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Meta-Analysis
. 2018 Oct 15;10(10):CD004780.
doi: 10.1002/14651858.CD004780.pub3.

Family therapy approaches for anorexia nervosa

Caroline A Fisher  1 , Sonja Skocic, Kathleen A Rutherford, Sarah E Hetrick
Affiliations
Meta-Analysis

Family therapy approaches for anorexia nervosa

Caroline A Fisher et al. Cochrane Database Syst Rev. .

Update in

  • Family therapy approaches for anorexia nervosa.
    Fisher CA, Skocic S, Rutherford KA, Hetrick SE. Fisher CA, et al. Cochrane Database Syst Rev. 2019 May 1;5(5):CD004780. doi: 10.1002/14651858.CD004780.pub4. Cochrane Database Syst Rev. 2019. PMID: 31041816 Free PMC article.

Abstract

Background: Anorexia nervosa (AN) is characterised by a failure to maintain a normal body weight due to a paucity of nutrition, an intense fear of gaining weight or behaviour that prevents the individual from gaining weight, or both. The long-term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality. 'Family therapy approaches' indicate a range of approaches, derived from different theories, that involve the family in treatment. We have included therapies developed on the basis of dominant family systems theories, approaches that are based on or broadly similar to the family-based therapy derived from the Maudsley model, approaches that incorporate a focus on cognitive restructuring, as well as approaches that involve the family without articulation of a theoretical approach.This is an update of a Cochrane Review first published in 2010.

Objectives: To evaluate the efficacy of family therapy approaches compared with standard treatment and other treatments for AN.

Search methods: We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and PsycINFO (OVID) (all years to April 2016). We ran additional searches directly on Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Ovid Embase, and PsycINFO (to 2008 and 2016 to 2018). We searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov, together with four theses databases (all years to 2018). We checked the reference lists of all included studies and relevant systematic reviews. We have included in the analyses only studies from searches conducted to April 2016.

Selection criteria: Randomised controlled trials (RCTs) of family therapy approaches compared to any other intervention or other types of family therapy approaches were eligible for inclusion. We included participants of any age or gender with a primary clinical diagnosis of anorexia nervosa.

Data collection and analysis: Four review authors selected the studies, assessed quality and extracted data. We used a random-effects meta-analysis. We used the risk ratio (with a 95% confidence interval) to summarise dichotomous outcomes and both the standardised mean difference and the mean difference to summarise continuous measures.

Main results: We included 25 trials in this version of the review (13 from the original 2010 review and 12 newly-included studies). Sixteen trials were of adolescents, eight trials of adults (seven of these in young adults aged up to 26 years) and one trial included three age groups: one adolescent, one young adult and one adult. Most investigated family-based therapy or variants. Reporting of trial conduct was generally inadequate, so that in a large number of studies we rated the risk of bias as unclear for many of the domains. Selective reporting bias was particularly problematic, with 68% of studies rated at high risk of bias in this area, followed by incomplete outcome data, with 44% of studies rated at high risk of bias in this area. For the main outcome measure of remission there was some low-quality evidence (from only two studies, 81 participants) suggesting that family therapy approaches might offer some advantage over treatment as usual on rates of remission, post intervention (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.49 to 8.23; I2 = 0%). However, at follow-up, low-quality evidence from only one study suggested this effect was not maintained. There was very low-quality evidence from only one trial, which means it is difficult to determine whether family therapy approaches offer any advantage over educational interventions for remission (RR 9.00, 95% CI 0.53 to 153.79; 1 study, N = 30). Similarly, there was very low-quality evidence from only five trials for remission post-intervention, again meaning that it is difficult to determine whether there is any advantage of family therapy approaches over psychological interventions (RR 1.22, 95% CI 0.89 to 1.67; participants = 252; studies = 5; I2 = 37%) and at long-term follow-up (RR 1.08, 95% CI 0.91 to 1.28; participants = 200; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 0%). There was no indication that the age group had any impact on the overall treatment effect; however, it should be noted that there were very few trials undertaken in adults, with the age range of adult studies included in this analysis from 20 to 27. There was some evidence of a small effect favouring family based therapy compared with other psychological interventions in terms of weight gain post-intervention (standardised mean difference (SMD) 0.32, 95% CI 0.01 to 0.63; participants = 210; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 11%) . Overall, there was insufficient evidence to determine whether there were any differences between groups across all comparisons for most of the secondary outcomes (weight, eating disorder psychopathology, dropouts, relapse, or family functioning measures), either at post-intervention or at follow-up.

