treatment reserved for medically severe cases For life threatening cases they might die outside treatment place This happens more with AN patients than BN o b c starvation is life threatening o residential treatment limited to individuals with resources insurance or income to cover costs disorders too severe to make progress without treatment but without treatment can still survive o outpatient treatment cost substantially lower for outpatient than inpatient residential treatment setting 4 000 for full course of cognitive behavioral therapy at 200 hr 1 689 for full course of CBT with medicare medical reimbursement level however have to consider safety and efficacy o if someone at risk of death or disability then outpatient treatment may not be cost effective saving money would not offset cost of disability or death how do we know if treatments work o Have to compare effect of treatment against control condition in controlled studies Have to do an experimental design Within subject design Between subject design o Within subject design AB ABA ABAB A establish parent s baseline symptom level B begin treatment reassess symptom level A discontinue alter effective component of treatment reassess symptom level B Resume treatment reassess symptom level If treatment is impacting symptoms then changes in symptoms should be observed with changing presence absence of active treatment o Within subject design AN agras et al 1974 Complaints from AN patients in INPATIENT treatment 1 Having to eat 2 Boring o between subject design compare outcome between people who receive intervention vs people who do NOT receive intervention important to use RANDOM ASSIGNMENT to condition intervention vs no intervention randomly assigning participants to active treatment vs control condition reduces likelihood that differences before treatment e g differences in symptom severity influence comparison of outcomes between conditions RCT randomized controlled trial Different control conditions different levels of support o Between subject design Waistline control People call in to be in the study Compare people who receive intervention to people placed on a waiting list for treatment Placebo control Compare people who receive intervention to people who receive fake treatment Alternative treatment control Compare people who receive intervention to people given a different kind of intervention Empirically supported interventions o TEST QUESTION o Interventions that produce superior outcomes compared to control conditions no treatment waitlist vs placebo vs alternative treatment Also known as evidence based treatments Comparison of Treatment Modes Gowers et al 2010 conducted a randomized controlled trial in 167 adolescent patients diagnosed with AN comparing Specialized inpatient treatment Specialized outpatient treatment General routine treatment through Child and Adolescent Mental Health Services in England Gowers et al Acceptance Satisfaction Greater acceptance of randomization to outpatient care 49 accepted inpatient treatment 77 accepted specialist outpatient treatment 71 accepted general outpatient treatment Satisfaction Both specialist treatments preferred over general outpatient treatment Gowers et al Outcome NO difference in outcome across treatment modalities but differed in course Improvement observed over time good but slow 19 have good outcome at 1 year 33 have good outcome at 2 years 64 have good outcome at 5 years Gowers et al Cost Effectiveness To achieve same outcomes specialist outpatient treatment cost less than general outpatient which cost less than inpatient care Gowers et al Conclusion Specialist outpatient treatment superior treatment modality Is acceptable to patients and results in higher satisfaction Produces outcomes that are just as good as other options Costs the least amount of money Psychotherapy Content Psychoeducation Psychodynamic Therapy family factors Cognitive Behavioral Therapy CBT looks different than psychodynamic therapy Interpersonal Therapy IPT focusing on cognitive in lecture but book details the other therapies so know these briefly Psychotherapy Content Psychoeducation Psychodynamic Therapy Cognitive Behavioral Therapy CBT Interpersonal Therapy IPT Description of CBT for BN Fairburn s CBT Stage 1 Control over eating with behavioral techniques Self monitoring of food intake and symptoms with diary Prescription of a regular pattern of eating every 2 to 3 hours 3 meals 2 to 3 snacks Stimulus control identify triggers to binge eating and avoid employ incompatible behaviors take a shower instead of eating this winds them down just like food and they cant do both at the same time Psychoeducation on weight regulation dieting and risks of purging girl with BN try to help patient gain control over their eating have a food diary right when you eat it write it DOWN as well as all behaviors and feelings dieting is a risk factor for BN Description of CBT for BN Fairburn s CBT Stage 2 Reduce dieting and body image disturbance through combination of behavioral and cognitive techniques engage in problem solving People will love me only if I m thin cognitive distortions dichotomous thinking Couples in public not always thin observation of couples and write down what they look like What is value of love that is contingent on thinness do you want to be loved by only superficial people I ll only love you if you re thin Does the patient love someone who isn t thin are there any people that you love who are NOT thin yes we all do People who truly care about me as a person will love me no matter what I weigh cognitive restructuring think of your lives in a different way Description of CBT for BN Fairburn s CBT Stage 3 Maintenance of progress and reduction of risk for future relapse Ex recognize and challenge dichotomous thinking to prevent lapses from becoming relapses tapering stage ends with once a month visits hopefully gotten so far in therapy they can accept their weight
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