Skip to main content Accessibility help
×
×
Home

Clinical effectiveness of treatments for anorexia nervosa in adolescents: Randomised controlled trial

  • Simon G. Gowers (a1), Andrew Clark (a2), Chris Roberts (a3), Alison Griffiths (a1), Vanessa Edwards (a4), Claudine Bryan (a1), Nicola Smethurst (a1), Sarah Byford (a5) and Barbara Barrett (a5)...

Abstract

Background

Treatment guidelines identify few adequately powered trials to guide recommendations for anorexia nervosa.

Aims

To evaluate the effectiveness of three readily available National Health Service treatments for adolescents (aged 12–18 years) with anorexia nervosa.

Method

Multicentre randomised controlled trial of 167 young people comparing in-patient, specialist out-patient and general child and adolescent mental health service (CAMHS) treatment.

Results

Each group made considerable progress at 1 year, with further improvement by 2 years. Full recovery rates were poor (33% at 2 years, 27% still with anorexia nervosa). Adherence to in-patient treatment was only 50%. Neither in-patient nor specialist out-patient therapy demonstrated advantages over general CAMHS treatment by intention to treat, although some CAMHS out-patients were subsequently admitted on clinical grounds. In-patient treatment (randomised or after out-patient transfer) predicted poor outcomes.

Conclusions

First-line in-patient psychiatric treatment does not provide advantages over out-patient management. Out-patient treatment failures do very poorly on transfer to in-patient facilities.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Clinical effectiveness of treatments for anorexia nervosa in adolescents
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Clinical effectiveness of treatments for anorexia nervosa in adolescents
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Clinical effectiveness of treatments for anorexia nervosa in adolescents
      Available formats
      ×

Copyright

Corresponding author

Professor S. G. Gowers, Academic Unit, Section of Adolescent Psychiatry, University of Liverpool, Chester CH2 IAW, UK. Email: simon.gowers@cwpnt.nhs.uk

Footnotes

Hide All

First-line in-patient psychiatric treatment does not provide advantages over out-patient management. Out-patient treatment failures do very poorly on transfer to in-patient facilities.

See pp. 436–440, this issue.

Declaration of Interest

None.

Funding detailed in Acknowledgements.

