Elsevier

The Lancet

Volume 383, Issue 9912, 11–17 January 2014, Pages 127-137
The Lancet

Articles
Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial

https://doi.org/10.1016/S0140-6736(13)61746-8Get rights and content

Summary

Background

Psychotherapy is the treatment of choice for patients with anorexia nervosa, although evidence of efficacy is weak. The Anorexia Nervosa Treatment of OutPatients (ANTOP) study aimed to assess the efficacy and safety of two manual-based outpatient treatments for anorexia nervosa—focal psychodynamic therapy and enhanced cognitive behaviour therapy—versus optimised treatment as usual.

Methods

The ANTOP study is a multicentre, randomised controlled efficacy trial in adults with anorexia nervosa. We recruited patients from ten university hospitals in Germany. Participants were randomly allocated to 10 months of treatment with either focal psychodynamic therapy, enhanced cognitive behaviour therapy, or optimised treatment as usual (including outpatient psychotherapy and structured care from a family doctor). The primary outcome was weight gain, measured as increased body-mass index (BMI) at the end of treatment. A key secondary outcome was rate of recovery (based on a combination of weight gain and eating disorder-specific psychopathology). Analysis was by intention to treat. This trial is registered at http://isrctn.org, number ISRCTN72809357.

Findings

Of 727 adults screened for inclusion, 242 underwent randomisation: 80 to focal psychodynamic therapy, 80 to enhanced cognitive behaviour therapy, and 82 to optimised treatment as usual. At the end of treatment, 54 patients (22%) were lost to follow-up, and at 12-month follow-up a total of 73 (30%) had dropped out. At the end of treatment, BMI had increased in all study groups (focal psychodynamic therapy 0·73 kg/m2, enhanced cognitive behaviour therapy 0·93 kg/m2, optimised treatment as usual 0·69 kg/m2); no differences were noted between groups (mean difference between focal psychodynamic therapy and enhanced cognitive behaviour therapy −0·45, 95% CI −0·96 to 0·07; focal psychodynamic therapy vs optimised treatment as usual −0·14, −0·68 to 0·39; enhanced cognitive behaviour therapy vs optimised treatment as usual −0·30, −0·22 to 0·83). At 12-month follow-up, the mean gain in BMI had risen further (1·64 kg/m2, 1·30 kg/m2, and 1·22 kg/m2, respectively), but no differences between groups were recorded (0·10, −0·56 to 0·76; 0·25, −0·45 to 0·95; 0·15, −0·54 to 0·83, respectively). No serious adverse events attributable to weight loss or trial participation were recorded.

Interpretation

Optimised treatment as usual, combining psychotherapy and structured care from a family doctor, should be regarded as solid baseline treatment for adult outpatients with anorexia nervosa. Focal psychodynamic therapy proved advantageous in terms of recovery at 12-month follow-up, and enhanced cognitive behaviour therapy was more effective with respect to speed of weight gain and improvements in eating disorder psychopathology. Long-term outcome data will be helpful to further adapt and improve these novel manual-based treatment approaches.

Funding

German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF), German Eating Disorders Diagnostic and Treatment Network (EDNET).

Introduction

Anorexia nervosa is associated with serious medical morbidity1, 2 and pronounced psychosocial comorbidity.3 It has the highest mortality rate of all mental disorders4, 5 and relapse happens frequently.6 The course of illness is very often chronic, particularly if left untreated.7 Partial syndromes are also associated with adverse health outcomes. Quality of life for patients is poor, and the cost and burden placed on individuals, families,1 and society is high.8 The overall incidence of anorexia nervosa is at least eight people per 100 000 per year, with an average prevalence of 0·3% in girls and young women.9 The severity, poor prognosis, and low prevalence of the disorder are reasons why large randomised controlled trials are needed and why difficulties arise in implementation of treatment studies.10

According to international treatment guidelines, psychotherapy is the treatment of choice for patients with anorexia, although no evidence clearly supports the efficacy of any specific form of psychotherapy.11 Guidelines from the UK's National Institute for Health and Care Excellence (NICE) outline 75 recommendations for the treatment of anorexia nervosa.12 74 of these treatments have received a grade of C, meaning that good quality, directly applicable clinical studies are absent and that recommendations are based solely on the opinions, clinical experience, or both of respected authorities in the field. According to NICE guidelines, psychological treatment of anorexia nervosa aims to lessen risk, encourage weight gain and healthy eating, reduce other symptoms related to the eating disorder, and facilitate psychological and physical recovery. In a Cochrane review of outpatient treatment for anorexia nervosa,13 only seven small trials were identified, two of which included children or adolescents. Findings of two of the trials implied that treatment as usual might be less effective than a specific psychotherapy. No particular treatment, however, was consistently superior to any other approach.

