Outpatient psychological therapy for adults with anorexia

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.

Authors' conclusions: 

There was a suggestion in one trial that focal psychodynamic therapy might be superior to TAU, but this is in the context of TAU performing poorly. An alternative control condition of dietary advice alone appeared to be unacceptable, but again this is based on just one trial. Owing to 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. Larger RCTs of longer treatment duration and follow-up are needed.

Read the full abstract...
Background: 

Anorexia nervosa is a disorder with high morbidity and significant mortality. It is most common 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 psychological therapies are presently used in treatment. This is an update of a Cochrane review which was last published in 2008.

Objectives: 

To assess the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents treated in an outpatient setting.

Search strategy: 

We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR) (16 July 2014). This register includes relevant randomised controlled trials from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We screened reference lists of all included studies and sent letters to identified, notable researchers requesting information on unpublished or ongoing studies.

Selection criteria: 

All randomised controlled trials of one or more individual outpatient psychological therapies for adults with anorexia nervosa, as defined by DSM-5 or similar international criteria.

Data collection and analysis: 

We selected a range of outcome variables, including physical state, severity of eating disorder attitudes and beliefs, interpersonal function, and general psychiatric symptom severity. Continuous outcome data comparisons used the mean or standardised mean difference (MD or SMD), and binary outcome comparisons used the risk ratio (RR). Two review authors (PH and AC or ST) extracted data independently.

Main results: 

We identified 10 trials from the search, with a total of 599 anorexia nervosa participants, and included them in the review. Seven had been identified in the previous versions of this review and we now include three new trials. We now deem one previously identified ongoing trial to be ineligible, and six ongoing trials are new for this update. Two of the 10 trials included children. Trials tested diverse psychological therapies and comparability was poor. Risks of bias were mostly evident through lack of blinded outcome assessments (in 60% of studies) and incomplete data reporting (attrition bias).

The results suggest that treatment as usual (TAU) when delivered by a non-eating-disorder specialist or similar may be less efficacious than focal psychodynamic therapy. This was suggested for a primary outcome of recovery by achievement of a good or intermediate outcome on the Morgan and Russell Scale (RR 0.70, 95% confidence interval (CI) 0.51 to 0.97; 1 RCT, 40 participants; very low-quality evidence). However there were no differences between cognitive analytic therapy and TAU for this outcome (RR 0.78, 95% CI 0.61 to 1.00; 2 RCTs, 71 participants; very low-quality evidence), nor for body mass index (BMI). There were no differences in overall dropout rates between individual psychological therapies and TAU.

Two trials found a non-specific specialist therapy (Specialist Supportive Clinical Management) or an Optimised TAU delivered by therapists with eating disorder expertise was similar in outcomes to cognitive behaviour therapy (BMI MD -0.00, 95% CI -0.91 to 0.91; 197 participants, low-quality evidence). When comparing individual psychological therapies with each other, 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 (35 participants). None of the trials identified any adverse effects. Insufficient power was problematic for the majority of trials.

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