Developments in the Treatment of Eating Disorders in Adolescents Over the Past 30 Years
By Lisa Hail, PhD, and Daniel Le Grange, PhD
The Status of Treatment Studies for Eating Disorders
Although studies of the treatment of eating disorders in youth have spanned the past 30 years, there is still much to be learned. In adults, there is a relatively large body of literature to guide the treatment of bulimia nervosa (BN). To date, there have been more than 100 published randomized controlled trials (RCTs)—pharmacotherapy, psychotherapy, and combined—with substantial evidence that cognitive behavior therapy (CBT) is the most efficacious treatment for many individuals (Agras et al., 2000). Pharmacotherapy, and fluoxetine in particular, has also received considerable support as an adjunctive treatment for this patient population (Shapiro et al., 2007). While there is clear guidance for the treatment of BN in adults, less is known about the treatment of anorexia nervosa (AN) in adults, and although recovery is possible (Eddy et al., 2017), there is little evidence for the effectiveness of any particular approach for this age group (Bulik et al., 2007; Bulik, 2014).
Family-based approaches have the most evidence and should be the first-line treatment for medically stable youth with restricting eating disorders such as AN (Watson & Bulik, 2013). Despite the clear support for CBT as the leading treatment for adults with BN, there have been only four RCTs for the treatment of BN in youth. The limited evidence base suggests that there is benefit to including caregivers in treatment; however, further investigation is necessary to better inform treatment for this population.
Evidence-Based Treatments for Anorexia Nervosa in Youth
There have been 13 published RCTs for the treatment of AN in adolescents, four of which included a higher level of care such as inpatient medical or psychiatric treatment and/or day programs. The majority (11 of 13) have involved family-focused approaches, while only three studies have included an individual therapy approach. To date, there have been no published RCTs of psychopharmacological interventions.
The predominant models of evidence-based treatment of AN are inpatient treatment for weight restoration in either a psychiatric or pediatric (medical) setting or outpatient psychosocial treatments. Three studies have evaluated inpatient treatment in psychiatric settings. A study by Gowers et al. (2007) in Liverpool, England, found no advantage to first-line inpatient psychiatric treatment over outpatient treatment. Those who struggled in outpatient treatment also did poorly when transferred into an inpatient setting. In France, Godart and colleagues (2012) found that the addition of family therapy focused on intra-familiar dynamics, not eating disorder symptoms, improved effectiveness of treatment as usual following discharge from the hospital. A six-site study based in Germany by Herpertz-Dahlmann and colleagues (2014) found that patients in a day program after a short inpatient stay had comparable outcomes to those who completed a longer inpatient stay to achieve weight restoration. These findings suggest that a day program may be a safe and less costly alternative to an extended hospitalization. Madden, Miskovic-Wheatley, Wallis, Kohn, Lock, and colleagues (2015) in Westmead, Australia, found similar outcomes when comparing inpatient admissions in a pediatric medical setting for either a brief medical stabilization or extended admission for full weight restoration—both followed by a course of family-based treatment (FBT). In terms of higher levels of care, there is no advantage to first-line inpatient psychiatric treatment over a day program or outpatient management. The addition of family therapy to treatment as usual, after hospitalization, improves outcome, and weight restoration at home can be successful.
Outpatient psychosocial treatment is the second predominant model for the treatment of AN in youth. Three primary models of outpatient treatment have been evaluated. FBT aims to empower parents to manage symptoms early in treatment, and parent-focused treatment (PFT) utilizes a very similar approach without the patient participating in the treatment session. Whereas systemic family therapy places the focus on the family system to draw on their existing strengths, adolescent-focused therapy (AFT) is an individual therapy that aims to promote self-efficacy, self-esteem, and self-management of eating problems.