In adults with anorexia nervosa, some evidence shows the effectiveness of outpatient focal psychodynamic therapy and cognitive behaviour therapy.14, 15, 16 In one trial,17 at the end of the treatment period, a supportive therapy delivered by specialists was superior to two specific psychotherapies, with respect to a combined global outcome measure. However, long-term follow-up of this trial showed that interpersonal therapy was the most successful treatment.18 Findings of intervention studies applying deep-brain stimulation19 or adapting psychotherapeutic approaches for patients with chronic anorexia nervosa20 have also showed some promising results for this cohort.

Evidence accumulated thus far does not support any one particular psychotherapeutic method for the treatment of adults with anorexia nervosa.1, 13 However, therapeutic support from a non-specialist clinician might be less successful than a specific form of psychotherapy provided by a specialist. Additionally, no evidence strongly advocates drug treatment either in the acute or maintenance phase of the illness.21 Large, well designed psychotherapeutic trials are needed urgently. We designed the Anorexia Nervosa Treatment of OutPatients (ANTOP) study to investigate the efficacy of two manual-based, psychotherapeutic, eating disorder-specific outpatient therapies for adults with anorexia nervosa—focal psychodynamic therapy and enhanced cognitive behaviour therapy—compared with optimised treatment as usual.

Section snippets

Study design and participants

ANTOP was a multicentre, randomised controlled efficacy trial in adult patients with anorexia nervosa. The trial protocol, outlining details on study design, has been published elsewhere.22 Over a 2-year period, we screened patients from outpatient departments of ten German university departments of psychosomatic medicine and psychotherapy (Bochum, Erlangen, Essen, Freiburg, Hamburg, Heidelberg, Munich, Münster, Tübingen, and Ulm) for inclusion in the study. Inclusion criteria were: adult

Results

Between May, 2007, and June, 2009, we screened 727 patients for eligibility; 242 underwent randomisation after baseline assessment (figure 1). The number of patients enrolled per study centre was between 12 and 35. Table 1 shows baseline characteristics. We did not record any differences between groups with respect to demographic characteristics, BMI, illness duration, subtype of anorexia nervosa, and affective disorders. However, a comorbid anxiety disorder was more frequent in patients

Discussion

Findings of the ANTOP study show that outpatient treatment of adults with anorexia nervosa by either optimised treatment as usual, focal psychodynamic therapy, or enhanced cognitive-behaviour therapy leads to relevant weight gains and a decrease in general and eating disorder-specific psychopathology during the course of treatment. These positive effects continue beyond treatment until 12-month follow-up. However, the primary hypothesis of the ANTOP study was not confirmed: no difference in

References (37)

  • N Stuhldreher et al.

    Cost-of-illness studies and cost-effectiveness analyses in eating disorders: a systematic review

    Int J Eat Disord

    (2012)
  • FR Smink et al.

    Epidemiology of eating disorders: incidence, prevalence and mortality rates

    Curr Psychiatry Rep

    (2012)
  • KA Halmi et al.

    Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs

    Arch Gen Psychiatry

    (2005)
  • S Herpertz et al.

    The diagnosis and treatment of eating disorders

    Dtsch Arztebl Int

    (2011)
  • Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders

  • PP Hay et al.

    Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa

    Cochrane Database Syst Rev

    (2009)
  • C Dare et al.

    Psychological therapies for adults with anorexia nervosa: randomised controlled trial of out-patient treatments

    Br J Psychiatry

    (2001)
  • KM Pike et al.

    Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa

    Am J Psychiatry

    (2003)
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