Which Level of Eating Disorder Treatment Is Right for Me?

From Hospitalization to Outpatient

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Treatment for eating disorders is complex. Not only does treatment commonly involve multiple providers (a medical doctor, psychotherapist, registered dietitian nutritionist, and psychiatrist, among possible others), but the United States system has a system of levels of care that is distinct to eating disorders.

The levels of care ranked from most- to least-intensive are as follows:

  • Medical hospitalization is 24-hour care in a medical hospital. This is typically for patients who are not medically stable and need round-the-clock medical monitoring, which can include intravenous fluids, tube feeds, and constant monitoring of vital signs.
  • Residential treatment (RTC) provides 24-hour care for those who are medically stable but require round-the-clock supervision of behaviors and meals.
  • Partial hospitalization (PHP) allows the patient to sleep at home and attend a treatment center during the day. Individuals can attend the program a minimum of five days a week for times usually ranging from six to 11 hours per day. A majority of meals take place at the treatment center, but the patient has some meals at home.
  • Intensive outpatient treatment (IOP) usually includes three hours of programming for two to three days a week. At this level of care, the client lives at home and is often able to work or attend school. Usually one meal or snack per visit is part of treatment.
  • Outpatient treatment usually consists of individual meetings once or twice a week with a therapist and/or dietitian.

The American Psychiatric Association (APA) developed guidelines for the various levels of care.

The APA guidelines state:

In determining a patient’s initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patient’s overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight.

This is a specific attempt to move past weight being the sole determinant of level of care, which has often been the case.

The APA provides a chart detailing suggested criteria for each stepped level of care. These criteria include the following factors:

  • Medical status
  • Suicidality
  • Weight (as a percentage of healthy body weight)
  • Motivation to recover, including cooperativeness, insight, and ability to control obsessive thoughts
  • Co-occurring disorders, including substance use, depression, and anxiety
  • Structure needed for eating and gaining weight
  • Ability to control compulsive exercising

Many considerations contribute to the determination of the right treatment level for an individual. Treatment should ideally start with the level of care required to manage symptoms and provide the most effective treatment setting for successful recovery. Often, and perhaps ideally, patients with severe symptoms begin treatment at higher levels of care and gradually step down to lower levels.

On the other hand, when treatment resources are constrained, many researchers and treating professionals advocate for a “stepped care” approach for those who are medically stable.

In a stepped care approach, the lowest level of intervention is tried first and if patients are not improving they are stepped up to the next higher level of care. In stepped care approaches, the lowest level of intervention may be self-help or guided self-help.

However, in cases where an individual is not medically stable, and in cases of anorexia nervosa, treatment should not begin with self-help or guided self-help. Professional help is needed to manage the severity of the disorder.

Finally, many insurance companies, largely driven by cost-containment, have their own guidelines and may dictate the level of treatment to which a patient has access.

While all of the previously cited factors—as well as availability of treatment and insurance—need to be considered, there are general indicators for the various levels of care:

Medical Hospitalization

Patients may begin treatment or transfer to inpatient if any of the following are present:

  • unstable heart rate or blood pressure
  • significant weight loss and/or food refusal
  • inability to stop exercising
  • need for supervision to eat (including tube feeding)
  • need for supervision to not purge
  • lack of treatment options near home
  • presence of suicidal thoughts with high lethality or intent
  • presence of other psychiatric disorders that would require hospitalization

Residential

A person entering a residential level of care should be medically stable so that intravenous fluids and tube feedings are not needed. But they might need a high level of structure and supervision of meals and prevention of exercise and purging due to poor to fair motivation, extreme anxiety, other psychiatric problems, and/or inability to self-control.

Partial Hospitalization

For this level of treatment, patients should be medically stable, but they typically require external structure to eat and/or gain weight and prevent purging or exercising. They have some ability to manage behaviors on their own for short periods of time and overnight and/or they have others in their lives who are able to provide at least some support and structure. They should live near a treatment center so that they can travel back and forth daily.

Intensive Outpatient

Patients in intensive outpatient treatment ought to be medically stable and have some motivation to work on recovery. They should typically—at least part of the time—be able to eat independently, prevent compulsive exercising, and reduce purging. They benefit from having others able to provide some structure and emotional support and live close enough to treatment to travel back and forth several times a week.

Outpatient

Patients in outpatient treatment are medically stable and should have good motivation. They can manage their own meals as well as compulsive exercise and can greatly reduce purging. They have others available to provide emotional support and structure and live near treatment.

It should be noted that Family Based Treatment for Adolescents shifts the provision of support and structure and meals from treatment providers to parents, and thus allows adolescents who might otherwise be in residential, PHP, or IOP levels of care to be safely managed at home by parents.

Recovery is a journey and many patients with eating disorders are in treatment through various levels of care. Relapses are normal and part of the process so don’t be discouraged if you need to take a few steps back before moving forward again.

Source:

American Psychiatric Association. American Psychiatric Association Practice Guidelines for the treatment of psychiatric disorders: compendium 2006. American Psychiatric Pub, 2006.

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