Key messages
1. One small study of people with severe and enduring anorexia nervosa compared two therapies: cognitive behaviour therapy and specialist supportive clinical management.
2. There is not enough evidence to say with certainty if any specific therapy is more effective than any other.
3. There is a need for larger studies to investigate the benefits of treatment for people with SEAN.
Why is this review important?
Anorexia nervosa is an eating disorder and serious mental illness. People with anorexia nervosa normally have a very low bodyweight, an intense fear of gaining weight, and a distorted perception of their weight. The main treatment for anorexia nervosa is specific psychological therapy combined with multidisciplinary physical and nutritional health care. The main available therapies are cognitive behaviour therapy (CBT), specialist supportive clinical management (SSCM), the Maudsley therapy for adults with anorexia nervosa (MANTRA), and focal psychodynamic therapy (FPT). They all provide advice and counselling on nutrition and physical care, but they differ in their psychological focus. CBT addresses the thoughts (cognitions) that underpin the behaviours of anorexia nervosa, such as fear of fatness, and provides active behavioural strategies (e.g. gentle reintroduction of foods that cause anxiety). SSCM provides supportive therapy and goal setting. MANTRA focusses on helping the person think more freely and finding reasons for change. FPT helps the person work through past relational experiences and explore parts of their identity that underpin the eating disorder. Some people with anorexia nervosa do not improve with usual treatments and develop a severe and enduring form of the illness that is very debilitating. There is very little published evidence to help clinicians manage people with severe and enduring anorexia nervosa (SEAN); in fact, there is not even a universal definition for this condition.
Who will be interested in this review?
People with lived experience of SEAN and those who care for them, including healthcare providers, will be most interested in this review. People more broadly affected by anorexia nervosa and other eating disorders will also be interested.
What did we want to find out?
We wanted to find out if any specific psychological therapies could improve the mental and physical health of people with SEAN. Specifically, we wanted to know if any specific psychological therapy could help people with SEAN to gain weight or complete treatment. We also wanted to find out if specific psychological therapies were associated with any unwanted effects.
What did we do?
We searched for studies that investigated any specific psychological therapy compared with any other specific psychological therapy, a non-specific psychological therapy for mental health disorders, no treatment or waiting list, antipsychotic or antidepressant medication, dietary counselling, or treatment as usual. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes
What did we find?
We found two eligible studies, but only one study in 63 adults provided data we could use in our review. It found that weight gain and completion of treatment improved with cognitive behaviour therapy and specialist supportive psychological therapy, but that neither therapy was better than the other. Both therapies had been adapted for people with SEAN. There was no information on unwanted effects of treatment.
What are the limitations of the evidence?
This review did not find adequate evidence to determine whether any form of therapy is more effective than any other. We have very little confidence in the evidence because it came from a single study that included only 63 people, and because the people in the studies knew which treatment they were getting. There is a need for larger studies to investigate the benefits of treatment for people with SEAN.
How up to date is this evidence?
The evidence is current to July 2022.
This review reports evidence from one trial that evaluated CBT-SEAN versus SSCM-SE. There was very low-certainty evidence of little or no difference in clinical improvement and treatment non-completion between the two therapies. There is a need for larger high-quality trials to determine the benefits of specific psychological therapies for people with SEAN. These should take into account the duration of illness as well as participants' previous experience with evidence-based psychological therapy for anorexia nervosa.
Anorexia nervosa is a psychological condition characterised by self-starvation and fear or wait gain or other body image disturbance. The first line of treatment is specific psychological therapy; however, there is no consensus on best practice for treating people who develop severe and enduring anorexia nervosa (SEAN). Notably, there is no universal definition of SEAN.
To evaluate the benefits and harms of specific psychological therapies for severe and enduring anorexia nervosa compared with other specific therapies, non-specific therapies, no treatment/waiting list, antidepressant medication, dietary counselling alone, or treatment as usual.
We used standard, extensive Cochrane search methods. The last search date was 22 July 2022.
We included parallel randomised controlled trials (RCTs) of people (any age) with anorexia nervosa of at least three years' duration. Eligible experimental interventions were any specific psychological therapy for improved physical and psychological health in anorexia nervosa, conducted in any treatment setting with no restrictions in terms of number of sessions, modality, or duration of therapy. Eligible comparator interventions included any other specific psychological therapy for anorexia nervosa, non-specific psychological therapy for mental health disorders, no treatment or waiting list, antipsychotic treatment (with or without psychological therapy), antidepressant treatment (with or without psychological therapy), dietary counselling, and treatment as usual as defined by the individual trials.
We used standard methodological procedures expected by Cochrane. Our primary outcomes were clinical improvement (weight restoration to within the normal weight range for participant sample) and treatment non-completion. Results were presented using the GRADE appraisal tool.
We found two eligible studies, but only one study provided usable data. This was a parallel-group RCT of 63 adults with SEAN who had an illness duration of at least seven years. The trial compared outpatient cognitive behaviour therapy for SEAN (CBT-SEAN) with specialist supportive clinical management for SEAN (SSCM-SE) over eight months. It is unclear if there is any difference between the effect of CBT-SEAN versus SSCM-SE on clinical improvement at 12 months (risk ratio (RR) 1.42, 95% confidence interval (CI) 0.66 to 3.05) or treatment non-completion (RR 1.72, 95% CI 0.45 to 6.59). There were no reported data on adverse effects. The trial was at high risk of performance and detection bias.
We rated the GRADE level of evidence as very low-certainty for both primary outcomes, downgrading for imprecision and risk of bias concerns.