Rethinking treatment goals improves results for 'untreatable' anorexics

(Medical Xpress)—Patients with the most severe and dangerous form of chronic anorexia are more likely to make a significant improvement towards recovery and stay in therapy if traditional psychological treatments are re-focused from weight gain to quality of life issues.

By focusing treatment on quality of life, researchers found that 85 per cent of participants with severe and enduring anorexia nervosa (SE-AN) completed their course of treatment – almost three times the usual retention rate. These findings are the first to show that people with SE-AN can be treated with an outpatient treatment programme.

Professor Hubert Lacey, the London lead for the study, from St George's, University of London said:

"Anorexia nervosa has the highest mortality rate of any psychiatric disorder, and patients with SE-AN are notoriously difficult to treat. Most sufferers have been through multiple unsuccessful treatment episodes. Repeated failure leaves them with low motivation and a self-image dominated by illness. After prolonged periods of malnourishment, many sufferers are disabled, unable to hold down a job and have neurocognitive, cardiac or liver problems as well as osteoporosis."

Study participants also reported improved quality of life, reduced symptoms of mood disorders and enhanced social adjustment. While weight targets were considered a secondary outcome of the study, most participants gained weight and none lost weight during the study period.

Professor Lacey said: "These findings challenge the view of some NHS services that individuals with an enduring course of anorexia have little or no motivation to change or are unlikely to respond to conventional psychosocial treatment."

The randomised controlled trial – by researchers from St George's, University of London, the University of Sydney and the University of Chicago – was published online by the journal Psychological Medicine this month (May 2013).

Current treatment tends to focus on weight recovery goals. In this study, researchers altered two standard treatments – cognitive behavioural therapy (CBT) and specialist supportive clinical management (SSCM) – to focus goals around improved quality of life.

Professor Lacey said:

"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. 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."

The study involved 63 patients, all women, at two clinical centres – one at St George's, University of London and the other at the University of Sydney. The average body mass index (BMI) of study participants was 16.2, with a minimum weight of BMI 11.8. All participants had suffered from SE-AN for at least seven years, with an average duration of illness for more than 15 years.

Thirty-one 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 the researchers describing improvements ranging from "moderate" to "large" on measures assessed. CBT had a greater impact on eating-disorder symptoms and readiness to change. SSCM produced larger improvements in health-related quality of life and depression. The average BMI of participants also increased, from 16.2 to 16.8, about four per cent.

"The results were far better than most people in the field would have expected," said Professor Daniel Le Grange from the University of Chicago, who led the study's data analysis. "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 behavioural approaches could overcome the high dropout rates and lead to meaningful positive change."

The researchers explain that limitations of the study include a moderate sample group and a relatively short follow-up period of 12 months but the St George's and Sydney research teams are now following up the patients for five years.

Professor Lacey said: "Despite these 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."