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Treatment outcomes for anorexia nervosa: a systematic review and meta-analysis of randomized controlled trials

Published online by Cambridge University Press:  13 August 2018

Stuart B. Murray ,
Daniel S. Quintana ,
Katharine L. Loeb ,
Scott Griffiths  and
Daniel Le Grange
Stuart B. Murray*
Affiliation:
Department of Psychiatry, University of California, San Francisco, CA, USA
Daniel S. Quintana
Affiliation:
NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, University of Oslo, and Oslo University Hospital, Oslo, Norway
Katharine L. Loeb
Affiliation:
School of Psychology, Fairleigh Dickinson University, Teaneck, NJ, USA
Scott Griffiths
Affiliation:
School of Psychology, University of Melbourne, Melbourne, VIC, Australia
Daniel Le Grange
Affiliation:
Department of Psychiatry, University of California, San Francisco, CA, USA Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, IL, USA
*
Author for correspondence: Stuart B. Murray, E-mail: stuart.murray@ucsf.edu, drstuartmurray@gmail.com
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Abstract

Background

To determine the impact of specialized treatments, relative to comparator treatments, upon the weight and psychological symptoms of anorexia nervosa (AN) at end-of-treatment (EOT) and follow-up.

Methods

Randomized controlled trials (RCTs) between January 1980 and December 2017 that reported the effects of at least two treatments on AN were screened. Weight and psychological symptoms were analyzed separately for each study. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed, and studies were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) criteria and Cochrane risk of bias tool.

Results

We identified 35 eligible RCTs, comprising data from 2524 patients. Meta-analyses revealed a significant treatment effect on weight outcomes at EOT [g = 0.16, 95% CI (0.05–0.28), p = 0.006], but not at follow-up [g = 0.11, 95% CI (−0.04 to 0.27), p = 0.15]. There was no significant treatment effect on psychological outcomes at either EOT [g = −0.03, 95% CI (−0.14 to 0.08), p = 0.63], or follow-up [g = −0.001, 95% CI (−0.11 to 0.11), p = 0.98]. There was no strong evidence of publication bias or significant moderator effects for illness duration, mean age, year of publication, comparator group category, or risk of bias (all p values > 0.05).

Conclusions

Current specialized treatments are more adept than comparator interventions at imparting change in weight-based AN symptoms at EOT, but not at follow-up. Specialized treatments confer no advantage over comparator interventions in terms of psychological symptoms. Future precision treatment efforts require a specific focus on the psychological symptoms of AN.

Keywords

Anorexia nervosaeating disordersmeta-analysistreatment outcome
Type
Review Article
Information
Psychological Medicine , Volume 49 , Issue 4 , March 2019 , pp. 535 - 544
Copyright
Copyright © Cambridge University Press 2018 

