ArticlesFocal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial
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)
- et al.
Eating disorders
Lancet
(2010) - et al.
Eating disorders
Lancet
(2003) - et al.
Long-term prognosis in anorexia nervosa: lessons from a 21-year follow-up study
Lancet
(2000) - et al.
Enhanced cognitive behaviour therapy for adults with anorexia nervosa: a UK-Italy study
Behav Res Ther
(2013) - et al.
Subcallosal cingulate deep brain stimulation for treatment-refractory anorexia nervosa: a phase 1 pilot trial
Lancet
(2013) - et al.
Factors associated with recovery from anorexia nervosa
J Psychiatr Res
(2013) - et al.
Medical findings and predictors of long-term physical outcome in anorexia nervosa: a prospective, 12-year follow-up study
Psychol Med
(1997) - et al.
Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies
Arch Gen Psychiatry
(2011) - et al.
Academy for eating disorders position paper: eating disorders are serious mental illnesses
Int J Eat Disord
(2009) - et al.
First recovery in anorexia nervosa patients in the long-term course: a discrete-time survival analysis
J Consult Clin Psychol
(1997)
Cost-of-illness studies and cost-effectiveness analyses in eating disorders: a systematic review
Int J Eat Disord
Epidemiology of eating disorders: incidence, prevalence and mortality rates
Curr Psychiatry Rep
Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs
Arch Gen Psychiatry
The diagnosis and treatment of eating disorders
Dtsch Arztebl Int
Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders
Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa
Cochrane Database Syst Rev
Psychological therapies for adults with anorexia nervosa: randomised controlled trial of out-patient treatments
Br J Psychiatry
Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa
Am J Psychiatry
Cited by (0)
- †
See end of report for ANTOP study group members