Authors' conclusions: There is a limited amount of low-quality evidence to suggest that family therapy approaches may be effective compared to treatment as usual in the short term. This finding is based on two trials that included only a small number of participants, and both had issues about potential bias. There is insufficient evidence to determine whether there is an advantage of family therapy approaches in people of any age compared to educational interventions (one study, very low quality) or psychological therapies (five studies, very low quality). Most studies contributing to this finding were undertaken in adolescents and youth. There are clear potential impacts on how family therapy approaches might be delivered to different age groups and further work is required to understand what the resulting effects on treatment efficacy might be. There is insufficient evidence to determine whether one type of family therapy approach is more effective than another. The field would benefit from further large, well-conducted trials.

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Conflict of interest statement

Caroline Fisher: None known; Sonja Skocic: None known; Katheleen Rutherford: None known; Sarah Hetrick: None known.

Figures

Figure 1
Figure 1
Study flow diagram (from searches conducted to April 2016).
Figure 2
Figure 2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figure 3
Figure 3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Analysis 1.1
Analysis 1.1
Comparison 1 Family therapy approaches vs standard care/treatment as usual, Outcome 1 Remission post‐intervention.
Analysis 1.2
Analysis 1.2
Comparison 1 Family therapy approaches vs standard care/treatment as usual, Outcome 2 Remission long‐term follow‐up.
Analysis 1.3
Analysis 1.3
Comparison 1 Family therapy approaches vs standard care/treatment as usual, Outcome 3 General Functioning.
Analysis 1.4
Analysis 1.4
Comparison 1 Family therapy approaches vs standard care/treatment as usual, Outcome 4 Dropouts during therapy.
Analysis 1.5
Analysis 1.5
Comparison 1 Family therapy approaches vs standard care/treatment as usual, Outcome 5 Eating disorder psychopathology post‐intervention.
Analysis 1.6
Analysis 1.6
Comparison 1 Family therapy approaches vs standard care/treatment as usual, Outcome 6 Weight (BMI).
Analysis 1.7
Analysis 1.7
Comparison 1 Family therapy approaches vs standard care/treatment as usual, Outcome 7 Relapse during treatment.
Analysis 2.1
Analysis 2.1
Comparison 2 Family therapy approaches vs psychological interventions, Outcome 1 Remission post‐intervention.
Analysis 2.2
Analysis 2.2
Comparison 2 Family therapy approaches vs psychological interventions, Outcome 2 Remission short‐term follow‐up.
Analysis 2.3
Analysis 2.3
Comparison 2 Family therapy approaches vs psychological interventions, Outcome 3 Remission long‐term follow‐up.
Analysis 2.4
Analysis 2.4
Comparison 2 Family therapy approaches vs psychological interventions, Outcome 4 Dropouts during treatment.
Analysis 2.5
Analysis 2.5
Comparison 2 Family therapy approaches vs psychological interventions, Outcome 5 Eating disorder psychopathology post‐intervention.
Analysis 2.6
Analysis 2.6
Comparison 2 Family therapy approaches vs psychological interventions, Outcome 6 Eating disorder psychopathology short‐term follow‐up.
Analysis 2.7
Analysis 2.7
Comparison 2 Family therapy approaches vs psychological interventions, Outcome 7 Eating disorder psychopathology long‐term follow‐up.
Analysis 2.8
Analysis 2.8
Comparison 2 Family therapy approaches vs psychological interventions, Outcome 8 Weight (BMI, BMI%ile, %ABW) post‐intervention.
