Why is this review important?
Anorexia nervosa is a severe and disabling mental health disorder of self starvation. In the general population the lifetime prevalence of anorexia nervosa may be as high as 5 in 100 women. About one in 10 people with anorexia nervosa is male. Psychological therapies are the main treatment and most people are treated as outpatients. A number of different types of therapy are used, from dynamic (where past issues are explored) to very directive cognitive-behavioural therapies (where specific advice is given and people are required to keep records of their eating behaviour). It is important to know which psychological therapy is most likely to help people recover. This review aimed to assess evidence about the effects of individual psychological therapy (therapy provided to one person as opposed to a group) delivered in outpatient settings to older adolescents and adults with anorexia nervosa.
Who will be interested in this review?
This review will be of interest to people with lived experience of anorexia nervosa and people involved in their care.
Which studies were included in the review?
We used search databases to find randomised controlled studies of individual psychological therapy delivered in outpatient settings to older adolescents and adults with anorexia nervosa (completed up to July 16 2014). We included 10 trials that covered 599 people with anorexia nervosa. These trials had some limitations: they were small and often lost a lot of people. The investigators and people involved usually knew which treatment group they were in, which may have affected how they reported results. The trials used different types of psychological therapies.
What does the evidence from the review tell us?
There was a limited amount of very low-quality evidence to suggest that people might do better when receiving focal psychodynamic therapy compared to no treatment or treatment as usual. With one exception, we found little difference between specific psychological therapies. Most therapies appeared as acceptable as any other approach, except for dietary advice which had a 100% non-completion rate in one small trial. Because of the risk of bias and limitations of studies, notably small sample sizes, we can draw no specific conclusions about the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents.
What should happen next?
We need more large multicentre randomised controlled trials of commonly-used psychological therapies in older adolescents and adults with anorexia nervosa.
Study design: Randomized controlled trial
Study grouping: Parallel group
Open Label:
Cluster RCT:
Baseline Characteristics
Fokus på kernesymtomer
Bredt fokus (ej kernesymptomer)
Included criteria: Adolescents (12-18 years). Meeting diagnostic criteria for the DSM-IV definition of AN, except for the amenorrhea criterion, and with weight up to 87% of their IBW.
Excluded criteria: Current psychotic illness, mental retardation, bipolar disorder, pregnancy, dependence on drugs or alcohol, previous family therapy for AN, taking medications that may induce weight loss, and medical instability, including being at a weight at or below 75% of the IBW.
Pretreatment: There were no significant differences between groups forany demographic or baseline variable.
Intervention Characteristics
Fokus på kernesymtomer
Bredt fokus (ej kernesymptomer)
Psykologiske spiseforstyrrelsessymptomer, EOT
Psykologiske spiseforstyrrelsessymptomer, LFU (1 år)
Adfærdssymptomer (restriktiv spisning, tvangsmotion, binge, purge), EOT
Adfærdssymptomer (restriktiv spisning, tvangsmotion, binge, purge), LFU (1 år)
Andel af sund kropsvægt/BMI, EOT
Andel af sund kropsvægt/BMI, LFU (1 år)
Recovery rate, LFU (1 år)
Dropout
Indlæggelser (antal dage)
Nkr 46 Anoreksi on 04/03/2016 15:52
Interventions
Agras 2014: Behandling med fokus på kernesymptomer=manualiseret FBT. Behandling med bredt fokus = systemisk familieterapi (SyFT)
Study design: Randomized controlled trial
Study grouping: Parallel group
Open Label:
Cluster RCT:
Baseline Characteristics
Fokus på kernesymptomer
Bredt fokus (ej kernesymptomer)
Included criteria: Severe and enduring AN (SE-AN). Aged ≥ 18 years and met DSM-IV criteria for AN, excluding criterion D (amenorrhea),for more than 7 years. Patients were also included if they met all DSM-IV criteria but presented with a BMI between 17.6 and18.5 kg/m2.
Excluded criteria: Current manic episode or psychosis, current alcohol or substance abuse or dependence, significant current medical or neurological illness (including seizure disorder), with the exception of nutrition-related alterations that impact on weight, were currently engaged in psychotherapy and not willing to suspend treatment for the duration of their participation in the study, had plans to move beyond commuting distance from the study site in the following 12 months, or did not live within commuting distance to the study site.
