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Meta-Analysis
. 2015 Jul 27;2015(7):CD003909.
doi: 10.1002/14651858.CD003909.pub2.

Individual psychological therapy in the outpatient treatment of adults with anorexia nervosa

Phillipa J Hay  1 , Angélica M Claudino, Stephen Touyz, Ghada Abd Elbaky
Affiliations
Meta-Analysis

Individual psychological therapy in the outpatient treatment of adults with anorexia nervosa

Phillipa J Hay et al. Cochrane Database Syst Rev. .

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 methods: 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reference lists of all included studies and sent letters to identified, notable researchers requesting information on unpublished or ongoing studies.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.

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.

PubMed Disclaimer

Conflict of interest statement

In the past PH has received reimbursement of expenses for speaking at medical meetings and attending symposia from Astra‐Zeneca, Solvay Pharmaceuticals, Bristol‐Myers Squibb, and Pfizer Pharmaceuticals, and for educational training for family doctors from Bristol‐Myers Squibb, Pfizer Pharmaceuticals and Lundbeck and has been funded by Jansen‐Cilag to attend educational symposia (none in the past 10 years).

PH and ST receive royalties from McGraw Hill Pubs and honoraria from Biomed Central.

ST has received honoraria for consultancy to a Shire Pharmaceuticals Advisory Board.

AC has received reimbursement for speaking at medical meetings or attending symposia from Eli‐Lilly and Lundbeck in the past (last in 2010).

GAB has no conflicts to declare.

PH and ST are authors on a trial deemed ineligible (Touyz 2013) and two ongoing trials referenced in this review (ACTRN12610000585022; ACTRN12611000725965).

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Individual psychological therapy versus treatment as usual (TAU), Outcome 1 Weight measured with BMI at one year follow‐up.
1.2
1.2. Analysis
Comparison 1 Individual psychological therapy versus treatment as usual (TAU), Outcome 2 Recovery not achieved according to Morgan and Russell narrow categories or similar.
1.3
1.3. Analysis
Comparison 1 Individual psychological therapy versus treatment as usual (TAU), Outcome 3 N participants not completing the trial for any reason.
1.4
1.4. Analysis
Comparison 1 Individual psychological therapy versus treatment as usual (TAU), Outcome 4 Recovery not achieved according to the Morgan 1988 broader scale ratings of average outcome or similar.
2.1
2.1. Analysis
Comparison 2 Individual psychological therapy versus a control therapy, Outcome 1 Weight measured with BMI.
2.2
2.2. Analysis
Comparison 2 Individual psychological therapy versus a control therapy, Outcome 2 Recovery not achieved according to Morgan and Russell narrow categories or similar.
2.3
2.3. Analysis
Comparison 2 Individual psychological therapy versus a control therapy, Outcome 3 Number of participants not completing therapy for any reason.
2.4
2.4. Analysis
Comparison 2 Individual psychological therapy versus a control therapy, Outcome 4 Mean eating disorder symptoms score.
2.5
2.5. Analysis
Comparison 2 Individual psychological therapy versus a control therapy, Outcome 5 General psychiatric symptoms.
2.6
2.6. Analysis
Comparison 2 Individual psychological therapy versus a control therapy, Outcome 6 Level of depression measured with the Hamilton Depression Rating Scale (HDRS).
2.7
2.7. Analysis
Comparison 2 Individual psychological therapy versus a control therapy, Outcome 7 Recovery not achieved according to the Morgan and Russell categories or similar at long term follow‐up.
2.8
2.8. Analysis
Comparison 2 Individual psychological therapy versus a control therapy, Outcome 8 Weight measured with BMI at long‐term follow‐up.
2.9
2.9. Analysis
Comparison 2 Individual psychological therapy versus a control therapy, Outcome 9 Mean eating disorder symptom score at long term follow‐up.
2.10
2.10. Analysis
Comparison 2 Individual psychological therapy versus a control therapy, Outcome 10 General psychiatric symptoms at long‐term follow‐up.
2.11
2.11. Analysis
Comparison 2 Individual psychological therapy versus a control therapy, Outcome 11 Level of depression measured with the Hamilton Depression Rating Scale (HDRS) at long term follow‐up.
3.1
3.1. Analysis
Comparison 3 Individual psychological therapy versus another individual psychological therapy, Outcome 1 Weight measured with BMI, or change in BMI.
3.2
3.2. Analysis
Comparison 3 Individual psychological therapy versus another individual psychological therapy, Outcome 2 Recovery not achieved according to Morgan and Russell narrow categories or similar.
3.3
3.3. Analysis
Comparison 3 Individual psychological therapy versus another individual psychological therapy, Outcome 3 Number of participants not completing treatment.
3.4
3.4. Analysis
Comparison 3 Individual psychological therapy versus another individual psychological therapy, Outcome 4 Mean eating disorder symptom scores at end of treatment.
3.5
3.5. Analysis
Comparison 3 Individual psychological therapy versus another individual psychological therapy, Outcome 5 General psychiatric symptoms.
3.6
3.6. Analysis
Comparison 3 Individual psychological therapy versus another individual psychological therapy, Outcome 6 Level of depression measured with the Hamilton Depression Rating Scale (HDRS).
3.7
3.7. Analysis
Comparison 3 Individual psychological therapy versus another individual psychological therapy, Outcome 7 Mean eating disorder symptoms scores at long term follow‐up.
3.8
3.8. Analysis
Comparison 3 Individual psychological therapy versus another individual psychological therapy, Outcome 8 Weight as measured with BMI at long term follow‐up.
3.9
3.9. Analysis
Comparison 3 Individual psychological therapy versus another individual psychological therapy, Outcome 9 Recovery not achieved according to the Morgan and Russell categorical outcome or similar at long term follow‐up.
3.10
3.10. Analysis
Comparison 3 Individual psychological therapy versus another individual psychological therapy, Outcome 10 General psychiatric symptoms at long term follow‐up.
3.11
3.11. Analysis
Comparison 3 Individual psychological therapy versus another individual psychological therapy, Outcome 11 Level of depression measured with the Hamilton Depression Rating Scale (HDRS) at long term follow‐up.
4.1
4.1. Analysis
Comparison 4 Individual psychological therapy versus wait‐list control, Outcome 1 Number not achieving remission defined by normal: body weight, psychology, test results, eating behaviour & social activities.
See this image and copyright information in PMC

Update of

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