Analysis 2.9
Analysis 2.9
Comparison 2 Family therapy approaches vs psychological interventions, Outcome 9 Weight (BMI%ile) short‐term follow‐up.
Analysis 2.10
Analysis 2.10
Comparison 2 Family therapy approaches vs psychological interventions, Outcome 10 Weight (BMI, BMI%ile, %ABW) long‐term follow‐up.
Analysis 2.11
Analysis 2.11
Comparison 2 Family therapy approaches vs psychological interventions, Outcome 11 Relapse during treatment.
Analysis 2.12
Analysis 2.12
Comparison 2 Family therapy approaches vs psychological interventions, Outcome 12 Relapse long‐term follow‐up.
Analysis 3.1
Analysis 3.1
Comparison 3 Family therapy approaches vs educational interventions, Outcome 1 Remission long‐term follow‐up.
Analysis 4.1
Analysis 4.1
Comparison 4 Family therapy approaches short‐term vs family therapy approaches long‐term, Outcome 1 Remission long‐term follow‐up (mean 3.96 years).
Analysis 4.2
Analysis 4.2
Comparison 4 Family therapy approaches short‐term vs family therapy approaches long‐term, Outcome 2 Return to functioning (school or work) follow‐up.
Analysis 4.3
Analysis 4.3
Comparison 4 Family therapy approaches short‐term vs family therapy approaches long‐term, Outcome 3 Dropouts during therapy.
Analysis 4.4
Analysis 4.4
Comparison 4 Family therapy approaches short‐term vs family therapy approaches long‐term, Outcome 4 Eating disorder psychopathology long‐term follow‐up (EDE) note large dropout.
Analysis 4.5
Analysis 4.5
Comparison 4 Family therapy approaches short‐term vs family therapy approaches long‐term, Outcome 5 Weight (BMI) post‐intervention.
Analysis 4.6
Analysis 4.6
Comparison 4 Family therapy approaches short‐term vs family therapy approaches long‐term, Outcome 6 Weight (BMI) follow‐up.
Analysis 4.7
Analysis 4.7
Comparison 4 Family therapy approaches short‐term vs family therapy approaches long‐term, Outcome 7 Relapse during treatment.
Analysis 5.1
Analysis 5.1
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 1 Remission post‐intervention.
Analysis 5.2
Analysis 5.2
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 2 Remission short‐term follow‐up.
Analysis 5.3
Analysis 5.3
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 3 Remission long‐term follow‐up.
Analysis 5.4
Analysis 5.4
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 4 Dropouts during therapy.
Analysis 5.5
Analysis 5.5
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 5 Dropouts during follow‐up (5 years).
Analysis 5.6
Analysis 5.6
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 6 Eating disorder psychopathology post‐intervention (EAT).
Analysis 5.7
Analysis 5.7
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 7 Eating disorder psychopathology follow‐up (EAT).
Analysis 5.8
Analysis 5.8
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 8 Eating disorder psychopathology post‐intervention (MR).
Analysis 5.9
Analysis 5.9
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 9 Eating disorder psychopathology post‐intervention (EDI).
Analysis 5.10
Analysis 5.10
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 10 Eating disorder psychopathology follow‐up (EDI).
Analysis 5.11
Analysis 5.11
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 11 Eating disorder psychopathology post‐intervention (EDE).
Analysis 5.12
Analysis 5.12
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 12 Eating disorder psychopathology short‐term follow‐up (EDE).
Analysis 5.13
Analysis 5.13
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 13 Eating disorder psychopathology long‐term follow‐up (EDE).
