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Out-patient psychological therapies for adults with anorexia nervosa: randomised controlled trial

  • Ulrike Schmidt (a1), Anna Oldershaw (a1), Fatima Jichi (a2), Lot Sternheim (a1), Helen Startup (a3), Virginia McIntosh (a4), Jennifer Jordan (a4), Kate Tchanturia (a1), Geoffrey Wolff (a3), Michael Rooney (a3), Sabine Landau (a2) and Janet Treasure (a1)...
Abstract
Background

Very limited evidence is available on how to treat adults with anorexia nervosa and treatment outcomes are poor. Novel treatment approaches are urgently needed.

Aims

To evaluate the efficacy and acceptability of a novel psychological therapy for anorexia nervosa (Maudsley Model of Anorexia Nervosa Treatment for Adults, MANTRA) compared with specialist supportive clinical management (SSCM) in a randomised controlled trial.

Method

Seventy-two adult out-patients with anorexia nervosa or eating disorder not otherwise specified were recruited from a specialist eating disorder service in the UK. Participants were randomly allocated to 20 once weekly sessions of MANTRA or SSCM and optional additional sessions depending on severity and clinical need (trial registration: ISRCTN62920529). The primary outcomes were body mass index, weight and global score on the Eating Disorders Examination at end of treatment (6 months) and follow-up (12 months). Secondary outcomes included: depression, anxiety and clinical impairment; neuropsychological outcomes; recovery rates; and additional service utilisation.

Results

At baseline, patients randomised to MANTRA were significantly less likely to be in a partner relationship than those receiving SSCM (3/34 v. 10/36; P < 0.05). Patients in both treatments improved significantly in terms of eating disorder and other outcomes, with no differences between groups. Strictly defined recovery rates were low. However, MANTRA patients were significantly more likely to require additional in-patient or day-care treatment than those receiving SSCM (7/34 v. 0/37; P=0.004).

Conclusions

Adults with anorexia nervosa are a difficult to treat group. The imbalance between groups in partner relationships may explain differences in service utilisation favouring SSCM. This study confirms SSCM as a useful treatment for out-patients with anorexia nervosa. The novel treatment, MANTRA, designed for this patient group may need adaptations to fully exploit its potential.

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Copyright
Corresponding author
Professor Ulrike Schmidt, Section of Eating Disorders Unit (PO59), Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. Email: ulrike.schmidt@kcl.ac.uk
Footnotes
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Joint last authors.

Declaration of interest

U.S. receives salary support from the NIHR (Mental Health Biomedical Research Centre) at South London and Maudsley NHS Foundation Trust and King's College London.

Footnotes
References
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Out-patient psychological therapies for adults with anorexia nervosa: randomised controlled trial

  • Ulrike Schmidt (a1), Anna Oldershaw (a1), Fatima Jichi (a2), Lot Sternheim (a1), Helen Startup (a3), Virginia McIntosh (a4), Jennifer Jordan (a4), Kate Tchanturia (a1), Geoffrey Wolff (a3), Michael Rooney (a3), Sabine Landau (a2) and Janet Treasure (a1)...
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eLetters

Re:Psychological therapies in anorexia nervosa: on the wrong track?

Ulrike H Schmidt, Professor of Eating Disorders
14 March 2013

We share Professor Gutierrez' frustration about the difficulty in treating adults with anorexia nervosa (AN). However, we disagree with his interpretation of our findings, and several other points he makes.

Firstly, in our trial specialist supportive clinical management (SSCM) was not superior to our new treatment, Maudsley Model of Anorexia Treatment for Adults (MANTRA). In fact, outcomes for both interventions were similar. Moreover, in the subgroup of patients with lower initial BMI(below 17.5 kg/m2 at the beginning of treatment) there was some suggestionthat MANTRA patients showed greater weight gain than those receiving SSCM,but this was not statistically significant (p =0.15) as the study was not powered to detect sub-group differences. Secondly, the original New Zealand trial where SSCM compared well against cognitive-behavioural treatment and interpersonal therapy, included many patients who had a relatively mild, less chronic form of AN. In this earlier trial, in the longer term SSCM effects seemed to wane (1).

Thirdly, contrary to Prof. Gutierrez' assertion there is plenty of evidence that the personality features, neuropsychological profile (thinking style) and aspects of altered socio-emotional processing found in AN are not just an epiphenomenon of malnutrition but have trait characteristics which are accentuated in the starved state (2).

Taken together these findings suggest a definite place for SSCM, especially in the treatment of less severe cases of AN. It may be that a more complex treatment such as MANTRA, which is trait-focused and where patients are taught skills that help them to tackle a range of maintainingfactors, is more effective in more severe cases. Our trial was too small to tease this out. However, a larger study is now under way that should beable to answer this question (Schmidt et al., submitted).

To suggest an 'either-or' dichotomy between a treatment focus on 'self' or starvation seems remarkably simplistic to us. In fact, if an exclusive focus on reducing starvation was the key curative step in treatment in-patient refeeding for AN should be used much more often, as this reverses poor nutrition most quickly. Yet, in-patient treatment has significant problems: it is unacceptable to many patients and has high relapse rates.

In a large scale international survey of eating disorders patients and their families there was strong agreement between these stakeholders that specialist expertise and personal qualities of staff, expert psychological interventions and nutritional assistance (advice and intervention) combined, are the key components of effective treatments andservices (3).

