It’s great to have a treatment that’s proven to work in a difficult psychiatric condition such as anorexia nervosa. It’s even better to have two treatments for such a disorder. But having multiple options also creates a quandary for psychiatrists: with a new patient, which treatment do you try first? Creatures of habit like the rest of us, many doctors will simply stick with the method they know best until given convincing evidence that it’s worth switching gears. To be the new treatment of choice, a method must beat out the current champion in a head-to-head battle.
One such comparison, conducted by researchers at the University of Chicago Medical Center and Stanford University, was published yesterday afternoon in the Archives of General Psychiatry. The trial compared the most common form of treatment for adolescents with anorexia, known as adolescent-focused therapy (AFT), with the newer, family-based treatment (FBT), also sometimes known as the Maudsley Approach. The latter name comes from the Maudsley Hospital in London, where Daniel Le Grange, now director of the Eating Disorders Clinic at the University of Chicago, helped develop a new approach to bringing anorexic teens back to healthy weight and eating habits.
Under adolescent-focused therapy, the therapist works directly with the patient on a one-to-one basis, emphasizing the importance of weight gain and helping them accept personal responsibility for healthy eating. Family-based treatment, as you might expect from the name, does more to incorporate the parents into that process, equipping the patient’s mother and father with the tools to encourage healthy eating at home. By doing so, the therapist hopes to avoid hospitalizing the patient while permanently adjusting the home environment, removing factors that could lead to relapse after therapy is completed.
“No one is more available to care for the kids than the parents are; no one would put the time aside in the way that parents would, and no one loves their kids more than parents do,” Le Grange told NPR’s Morning Edition (where you can also hear the perspective of one patient’s mother on family-based treatment).
The two therapies had been compared previously, but in smaller studies with only two or three dozen patients. True convincing evidence requires a randomized trial, with enough patients for the statistics to make a strong case for one of the treatments. So, combining forces between Chicago and Stanford, Le Grange and his collaborator, James Lock at Stanford, were able to gather 120 patients with anorexia nervosa (with an average age of 14-1/2) for the study.
Split evenly between FBT and AFT, the patients were followed for a year of therapy and another year of follow-up. At the end of treatment, 42 percent of those enrolled in FBT showed full remission back to at least 95 percent of expected body weight, compared to only 23 percent of those enrolled in AFT. While that comparison fell just short of statistical significance, with a p-value of .055, Le Grange said that the higher standards used in the study spoke to the effectiveness of FBT.
“We used the higher yardstick for remission of 95 percent of body weight, which we felt was clinically more appropriate,” said Le Grange, a professor of psychiatry and behavioral neuroscience.
Over the course of follow-up, the difference between FBT and AFT crossed the line of statistical significance. At 6 months and 12 months following the end of therapy, more than twice as many patients from the FBT group had avoided relapse, compared to patients in the AFT group. A year after treatment, close to half of patients who had received family-based treatment remained at a healthy weight – a very encouraging result for a very hard-to-treat disorder that hasn’t seen many trials of this size and strength.
“This is only the sixth randomized controlled study for adolescents with anorexia nervosa in the over 130 years since this illness was first described,” Le Grange said. “For the first time, we can confidently present parents with a treatment we consider the gold standard for this patient population.”
Of course, treatments are rarely one size fits all, and there may still be a role for individual, AFT-style therapy in certain patients where family-based treatment is impractical, or fails. Le Grange and his collaborators are also testing FBT for other eating disorders, such as bulimia nervosa, and looking at ways to modify the FBT protocol for patients who don’t quickly respond to the methods. But while those further studies are conducted, Le Grange hopes that the new results are enough to change the entrenched habits of psychiatrists who treat anorexic adolescents.
“What this study unequivocally demonstrates is if you have an adolescent with anorexia nervosa who is medically stable, family based treatment should be the first line of treatment,” Le Grange said.
[Dr. Le Grange answered questions on video about the Maudsley Approach and the future of eating disorders research in a Dr. FAQ installment from March.]
Lock, J., Le Grange, D., Agras, W., Moye, A., Bryson, S., & Jo, B. (2010). Randomized Clinical Trial Comparing Family-Based Treatment With Adolescent-Focused Individual Therapy for Adolescents With Anorexia Nervosa Archives of General Psychiatry, 67 (10), 1025-1032 DOI: 10.1001/archgenpsychiatry.2010.128