Analysis 5.14
Analysis 5.14
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 14 Weight (%Median BMI) post‐intervention.
Analysis 5.15
Analysis 5.15
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 15 Weight (%Median BMI) short‐term follow‐up.
Analysis 5.16
Analysis 5.16
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 16 Weight (%Median BMI) long‐term follow‐up.
Analysis 5.17
Analysis 5.17
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 17 Weight (%ABW) post‐intervention.
Analysis 5.18
Analysis 5.18
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 18 Weight (%ABW) follow‐up (5 years).
Analysis 5.19
Analysis 5.19
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 19 Relapse post‐intervention.
Analysis 5.20
Analysis 5.20
Comparison 5 Family therapy approaches conjoint vs family therapy approaches separated, Outcome 20 Relapse follow‐up (5 years).
Analysis 6.1
Analysis 6.1
Comparison 6 Family therapy approaches vs family therapy approaches plus meal, Outcome 1 Remission post‐intervention.
Analysis 6.2
Analysis 6.2
Comparison 6 Family therapy approaches vs family therapy approaches plus meal, Outcome 2 Remission short‐term follow‐up.
Analysis 6.3
Analysis 6.3
Comparison 6 Family therapy approaches vs family therapy approaches plus meal, Outcome 3 Remission long‐term follow‐up.
Analysis 6.4
Analysis 6.4
Comparison 6 Family therapy approaches vs family therapy approaches plus meal, Outcome 4 Family function post‐intervention Family Health Scale.
Analysis 6.5
Analysis 6.5
Comparison 6 Family therapy approaches vs family therapy approaches plus meal, Outcome 5 Dropouts.
Analysis 6.6
Analysis 6.6
Comparison 6 Family therapy approaches vs family therapy approaches plus meal, Outcome 6 Eating disorder psychopathology post‐intervention (MR).
Analysis 6.7
Analysis 6.7
Comparison 6 Family therapy approaches vs family therapy approaches plus meal, Outcome 7 Eating disorder psychopathology short‐term follow‐up (MR).
Analysis 6.8
Analysis 6.8
Comparison 6 Family therapy approaches vs family therapy approaches plus meal, Outcome 8 Eating disorder psychopathology long‐term follow‐up (MR).
Analysis 6.9
Analysis 6.9
Comparison 6 Family therapy approaches vs family therapy approaches plus meal, Outcome 9 Weight (BMI, EBW%) post‐intervention.
Analysis 6.10
Analysis 6.10
Comparison 6 Family therapy approaches vs family therapy approaches plus meal, Outcome 10 Weight (EBW%) short‐term follow‐up.
Analysis 6.11
Analysis 6.11
Comparison 6 Family therapy approaches vs family therapy approaches plus meal, Outcome 11 Weight (BMI) long‐term follow‐up.
Analysis 7.1
Analysis 7.1
Comparison 7 Individual family therapy approaches vs group family therapy approaches, Outcome 1 Family function post‐intervention (carers' LEE).
Analysis 7.2
Analysis 7.2
Comparison 7 Individual family therapy approaches vs group family therapy approaches, Outcome 2 Family function follow‐up (carers' LEE).
Analysis 7.3
Analysis 7.3
Comparison 7 Individual family therapy approaches vs group family therapy approaches, Outcome 3 Dropouts.
Analysis 7.4
Analysis 7.4
Comparison 7 Individual family therapy approaches vs group family therapy approaches, Outcome 4 Eating disorder psychopathology post‐intervention (SEED‐AN).
Analysis 7.5
Analysis 7.5
Comparison 7 Individual family therapy approaches vs group family therapy approaches, Outcome 5 Eating disorder psychopathology follow‐up (SEED‐AN).
Analysis 7.6
Analysis 7.6
Comparison 7 Individual family therapy approaches vs group family therapy approaches, Outcome 6 Weight (BMI) post‐intervention.
Analysis 7.7
Analysis 7.7
