A pragmatic randomised multi-centre trial of multifamily and single family therapy for adolescent anorexia nervosa.

BACKGROUND: Considerable progress has been made in recent years in developing effective treatments for child and adolescent anorexia nervosa, with a general consensus in the field that eating disorders focussed family therapy (often referred to as Maudsley Family Therapy or Family Based Treatment) currently offers the most promising outcomes. Nevertheless, a significant number do not respond well and additional treatment developments are needed to improve outcomes. Multifamily therapy is a promising treatment that has attracted considerable interest and we report the results of the first randomised controlled trial of multifamily therapy for adolescent anorexia nervosa. METHODS: The study was a pragmatic multicentre randomised controlled superiority trial comparing two outpatient eating disorder focussed family interventions - multifamily therapy (MFT-AN) and single family therapy (FT-AN). A total of 169 adolescents with a DSM-IV diagnosis of anorexia nervosa or eating disorder not otherwise specified (restricting type) were randomised to the two treatments using computer generated blocks of random sizes to ensure balanced numbers in the trial arms. Independent assessors, blind to the allocation, completed evaluations at baseline, 3 months, 12 months (end of treatment) and 18 months. RESULTS: Both treatment groups showed clinically significant improvements with just under 60% achieving a good or intermediate outcome (on the Morgan-Russell scales) at the end of treatment in the FT-AN group and more than 75% in the MFT-AN group - a statistically significant benefit in favour of the multifamily intervention (OR = 2.55 95%; CI 1.17, 5.52; p = 0.019). At follow-up (18 months post baseline) there was relatively little change compared to end of treatment although the difference in primary outcome between the treatments was no longer statistically significant. Clinically significant gains in weight were accompanied by improvements in mood and eating disorder psychopathology. Approximately half the patients in FT-AN and nearly 60% of those in MFT-AN had started menstruating. CONCLUSIONS: This study confirms previous research findings demonstrating the effectiveness of eating disorder focused family therapy and highlights the additional benefits of bringing together groups of families that maximises the use of family resources and mutual support leading to improved outcomes. TRIAL REGISTRATION: Current Controlled Trials ISRCTN11275465 ; Registered 29 January 2007 (retrospectively registered).

Comparison of specialist and nonspecialist care pathways for adolescents with anorexia nervosa and related eating disorders.

OBJECTIVE: To explore the role of specialist outpatient eating disorders services and investigate how direct access to these affects rates of referral, admissions for inpatient treatment, and continuity of care. METHOD: Services beyond primary care in Greater London retrospectively identified adolescents who presented with an eating disorder over a 2-year period. Data concerning service use were collected from clinical casenotes. RESULTS: In areas where specialist outpatient services were available, 2-3 times more cases were identified than in areas without such services. Where initial outpatient treatment was in specialist rather than nonspecialist services, there was a significantly lower rate of admission for inpatient treatment and considerably higher consistency of care. DISCUSSION: Developing specialist outpatient services with direct access from primary care is likely to lead to improvements in treatment and reduce overall costs.

Risk factors, correlates, and markers in early-onset bulimia nervosa and EDNOS.

OBJECTIVE: This study aimed to investigate the specific risk factors, correlates, and markers associated with the development of symptomatology of early-onset BN and subclinical BN. METHOD: Two semi-structured interviews were used to examine symptomatology and antecedent factors of bulimic symptoms in a sample of British adolescents. RESULTS: Adolescents with early-onset eating pathology were significantly more likely to report an earlier age of menarche than those developing the disorder at the typical age, and were found to have a different pathway of symptom development. DISCUSSION: Increased awareness of this may help identify those particularly at risk for developing an early-onset of eating pathology.

Do adolescents with eating disorder not otherwise specified or full-syndrome bulimia nervosa differ in clinical severity, comorbidity, risk factors, treatment outcome or cost?

OBJECTIVE: We wanted to know whether adolescents with eating disorder not otherwise specified (EDNOS) differ from those with bulimia nervosa (BN) in clinical features, comorbidity, risk factors, treatment outcome or cost. METHOD: Adolescents with EDNOS (n = 24) or BN (n = 61) took part in a trial of family therapy versus guided self-care. At baseline, eating disorder symptoms, risk factors, and costs were assessed by interview. Patients were reinterviewed at 6 and 12 months. RESULTS: Compared with EDNOS, BN patients binged, vomited and purged significantly more, and were more preoccupied with food. Those with EDNOS had more depression and had more current and childhood obsessive-compulsive disorder. 66.6% of EDNOS versus 27.8% of BN patients were abstinent from bingeing and vomiting at 1 year. Diagnosis did not moderate treatment outcome. Costs did not differ between groups. CONCLUSION: EDNOS in adolescents is not trivial. It has milder eating disorder symptoms but more comorbidity than BN.