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References

Agras, WS, Lock, J, Brandt, H, Bryson, SW, Dodge, E, Halmi, KA, Jo, B, Johnson, C, Kaye, W, Wilfley, D and Woodside, B (2014) Comparison of 2 family therapies for adolescent anorexia nervosa: a randomized parallel trial. JAMA Psychiatry 71, 1279–1286.Google Scholar
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, DC: American Psychiatric Association.Google Scholar
Arcelus, J, Mitchell, AJ, Wales, J and Nielson, S (2011) Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Archives of General Psychiatry 68, 724–731.Google Scholar
Attia, E, Haiman, C, Walsh, BT and Flater, SR (1998) Does fluoxetine augment the inpatient treatment of anorexia nervosa? American Journal of Psychiatry 155, 548–551.Google Scholar
Attia, E, Kaplan, AS, Walsh, BT, Gershkovich, M, Yilmaz, Z, Musante, D and Wang, Y (2011) Olanzapine versus placebo for out-patients with anorexia nervosa. Psychological Medicine 41, 2177–2182.Google Scholar
Ball, J and Mitchell, P (2004) A randomized controlled study of cognitive behavior therapy and behavioral family therapy for anorexia nervosa patients. Eating Disorders 12, 303–314.Google Scholar
Brambilla, F, Garcia, CS, Fassino, S, Daga, GA, Favaro, A, Santonastaso, P, Ramaciotti, C, Bondi, E, Mellado, C, Borriello, R and Montelone, P (2007) Olanzapine therapy in anorexia nervosa: psychobiological effects. International Clinical Psychopharmacology 22, 197–204.Google Scholar
Court, A, Mulder, C, Kerr, M, Yuen, HP, Boasman, M, Goldstone, S, Fleming, J, Weigall, S, Derham, H, Huang, C, McGory, P and Berger, G (2010) Investigating the effectiveness, safety and tolerability of quetiapine in the treatment of anorexia nervosa in young people: a pilot study. Journal of Psychiatric Research 44, 1027–1034.Google Scholar
Cuijpers, P, Weitz, E, Cristea, IA and Twisk, J (2017) Pre-post effect sizes should be avoided in meta-analyses. Epidemiology and Psychiatric Sciences 26, 364–368.Google Scholar
Dalle-Grave, R, Calugi, S, Conti, M, Doll, H and Fairburn, CG (2013) Inpatient cognitive behavior therapy for anorexia nervosa: a randomized controlled trial. Psychotherapy and Psychosomatics 82, 390–398.Google Scholar
DeJong, H, Broadbent, H and Schmidt, U (2012) A systematic review of dropout from treatment in outpatients with anorexia nervosa. International Journal of Eating Disorders 45, 635–647.Google Scholar
DuBois, RH, Rogers, RF, Franko, DL, Eddy, KT and Thomas, JJ (2017) A network analysis investigation of the cognitive-behavioral theory of eating disorders. Behaviour Research and Therapy 97, 213–221.Google Scholar
Egger, M, Smith, GD, Schneider, M and Minder, C (1997) Bias in meta-analysis detected by a simple, graphical test. British Medical Journal 315, 629–634.Google Scholar
Eisler, I, Dare, C, Hodes, M and Russell, G (2000) Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family interventions. Journal of Child Psychology & Psychiatry 41, 727–736.Google Scholar
Eisler, I, Simic, M, Hodsol, J, Asen, E, Berelowitz, M, Connan, F, Ellis, G, Hugo, P, Schmidt, U, Treasure, J, Yi, I and Landau, S (2016) A pragmatic randomized multi-centre trial of multifamily and single family therapy for adolescent anorexia nervosa. BMC Psychiatry 16, 422.Google Scholar
Fairburn, CG (2005) Evidence-based treatment of anorexia nervosa. International Journal of Eating Disorders 37, S26–S30.Google Scholar
Fairburn, CG, Shafran, R and Cooper, Z (1999) A cognitive behavioural theory of anorexia nervosa. Behaviour, Research and Therapy 37, 1–13.Google Scholar
Fassino, S, Leombruni, P, Abbate-Daga, G, Brustolin, A, Migliaretti, G, Cavallo, F and Rovera, GG (2002) Efficacy of citalopram in anorexia nervosa: a pilot study. European Neuropsychopharmacology 12, 453–459.Google Scholar
Fichter, MM, Quadflieg, N, Crosby, RD and Koch, S (2017) Long-term outcome of anorexia nervosa: results from a large clinical longitudinal study. International Journal of Eating Disorders 50, 1018–1030.Google Scholar
Friedman, K, Ramirez, A, Murray, SB, Anderson, LK, Cuasck, A, Boutelle, KN and Kaye, WH (2016) A narrative review of outcome studies for residential and partial hospital-based treatment of eating disorders. European Eating Disorders Review 24, 263–276.Google Scholar
Geist, R, Heinmaa, M, Stephens, D, Davis, R and Katzman, DK (2000) Comparison of family therapy and family group psychoeducation in adolescents with anorexia nervosa. Canadian Journal of Psychiatry 45, 173–178.Google Scholar
Godart, N, Berthoz, S, Curt, F, Perdereau, F, Rein, Z, Wallier, J, Horreard, AS, Kaganski, I, Lucet, R, Atger, F, Corcos, M, Fermanian, J, Falissard, B, Flament, M, Eisler, I and Jeameant, P (2012) A randomized controlled trial of adjunctive family therapy and treatment as usual following inpatient treatment for anorexia nervosa adolescents. PLoS ONE 7, e28249.Google Scholar
