CBT is Effective for Post-Hospitalization Treatment of Anorexia Nervosa

Adults with anorexia nervosa (AN) have a high rate of relapse, continuing serious illness, and a mortality rate estimated at 5% per decade of follow-up. In what is believed to be the first empirical study of the efficacy of any form of psychotherapy for patients after inpatient treatment, Dr. Kathleen M. Pike and co-workers found that cognitive behavioral therapy, or CBT, was particularly effective for adults with AN (Am J Psychiatry 2003; 160:2046)

Patients were eligible to participate in the outpatient study if they had successfully completed inpatient treatment (defined as achieving at least 90% of ideal body weight) for at least 2 weeks, had normalized eating, and lived within commuting distance of the hospital. Thirty-three women were selected for the study.

CBT or nutrition counseling

The women were placed into one of two intervention groups: CBT or nutrition counseling, given in 50 individual sessions over the year after hospitalization. In both cases, the goal was to maintain the objectives achieved on the inpatient unit, to help patients improve and recover, and to prevent relapse.

The women were randomly assigned to their treatment group immediately before their first session in the outpatient trial, which was scheduled within one week after they were released from inpatient treatment. The nutritional counseling intervention was manual-based, and followed well-established principles of nutrition education and food exchanges. Treatment focused on specific dietary analyses and balanced meal planning.

CBT was given in a manual-based method consistent with recommendations specific to CBT for anorexia nervosa. Study physicians met with the patients monthly to monitor their medical condition. Antidepressant medication was continued throughout the outpatient trial and monitored by the study physician.

The patients were released from the study if their weight fell below a body mass index of 17.5 kg/m2, or about 80% of ideal body weight for more than 10 days; if the subject’s medical condition was affected by exacerbation of anorexia nervosa to the point where inpatient care was once again required; or after exacerbation of non-eating-disorder psychopathology (such as attempted suicide) required additional care.

And, after a year…

The findings offered preliminary support for the use of CBT in the post-hospitalization treatment of adult anorexia nervosa. The criteria for relapse were met by 53% of the patients in the nutrition-counseling group, compared with 22% of those in the CBT group. Three women in the CBT group had relapses, due to weight loss, and one relapsed because of weight loss and increased suicidality. In the nutrition-counseling group, 5 women relapsed because of weight loss, and 3 were referred for alternative care because of severe depression, including active suicidal ideation in 2. The number of patients who dropped out early (defined as patients who discontinued treatment before session 10), was higher for those receiving nutrition counseling (3 of 15,or 20%) than for those receiving CBT (0).

A significantly higher percentage of women in the CBT group (44%, or 8 of 18) than in the nutrition-counseling group (7%, or 1 of 15) met modified Morgan-Russell criteria for a “good outcome.” However, the authors point out that one of the limitations of these particular criteria is that they do not cover related psychological and behavioral variables that make up core criteria in anorexia nervosa. Thus, a person could have meet the study criteria for a good outcome but might still not be free of concerns about shape and weight or eating behavior.

‘Full recovery’ better among the CBT group

To counter this, the authors established an operational definition of full recovery by using the Eating Disorder Examination interview. Patients had to meet the criteria for good outcome and eating attitudes, and weight concerns had to be less than one standard deviation above the mean of a comparison group without eating disorders, and binge eating or purging behaviors had to be absent. Using these criteria, 17% of the women in the CBT group met the criteria for “full recovery,” compared with none of the individuals in the nutrition-counseling group.

At the time they were randomly assigned to CBT or nutrition counseling, 17 women were taking antidepressants; all the medications were begun on the inpatient unit because significant disturbances of mood continued despite weight restoration. The authors also attempted to determine if antidepressants affected outcome. No significant side effects from the medication effects were identified among those in the nutrition-oriented group. In contrast, the findings among the CBT treatment group suggested a medication effect: 7 of the 8 patients who met the criteria for “good outcome” were receiving medication, compared to 4 of the 10 who did not meet the criteria for good outcome.