Comparison 7 Individual family therapy approaches vs group family therapy approaches, Outcome 7 Weight (BMI) follow‐up.
Analysis 8.1
Analysis 8.1
Comparison 8 Family‐based therapy vs systemic family therapy, Outcome 1 Remission post‐intervention.
Analysis 8.2
Analysis 8.2
Comparison 8 Family‐based therapy vs systemic family therapy, Outcome 2 Remission short‐term follow‐up.
Analysis 8.3
Analysis 8.3
Comparison 8 Family‐based therapy vs systemic family therapy, Outcome 3 Dropouts during therapy.
Analysis 9.1
Analysis 9.1
Comparison 9 Inpatient family therapy approaches vs day‐patient family therapy approaches, Outcome 1 Remission short‐term follow‐up.
Analysis 9.2
Analysis 9.2
Comparison 9 Inpatient family therapy approaches vs day‐patient family therapy approaches, Outcome 2 Dropouts.
Analysis 9.3
Analysis 9.3
Comparison 9 Inpatient family therapy approaches vs day‐patient family therapy approaches, Outcome 3 Eating disorder psychopathology short‐term follow‐up (EDI).
Analysis 9.4
Analysis 9.4
Comparison 9 Inpatient family therapy approaches vs day‐patient family therapy approaches, Outcome 4 Weight (%EBW) short‐term follow‐up.
Analysis 9.5
Analysis 9.5
Comparison 9 Inpatient family therapy approaches vs day‐patient family therapy approaches, Outcome 5 Relapse at short‐term follow‐up.
Analysis 10.1
Analysis 10.1
Comparison 10 Family‐based therapy vs family‐based therapy plus parent coaching, Outcome 1 Remission post‐intervention.
Analysis 10.2
Analysis 10.2
Comparison 10 Family‐based therapy vs family‐based therapy plus parent coaching, Outcome 2 Dropouts.
Analysis 10.3
Analysis 10.3
Comparison 10 Family‐based therapy vs family‐based therapy plus parent coaching, Outcome 3 Eating disorder psychopathology post‐intervention (EDE).
Analysis 10.4
Analysis 10.4
Comparison 10 Family‐based therapy vs family‐based therapy plus parent coaching, Outcome 4 Weight (BMI) post‐intervention.
Analysis 11.1
Analysis 11.1
Comparison 11 Family‐based therapy plus medical stability vs family‐based therapy plus weight restoration, Outcome 1 Remission post‐intervention.
Analysis 11.2
Analysis 11.2
Comparison 11 Family‐based therapy plus medical stability vs family‐based therapy plus weight restoration, Outcome 2 Remission short‐term follow‐up.
Analysis 11.3
Analysis 11.3
Comparison 11 Family‐based therapy plus medical stability vs family‐based therapy plus weight restoration, Outcome 3 Remission long‐term follow‐up.
Analysis 11.4
Analysis 11.4
Comparison 11 Family‐based therapy plus medical stability vs family‐based therapy plus weight restoration, Outcome 4 Dropouts.
Analysis 11.5
Analysis 11.5
Comparison 11 Family‐based therapy plus medical stability vs family‐based therapy plus weight restoration, Outcome 5 Eating disorder psychopathology (EDE) long‐term follow‐up.
Analysis 11.6
Analysis 11.6
Comparison 11 Family‐based therapy plus medical stability vs family‐based therapy plus weight restoration, Outcome 6 Weight (%EBW change) long‐term follow‐up.
Analysis 11.7
Analysis 11.7
Comparison 11 Family‐based therapy plus medical stability vs family‐based therapy plus weight restoration, Outcome 7 Relapse at long‐term follow‐up.
Analysis 12.1
Analysis 12.1
Comparison 12 Family‐based therapy vs family‐based therapy plus consultation, Outcome 1 Remission post‐intervention.
Analysis 13.1
Analysis 13.1
Comparison 13 Family therapy approaches vs standard care/treatment as usual (subgroup by age), Outcome 1 Remission post‐intervention (subgroup by age).
Analysis 13.2
Analysis 13.2
Comparison 13 Family therapy approaches vs standard care/treatment as usual (subgroup by age), Outcome 2 Remission long‐term follow‐up.