Gowers, SG, Clark, A, Roberts, C, Griffiths, A, Edwards, S, Bryan, C, Smethurst, N, Byford, S and Barrett, B (2007) Clinical effectiveness of treatments for anorexia nervosa in adolescents. British Journal of Psychiatry 191, 427–435.Google Scholar
Guarda, AS, Schreyer, CC, Fischer, LK, Hansen, JL, Coughlin, JW, Kaminsky, MJ, Attia, E and Redgrave, GW (2017) Intensive treatment for adults with anorexia nervosa: the cost of weight restoration. International Journal of Eating Disorders 50, 302–306.Google Scholar
Guyatt, G, Oxman, AD, Akl, EA, Kunz, R, Vist, G, Brozek, J, Norris, S, Falck-Ytter, Y, Glasziou, P, DeBeer, H, Jaeschke, R, Rind, D, Meerpohl, J, Dahm, P and Schünemann, HJ (2011) GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. Journal of Clinical Epidemiology 64, 383–394.Google Scholar
Hagman, J, Gralla, J, Sigel, E, Ellert, S, Dodge, M, Gardner, R, O'Lonergan, T, Frank, G and Wamboldt, MZ (2011) A double-blind placebo controlled study of risperidone for the treatment of adolescents and young adults with anorexia nervosa: a pilot study. Journal of the American Academy of Child & Adolescent Psychiatry 50, 915–924.Google Scholar
Hedges, LV, Tipton, E and Johnson, MC (2010) Robust variance estimation in meta-regression with dependent effect size estimates. Research Synthesis Methods 1, 39–65.Google Scholar
Herpertz-Dahlmann, B, Schwarte, R, Krei, M, Egberts, K, Warnke, A, Wewetzer, C, Preiffer, E, Fleischhaker, C, Scherag, A, Holtkamp, K, Hagenah, U, Bühren, K, KLonrad, K, Schmidt, U, Schade-Brittinger, C, Timmesfeld, N and Dempfle, A (2014) Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa (ANDI): a multicentre, randomized, open-label non-inferiority trial. The Lancet 383, 5–11.Google Scholar
Herscovici, CR, Kovalskys, I and Orellana, L (2017) An exploratory evaluation of the family meal intervention for adolescent anorexia nervosa. Family Process 56, 364–375.Google Scholar
Higgins, JPT, Altman, DG, Gøtzsche, PC, Jüni, P, Moher, D, Oxman, AD, Savocić, J, Schulz, KF, Weeks, L and Sterne, JAC (2011) The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. British Medical Journal 343.Google Scholar
Kaye, WH, Nagata, T, Weltzin, TE, Hsu, LKG, Sokol, MS, McConaha, C, Plotnicov, KH, Weise, J and Deep, D (2001) Double-blind placebo-controlled administration of fluoxetine in restricting- and restricting-purging-type anorexia nervosa. Biological Psychiatry 49, 644–652.Google Scholar
Keel, PK, Dorer, DJ, Eddy, KT, Franko, D, Charatan, DL and Herzog, DB (2003) Predictors of mortality in eating disorders. Archives of General Psychiatry 60, 179–183.Google Scholar
Keel, PK, Dorer, DJ, Franko, DL, Jackson, SC and Herzog, DB (2005) Postremission predictors of relapse in women with eating disorders. American Journal of Psychiatry 162, 2263–2268.Google Scholar
Le Grange, D, Hughes, EK, Court, A, Yeo, M, Crosby, RD and Sawyer, SM (2016) Randomized clinical trial of parent-focused treatment and family-based treatment for adolescent anorexia nervosa. Journal of the American Academy of Child & Adolescent Psychiatry 55, 683–692.Google Scholar
Lock, J, Agras, WS, Bryson, S and Kraemer, HC (2005) A comparison of short- and long-term family therapy for adolescent anorexia nervosa. Journal of the American Academy of Child & Adolescent Psychiatry 44, 632–639.Google Scholar
Lock, J, Le Grange, D, Agras, WS, Moye, A, Bryson, SW and Jo, B (2010) Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry 67, 1025–1032.Google Scholar
Madden, S, Miscovic-Wheatley, J, Wallis, A, Kohn, M, Lock, J, Le Grange, D, Jo, B, Clarke, S, Rhodes, P, Hay, P and Touyz, SW (2015) A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents. Psychological Medicine 45, 415–427.Google Scholar
Matthews, RRS, Hall, WD, Vos, T, Patton, GC and Degenhardt, L (2011) What are the major drivers of prevalent disability burden in young Australians? Medical Journal of Australia 194, 232–235.Google Scholar
McIntosh, VVW, Jordan, J, Carter, FA, Luty, SE, McKenzie, JM, Bulik, CM, Frampton, CMA and Joyce, PR (2005) Three psychotherapies for anorexia nervosa: a randomized, controlled trial. American Journal of Psychiatry 162, 741–747.Google Scholar
Mitchell, JE and Crow, S (2006) Medical complications of anorexia nervosa and bulimia nervosa. Current Opinion in Psychiatry 19, 438–443.Google Scholar
Moher, D, Liberati, A, Tetzlaff, J and Altman, DG, The PRISMA Group. (2009). PRISMA group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine 6: e1000097.Google Scholar
Mondraty, N, Birmingham, CL, Touyz, SW, Sunkadov, V, Chapman, L and Beumont, P (2005) Randomized controlled trial of olanzapine in the treatment of cognitions in anorexia nervosa. Australasian Psychiatry 13, 72–75.Google Scholar
