Dr. Sarah Ravin | Eating Disorders, Depression, Anxiety, Psychotherapy
Dr. Sarah Ravin, the Florida Licensed Psychologist and trained scientist-practitioner. She shares the thoughts and opinions on Eating Disorders, Depression, Anxiety, Psychotherapy and also about psychological issues, with scientific research and clinical experience sprinkled in for good measure, so that it can help to bridge the gap between research and treatment.
This analysis includes all patients with a primary diagnosis of Anorexia Nervosa (AN) who participated in an evaluation followed by a minimum of one therapy session with me between the start of my practice in 2009 and spring 2017. Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample. Patients and families whom I saw only for evaluations or consultations rather than treatment were not included in this sample.
The sample includes 60 individuals (93% female) who ranged in age from 10 – 37 years old, with a median age of 16 and a modal age of 13. The majority of patients identified as Caucasian (69%) or Hispanic (29%), with less than 3% identifying with other racial/ethnic groups.
Twenty percent of patients in this sample met criteria for the Binge-Purge Subtype of AN, while the remaining 80% had Restricting Subtype.
Half of patients in this sample had a comorbid diagnosis. The two most common comorbid diagnosis were ADHD and Major Depressive Disorder, with 13% of patients meeting criteria for each of these disorders.
Duration of illness before beginning treatment with me ranged from 2 months to 21 years, with older patients, on average, having been sick for a longer duration of time. The mean duration of illness before entering treatment with me was just under 3 years.
Most patients had a history of unsuccessful outpatient treatment with other providers prior to beginning treatment with me. In addition, 28% percent of patients had a history of hospitalization for AN prior to beginning treatment with me and 15% had a history of residential treatment.
Ten percent of the sample paid a reduced rate for services due to financial need.
40% of patients over age 18 received FBT, either alone or in conjunction with individual therapy. The remaining 60% received individual therapy.
Some adolescent FBT patients received individual therapy for a co-morbid condition after their course of FBT was complete.
All patients received medical monitoring by their physician during treatment with me.
58% of patients took psychotropic medication at some point during their treatment with me.
Average number of sessions attended was 23.
Average duration of treatment was 13 months.
Reasons for Treatment Ending
50% of patients completed a full course of treatment with me
26% dropped out of treatment prematurely
22% were referred to other providers
3% moved to other geographic locations during treatment
97% of patients who completed treatment achieved full recovery. The remaining 3% achieved physical remission.
The majority of patients who completed treatment did so in a time frame of somewhere between 7 months and 2 years.
A full course of treatment required, on average, 27 sessions over the course of 17 months.
Patients with co-morbid conditions required more sessions, on average, than those without co-morbid conditions.
All patients who completed treatment achieved 100% full weight restoration, as indicated by a return to their pre-AN percentile patterns of growth for height and weight.
Average time to achieve weight restoration was 3.6 months.
Patients who recovered with individual therapy took longer, on average, to achieve weight restoration than those who recovered through FBT.
26% of patients dropped out of treatment prematurely.
Patients receiving individual therapy were almost twice as likely as those receiving FBT to drop out of treatment prematurely.
For treatment drop-outs, there was a significant correlation between length of time spent in treatment and progress made.
All treatment dropouts who were in treatment with me for at least 2 months had made significant progress at the time of drop-out.
Patients who dropped out of treatment after one month or less had not made any progress at the time of drop-out.
Status at End of Treatment with Me
Recovery status was assessed for each patient as of his/her final session with me, regardless of the reason for treatment ending. The statistics listed below are for the entire sample of patients, including those who completed a full course of treatment, those who dropped out prematurely, and those who were referred to other providers due to a geographic move or a need for a different level of care or type of care.
48% had achieved full recovery
2% achieved physical remission
22% made significant progress
5% made some progress
18% made no progress
Predictors of Positive Treatment Outcome
Completion of a full course of treatment: 97% of those who completed treatment achieved full remission.
Younger age (Children under 13 had the highest rates of full recovery, followed by adolescents ages 13-17).