A randomized controlled trial of family therapy and cognitive behavior therapy guided self-care for adolescents with bulimia nervosa and related disorders.

OBJECTIVE: To date no trial has focused on the treatment of adolescents with bulimia nervosa. The aim of this study was to compare the efficacy and cost-effectiveness of family therapy and cognitive behavior therapy (CBT) guided self-care in adolescents with bulimia nervosa or eating disorder not otherwise specified. METHOD: Eighty-five adolescents with bulimia nervosa or eating disorder not otherwise specified were recruited from eating disorder services in the United Kingdom. Participants were randomly assigned to family therapy for bulimia nervosa or individual CBT guided self-care supported by a health professional. The primary outcome measures were abstinence from binge-eating and vomiting, as assessed by interview at end of treatment (6 months) and again at 12 months. Secondary outcome measures included other bulimic symptoms and cost of care. RESULTS: Of the 85 study participants, 41 were assigned to family therapy and 44 to CBT guided self-care. At 6 months, bingeing had undergone a significantly greater reduction in the guided self-care group than in the family therapy group; however, this difference disappeared at 12 months. There were no other differences between groups in behavioral or attitudinal eating disorder symptoms. The direct cost of treatment was lower for guided self-care than for family therapy. The two treatments did not differ in other cost categories. CONCLUSIONS: Compared with family therapy, CBT guided self-care has the slight advantage of offering a more rapid reduction of bingeing, lower cost, and greater acceptability for adolescents with bulimia or eating disorder not otherwise specified.

Predictors of mental health problems and negative caregiving experiences in carers of adolescents with bulimia nervosa.

OBJECTIVE: This exploratory study focuses on the mental health (MH) and caregiving experience of carers of adolescents with Bulimia Nervosa (BN)/Eating Disorder not otherwise specified (EDNOS), aiming to determine: levels of MH problems in carers and if a negative experience of caregiving predicts carer MH status and which factors predict a negative experience of caregiving. METHOD: Hundred and twelve carers and 68 adolescents with BN/EDNOS completed self-report measures (General Health Questionnaire, Experience of Caregiving Inventory, Level of Expressed Emotion, Self-report Family Inventory, Inventory of Interpersonal Problems). RESULTS: Over half of the carers reported some MH problems and a minority (5.4%) were experiencing considerable difficulties. A negative experience of caregiving predicted carer MH status. Higher weekly contact hours and patient ratings of expressed emotion (EE) predicted a negative experience of caregiving. CONCLUSIONS: Interventions focusing on reducing EE and contact hours could prove beneficial for both patient and caregiver outcomes.

Why do adolescents with bulimia nervosa choose not to involve their parents in treatment?

BACKGROUND: Although the use of family therapy for adolescents with anorexia nervosa is well established, there has been limited research into the efficacy of family therapy in adolescents with bulimia nervosa (BN). No previous research has investigated why individuals with BN do or do not involve their parents in treatment. This is an exploratory study aimed at determining whether there are any differences between these individuals in terms of eating disorder symptomatology, psychopathology, familial risk factors, patients' perception of parental expressed emotion (EE) and family functioning. METHODS: Participants were 85 adolescents with BN or Eating Disorder Not Otherwise Specified, recruited to a randomised controlled evaluation of the cost-effectiveness of cognitive-behavioural guided self-care vs. family therapy. Participants were interviewed regarding the history of their eating disorder and completed self-report measures. RESULTS: Patients who did not involve their parents in treatment were significantly older, had more chronic eating disorder symptoms, exhibited more co-morbid and impulsive behaviours and rated their mothers higher in EE. However, they did not have more severe eating disorder symptomatology. CONCLUSIONS: These preliminary findings, although in need of replication with a larger sample and limited by the attrition rate in some of the self-report measures, indicate that patients who did not involve their parents in treatment may perceive their mothers as having a more blaming and negative attitude towards the patient's illness. Public awareness about BN needs to be raised, focusing on reducing the stigma and negative views attached to this illness.