Clearly, we are a long way away from having a cure for adults with AN. Given the very limited evidence base there is still much to learn about what works for whom at what stage of illness. The last few years have seen the burgeoning of neuroscience data related to AN, which opens the way to treatments targeted at dysfunctional neurocircuitry (4,5). Ultimately, we predict that significant improvements in treatment outcomesin adults with AN are only going to be achieved through adding such 'targeted brain-directed' adjuncts to talking therapies and nutritional intervention.

References

(1) Carter FA, Jordan J, McIntosh VV, Luty SE, McKenzie JM, Frampton CM, et al. The long-term efficacy of three psychotherapies for anorexia nervosa: arandomized, controlled trial. Int J Eat Disord 2011: 44: 647-54.

(2) Treasure J, Schmidt U. The Cognitive-Interpersonal Maintenance Model of Anorexia Nervosa Revisited: A summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors. J Eat Disord 2013: In press.

(3) Nishizono-Maher A, Escobar-Koch T, Ringwood S, Banker J, van Furth E, Schmidt U. What are the top five essential features of a high quality eating disorderservice? A comparison of the views of US and UK eating disorder sufferers,carersand health professionals. Eur Eat Disord Rev. 2010, Dec 20. [Epub ahead ofprint].

(4) Van den Eynde F, Guillaume S, Broadbent H, Campbell IC, Schmidt U. Repetitive transcranial magnetic stimulation in anorexia nervosa: A pilot study. Eur Psychiatry 2013: 28: 98-101.

(5) Lipsman N, Woodside DB, Giacobbe P, Hamani C, Carter JC, Norwood SJ, et al. Subcallosal cingulate deep brain stimulation for treatment-refractory anorexia nervosa: a phase 1 pilot trial. The Lancet, Early Online Publication, 7 March 2013. doi:10.1016/S0140-6736(12)62188-6.

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Conflict of interest: None declared

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Psychological therapies in anorexia nervosa: on the wrong track?

Emilio Gutierrez, Professor Clinical Psychology
25 February 2013

Recently, in a randomized controlled trial, Specialist Supportive Clinical Management (SSCM) has proven to be more effective than the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA), a treatment specially designed to address the disorder according to a rather complex rationale in comparison to SSCM (Schmidt et al., 2012). SSCM, originally a “Nonspecific Supportive Clinical Management” administered to a control group in a previous randomized controlled trial (McIntosh et al., 2005), was found to be more effective than two specialized treatments i.e., cognitive behavioral therapy and interpersonal therapy, and was as effective as these treatments in a 5-years follow-up (Carter et al, 2011).

SSCM was originally defined as clinical management and supportive psychotherapy, as revealed by its original definition: “Nonspecific supportive clinical management was developed for the present study, and its aim was to mimic outpatient treatment that could be offered to individuals with anorexia nervosa in usual clinical practice. It combined features of clinical management and supportive psychotherapy. Clinical management includes education, care, and support and fostering a therapeutic relationship that promotes adherence to treatment. Supportive psychotherapy aims to assist the patient through use of praise, reassurance, and advice. The abnormal nutritional status and dietary patterns typical of anorexia nervosa were central to nonspecific supportive clinical management, which emphasized the resumption of normal eating and the restoration of weight and provided information on weight maintenance strategies, energy requirements, and relearning to eat normally. Information was provided verbally and as written handouts” (2, p. 742)

In contrast, MANTRA claims to be novel in several respects: (a) it is biologically informed and trait-focused, drawing on neuropsychological, social cognitive and personality trait research; (b) it includes both intra- and interpersonal maintaining factors and strategies to address these; and (c) it is modularized with a hierarchy of procedures tailored to the individuals (as described in their Supplementary Table 1).

Current treatment of anorexia nervosa (AN) is disheartening. Following successful weight restoration, almost 50% of patients relapse after 1-year follow-up, and pharmacological or psychological treatment persistently fail to neutralize the purported mechanisms underlying AN psychopathology (Attia& Walsh, 2009). Against this backdrop, according to the American Psychological Association Task Force criteria for the Promotion and Dissemination of Psychological Procedures SSCM could be first treatment for adult AN to attain the consideration of a “well established psychosocial intervention”. However, the acronym SSCM disguises the fact that it has entered the stage through the backdoor of nonspecific supportive treatments originally assigned to control groups, and SSMC efficacy over advanced treatments that have a sound theoretical basis raises perplexing questions. Maybe we are on the wrong track either by persistently failing to understand the fundamental features articulating the current concept of the disorder in terms of symptoms, personality traits, psychopathology and neuropsychological profile or that these features are an epiphenomenon of malnutrition, and are thus irrelevant as targets for AN treatment. Rather than delving on the self, perhaps the focus should be on the starvation side of self-starvation(Gutierrez, 2013).

Attia, E., Walsh, B.T. (2009) Behavioral management for anorexia nervosa. New England Journal of Medicine,360, 500-506.

Carter, F.A., Jordan, J., McIntosh, V.V., et al (2011) The long-term efficacy of three psychotherapies for anorexia nervosa: a randomized, controlled trial. International Journal of Eating Disorders,44, 647-654.

Gutierrez, E. (2013)A rat in the labyrinth of anorexia nervosa: Contributions of the activity-based anorexia rodent model to the understanding of anorexia nervosa.International Journal of Eating Disorders,doi: 10.1002/eat.22095

McIntosh, V.V., Jordan, J., Carter, F.A., et al (2005) Three psychotherapies for anorexia nervosa: a randomized, controlled trial. American Journal ofPsychiatry,162, 741-747.

Schmidt U, Oldershaw A, Jichi F, et al (2012) Out-patient psychological therapies for adults with anorexia nervosa: randomised controlled trial. British Journal of Psychiatry,201, 392-399.
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Conflict of interest: None declared

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