Psychotherapeutic Treatment for Anorexia Nervosa: A Systematic Review and Network Meta-Analysis

Abstract

Background: The aim of the study was a systematic review of studies evaluating psychotherapeutic treatment approaches in anorexia nervosa and to compare their efficacy. Weight gain was chosen as the primary outcome criterion. We also aimed to compare treatment effects according to service level (inpatient vs. outpatient) and age group (adolescents vs. adults). Methods:The data bases PubMed, Cochrane Library, Web of Science, Cinahl, and PsychInfo were used for a systematic literature search (until Feb 2017). Search terms were adapted for data base, combining versions of the search terms anorexia, treat^*/therap^* and controlled trial. Studies were selected using pre-defined in- and exclusion criteria. Data were extracted by two independent coders using piloted forms. Network-meta-analyses were conducted on all RCTs. For a comparison of service levels and age groups, standard mean change (SMC) statistics were used and naturalistic, non-randomized studies included. Results: Eighteen RCTs (trials on adults: 622 participants; trials on adolescents: 625 participants) were included in the network meta-analysis. SMC analyses were conducted with 38 studies (1,164 participants). While family-based approaches dominate interventions for adolescents, individual psychotherapy dominates in adults. There was no superiority of a specific approach. Weight gains were more rapid in adolescents and inpatient treatment. Conclusions: Several specialized psychotherapeutic interventions have been developed and can be recommended for AN. However, adult and adolescent patients should be distinguished, as groups differ in terms of treatment approaches considered suitable as well as treatment response. Future trials should replicate previous findings and be multi-center trials with large sample sizes to allow for subgroup analyses. Patient assessment should include variables that can be considered relevant moderators of treatment outcome. It is desirable to explore adaptive treatment strategies for subgroups of patients with AN. Identifying and addressing maintaining factors in AN remains a major challenge.

Keywords: anorexia nervosa; eating disorders; meta-analysis; psychotherapy; systematic review.

Figure 1

PRISMA flow chart, study selection procedure.

Figure 2

Forest plots and graphs of network meta-analyses. (A) Forest plot adult samples: SSCM was chosen as the reference treatment. Random effects model. If the 95%-CI includes Zero, then the SMD is not significantly different from Zero. No significant effects. Forst plot adolescent samples: FT_AN was chosen as the reference treatment. Random effects model. No significant effects. Complex-ipS = Complex-ip, “short” inpatient treatment. Net adult samples: All treatment categories are located on a circle in alphabetical order (counterclockwise, starting with CAT). All direct comparisons are represented by a connecting line. Only three direct comparisons were investigated more than once. The thickness of a connecting line is proportional to 1/SE of the respective SMD. (B) Net adolescent samples: FT_AN was chosen as the reference treatment. Only two direct comparisons were investigated more than once.

Figure 3

Ratings of items related to risk of bias. Risk of bias across all studies included in the network meta-analysis (coders assessment), presented as percentages of ratings (low risk: rated “yes;” high risk: rated “no”). Further possible risks of bias: Selective outcome reporting: Registration in a trial register or published study protocols were available for more recent studies only. Therefore, selective outcome reporting could not be assessed. Researcher allegiance (RA): It was taken care of that coders were independent and not involved in the studies they had to rate. The study group consisted of experts representing a broad range of therapeutic orientations (CBT, psychodynamic, family) and backgrounds (psychology, psychosomatic medicine, child, and adolescent psychiatry).