Patients receiving FBT were almost twice as likely as those receiving individual therapy to achieve full recovery.
Males were more likely to achieve full recovery than females.
Patients with Restricting Anorexia Nervosa were more than twice as likely as those with Binge-Purge Anorexia Nervosa to achieve full recovery.
Patients taking psychotropic medication during treatment were somewhat more likely to achieve full recovery than those who did not take psychotropic medication.
Patients who paid full rate for treatment were somewhat more likely to achieve full recovery than those who paid a reduced rate due to financial need.
Caucasian (non-Hispanic) patients were somewhat more likely than Hispanic patients to achieve full recovery.
This analysis includes all patients with a primary diagnosis of a mood disorder who participated in an evaluation followed by a minimum of one therapy session with me between the start of my practice in 2009 and spring 2017. Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample.
Approximately 30% of the sample had a history of psychiatric hospitalization, most commonly for suicide attempts or suicidal ideation, prior to staring treatment with me.
Description of Treatment Received
The length of treatment varied dramatically, from one week to 3.7 years. Number of sessions attended also varied dramatically, from 1 session to 135 sessions. The broad range of treatment duration and sessions attended reflects the reality that some individuals decided not to proceed with treatment after one or two sessions, whereas other individuals attended sessions off and on, as needed, for the duration of their high school or college years. The average duration of treatment was 11.9 months and the average number of sessions attended was 28. So, a typical patient with a mood disorder attended approximately 28 sessions over the course of one year.
Level of family involvement varied depending on the patient’s age, presenting symptoms, preferences, and living circumstances. For the purposes of this assessment, high level of family involvement means that at least one family member attended all or most sessions with the patient. Moderate level of family involvement means that family members attended some sessions and maintained ongoing communication with me throughout treatment. Low level of family involvement means that at a family member was involved in the evaluation and/or at least one session, but most sessions were individual. Among all patients in this sample, 18% had a high level of family involvement, 21% had a moderate level of family involvement, 18% had a low level of family involvement, and 44% had no family involvement. Degree of family involvement was higher, in general, for adolescent patients than for adult patients, with all patients under age 18 having at least some family involvement in their treatment. Fifty percent of adolescent patients (under age 18) had a high level of family involvement, while 42% had a moderate level of family involvement and the remaining 8% had a low level of family involvement.
Nearly ¾ of patients saw a psychiatrist and took psychotropic medications during treatment. Nearly ¼ of patients were hospitalized during treatment, most commonly for suicidal ideation or suicidal gestures.
Treatment Completion and Recovery Rates
Of all patients who began treatment with me for a mood disorder, 15% achieved complete recovery, 24% made significant progress, 41% made some progress, 15% made no progress, and 6% regressed. For a detailed description of what terms such as “complete recovery” and “significant progress” mean, please see this blog post from 2013.
Eighteen percent of patients completed a full course of treatment with me. Completing a “full course of treatment” was defined as a mutual ending in which the patient, his/her family (in cases where family was involved) and I mutually agree that treatment goals have been met and treatment is no longer needed. Of these “treatment completers,” 83% achieved full recovery and the remaining 17% made significant progress towards treatment goals.
The length of time required to complete a full course of treatment varied dramatically from person to person, depending on symptom severity and progress in treatment. Time required to complete treatment ranged from 1 month to 3 years, with a mean of 16.6 months. Likewise, number of sessions required to complete treatment varied dramatically between individuals. Number of sessions attended for treatment completers ranged from 4 – 96 sessions, with an average of 23 sessions. So, on average, individuals who were most successful in treatment (e.g., those who completed treatment and achieved full remission from their mood disorders) attended an average of 23 sessions over the course of 16 months.
Fifteen percent of patients moved to another geographic location during their treatment (either to attend college or to live elsewhere permanently), prior to completing a full course of treatment with me. As of their last session with me, 60% of these “movers” had made significant progress in their treatment and the remaining 40% had made some progress. These individuals were referred to other treatment providers in near their universities or new homes for continued treatment.
