Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa
Abstract
Background
Anorexia nervosa is a disorder with high morbidity and significant mortality. It is commonest in young adult women, in whom the incidence may be increasing. The focus of treatment has moved to an outpatient setting and a number of differing psychotherapies are presently used in treatment.
Objectives
The aim of the present review was to evaluate the evidence from randomised controlled trials for the efficacy of outpatient psychotherapies used in the treatment of older adolescents and adults with anorexia nervosa.
Search methods
CCDANCTR‐Studies and CCDANCTR‐References were searched on 12/2/2008. Further database searches of MEDLINE, EXTRAMED, EMBASE, PSYCLIT, CURRENT CONTENTS were carried out, hand‐search of The International Journal of Eating Disorders, and the reference lists of all papers selected. Personal letters were sent to identified notable researchers who had published in the area, requesting information on trials that are unpublished or in progress. The search was updated to December 2005 (MEDLINE and CCDAN registers) and then to Feb 2008 (MEDLINE, SCOPUS, and CCDAN registers).
Selection criteria
All randomised controlled trials of adult individual outpatient therapy for anorexia nervosa, as defined by DSM‐IV or similar international criteria. Quality assessment was made according to Quality Rating Scale criteria and in addition, whether the trial had examined treatment integrity.
Data collection and analysis
A range of outcome variables were selected, including physical state, severity of eating disorder attitudes and beliefs, interpersonal function, and general psychiatric symptom severity. Continuous outcome data comparisons used the standardised mean difference statistic, and binary outcome comparisons used relative risk. Reliability of data extraction and quality assessment were made with the kappa statistic. Sensitivity analyses to evaluate the effects of trial quality and subgroup analyses to explore specific questions of treatment effects from different settings, frequency and duration of therapies were planned.
Main results
Seven small trials only, two of which included children or adolescents, were identified from the search, and aggregation of data was not possible. Bias was possible due particularly to lack of blinding of outcome assessments. The results in two trials suggested that 'treatment as usual' or similar may be less efficacious than a specific psychotherapy. No specific treatment was consistently superior to any other specific approach. Dietary advice as a control arm had a 100% non‐completion rate in one trial. One trial found a nonspecific therapy was favoured over two specific psychotherapies.
Authors' conclusions
No specific approach can be recommended from this review. It is unclear why 'treatment as usual' performed so poorly, or why dietary advice alone appeared so unacceptable, as the reasons for non‐completion were not reported. There is an urgent need for large well‐designed trials in this area.
PICOs
Plain language summary
Outpatient psychotherapy for anorexic adults
This review aimed to assess evidence about the effects of outpatient psychotherapy on older adolescents and adults with anorexia nervosa. Although anorexia nervosa is a severe and disabling disorder, only seven trials were found. The trials used different types of psychotherapy. It was not possible to make firm conclusions about the therapies tested. Participants who did not receive psychotherapy (e.g. were in a waiting‐list control group or who got 'treatment as usual') did poorly. In one study, all those in the control group who got only 'dietary advice' dropped out. There is an urgent need for multi‐centre, large randomized controlled trials of commonly used psychotherapies in older adolescents and adults with anorexia nervosa.