A United States–based study compared FBT with AFT and found that FBT brings about faster weight gain in early treatment, with fewer days of hospital admission (Le Grange et al., 2014; Lock et al., 2010). Therefore, FBT is more efficient than AFT in facilitating remission at short-term (6- and 12-month) follow-up (Lock et al., 2010). However, at four-year follow-up, AFT “catches up” with FBT and remission rates are stable (Le Grange et al., 2014). The Research in Anorexia Nervosa trial compared two family therapies (FBT and systemic family therapy) at six outpatient North American clinics. FBT was found to bring about faster weight gain earlier in treatment, with fewer hospital days; however, there were no differences at end of treatment (EOT) (Agras et al., 2014). In Melbourne, Australia, Le Grange and colleagues (2016) compared PFT with FBT and found that weight restoration was accomplished more efficiently in PFT where the adolescent was monitored by a nurse and did not participate in the treatment session. Eisler and colleagues (2016) compared multifamily and single-family therapy treatment formats across six specialist eating disorder services in the United Kingdom near London. At EOT, the multifamily group fared better, with significantly more participants in the good- or intermediate-outcome categories, but this statistical advantage was not maintained at follow-up. According to the authors, their study furthers the evidence for typical single-family approaches and confirmed the utility of an intensive multifamily format.
Based on the evidence thus far, FBT should be the first-line outpatient treatment for adolescents with AN who are medically stable, and it seems to be particularly effective at reducing the need for hospitalization. In addition, there is support for both intensive multifamily formats, as well as separated formats (PFT), of family therapy. AFT and systemic family therapy are both feasible alternatives when FBT is not an option (Agras et al., 2014; Le Grange et al., 2007).
Predictors of Treatment Outcome for Anorexia Nervosa
With the expanding literature to support family-based approaches to the treatment of adolescent AN, new studies are shifting to identify predictors of outcome and moderator effects. There is substantial support indicating that early weight gain (more than 2 kilograms by week four of treatment) characterizes nearly 80 percent of treatment responders, i.e., at or above 95 percent median body mass index at EOT (Doyle et al., 2010; Le Grange et al., 2014; Lock et al., 2005; Madden, Miskovic‐Wheatley, Wallis, Kohn, Hay, & Touyz, 2015). Recognizing the importance of early weight gain, Lock and Le Grange, with their colleagues (2015), in a pilot study developed a three-session, intensive parent coaching adaptation to FBT for poor early responders, with promising results.
Evidence-Based Treatments for Bulimia Nervosa in Youth
While the evidence to inform treatment of AN in youth and BN in adults has grown, there continues to be few systematic studies of the treatment of BN in youth, although this landscape is slowly changing, too. Four RCTs for youth with BN have now been published in the past decade (Le Grange et al., 2007; 2015; Schmidt et al., 2007; Stefini et al., 2017). Family-focused approaches are leading the field in the treatment of AN in youth, while three of the four published RCTs for youth with BN have also included a family-focused approach. All four studies have included an individual approach. To date, there have been no RCTs of psychopharmacological interventions.
Le Grange and colleagues (2007; 2015) conducted two RCTs comparing FBT adapted for BN with individual treatment approaches in the U.S. The first study utilized supportive psychotherapy, a nondirective treatment that is comparable to nonspecialized treatment that might be received in the community (Le Grange et al., 2007). The follow-up study evaluated FBT-BN against CBT, the most efficacious treatment for BN in adults (Agras et al., 2000), adapted for adolescents (CBT-A) (Le Grange et al., 2015). Both studies found FBT-BN to be more effective, with significantly higher rates of abstinence from binge eating and purging the month prior to EOT—just under 40 percent for FBT-BN versus just under 20 percent abstinence for either individual approach. During the six-month follow-up period, there was a decrease in abstinence across both treatment groups in the first study (2007) and continued improvement across both groups in the second study (2015).
Schmidt and colleagues (2007) published the first RCT for the treatment of BN in adolescents. This study compared a guided self-care format of CBT, the first-line intervention for adults with BN in the U.K., with family therapy adapted from the Maudsley model of treatment for AN. When looking at abstinence from both objective binge eating and purging, there was no difference between conditions at EOT and both groups continued to improve during follow-up. However, CBT-guided self-care was more effective at achieving abstinence from objective binge eating (in isolation from purging behavior) at EOT, but this advantage was not maintained at follow-up. The most recently published RCT conducted by Stefini and colleagues (2017) compared psychodynamic therapy, the most commonly practiced treatment in Germany, with CBT. Unlike the prior three studies, both treatments spanned a full year. There were no differences found between groups at EOT, with a slight, but not significant, continued improvement for the CBT group during the follow-up period.