The dropout rate for patients with mood disorders was fairly high: 50% of patients discontinued treatment with me prematurely. As of their last session with me, 18% of these “discontinuers” had made significant progress towards treatment goals, 59% had made some progress, and 24% had made no progress. On average, individuals who discontinued treatment sooner made less progress, while those who remained in treatment longer made more progress towards their treatment goals. Three quarters of the individuals who made no progress dropped out of treatment after just one or two sessions, and the remaining one quarter dropped out after 5 sessions. In contrast, those who made significant progress prior to dropping out of treatment attended an average of 20 sessions.
I do not have data on what happens to patients after they discontinue treatment, so this is purely speculation, but I believe several factors contribute to the high dropout rate among patients with mood disorders. First, depression frequently interferes with a person’s motivation and ability to carry out tasks, and tends to make people hopeless and pessimistic. Individuals with these symptoms may have a more difficult time persisting towards a goal, such as scheduling appointments and continuing with treatment over a number of months, and they may feel less hopeful about having a positive outcome in treatment. Second, some patients and families may be satisfied with “good enough,” and may drop out of treatment after making good progress but before achieving all treatment goals. In contrast, I have high standards for my patients: I believe that full recovery is possible for most people, and when full recovery does not seem achievable, then a full and meaningful life with well-managed symptoms is an alternative good outcome. I work diligently with patients and their families in pursuit of these goals.
Eighteen percent of patients with mood disorders were referred to other clinicians who could better meet their needs. I made these referrals when a patient was not progressing in treatment, and when it did not appear likely that they would make progress in the near future. As of their last session with me, 17% of referred patients had made significant progress, 33% had made some progress, 17% had made no progress, and 33% had regressed.
Predictors of Treatment Outcome
Not surprisingly, completion of a full course of treatment emerged as a strong predictor of positive treatment outcome. 83% of individuals who completed treatment achieved full recovery, while the remaining 17% made significant progress towards treatment goals. None of the individuals who discontinued treatment prematurely achieved full recovery.
Another strong predictor of positive treatment outcome in this sample was referral source. Eighty percent of individuals who achieved full recovery were self-referred (e.g., they found my practice through an online search), while the remaining 20% were referred by word of mouth (e.g., by a friend). In contrast, none of the individuals who were referred to my practice by their psychiatrist, pediatrician, or another therapist completed a full course of treatment or achieved full recovery, although a number of them made significant progress. My interpretation of this finding is that individuals who proactively sought my services of their own volition may be especially dedicated to improving their mental health, more invested in their treatment, and thus more likely to persevere through a full course of treatment and achieve recovery. In the case of self-referred adolescents, their parents were the ones who actually brought their children to treatment. These parents, on the whole, were particularly attuned to their child’s needs and struggles, researched their child’s symptoms and the variety of treatment approaches available, sought my services proactively, and were especially motivated to help their child recover. Perhaps this parental conscientiousness, attunement, and empowerment helped facilitate recovery for their children.
Level of family involvement in treatment predicted treatment completion and full recovery for adolescent patients but not for adult patients. All of the adolescents who completed treatment and recovered had moderate or high levels of family involvement. In contrast, 75% of the adults who completed treatment and achieved full recovery had no family involvement in their treatment, while the remaining 25% had a low level of family involvement.
Individuals who took psychotropic medication were somewhat less likely to recover than those who did not: 40% of individuals who achieved full recovery were taking medication during treatment, whereas 76% of individuals who did not achieve full recovery were taking medication during treatment. It is unlikely that taking psychotropic medication caused patients to have a worse outcome. I believe the most likely explanation for this finding is that taking psychotropic medication is a marker of severity: individuals with more severe forms of mood disorders (e.g., Bipolar Disorder, Severe Recurrent Major Depressive Disorder) are more likely to need medication and are perhaps less likely to achieve complete remission of symptoms.
Hospitalization during treatment emerged as a predictor of less favorable outcome. None of the individuals who were hospitalized during their treatment with me completed a full course of treatment or achieved full recovery. It is unlikely that being hospitalized actually caused patients to quit treatment or caused them to make less progress in their treatment. It is more likely that hospitalization, like taking psychotropic medication, is a marker of severity, and those individuals with more severe illnesses are less likely to experience complete remission of symptoms.
The following variables did NOT predict treatment outcome: age, gender, ethnicity, duration of illness, diagnosis, presence of co-morbid diagnoses, rate paid for services, type of treatment received, or history of hospitalization prior to starting treatment.
In an effort to improve the quality of services I offer, and in the service of full transparency to those who seek treatment, I am committed to compiling and sharing outcome data every few years on the patients I have treated. The last time I compiled and shared my treatment outcome data was in 2013, so it is time for another round, this time with a larger sample to describe.
Description of the Sample
This analysis includes all patients with a primary diagnosis of an anxiety disorder who participated in an evaluation followed by a minimum of one therapy session with me at any time between the start of my private practice in 2009 and spring of 2017. Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample.
This sample includes 16 patients, all female, who ranged in age from 10 – 42 years old, with a median age of 20.
Length of treatment and number of sessions attended varied considerably among these individuals. The vast majority of patients were in treatment with me for somewhere between 2 – 19 months and attended somewhere between 3-17 sessions. The median duration of treatment was 4.5 months, and the median number of sessions attended was 12.
Degree of family involvement varied based on the patient’s age and living circumstances. All patients under age 18 had at least a moderate level of family involvement, and 83% of patients under age 18 had a high level of family involvement. Patients of college age had low- to moderate levels of family involvement, and most adult patients in their 30’s and 40’s had minimal, if any, family involvement.
Forty-four percent of patients were taking psychotropic medication, prescribed by their psychiatrist, during their treatment with me. None of the patients in this sample were hospitalized during the course of their treatment with me.
Treatment Completion and Recovery Rates
Of all patients who entered treatment with me for anxiety disorders, 44% percent recovered completely from their anxiety disorder, while 38% made significant progress in terms of reduction of symptoms and improvement in functioning, and 19% made some progress towards recovery. In sum, all of the patients in this sample made at least some progress towards their treatment goals. For a detailed description of the criteria used to determine “full recovery,” “significant progress,” and “some progress,” see this blog post from 2013.
Half of the patients who entered treatment with me for anxiety disorders completed a full course of treatment. Completing a “full course of treatment” was defined as remaining in treatment until the patient, her family (when involved), and I collaboratively agreed that treatment goals had been met and further treatment was not needed. The number of sessions required to complete a full course of treatment ranged from 3 – 25 sessions, with a median of 4 sessions. The duration of treatment for those who completed a full course of treatment ranged from 1-19 months, with a median duration of 3 months. Of those who completed a full course of treatment, 88% achieved full recovery and 12% made significant progress since starting treatment.
The remaining half of patients did not complete a full course of treatment with me, either because they quit treatment prematurely, they moved to another geographic location, or I referred them to another clinician. Among those who did not complete a full course of treatment, 63% had made significant progress in their recovery at the time they left treatment with me, and the remaining 37% had made some progress. It is important to note that I do not have data on what happens to patients after they leave my practice, so these treatment outcomes are based on an assessment of the patient’s symptoms and functioning as of the last session they attended with me. It is possible that some individuals who left treatment prematurely achieved full recovery later on their own, or in treatment with another clinician, after leaving my practice. It is also possible that some individuals experienced a worsening of their condition after leaving treatment.
Predictors of Treatment Outcomes
A high level of family involvement in treatment emerged as the strongest predictor of successful treatment outcome. 100% of patients who had high levels of family involvement in treatment completed a full course of treatment and achieved full recovery.
Completion of a full course of treatment was the second strongest predictor of successful outcome. 88% of patients who completed a full course of treatment achieved full recovery from their anxiety disorder. The remaining 12% of treatment completers had made significant progress since the start of treatment.
Younger age was also a predictor of successful treatment outcome. Younger age was strongly correlated with both high family involvement and completion of treatment.
