Two different family-based therapies are both effective at combating anorexia nervosa in teenagers, according to the largest study ever to compare two such treatments for the life-threatening eating disorder.
The findings, from a multisite study led by researchers at the Stanford University School of Medicine, add to a growing body of evidence supporting the value of parents' involvement in anorexia treatment.
The results, which will be published Sept. 24 in JAMA Psychiatry, follow prior Stanford research that found a family-based approach was twice as effective as individual therapy for treating adolescent anorexia patients.
"The take-away message for parents is that, first, there is good treatment available for their child who is struggling with anorexia," said Stewart Agras, MD, professor emeritus of psychiatry and behavioral sciences at Stanford and the lead author of the new study. "Second, the preferred treatment is family-based therapy in which parents help their child regain weight."
Anorexia nervosa patients suffer distorted body image, erroneously believing they are overweight. They overexercise and refuse to eat enough to maintain a healthy body weight. The disease, which affects about 0.5 to 0.7 percent of adolescent girls, has one of the highest suicide rates of any psychiatric disorder.
Involving, not blaming, families
"For a long time, people blamed families for causing anorexia and thought they should be left out of treatment," said James Lock, MD, PhD, professor of psychiatry and behavioral sciences at Stanford and a co-author of the study. "But this study suggests that, however you involve them, families can be useful, and that more focused family treatment works faster and more cost-effectively for most patients." Lock directs the Comprehensive Eating Disorders Program at Lucile Packard Children's Hospital Stanford.
The study, a randomized, controlled trial of 164 patients conducted at six sites in the United States and Canada, compared two forms of anorexia treatment that involved regular therapy sessions with adolescents and their families. One approach focused on teaching parents to help their children eat normally and regain weight at home. The other therapy attempted to resolve difficult family dynamics. Both therapies produced similar rates of recovery from anorexia, but patients treated with the first approach gained weight faster and needed less hospitalization, the study found.
The patients were ages 12-18 and had been ill with anorexia for an average of 13.5 months. At the start of the study, all patients had body weights of at least 75 percent of what was considered ideal, meaning that physicians considered it safe for them to receive outpatient treatment. Nearly 90 percent of the patients were female. All had at least one parent who agreed to participate in treatment, which consisted of 16 one-hour therapy sessions over a nine-month period. The success of the treatments was evaluated at the end of the nine-month period and again a year later.
In both forms of family therapy, patients experienced similar weight gain by the end of treatment and at the one-year follow-up. The therapy that focused on teaching parents to help their children eat normally again was about half as expensive as the family-dynamics approach, mostly because patients spent less time in the hospital. However, the therapy that focused on family dynamics was more effective for one specific sub-group of patients: those who also had severe symptoms of obsessive-compulsive disorder.
Hope for long-term remission
Lock, who has conducted several prior studies of the therapy that teaches parents to help their children eat normally again, said he thinks this approach works by interrupting the patient's behaviors that are supporting erroneous thinking patterns. "We think that parents are able to disrupt the maintaining behaviors of anorexia long enough that the thoughts and cognitions that go with the disease diminish," he said. "At that point, the cognitions themselves have very little staying power."
Addressing anorexia during the teenage years offers the best hope for long-term remission, Agras said. "The longer anorexia goes on, the more difficult it is to treat," he said. "A great many people live chronically restricted lives because of this disease — they plan their days around undereating and overexercise — and quite a few die. The idea is to treat the disorder in adolescence to prevent more adults from becoming anorexic."
Other Stanford co-authors of the study are statisticians Susan Bryson, MS, and Booil Jo, PhD, associate professor of psychiatry and behavioral sciences. Lock is a member of the Child Health Research Institute at Stanford.
The study's coordinating center was at Stanford, and the other intervention sites were at Weill Cornell Medical College in New York City, Sheppard-Pratt Medical Center in Baltimore, the University of California-San Diego, the University of Toronto and Washington University in St. Louis.
The study was funded by the National Institute of Mental Health (grants 1U01MH076290, MH076254, MH076251, MH076250, MH076255 and MH076252).
Agras and Lock receive royalties from Oxford University Press for contributions to a textbook about eating disorders. Lock also receives royalties from Guildford Press for books he has written about family-based treatment for anorexia nervosa and bulimia nervosa, and payments from the Training Institute for Child and Adolescent Eating Disorders, where he is a faculty member who trains other clinicians in evidence-based treatment methods for eating disorders.
Information about Stanford's Department of Psychiatry and Behavioral Sciences, which also supported the work, is available at http://psychiatry.stanford.edu/.
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