Analysis 13.3
Analysis 13.3
Comparison 13 Family therapy approaches vs standard care/treatment as usual (subgroup by age), Outcome 3 General Functioning.
Analysis 13.4
Analysis 13.4
Comparison 13 Family therapy approaches vs standard care/treatment as usual (subgroup by age), Outcome 4 Dropouts during therapy.
Analysis 13.5
Analysis 13.5
Comparison 13 Family therapy approaches vs standard care/treatment as usual (subgroup by age), Outcome 5 Eating disorder psychopathology post‐intervention.
Analysis 13.6
Analysis 13.6
Comparison 13 Family therapy approaches vs standard care/treatment as usual (subgroup by age), Outcome 6 Weight (BMI).
Analysis 13.7
Analysis 13.7
Comparison 13 Family therapy approaches vs standard care/treatment as usual (subgroup by age), Outcome 7 Relapse during treatment.
Analysis 14.1
Analysis 14.1
Comparison 14 Family therapy approaches vs psychological interventions (sugroup by age), Outcome 1 Remission post‐intervention.
Analysis 14.2
Analysis 14.2
Comparison 14 Family therapy approaches vs psychological interventions (sugroup by age), Outcome 2 Remission short‐term follow‐up.
Analysis 14.3
Analysis 14.3
Comparison 14 Family therapy approaches vs psychological interventions (sugroup by age), Outcome 3 Remission long‐term follow‐up.
Analysis 14.4
Analysis 14.4
Comparison 14 Family therapy approaches vs psychological interventions (sugroup by age), Outcome 4 Dropouts during treatment.
Analysis 14.5
Analysis 14.5
Comparison 14 Family therapy approaches vs psychological interventions (sugroup by age), Outcome 5 Eating disorder psychopathology post‐intervention.
Analysis 14.6
Analysis 14.6
Comparison 14 Family therapy approaches vs psychological interventions (sugroup by age), Outcome 6 Eating disorder psychopathology short‐term follow‐up (Lock 2010‐EDE).
Analysis 14.7
Analysis 14.7
Comparison 14 Family therapy approaches vs psychological interventions (sugroup by age), Outcome 7 Eating disorder psychopathology long‐term follow‐up.
Analysis 14.8
Analysis 14.8
Comparison 14 Family therapy approaches vs psychological interventions (sugroup by age), Outcome 8 Weight (BMI, BMI%ile, %ABW) post‐intervention.
Analysis 14.9
Analysis 14.9
Comparison 14 Family therapy approaches vs psychological interventions (sugroup by age), Outcome 9 Weight (BMI%ile) short‐term follow‐up.
Analysis 14.10
Analysis 14.10
Comparison 14 Family therapy approaches vs psychological interventions (sugroup by age), Outcome 10 Weight (BMI, BMI%ile, %ABW) long‐term follow‐up.
Analysis 14.11
Analysis 14.11
Comparison 14 Family therapy approaches vs psychological interventions (sugroup by age), Outcome 11 Relapse during treatment.
Analysis 14.12
Analysis 14.12
Comparison 14 Family therapy approaches vs psychological interventions (sugroup by age), Outcome 12 Relapse long‐term follow‐up.
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Update of

References

References to studies included in this review

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References to ongoing studies

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References to other published versions of this review

    1. Fisher CA, Rushford N, Hetrick SE. Family therapy for anorexia nervosa. Cochrane Database of Systematic Reviews 2008, Issue 2008. [DOI: 10.1002/14651858.CD004780] - DOI - PubMed
    1. Fisher CA, Hetrick SE, Rushford N. Family Therapy for Anorexica Nervosa. Cochrane Database of Systematic Reviews 2010, Issue 6. [DOI: 10.1002/14651858.CD004780.pub2] - DOI - PubMed

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