Gowers, S.G., Clark, A., Roberts, C., Griffiths, A., Edwards, V., Bryan, C., Smethurst, N., Byford, S., Barrett, B.

Clinical effectiveness of treatments for anorexia nervosa in adolescents

BACKGROUND:; ; Treatment guidelines identify few adequately powered trials to guide recommendations for anorexia nervosa.; AIMS:; ; To evaluate the effectiveness of three readily available National Health Service treatments for adolescents (aged 12-18 years) with anorexia nervosa.; METHOD:; ; Multicentre randomised controlled trial of 167 young people comparing in-patient, specialist out-patient and general child and adolescent mental health service (CAMHS) treatment.; RESULTS:; ; Each group made considerable progress at 1 year, with further improvement by 2 years. Full recovery rates were poor (33% at 2 years, 27% still with anorexia nervosa). Adherence to in-patient treatment was only 50%. Neither in-patient nor specialist out-patient therapy demonstrated advantages over general CAMHS treatment by intention to treat, although some CAMHS out-patients were subsequently admitted on clinical grounds. In-patient treatment (randomised or after out-patient transfer) predicted poor outcomes.; CONCLUSIONS:; ; First-line in-patient psychiatric treatment does not provide advantages over out-patient management. Out-patient treatment failures do very poorly on transfer to in- patient facilities.

British Journal of Psychiatry, 191(5) : 427-435

Rigaud, Daniel, Brondel, Laurent, Poupard, Anne Therese, Talonneau, Isabelle, Brun, Jean Marcel

A randomized trial on the efficacy of a 2-month tube feeding regimen in anorexia nervosa: A 1-year follow-up study

BACKGROUND & AIMS: Despite the high mortality rate in malnourished anorexia nervosa (AN) patients, very few trials have prospectively studied the efficacy of tube feeding. METHODS: This open prospective study was conducted in malnourished AN patients, who were randomized in tube feeding (n=41) or control (n=40) groups during a 2- month period. Thereafter, body weight, body mass gain, energy intake, eating behavior and relapse rates were compared during a 1-year follow-up, using paired Student t-test and ANOVA. RESULTS: At the end of the 2-months period, weight gain was 39% higher in the tube feeding group than in the control group (194+/-14 vs 126+/-19g/day; P<0.01). The fat-free mass gain was greater in the tube-feeding group: 109+/-14 vs 61+/-17g/day (P<0.01). Energy intake was higher in the tube feeding group than in the control group (P<0.05), as well as the decrease in bingeing episodes (P<0.01). Most patients thought that CEN improved their eating disorder. After discharge, the relapse-free period was longer in the CEN group than in the control one: 34.3+/-8.2 weeks vs 26.8+/-7.5 weeks (P<0.05). CONCLUSION: CEN is helpful in malnourished AN patients for weight restoration, without hindrance on the eating behavior therapy nor inducing a more rapid relapse.

Clinical Nutrition, 26(4) : 421- 9

Walsh, B. Timothy, Kaplan, Allan S., Attia, Evelyn, Olmsted, Marion, Parides, Michael, Carter, Jacqueline C., Pike, Kathleen M., Devlin, Michael J., Woodside, Blake, Roberto, Christina A., Rockert, Wendi

Fluoxetine after weight restoration in anorexia nervosa: A randomized controlled trial.

CONTEXT: Antidepressant medication is frequently prescribed for patients with anorexia nervosa. OBJECTIVE: To determine whether fluoxetine can promote recovery and prolong time-to- relapse among patients with anorexia nervosa following weight restoration. DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-blind, placebo- controlled trial. From January 2000 until May 2005, 93 patients with anorexia nervosa received intensive inpatient or day-program treatment at the New York State Psychiatric Institute or Toronto General Hospital. Participants regained weight to a minimum body mass index (calculated as weight in kilograms divided by the square of height in meters) of 19.0 and were then eligible to participate in the randomized phase of the trial. INTERVENTIONS: Participants were randomly assigned to receive fluoxetine or placebo and were treated for up to 1 year as outpatients in double-blind fashion. All patients also received individual cognitive behavioral therapy. MAIN OUTCOME MEASURES: The primary outcome measures were time-to-relapse and the proportion of patients successfully completing 1 year of treatment. RESULTS: Forty-nine patients were assigned to fluoxetine and 44 to placebo. Similar percentages of patients assigned to fluoxetine and to placebo maintained a body mass index of at least 18.5 and remained in the study for 52 weeks (fluoxetine, 26.5%; placebo, 31.5%; P = .57). In a Cox proportional hazards analysis, with prerandomization body mass index, site, and diagnostic subtype as covariates, there was no significant difference between fluoxetine and placebo in time-to-relapse (hazard ratio, 1.12; 95% CI, 0.65-2.01; P = .64). CONCLUSIONS: This study failed to demonstrate any benefit from fluoxetine in the treatment of patients with anorexia nervosa following weight restoration. Future efforts should focus on developing new models to understand the persistence of this illness and on exploring new psychological and pharmacological treatment approaches. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00288574.