Pretreatment: Twelve participants in CBT-AN (38.7%)and 14 in SSCM (43.8%) were taking psychotropicmedication.
Intervention Characteristics
Fokus på kernesymptomer
Bredt fokus (ej kernesymptomer)
Psykologiske spiseforstyrrelsessymptomer, EOT
Psykologiske spiseforstyrrelsessymptomer, LFU (1 år)
Adfærdssymptomer (restriktiv spisning, tvangsmotion, binge, purge), EOT
Adfærdssymptomer (restriktiv spisning, tvangsmotion, binge, purge), LFU (1 år)
Andel af sund kropsvægt/BMI, EOT
Andel af sund kropsvægt/BMI, LFU (1 år)
Recovery rate, LFU (1 år)
Dropout
Indlæggelser (antal patienter) (LFU)
Livskvalitet, LFU (1 år)
Nkr 46 Anoreksi on 04/03/2016 02:29
Select
Studiet undersøger CBT-AN overfor SSCM - dvs begge to studier med fokus på kernesymptomer.
Nkr 46 Anoreksi on 04/03/2016 03:21
Select
konsensus: subgruppe til SE-AN: SSCM er kun ganske let kerne-fokuseret men meget ikke-direktiv
Nkr 46 Anoreksi on 04/03/2016 15:58
Interventions
Both treatments involved 30 individual treatment sessions provided over 8 months in an out-patient setting. Focus of treatment was improving quality of life and minimize harm, rather than weight gain per se. OBS: ingen af behandlingsarmene har fokus på vægtøgning pga. populationen, men CBT-AN mere aktivt og dirigerende fokus på at udfordre kernesymptomer.The treatments were distinct in that CBT-AN made use of specific cognitive and behavioral strategies whereas SSCM made use of more general, supportive therapeutic strategies.Fokus på kernesymptomer: CBT-ANCBT-AN was modified: treatment goals were set collaboratively and weight gain was encouraged but not identified as the primary goal. Eating behaviors are directly challenged through use of behavioral experiments and cognitive strategies. Changes to eating behaviors are encouraged using advice and education around nutrition rather than specific strategies. Highly structured, therapist-directed. Patients are given homework in each session.Bredt fokus:Fostering a therapeutic relationship that promotes adherence to treatment. Aims to assist the patient through use of praise, reassurance and advice. Changes to eating behaviors are encouraged using advice and education around nutrition rather than specific strategies. SSCM was modified for this trial such that weight gain was not prioritized. Instead, SSCM encouraged patients to make changes to improve their quality of life and physical well-being.Less structured sessions, based on what the patient brings to the session.
Participants were randomized within sites to one of the 2 family therapies using a computer-generated program.
From Hay 2015
From Fisher 2010
Randomization was performed by a biostatistician in the Data and Coordinating Centre (DCC, The University of Chicago), independent from either inter- vention site.
From Hay 2015
From Hay 2015
Judgement Comment: Not reported
From Hay 2015
From Fisher 2010
Judgement Comment: Not reported
From Hay 2015
From Hay 2015
blinding of participants and therapists not possible.
(not included in Hay 2015)
From Fisher 2010
Blinding of participants and therapist not possible.
(not included in Hay 2015)
(not included in Hay 2015)
Assessors were blinded to treatment assignment
From Hay 2015
From Fisher 2010
Independent assessors blind to treatment assignment conducted all assessments.
From Hay 2015
From Hay 2015
Missing data points were treated as missing at random conditional on observed information using maxi- mum likelihood estimation.
Dropout er lav, og analyser tager højde for missing data.
From Hay 2015
From Fisher 2010
All outcome analyses were based upon an intention-to-treat (ITT) approach. Missing data for con- tinuous outcome measures at EOT and follow-ups were imputed using multiple imputation based upon fully conditional Markov chain Monte Carlo modeling (Schafer, 1997).
COMMENTS
Dropout er lav, og der tages højde for missing data i analyser.
From Hay 2015
From Hay 2015
Judgement Comment: Der er ikke opgivet estimat for usikkerked for EOT og FU data, kun for baseline data. Alle planlagte outcomes rapporteres.
From Hay 2015
From Fisher 2010
Judgement Comment: All intended outcomes are reported. Der oplyses ikke usikkerheds-estimater.
From Hay 2015
From Hay 2015
no information
From Hay 2015
From Fisher 2010
no comments
From Hay 2015
From Hay 2015