Parling, T, Cernvall, M, Ramklint, M, Holmgren, S and Ghaderi, A (2016) A randomised trial of acceptance and commitment therapy for anorexia nervosa after daycare treatment, including five-year follow-up. BMC Psychiatry 272.Google Scholar
Peters, JL, Sutton, AJ, Jones, DR, Abrams, KR and Rushton, L (2008) Contour-enhanced meta-analysis funnel plots help distinguish publication bias from other causes of asymmetry. Journal of Clinical Epidemiology 61, 991–996.Google Scholar
Powers, PS, Klabunde, M and Kaye, WH (2012) Double-blind placebo-controlled trial of quetiapine in anorexia nervosa. European Eating Disorders Review 20, 331–334.Google Scholar
Rigaud, D, Brondel, L, Poupard, AT, Talonneau, I and Brun, JM (2007) A randomized trial on the efficacy of a 2-month tube feeding regimen in anorexia nervosa: a 1-year follow-up study. Clinical Nutrition 26, 421–429.Google Scholar
Robin, AL, Siegel, PT, Moye, AW, Gilroy, M, Dennis, AB and Sikand, A (1999) A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa. Journal of the American Academy of Child & Adolescent Psychiatry 38, 1482–1489.Google Scholar
Rücker, G, Cates, CJ and Schwarzer, G (2017) Methods for including information from multi-arm trials in pairwise meta-analysis. Research Synthesis Methods 8, 392–403.Google Scholar
Russell, J, Maguire, S, Hunt, GE, Kesby, A, Suraev, A, Stuart, J, Booth, J and McGregor, IS (2018) Intranasal oxytocin in the treatment of anorexia nervosa: randomized controlled trial during re-feeding. Psychoneuroendocrinology 87, 83–92.Google Scholar
Schmidt, U, Oldershaw, A, Jicji, F, Sternheim, L, Startup, H, McIntosh, V, Jordan, J, Tchanturia, K, Wolff, G, Rooney, M, Landau, S and Treasure, J (2012) Out-patient psychological therapies for adults with anorexia nervosa: randomized controlled trial. British Journal of Psychiatry 201, 392–399.Google Scholar
Schmidt, U, Magill, N, Renwick, B, Keyes, A, Kenyon, M, Dejong, H, Lose, A, Broadbent, H, Loomes, R, Yasin, H, Watson, C, Ghelani, S, Bonin, EM, Serpell, L, Richards, L, Johnson-Sabine, E, Boughton, N, Whitehead, L, Beecham, J, Treasure, J and Landau, S (2015) The Maudsley outpatient study of treatments for anorexia nervosa and related conditions (MOSAIC): comparison of the Maudsley model of anorexia nervosa treatment for adults (MANTRA) with specialist supportive clinical management (SSCM) in outpatients with broadly defined anorexia nervosa: a randomized controlled trial. Journal of Consulting and Clinical Psychology 83, 796–807.Google Scholar
Smith, C, Fogarty, S, Touyz, SW, Madden, S, Buckett, G and Hay, P (2014) Acupuncture and acupressure and massage health outcomes for patients with anorexia nervosa: findings from a pilot randomized controlled trial and patient interviews. Journal of Alternative and Complementary Medicine 20, 103–112.Google Scholar
Steinhaussen, HC (2002) The outcome of anorexia nervosa in the 20th century. American Journal of Psychiatry 159, 1284–1293.Google Scholar
Touyz, SW, Le Grange, D, Lacey, H, Hay, P, Smoth, R, Maguire, S, Bamford, B, Pike, KM and Crosby, RD (2013) Treating severe and enduring anorexia nervosa: a randomized controlled trial. Psychological Medicine 43, 2501–2511.Google Scholar
Walsh, BT, Kaplan, AS, Attia, E, Olmsted, M, Parides, M, Carter, JC, Pike, KM, Devlin, MJ, Woodside, B, Roberto, CA and Rockert, W (2006) Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. JAMA 295, 2605–2612.Google Scholar
Watson, HJ and Bulik, CM (2013) Update on the treatment of anorexia nervosa: review of clinical trials, practice guidelines and emerging interventions. Psychological Medicine 43, 2477–2500.Google Scholar
Whitney, J, Murphy, T, Landau, S, Gavan, K, Todd, G, Whitaker, W and Treasure, J (2011) A practical comparison of two types of family intervention: an exploratory RCT of family day workshops and individual family work as a supplement to inpatient care for adults with anorexia nervosa. European Eating Disorders Review 20, 142–150.Google Scholar
Woodside, DB, Carter, JC and Blackmore, E (2004) Predictors of premature termination of inpatients treatment for anorexia nervosa. American Journal of Psychiatry 161, 2277–2281.Google Scholar
Zipfel, S, Wild, B, Grob, B, Friederich, HC, Teufel, M, Schellberg, D, Giel, KE, de Zwaan, M, Dinkel, A, Herpertz, S, Burgmer, M, Löwe, B, Tagay, S, von Wietersheim, J, Zeeck, A, Schade-Brittinger, C, Schauenburg, H and Herzog, W (2014) Focal dynamic psychotherapy, cognitive behavior therapy, and optimized treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomized controlled trial. The Lancet 383, 127–137.Google Scholar
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