JAMA, 295(22) : 2605-12

Richards, P. Scott, Berrett, Michael E., Hardman, Randy K., Eggett, Dennis L.

Comparative efficacy of spirituality, cognitive, and emotional support groups for treating eating disorder inpatients

Spiritual interventions are rarely used in contemporary treatment programs and little empirical evidence is available concerning their effectiveness. The purpose of the present study was to evaluate the effectiveness of a spiritual group intervention for eating disorder inpatients. We compared the effectiveness of a Spirituality group with Cognitive and Emotional Support groups using a randomized, control group design. Participants were 122 women receiving inpatient eating disorder treatment. Patients in the Spirituality group tended to score significantly lower on psychological disturbance and eating disorder symptoms at the conclusion of treatment compared to patients in the other groups, and higher on spiritual well-being. On weekly outcome measures, patients in the Spirituality group improved significantly more quickly during the first four weeks of treatment. This study provides preliminary evidence that attending to eating disorder patients' spiritual growth and well- being during inpatient treatment may help reduce depression and anxiety, relationship distress, social role conflict, and eating disorder symptoms.

Brunner-Mazel Eating Disorders Monograph Series, 14(5) : 401-15

Lock, James, Couturier, Jennifer, Agras, W. Stewart

Comparison of long-term outcomes in adolescents with anorexia nervosa treated with family therapy

OBJECTIVE: To describe the relative effectiveness of a short versus long course of family-based therapy (FBT) for adolescent anorexia nervosa at long-term follow-up. METHOD: This study used clinical and structured interviews to assess psychological and psychosocial outcomes of adolescents (ages 12-18 years at baseline) who were previously treated in a randomized clinical trial using family therapy between 1999 and 2002. RESULTS: Eighty-three percent (71/86) of subjects participated in follow-up assessments of current psychological and psychosocial functioning. In addition, 49% (35) were interviewed using the Eating Disorder Examination. Mean length of follow-up was 3.96 years (range 2.3-6.0 years). There were no statistically significant differences between the two groups on any measure at long-term follow-up. As a whole, the group was doing well with 89% above 90% ideal body weight, 74% with Eating Disorder Examination scores within the normal range, and 91% of postmenarcheal females not on birth control had menstrual return. CONCLUSIONS: A short course of family therapy is as effective as a longer course at follow-up.

Journal of the American Academy of Child & Adolescent Psychiatry, 45(6) : 666-72

Lock, James, Agras, W. Stewart, Bryson, Susan, Kraemer, Helena C.

A comparison of short- and long-term family therapy for adolescent anorexia nervosa

OBJECTIVE: Research suggests that family treatment for adolescents with anorexia nervosa may be effective. This study was designed to determine the optimal length of such family therapy. METHOD: Eighty-six adolescents (12-18 years of age) diagnosed with anorexia nervosa were allocated at random to either a short-term (10 sessions over 6 months) or long-term treatment (20 sessions over 12 months) and evaluated at the end of 1 year using the Eating Disorder Examination (EDE) between 1999 and 2002. RESULTS: Although adequately powered to detect differences between treatment groups, an intent-to- treat analysis found no significant differences between the short-term and long-term treatment groups. Although a nonsignificant finding does not prove the null hypothesis, in no instance does the confidence interval on the effect size on the difference between the groups approach a moderate .5 level. However, post hoc analyses suggest that subjects with severe eating-related obsessive-compulsive features or who come from nonintact families respond better to long-term treatment. CONCLUSIONS: A short-term course of family therapy appears to be as effective as a long-term course for adolescents with short-duration anorexia nervosa. However, there is a suggestion that those with more severe eating-related obsessive-compulsive thinking and nonintact families benefit from longer treatment.

Journal of the American Academy of Child & Adolescent Psychiatry, 44(7) : 632-9

McIntosh, V. V. W, Jordan, J., Carter, F. A., Luty, S. E., McKenzie, J. M., Bulik, C. M., Frampton, C. M. A., Joyce, P. R.

Three psychotherapies for anorexia nervosa: a randomized, controlled trial

American Journal of Psychiatry, 162(4) : 741- 747

Mondraty, Naresh, Birmingham, C. Laird, Touyz, Stephen, Sundakov, Viktoria, Chapman, Lucy, Beumont, Pierre

Randomized controlled trial of olanzapine in the treatment of cognitions in anorexia nervosa

OBJECTIVE: Recovery from anorexia nervosa is confounded by intrusive anorectic cognitions and rituals. It has been observed that olanzapine, an atypical antipsychotic, can reduce this anorexic rumination. A pilot study was designed to test the effectiveness of olanzapine in this role. METHODS: A randomized trial of olanzapine versus chlorpromazine, with anorexic rumination as the primary outcome, was conducted. Of the 26 patients who presented, 15 were randomized in a balanced block design, eight to olanzapine and seven to chlorpromazine. RESULTS: Only the olanzapine group had a significant reduction in the degree of rumination. CONCLUSION: Olanzapine may be of benefit in anorexia nervosa by causing a reduction in anorexic rumination.