Of the few systematic studies of treatment of BN in youth, the preliminary evidence suggests the value of including caregivers in treatment; however, there remains substantial room for improvement. In a stepped care model or in areas with limited resources, a guided self-care format of CBT may be a first-line intervention. CBT-A also seems like a feasible alternative if caregivers are unable to participate in treatment. Although psychodynamic therapy and CBT demonstrated similar outcomes when a full year of treatment is offered, it remains unclear if the extended format of CBT (60 sessions over one year) (Stefini et al., 2017) has any benefit over the more traditional time-limited CBT (20 sessions over six months) (Le Grange et al., 2015; Fairburn et al., 2009).
Higher levels of care such as first-line inpatient psychiatric treatment for AN do not provide advantages over outpatient management, including day programs. For youth who are medically stable, FBT should be the first-line outpatient treatment. There is emerging evidence that different adaptations of FBT, such as the addition of intensive parent coaching for early poor responders, or PFT, may under certain circumstances be even more effective. Although fewer studies have been conducted for youth with BN, utilizing families in treatment for this patient population looks promising. While many advances can and should be celebrated, clearly more work to refine the best treatments for adolescents with eating disorders is required.
About the authors:
Daniel Le Grange, PhD, holds a Distinguished Professorship at the University of California, San Francisco (UCSF), where he is Benioff UCSF Professor in Children’s Health in the Department of Psychiatry UCSF Weill Institute for Neurosciences, and Eating Disorders Director in the Division of Child and Adolescent Psychiatry. Dr. Le Grange also is Emeritus Professor of Psychiatry and Behavioral Neuroscience at The University of Chicago. He received his doctoral education at the Institute of Psychiatry and the Maudsley Hospital, the University of London, and completed postdoctoral training at the University of London and the Maudsley Hospital, and at Stanford University School of Medicine, California. Dr. Le Grange’s research interests focuses primarily on treatment trials for adolescents with eating disorders. He has authored or co-authored more than 475 manuscripts, books, book chapters, and abstracts, and presented more than 200 presentations at national and international scientific meetings. Dr. Le Grange is a Fellow of the Academy for Eating Disorders, a Member of the Eating Disorders Research Society, Associate Editor for the Journal of Eating Disorders and BMC Psychiatry, and serves on the Editorial Boards of the European Eating Disorders Review and the International Journal of Eating Disorders. He has lectured extensively across North America, Europe, Australia, South East Asia, and South Africa. Dr. Le Grange has been Principal Investigator on numerous randomized clinical trials funded by the National Institute of Mental Health (United States), the National Health and Medical Research Council (Australia), and private foundations (United States and Australia). Dr. Le Grange is the 2013 recipient of the UCSF Presidential Chair Award, the 2014 recipient of the Academy for Eating Disorders Leadership in Research Award, and the 2017 recipient of the Eating Disorder Recovery Support Hall of Fame Award for Research.
Lisa Hail, PhD, is a postdoctoral fellow mentored by Daniel Le Grange, PhD, in the Eating Disorders Program at the University of California, San Francisco. Dr. Hail completed her doctoral education in Clinical Psychology at Fairleigh Dickinson University mentored by Katharine Loeb, PhD.
Dr. Hail’s first exposure to collaborating in eating disorders research was as an undergraduate at the University of Colorado at Boulder which lead her to diverge from her initial career path as a pre-medical student. Her current research is focused on approaches to improving treatment outcomes in youth. In addition to her research and clinical work in the field of eating disorders, Dr. Hail enjoys participating in advocacy initiatives with the Eating Disorders Coalition and co-chairing Special Interest Groups within the Academy for Eating Disorders.
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