Adolescent eating disorders: treatment and response in a naturalistic study

Psychotherapies for eating disorders: findings from a rapid review

BACKGROUND

Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development.

METHODS

The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper.

RESULTS

281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence.

CONCLUSIONS

Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.

A systematic review of cognitive behavior therapy and dialectical behavior therapy for adolescent eating disorders

BACKGROUND

Eating disorders have serious psychological and physical consequences. Current evidence-based treatments for adolescents with eating disorders have modest effects, underscoring the need to improve current treatment approaches. Cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) have been proposed as alternative treatment options, with burgeoning research in this area. This review aims to summarize and critically analyze the current literature on the feasibility, acceptability, effectiveness, and efficacy of CBT and DBT for adolescent eating disorders, and then proposes areas of future research.

METHODS

PsycINFO and PubMed were searched using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify studies examining the feasibility, acceptability, effectiveness and/or efficacy of CBT or DBT for adolescent eating disorders.

RESULTS

Eligible studies (N = 50; CBT: n = 40, DBT: n = 10) indicated that both treatments are reasonably feasible, acceptable, and possibly effective for adolescent eating disorders across diagnoses and levels of care, though efficacy trials are lacking.

CONCLUSIONS

CBT and DBT demonstrate promise as alternatives to family-based approaches for adolescent eating disorders. Adequately powered trials to establish the effectiveness and efficacy of CBT and DBT are needed, particularly ones that compare these treatments against other leading approaches. Despite high rates of relapse and likelihood for severe and enduring illness, there is a dearth of evidence-based treatment options for adolescents with eating disorders. Potentially viable but less well-studied treatments for adolescents with eating disorders include cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT). This systematic review of CBT and DBT for adolescent eating disorders focuses on feasibility (i.e., how easy it was to implement the treatment), acceptability (i.e., how well the intervention was received by patients and therapists), effectiveness (i.e., how well the intervention performed under routine, real-world circumstances), and efficacy (i.e., how well the intervention performed in highly-controlled research settings). This review concludes that research supports the feasibility and acceptability of these approaches, as well as preliminary evidence of their effectiveness. However, the field is lacking studies that systematically compare CBT and DBT to other evidence-based approaches. Recommendations to advance research on CBT and DBT for adolescent eating disorders are provided, including a call for efficacy studies that clarify their performance compared to other leading approaches.

Adolescents with full or subthreshold anorexia nervosa in a naturalistic sample: treatment interventions and patient satisfaction

BACKGROUND

Despite major research efforts, current recommendations of treatment interventions for adolescents with anorexia nervosa are scarce, and the importance of patient satisfaction for treatment outcome is yet to be established. The overall aim of the present study was to examine treatment interventions and patient satisfaction in a naturalistic sample of adolescents with anorexia nervosa or subthreshold anorexia nervosa and possible associations to outcome defined as being in remission or not at treatment follow-up.

METHODS

Participants were identified through the Swedish national quality register for eating disorder treatment (SwEat). The samples consisted of 1899 patients who were follow-up registered 1 year after entering treatment and 474 patients who had completed a 1-year patient satisfaction questionnaire. A two-step cluster analysis was used for identifying subgroups of patients who received certain combinations and various amounts of treatment forms.

RESULTS

Patients who received mainly family-based treatment and/or inpatient care were most likely to achieve remission at 1-year follow-up, compared to patients in the other clusters. They were also younger, in general. Individual therapy was the most common treatment form, and was most appreciated among the adolescents. At 1-year follow-up, many patients reported improvements in eating habits, but far fewer reported improvements regarding cognitive symptoms. Overall, the patients rated the therapist relationship in a rather positive way, but they gave quite low ratings to statements associated with their own participation in treatment.

CONCLUSIONS

The results indicate that young adolescents who receive mainly family-based treatment and/or inpatient care respond more rapidly to treatment compared to older adolescents who receive mainly individual therapy or mixed treatment interventions. At 1-year follow-up, the adolescents reported improvements in behavioral symptoms and seemed quite satisfied with the therapist relationship.

Predictors of Weight Restoration in a Day-Treatment Program that Supports Family-Based Treatment for Adolescents with Anorexia Nervosa

Family-Based Treatment (FBT) is considered a first-line treatment for adolescents with eating disorders. The traditional outpatient model of FBT may not, however, be appropriate for adolescents requiring more intensive treatment due to severe medical complications or insufficient progress in traditional outpatient FBT. In response, efforts have been made to incorporate FBT into higher levels of care, such as day-treatment programs (DTPs), for families who need additional support. Little is known about the factors that predict weight restoration for DTPs intended to support FBT. The current study examined the ability of specific adolescent and caregiver variables to predict weight restoration at discharge for adolescents with anorexia nervosa (AN) enrolled in a skills-based DTP that supports FBT. Participants were 87 adolescents diagnosed with AN and their caregivers (N = 74). Body Mass Index (BMI) at baseline, percentage of Expected Body Weight (%EBW) gain within the first 4 weeks, and caregiver empowerment level at baseline were found to significantly predict weight restoration. Higher BMI at baseline and higher %EBW gained in the first 4 weeks of treatment were predictive of weight restoration, whereas lower caregiver empowerment at baseline was predictive of weight restoration. Additionally, the rate of weight gain is reported for this DTP grounded in FBT philosophy.

Adolescents with full or subthreshold anorexia nervosa in a naturalistic sample - characteristics and treatment outcome

BACKGROUND

Anorexia Nervosa (AN) destroys developmentally important early years of many young people and knowledge is insufficient regarding course, treatment outcome and prognosis. Only a few naturalistic studies have been conducted within the field of eating disorder (ED) research. In this naturalistic study we included adolescents with AN or subthreshold AN treated in outpatient care, and the overall aim was to examine sample characteristics and treatment outcome. Additional aims were to examine potential factors associated with remission as an outcome variable, and possible differences between three time periods for treatment onset.

METHODS

Participants were identified through the Swedish national quality register for eating disorder treatment (SwEat), in which patients are registered at treatment onset and followed up once a year until end of treatment (EOT). Inclusion criteria were: medical or self-referral to one of the participating treatment units between 1999 and 2014, 13-19 years of age at initial entry into SwEat and diagnosed with AN or subthreshold AN. The total sample consisted of 3997 patient from 83 different treatment units.

RESULTS

The results show that 55% of the participants were in remission and approximately 85% were within a healthy weight range at EOT. Of those who ended treatment according to plan, 70% were in remission and 90% within a healthy weight range. The average treatment duration was approximately 15 months. About one third of the patients terminated treatment prematurely, which was associated with a decreased chance of achieving remission. Remission rates and weight recovery increased over time, while treatment duration decreased. Considering treatment outcome, the results did not show any differences between patients with AN or subthreshold AN.

CONCLUSIONS

The present study shows a relatively good prognosis for adolescent patients with AN or subthreshold AN in routine care and the results indicate that treatment for adolescents with ED in Sweden has become more effective over the past 15 years. The results of the present study contribute to the scope of treatment research and the large-scale naturalistic setting secures the generalizability to a clinical environment. However, more research is needed into different forms of evidence, new research strategies and diversity of treatment approaches.

TRIAL REGISTRATION

Registered in FOU in Sweden (Researchweb.org) 2014-04-14, ID nr 147301.