Footnotes

References

Hide All
American Psychiatric Association (1994) Diagnostic and Statistical Manual for Mental Disorders (4th edn) (DSM–IV). APA.
Angold, A., Costello, E. J., Messer, S. C., et al (1995) The development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. International Journal of Methods in Psychiatric Research, 5, 237249.
Byford, S., Barrett, B., Roberts, C., et al (2007) Economic evaluation of a randomised controlled trial for anorexia nervosa in adolescents. British Journal of Psychiatry, 191, 436440.
Crisp, A. H., Norton, K., Gowers, S., et al (1991) Acontrolled study of the effect of therapies aimed at adolescent and family psychopathology in anorexia nervosa. British Journal of Psychiatry, 159, 325333.
Efron, B. & Tibshirani, R. J. (1993) An Introduction to the Bootstrap. Chapman & Hall.
Eisler, I., Dare, C., Russell, G. F. M., et al (1997) Family and individual therapy in anorexia nervosa. A 5-year follow-up. Archives of General Psychiatry, 54, 10251030.
Eisler, I., Dare, C., Hodes, M., et al (2000) Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry, 41, 727736.
Epstein, N., Bishop, D. & Levin, S. (1983) The McMaster Family Assessment Device. Journal of Marital and Family Therapy, 9, 171180.
Fairburn, C., Cooper, Z. & Shafran, R. (2003) Cognitive behaviour therapy for eating disorders; a ‘transdiagnostic’ theory and treatment. Behaviour Research and Therapy, 41, 509528.
Garner, D. M. (1991) Eating Disorder Inventory – 2. Psychological Assessment Resources.
Garralda, M. E., Yates, P. & Higginson, I. (2000) Child and adolescent mental health service use: HoNOSCA as an outcome measure. British Journal of Psychiatry, 177, 5258.
Geller, J., Cockell, S. J. & Drab, D. L. (2001) Assessing readiness for change in the eating disorders: the psychometric properties of the readiness and motivation interview. Psychological Assessment, 13, 189198.
Gowers, S. G. (2006) Evidence based research in CBT with adolescent eating disorders. Child and Adolescent Mental Health, 11, 912.
Gowers, S. G. & Bryant-Waugh, R. (2004) Management of child and adolescent eating disorders: the current evidence base and future directions Journal of Child Psychology and Psychiatry, 45, 6383.
Gowers, S. & Smyth, B. (2004) The impact of a Motivational Assessment Interview on intitial response to treatment in adolescent anorexia nervosa. European Eating Disorders Review, 12, 8793.
Gowers, S. G., Norton, K. R. W., Halek, C., et al (1994) Outcome of out-patient psychotherapy in a random allocation treatment study of anorexia nervosa. International Journal of Eating Disorders, 15, 165177.
Gowers, S. G., Harrington, R. C., Whitton, A., et al (1999) Brief scale for measuring the outcomes of emotional and behavioural disorders in children. Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). British Journal of Psychiatry, 174, 413416.
Gowers, S. G., Weetman, J., Shore, A., et al (2000) Impact of hospitalisation on the outcome of adolescent anorexia nervosa. British Journal of Psychiatry, 176, 138141.
Gowers, S., Levine, W., Bailey-Rogers, S., et al (2002) Use of a routineself-report outcome measure (HoNOSCA–SR) in two adolescent mental health services. British Journal of Psychiatry, 180, 266269.
Herzog, W. (1992) Long term course of anorexia nervosa; a review of the literature. In: The Course of Eating Disorders (eds Herzog, W., Deter, H.-C. & Vandereycken, W.) pp. 1529. Springer-Verlag.
Le Grange, D., Eisler, I., Dare, C., et al (1992) Evaluation of family therapy in anorexia nervosa: a pilot study. International Journal of Eating Disorders, 12, 347357.
Lock, J., Agras, W. S., Bryson, S., et al (2005) A comparison of short- and long-term family therapy for adolescent anorexia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 632639.
McCullagh, P. (1980) Regression models for ordinal data (with discussion). Journal of the Royal Statistical Society, 42, 109142.
McIntosh, V. V. W., Jordan, J., Carter, F. A., et al (2005) Three psychotherapies for anorexia nervosa: a randomised controlled trial. American Journal of Psychiatry, 162, 741747.
McIntosh, V., Jordan, J., Luty, S., et al (2006) Specialist supportive clinical management for anorexia nervosa. International Journal of Eating Disorders, 39, 625632.
Meads, C., Gold, L. & Burls, A. (2001) How effective is out-patient compared to in-patient care for treatment of anorexia nervosa? A systematic review. European Eating Disorders Review, 9, 229241.
Morgan, H. G. & Hayward, A. E. (1988) Clinical assessment of anorexia nervosa. The Morgan–Russell outcome assessment schedule. British Journal of Psychiatry, 152, 367371.
National Collaborating Centre for Mental Health (2004) Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders. British Psychological Society & Gaskell.
North, C. & Gowers, S. G. (1999) Anorexia nervosa, psychopathology and outcome. International Journal of Eating Disorders, 26, 386391.
O'Herlihy, A., Worrall, A., Lelliott, P., et al (2003) Distribution and characteristics of in-patientchild and adolescent mental health services in England and Wales. Clinical Child Psychology and Psychiatry, 9, 579588.
Robin, A., Siegel, P. T., Moye, A. W., et al (1999) A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa. Journal of American Academy of Child and Adolescent Psychiatry, 38, 14821489.
Roots, P., Hawker, J. & Gowers, S. G. (2006) The use of target weightsin the in-patient treatment of adolescent anorexia nervosa. European Eating Disorders Review, 14, 323328.
Russell, G. F., Szmukler, G. I., Dare, C., et al (1987) An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 44, 10471056.
Treasure, J. & Schmidt, U. (2004) Anorexia nervosa. In Clinical Evidence Mental Health (3rd edn) pp. 112. Gaskell & BMJ Publishing.
Vitousek, K., Watson, S. & Wilson, G. T. (1998) Enhancing motivation for change in treatment resistant eating disorders. Clinical Psychology Review, 18, 391400.
Wood, A., Kroll, L., Moore, A., et al (1995) Properties of the mood and feelings questionnaire in adolescent psychiatric out-patients: a research note. Journal of Child Psychology and Psychiatry, 36, 327334.
Yates, P., Garralda, M. E. & Higginson, I. (1999) Paddington Complexity Scale and Health of the Nation Outcome Scales for Children and Adolescents. British Journal of Psychiatry, 174, 417423.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×
Type Description Title
PDF
Supplementary materials

Gowers et al. supplementary material
Supplementary Table S1

 PDF (31 KB)
31 KB
UNKNOWN
Supplementary materials

Gowers et al. supplementary material
Supplementary Material

 Unknown (576 bytes)
576 bytes

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Clinical effectiveness of treatments for anorexia nervosa in adolescents: Randomised controlled trial

  • Simon G. Gowers (a1), Andrew Clark (a2), Chris Roberts (a3), Alison Griffiths (a1), Vanessa Edwards (a4), Claudine Bryan (a1), Nicola Smethurst (a1), Sarah Byford (a5) and Barbara Barrett (a5)...
Submit a response

eLetters

Readiness for treatment in Anorexia Nervosa

Lalana K Dissanayake, AssociateSpecialist
28 November 2007

Article; Clinical Effectiveness of treatments for Anorexia Nervosa inAdolescents.

