Academic journal article Journal of Eating Disorders

Comparative Efficacy of Pharmacological and Non-Pharmacological Interventions for the Acute Treatment of Adult Outpatients with Anorexia Nervosa: Study Protocol for the Systematic Review and Network Meta-Analysis of Individual Data

Academic journal article Journal of Eating Disorders

Comparative Efficacy of Pharmacological and Non-Pharmacological Interventions for the Acute Treatment of Adult Outpatients with Anorexia Nervosa: Study Protocol for the Systematic Review and Network Meta-Analysis of Individual Data

Article excerpt

Author(s): Tracey D. Wade[sup.1], Janet Treasure[sup.2], Ulrike Schmidt[sup.2], Christopher G. Fairburn[sup.3], Susan Byrne[sup.4], Stephan Zipfel[sup.5] and Andrea Cipriani[sup.3]

Background

Anorexia nervosa (AN) is an eating disorder characterised by behavioural disturbance related to eating or weight control practices that leads to a significantly low body weight, a disturbance in the experience of body shape and/or weight, and a significant impairment in physical, social, vocational and psychological functioning. The restricting subtype involves energy restriction, increased energy expenditure, fasting and other non-purging compensatory behaviours in the absence of binge eating; the binge-eating/purging type includes the presence of binge eating or purging behaviours (or both). The proposed ICD-11 and DSM-5 criteria for AN are similar, including the weight specification and removal of the requirement of amenorrhoea that was present in previous systems of diagnosis.

While severe AN is typically treated in an inpatient or residential environment using multimodal treatment delivered by multidisciplinary teams [1], there is consensus that outpatient psychotherapy is required in addition to specialist care that includes nutritional rehabilitation and weight restoration in order to achieve recovery [2]. While there is evidence for the benefit of including parents in outpatient treatments for young people (i.e., < 18 years) [3-5], no specific outpatient psychotherapy has shown superiority for adults with AN [1]. A meta-analysis of 57 psychological treatment studies was inconclusive [6], yielding no salient results supporting a particular therapy technique, setting or procedure. Additionally, there is no clarity on the most effective pharmacotherapy for this disorder. In a meta-analysis of a small number of pharmacotherapy studies, pooled effect sizes of the difference between placebo and both antidepressants and antipsychotics on weight were not significant [7]. Hormonal therapy had a significantly larger effect on weight compared to placebo but heterogeneity was high, indicating caution with respect to interpretation of the results.

In part, these inconclusive findings are explained by a lack of power. Given the high mortality rate associated with AN, the use of non-active comparator conditions is rare, and there are relatively small numbers of participants in any given study due to the ambivalence of this client group to receive and remain in treatment [8]. This also means that treatment studies have not been able to sufficiently address the more complex treatment approaches seen in routine clinical practice [1], such as multidisciplinary treatment or adjunctive use of hospital admission for physical safety.

However the number of studies investigating outpatient treatment approaches for AN is rapidly increasing. For example, in 2013 there were 40 randomised controlled trials (RCTs) in progress around the same amount of trials that had emerged over a 30 year period between 1981 and 2013 [1]. Given the last meta-analysis of psychological treatments was conducted in 2011 and the results of the 40 RCTs have not yet been captured in systematic reviews, it is now timely to consider another meta-analysis. In particular, network meta-analysis (NMA) is an ideal tool to apply to such an area in terms of advancing knowledge about what works best for whom as it is a statistical technique that allows both direct and indirect comparisons to be undertaken, even when pairs of the treatments have not been compared directly (head to head) in the same trial [9, 10]. Of the 40 studies mentioned above, only 9 (23%) directly compared different types of therapy (as opposed to studies which compare medications, or forms of cognitive behaviour therapy [CBT] or forms of family therapy). Traditional meta-analyses would be unable to provide direct comparisons but NMA can provide point estimates of relative efficacy between all interventions even though some have never been compared head to head, as well as an estimate of inconsistency e. …

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