Treatment of Eating Disorders in Adults and Adolescents
The outpatient setting is the mainstay of treatment for eating disorders, as it is less costly and disruptive than intensive levels of care. In outpatient settings, adolescents are usually treated with family-based approaches, while adults with different forms of individual psychotherapy. Hospitalization for both adolescents and adults is recommended when they are medically unstable or present a suicide risk, while residential and day treatment may be indicated for patients, irrespective of age, who do not respond to well-conducted outpatient treatment.
Despite the availability of several different types of treatments and levels of care, anorexia nervosa, bulimia nervosa, and other similar states remain difficult to manage. Patients of all ages are often challenging to engage, and outcomes are often poor, even in those who do agree to start treatment. Nonetheless, in the last years, the efficacy of some forms of family-based and individual treatments has been empirically supported.
Evidence-based treatments for adolescents with eating disorders
A specific type of family therapy, called family-based treatment (FBT), is the most empirically supported intervention for adolescents with eating disorders. Six randomized, controlled trials have assessed the efficacy of manualized FBT for anorexia nervosa in adolescents. The data emerging from these studies, however, indicate that the treatment produces only a mean remission rate <40 percent across all participants at the end of treatment. Moreover, although criticized by some investigators, a recent Cochrane database review described a substantial risk for bias in many of the studies in adolescents with anorexia nervosa, and concluded that there is limited low-quality evidence to support family therapy approaches over “treatment as usual”.
Two trials have also shown that FBT is a promising treatment for adolescents with bulimia nervosa, although the difference in abstinence rates from binge-eating episodes between FBT and a form of cognitive behavior therapy adapted for adolescents was not statistically significant at 12-month follow-up (49 percent vs 32 percent).
Few evidence-based data on the efficacy of intensive treatments (i.e., day-hospital, residential, or inpatient) in adolescents with eating disorders are available. A study of inpatient enhanced cognitive behavior therapy (CBT-E) -E in adolescents with anorexia nervosa reported that 67 percent of patients had a normal body weight at 12-month after discharge. Another study found that the outcomes with short-term hospitalization (for medical stabilization) followed by FBT were similar to those with longer-term inpatient treatment (until weight restoration).
For adolescents with eating disorders, no evidence-based pharmacologic treatments are available.
Evidence-based treatments for adults with eating disorders
CBT-E is the most efficacy intervention available for adult patients with bulimia nervosa. Evidence suggests that two-thirds of adult patients who complete the treatment with CBT-E make a full and well-maintained recovery. CBT-E has shown to be more efficacy than interpersonal psychotherapy and psychoanalytic psychotherapy.
For the treatment of anorexia nervosa in adults, the available data, although limited, do not support the superiority of any one psychological treatment over another or with respect to usual care. Despite this, CBT-E, Maudsley Model of Anorexia Treatment for Adults (MANTRA), psychodynamic oriented therapy, and Specialist Supportive Clinical Management (SSCM), are the four psychological recommended treatments by the NICE guidelines, as they have shown to determine a similar improvement of psychopathology and normalization of body weight in about 40 to 60 percent of patients.
Day-hospital, residential, and inpatient treatments are often recommended for adult patients with eating disorders, especially those with anorexia nervosa who do not respond to less-intensive outpatient treatments or who have an eating disorder that cannot be managed safely in the outpatient setting. The available findings indicate that intensive treatments are associated with weight restoration and improvements in eating disorder and general psychopathology in a large percentage of patients with AN, but a large subgroup of patients experiences relapse after discharge.
The evidence of the use of any pharmacologic agents in the treatment of adults with anorexia nervosa is weak. Fluoxetine is the only medication approved by the US Food and Drug Administration for use in the treatment of bulimia nervosa. However, a recent review concluded that fluoxetine treatment had negligible efficacy in promoting remission in comparison to other treatments for bulimia nervosa.
CBT-E: The advantages of a unified treatment
Several clinical services, despite the availability of evidence-based treatments for both adolescents and adults, still do not provide patients with evidence-based psychological treatments. Another problem is that, even though the peak age of onset of eating disorders is in adolescence and emerging adulthood, the clinical services for adolescents and adults are separate in some countries. Therefore, patients and their families are often obliged to change the nature of treatment in adolescent patients who are transferred to adult services on reaching their age of majority. A radical change in the nature of treatment during these transitions may cause distress in patients and their families, and dangerous delays in starting or continuing treatment. Changes in the nature of treatment also often occur when patients move from less intensive types of care to more intensive treatment, and vice versa. These transitions may create a discontinuity in the care pathway and disorient patients and their significant others about the strategies and procedures used for addressing eating problems.
CBT-E, a personalized “transdiagnostic” psychological treatment for all forms of eating disorders, has the potential to overcome the above challenges. The treatment, originally developed for adults with eating disorders, has been subsequently adapted for being used also in adolescents. This adaptation stemmed from the observation that adults and adolescents share essentially the same eating disorder psychopathology. Therefore, it was assumed that CBT-E, an effective treatment specifically designed to address eating disorder psychopathology in adult patients, should be also effective in adolescent patients. The main modification of adult CBT-E was the involvement of parents in treatment as a “helper” of their child, given the adolescents' age and dependent needs. CBT-E has yielded promising results in trials in cohorts of adolescent outpatients with anorexia nervosa, with a remission rate of about 50 percent at 12-month follow-up, and now is recommended as an alternative to FBT in adolescent patients by the NICE guideline.
CBT-E has been also adapted for intensive care settings (i.e., inpatient, day hospital, and intensive outpatient), and its effectiveness has been recently evaluated both in adolescents and adults with anorexia nervosa. The study found that about 50 percent of patients, who had previously failed an outpatient treatment, had a good outcome at 60-weeks after the discharge.
With a unified treatment such as CBT-E, which has been designed to treat all the eating-disorder diagnostic categories in both adults and adolescents across the spectrum of care, some issues that plague conventional eating disorder services could be potentially overcome. First, the clinicians who deliver CBT-E can treat all eating disorders from adolescent to adult age with an evidence-based treatment without the need to learn and use different psychological approaches for the age of patients and specific eating disorder diagnostic categories. Second, patients can move seamlessly from adolescence to adulthood and through different levels of care, with no change in the nature of the treatment itself.
It goes without saying, however, that a different form of treatment must be offered to any patients who do not respond to CBT-E.