The study of clinical effectiveness of different types of anorexia nervosa brings out interesting issues.

The background of not having many adequately powered trials to guide recommendations for treatment is appreciated.

In this multi-centre randomised controlled trial, in-patient, specialist out-patient and general CAMH treatment s were compared.

However, the patient recruitment strategy for each treatment in the methodology raises doubts in mind. In the study treatment allocation was carried out by an independent randomisation service. But the treatment options such as motivation studies are supposed to be decided on the 'chain', pychological stage the patient is on. Therefore, randomisation ofa sample of patients into each category must not have matched to the readiness of the patient at the stage to accept the treatment option offered, thus affecting the outcome.(Ref.)

As mentioned in the discussion, it is appreciated that stepped-care approach is advisable in treatment of anorexia-nervosa.

Also, family support, motivation for treatment, illness identity and emotional adjustment are amongst of many other factors that can influence the outcome in treatment. In randomisation the patient’s psychological stage does not take these into account.

Reference;Stockford K., Turner H., Cooper, M., Illness perception and it’s relationship to readiness to change in the eating disorders, Br J Clin Psychol 2007 Jun; 46(pt2); 139-54

Quiles Marcos Y, Terol Cantero M. C., Romero Escobar C., Paqan AcostaG., Illness perceptionin eating disorders and psychological adaptation, Eur Eat Disorderd Rev. 2007 Sep 15 (5). 373-84

Contact Telephone 07966597078
... More

Conflict of interest: None Declared

Write a reply

The benefits of specialist outpatient care.

Mark Berelowitz, Consultant Child and Adolescent Psychiatrist
28 November 2007

Dear Editor

I was heartened to read the latest contribution by Gower’s group to the discussion of the effectiveness and cost effectiveness of inpatient treatment for adolescent Anorexia Nervosa. It seems increasingly clear that medium term or long term inpatient treatment has relatively little tooffer to patients in terms of real health gain, or to PCT’s in terms of value for money.

However, I wonder whether Gower’s group might have taken their challenge to the status quo even further than they have already done. I note that within their study, about 28% of “outpatients” were admitted, and these admissions accounted for over 80% of the £3.7 million spent on treating 110 patients.

At the Royal Free we run an intensive specialized ambulatory outpatient service for children and adolescents from 7 PCT’s. We see about 90 new patients a year, and the service has in total treated more than 1100 patients, most of whom have Anorexia Nervosa or EDNOS. There have been no serious untoward events, and no deaths. There have been three complaints, two of which came from parents who had a relatively fixed view, at the time of initial referral, that their child needed long term inpatient care, and one from parents whose child had previously had long term inpatient treatment elsewhere, which had brought about short term weight gain but no psychological change.

The key point is that our admission rate is close to 3%, and if it had not been for one patient who has been an inpatient for 4 years, in 4 different units (which rather proves the point), the average total annual spend from our service on inpatient care would have been less than £200 000. And even when we include that unfortunate patient in our financial analysis, our average annual cost per patient is still less than 25% of that that for the patients in the “general CAMHS” arm of the trial

We achieve this by offering an intensive ambulatory service, closely linked to paediatrics and to the general CAMHS team. The treatment modalities offered differ from those in the specialist arm of the trial, in that we offer more whole family therapy, more brief psychodynamic psychotherapy, and somewhat less CBT than Gowers’ group. We are also available all day long on the telephone, and squeeze in emergency appointments whenever they are needed. Of course we have more flexibility with duration of treatment than was possible in the reported clinical trial. Our outcomes are closely audited, and, when compared with those published in the trial, are more than acceptable.

So it is certainly possible to run a specialist service with a very low admission rate, without any obvious disadvantage to patients and theirfamilies, and with substantial advantages in terms of clinical outcomes, lack of disruption to family life, and cost effectiveness.

Dr Mark Berelowitz FRCPsych

Consultant Child and Adolescent Psychiatrist

Royal Free Hampstead NHS Trust

Pond Street, London NW3 2QG

Tel: 020 7830 2931; 020 7472 6850
... More

Conflict of interest: None Declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *