Predictors of readmission in adolescent anorexia nervosa: a 24- month retrospective cohort study
This 24-month retrospective cohort study of 113 Portuguese adolescents with anorexia nervosa identifies that readmission is independently predicted by comorbid depression, the need for nasogastric tube feeding during hospitalization, and missed outpatient consultations, rather than the severity of nutritional status at admission.
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When a young person is admitted to a hospital for anorexia nervosa, the immediate goal is to restore their physical health and return them to their family. Doctors work to reverse the dangerous weight loss and stabilize the body. Yet, for a significant number of these adolescents, the recovery achieved inside the hospital walls does not hold once they go home. They return to the ward, often within a few months, trapped in a cycle of discharge and readmission. This pattern is not just a matter of numbers; it represents a profound struggle to maintain recovery in the real world, where the pressures of daily life, family dynamics, and the illness itself collide. Understanding why some young people slip back into the illness while others sustain their recovery is critical. It is the difference between a single, difficult chapter in a life story and a recurring loop that threatens their future.
Researchers in Portugal set out to understand exactly what happens in this critical window between hospital discharge and a potential return. They looked back at the medical records of 113 adolescents, aged 12 to 17, who had been treated for anorexia nervosa in a public psychiatric unit over a nine-year period. The team followed these patients for two years after they left the hospital, tracking who came back and who stayed well. Their goal was to find the specific signs that predicted a return to the hospital, moving beyond simple assumptions about how sick a patient was when they first arrived. They wanted to know if the length of the hospital stay, the severity of the weight loss at the start, or other factors were the true drivers of relapse.
The study revealed a striking reality: the severity of the illness when the patient first walked into the hospital was not the main predictor of whether they would return. Instead, the factors that mattered most were what happened after they left. Among the 113 young people, 39 were readmitted within the two-year period. Most of these returns happened relatively quickly, with the median time to a first readmission being about four months after discharge. When these adolescents returned, their health had deteriorated significantly, with their body mass index dropping to a median of 13.9, a level indicating severe malnutrition. This suggests that the transition from the structured safety of the hospital to the home environment is where the battle is often lost.
The researchers identified three powerful warning signs that pointed toward a higher risk of returning to the hospital. The strongest predictor was the presence of depression. Adolescents who were diagnosed with comorbid depression at their first follow-up appointment after leaving the hospital were far more likely to be readmitted than those without it. This finding is significant because it suggests that the depression was not merely a temporary result of starvation that would vanish once the patient ate enough. Instead, it appeared to be a separate, persistent condition that continued to drive the illness even after weight restoration had begun. The second major predictor was the need for a feeding tube during the initial hospital stay. Patients who required a tube to receive nutrition were much more likely to return. This was not because the tube itself caused the relapse, but rather because the need for a tube signaled a level of severity and a lack of engagement with food that made the path to recovery much harder. The third predictor was related to how the patient engaged with care after leaving the hospital. Every time a patient missed a scheduled outpatient appointment, their risk of returning to the hospital increased. Missing these check-ins was a clear signal that the support system was fraying.
Interestingly, the study found that other factors often assumed to be critical did not show a strong link to readmission in this group. The length of time a patient spent in the hospital did not determine whether they would return; staying longer did not guarantee a better outcome. Similarly, the specific body mass index at the moment of discharge was not a reliable predictor, although those who returned tended to have slightly lower weights. The study also noted that family dysfunction was a significant factor in the group that returned, with a much higher prevalence of family conflict and involvement from child protection services among those who were readmitted. However, when the researchers looked at all the factors together, the influence of family issues was slightly less clear than the impact of depression, feeding tube use, and missed appointments, though it remained a serious concern.
The implications of these findings shift the focus of care from the hospital bed to the months that follow. The data suggests that the most effective way to prevent a return to the hospital is not necessarily to keep patients in longer, but to ensure they have robust support immediately after they leave. This means actively treating depression alongside nutritional recovery, rather than assuming it will resolve on its own. It also means paying close attention to patients who required feeding tubes, recognizing them as a high-risk group that needs extra transitional care. Finally, it highlights the importance of attendance; a missed appointment is not just a scheduling error but a potential early warning sign of a relapse in progress. By monitoring these specific indicators—depression, the intensity of the initial treatment, and engagement with follow-up care—clinicians can better identify which young people need the most support to break the cycle of readmission and sustain their recovery in the long term.
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