Australasian Psychiatry, 13(1) : 72-5

Tierney, S., Wyatt, K.

What works for adolescents with AN? A systematic review of psychosocial interventions

OBJECTIVE: To determine the effectiveness of psychosocial interventions for adolescents with AN. METHODS: An extensive and systematic literature search was conducted for randomised controlled trials (RCTs) addressing the effectiveness of psychosocial interventions for teenagers (11-18 years) with AN. RESULTS: Eight RCTs were located meeting the review's inclusion criteria, the majority of which focused on some form of family-related intervention. DISCUSSION: Unfortunately, a lack of robust primary research on which to base the review meant that clear recommendations could not be made. More good quality research, examining a range of interventions, and involving larger samples, is required before a similar systematic review is executed. [References: 43]

Eating & Weight Disorders, 10(2) : 66-75

Ball, Jillian, Mitchell, Philip

A randomized controlled study of cognitive behavior therapy and behavioral family therapy for anorexia nervosa patients

Very few studies have examined the role of cognitive behavior therapy (CBT) in the outpatient treatment of anorexia nervosa. This study used a randomized, controlled design to evaluate a 12- month, manual based program of CBT, with behavioral family therapy as the comparison group. Twenty-five adolescents and young adults with anorexia nervosa, currently living with their families, were recruited into the study with both treatment groups receiving 21-25 sessions of therapy. Outcome measures included nutritional status, eating behaviors, mood, self-esteem, and family communication. Sixty percent of the total sample and 72% of treatment completers had \"good\" outcome (defined as maintaining weight within 10% of average body weight and regular menstrual cycles) at post-treatment and at six months follow-up. No significant differences between treatment groups were found and the majority of patients did not reach symptomatic recovery. While limited by the small sample size, the findings compliment and extend previous research. (PsycINFO Database Record (c) 2008 APA, all rights reserved) (journal abstract).

Eating Disorders, 12(4) : 303-314

Pike, Kathleen M., Walsh, B., Vitousek, Kelly, Wilson, G., Bauer, Joy

Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa

OBJECTIVE: This study provides what the authors believe is the first empirical evaluation of cognitive behavior therapy as a posthospitalization treatment for anorexia nervosa in adults. METHOD: After hospitalization, 33 patients with DSM-IV anorexia nervosa were randomly assigned to 1 year of outpatient cognitive behavior therapy or nutritional counseling. RESULTS: The group receiving nutritional counseling relapsed significantly earlier and at a higher rate than the group receiving cognitive behavior therapy (53% versus 22%). The overall treatment failure rate (relapse and dropping out combined) was significantly lower for cognitive behavior therapy (22%) than for nutritional counseling (73%). The criteria for \"good outcome\" were met by significantly more of the patients receiving cognitive behavior therapy (44%) than nutritional counseling (7%). CONCLUSIONS: Cognitive behavior therapy was significantly more effective than nutritional counseling in improving outcome and preventing relapse. To the authors' knowledge, these data provide the first empirical documentation of the efficacy of any psychotherapy, and cognitive behavior therapy in particular, in posthospitalization care and relapse prevention of adult anorexia nervosa. (PsycINFO Database Record (c) 2008 APA, all rights reserved) (journal abstract).

American Journal of Psychiatry, 160(11) : 2046- 2049

Robb, A. S., Silber, T. J., Orrell-Valente, J. K., Valadez- Meltzer, A., Ellis, N., Dadson, M. J., Chatoor, I.

Supplemental nocturnal nasogastric refeeding for better short-term outcome in hospitalized adolescent girls with anorexia nervosa

Objective: Although controversy exists regarding nasogastric refeeding for patients with anorexia nervosa, current methods of inpatient care often result in low discharge weight, a critical risk factor in relapse. This study compared the short-term outcomes of standard oral refeeding and supplemental nocturnal nasogastric refeeding. Method: Subjects were 100 hospitalized Caucasian adolescent girls who met DSMIV criteria for anorexia nervosa. Subjects were partitioned into two groups: oral refeeding(N=48, mean age=15.0 years, SD= 1.8) and nocturnal nasogastric refeeding (N=52, mean age=14.8 years, SD=1.9). Unpaired t tests, with Bonferroni correction, were used to compare groups at hospital admission and at discharge. Multivariate linear regression was used to establish the independent effects of nocturnal nasogastric refeeding after adjustment for potential confounding variables. Results: On admission, the groups were comparable in terms of age, weight, and other factors but differed significantly in number of prior hospitalizations (the nocturnal nasogastric refeeding group had more than the oral refeeding group). A series of separate multivariate linear regression models revealed that nocturnal nasogastric refeeding was a significant predictor of weight at discharge and absolute weight gain. Conclusions: Over a comparable period of time, patients treated with nocturnal nasogastric refeeding had a greater and more rapid weight gain than patients treated with traditional oral refeeding. Supplemental nocturnal nasogastric refeeding was more effective than oral refeeding alone in weight restoration during hospitalization. However, further study is needed on its short- term and long-term effectiveness.

American Journal of Psychiatry., 159(8) : 1347-1353