A new clinical trial has found that focusing on quality of life and enhanced social adjustment, rather than weight gain, improved results for patients with severe and enduring anorexia nervosa.
Researchers report that more than 85 percent of patients enrolled in the trial completed treatment, which is almost three times the usual retention rate. After eight months of outpatient treatment, patients reported improved quality of life, reduced symptoms of mood disorders and enhanced social adjustment, researchers noted.
The key difference, according to researchers, was reprioritizing how the goals of treatment were presented to the patients.
Typically, treatment focuses on weight recovery. But for this study, conducted at the University of Sydney, University of London and University of Chicago, there was less emphasis on weight gain and more on quality of life, reduction of mood disorders, and enhanced social adjustment.
“Our goal was to peel back the negative impact of anorexia and to shift the traditional pressure to gain weight to an emphasis on improving quality of life and overall functioning,” said the study’s lead author Stephen Touyz, Ph.D., from the University of Sydney.
“By refocusing the core of treatment, we were able to engage highly resistant individuals with severe and enduring anorexia nervosa in treatment, circumvent the notoriously high dropout rates and help them make their lives a little better.”
Patients with severe and enduring anorexia nervosa (SE-AN) are difficult to treat, he noted. Most develop anorexia as adolescents and do not respond to treatment. Participants in the study had suffered from severe anorexia for at least seven years, with an average duration of more than 15 years.
Anorexia nervosa has the highest mortality rate of any psychiatric disorder, according to the researchers. Most of the individuals who have it have been through many unsuccessful treatments. Repeated failure leaves them with low motivation and a self-image dominated by illness.
This is compounded by the physical effects of the disease. After prolonged malnourishment, many are disabled and unable to hold a job. They can suffer from neurocognitive, cardiac or liver problems, as well as osteoporosis. Insurance companies frequently refuse to pay for treatment because so few individuals improve.
The new study compared two standard treatments — cognitive behavior therapy (CBT) and special supportive clinical management (SSCM) — but modified them to focus on retention, improved quality of life and to avoid further failure.
The researchers enrolled 63 patients, all female, at clinical centers at the University of Sydney and St George’s Hospital, University of London. The average body mass index of study participants was 16.2, with a range from 11.8 to 18.5. Normal BMI ranges from 18.5 to 25, researchers noted. The University of Chicago served as the data-coordinating center.
For the study, 31 patients were assigned to CBT and 32 to SSCM. Both treatments involved 30 outpatient therapy sessions over eight months. Patients were assessed at the end of treatment, with follow-up assessments six and 12 months later.
Results from both treatments were comparable, with improvements ranging from “moderate” to “large” on many measures, the researchers reported.
CBT had a greater impact on eating-disorder symptoms and readiness to change, they said. SSCM produced larger improvements in health-related quality of life and depression. Average BMI for both groups increased from 16.2 to 16.8, about 4 percent.
“The results were far better than most people in the field would have expected,” said Daniel Le Grange, Ph.D., professor of psychiatry and director of the eating disorders program at the University of Chicago and the principal investigator for the data-coordinating center. “Many of these patients were profoundly ill.
“The prevailing wisdom is that current treatments have not been effective and patients are best served by refeeding in the hospital setting. This study showed that specific modification of these behavioral approaches could overcome the high dropout rates and lead to meaningful positive change.”
The researchers acknowledged there were limitations to the study, including the moderate sample size of 63 study participants, and a relatively short follow-up period of 12 months for a disorder that had been present for more than seven years.
Despite the limitations, the high retention rate and the magnitude of improvement in most of the outcome measures were very encouraging, especially in the setting of a disorder with poor compliance and limited previous clinical success, the researchers reported.
“This study clearly shows that SE-AN patients do respond to, and benefit from, two specialized treatments when done by clinicians with specialist knowledge,” the researchers wrote in the study, which was published in the journal Psychological Medicine.
“This study should provide hope for those suffering from severe and enduring AN as well as stimulate interest in the development of new psychosocial treatment approaches.”