Other factors associated with successful treatment outcome include shorter duration of illness, good attendance at therapy sessions, paying full rate for services, and being self-referred to my practice.
Not surprisingly, discontinuing treatment prematurely was associated with less favorable outcomes. Even so, 63% of individuals who discontinued treatment prematurely had made significant progress since beginning treatment with me, and the remaining 37% had made some progress. These data indicate that the majority of individuals with anxiety disorders experienced significant benefits from treatment in terms of reduction of symptoms and improvement in functioning, whether or not they completed treatment a full course of treatment.
Other factors strongly associated with a less favorable treatment outcome included the presence of a comorbid diagnosis, taking psychotropic medication during treatment, and being referred to my practice by a psychiatrist. Interestingly, these three factors were strongly correlated with one another: all of the individuals who were referred to my practice by their psychiatrist were taking psychotropic medication and 80% of individuals referred by their psychiatrist had comorbid diagnoses.
The following factors were modestly associated with less favorable treatment outcomes: older age, longer duration of illness, lower levels of family involvement, poor attendance at therapy sessions, and paying reduced rate for services. Again, these factors tended to co-occur with one another, and also tended to co-occur with the three negative prognostic factors listed above.
These statistics reflect overall trends, not absolutes. Some individuals in this sample did achieve full recovery despite being adults with long duration of illness and no family involvement, or having other characteristics typically associated with less favorable treatment outcome.
For a more detailed description and interpretation of these statistics, click here.
Most of the teenagers and college students I work with are far beyond the old pen-and-paper logs and worksheets I was trained to use during graduate school. It seems there’s an app for everything these days, and so many of these apps are relevant to mental health and wellness. Today’s young people organize their lives on their smart phones anyway, so it is only natural that we would look to the smartphone to help them self-monitor their symptoms, complete their therapy assignments, and keep track of the strategies they use to help themselves.
There are literally hundreds, if not thousands, of apps that are useful to people with mental health conditions. Here are a few of my favorites:
The Recovery Record app helps patients with eating disorders self-monitor their meals and snacks as well as thoughts, feelings, and urges that arise around food.
The Insight Timer app offers a meditation timer, thousands of free guided meditation tracks, groups for like-minded meditators, and the ability to track quantitative statistics such as how many minutes the user spends each day in meditation.
DBT Diary Card and Skills Coach is an electronic version of the Diary Card used in standard DBT practice, which helps the patient track target behaviors and utilize DBT skills from the modules of Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness.
The nOCD app helps patients with Obsessive Compulsive Disorder implement their exposure and response prevention treatment while compiling objective, real-time data on their experience.
I am a firm believer that what transpires in the therapist’s office is only a fraction of the treatment package. Most of the healing process results from consistent changes that patients and their families make on a daily basis at home, at school, and in various social settings. Thanks to modern technology, individuals who are committed to improving their well-being are now able to hold new tools, literally, in the palms of their hands.
Today is the second annual World Eating Disorders Action Day, and I am proud to be a part of this international movement. World Eating Disorders Action Day (#WeDoAct) is a grassroots movement designed for and by people affected by eating disorders, their families, and the healthcare professionals who support them. Uniting activists across the globe, the aim is to expand global awareness of eating disorders as genetically linked, treatable illnesses which affect both males and females across the weight spectrum, as well as people of all ages, ethnic backgrounds, and nationalities.
In honor of today, I would like to bring attention to films, podcasts, and websites which are spreading the messages that I am passionate about – the messages upon which I have built my practice and established my professional identity. These messages are:
Here are the informative resources that promote these vital messages:
New Plates: A Podcast Series on eating disorders by Laura Collins Lyster-Mensh. I was thrilled to be interviewed for the first two episodes of New Plates, and my lovely associate, Dr. Tarah Martos, was featured in Episode 10.
I have seen tremendous growth within this field over the past decade, in large part due to the work of tireless parent advocates and a handful of progressive clinicians. But still, we’ve got a long way to go. Join me in spreading the truth about eating disorders and recovery.