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A randomised controlled trial of three psychological treatments for anorexia nervosa

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There is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). Susan Byrne discusses three psychological treatments for AN

Image courtesy of interviewee. May 23, 2024

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Anorexia nervosa is a severe psychiatric eating disorder with high morbidity and mortality rates, being the deadliest among psychiatric conditions. Treatment for anorexia is complex, but research has developed specialist supportive clinical management (SSCM), the MANTRA model (Mosley Anorexia Nervosa Treatment for Adults), and enhanced cognitive behavioral therapy (CBTE) as potential interventions.

The SWAN study was a significant randomized controlled trial that compared these three psychological treatments for anorexia nervosa among 120 adults across three Australian sites. Participants underwent up to 40 therapy sessions over about a year. All three treatments demonstrated significant improvements in body weight and eating disorder psychopathology, with the improvements maintained at 12-month follow-ups. About 50% of participants showed good outcomes regarding healthy weight and reduced eating disorder symptoms by the end of treatment.

Although the recovery rates based on strict criteria were lower (around 25%), the overall findings indicate that these treatments yielded meaningful benefits for participants. Future research is essential to explore treatment efficacy further and determine which treatment may be best suited for different individuals, as only about half of the patients showed significant improvements and many faced challenges in completing treatment. The study highlighted the urgent need for continued research in this difficult-to-treat condition to further improve outcomes for patients and their families.

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Anorexia nervosa is a serious psychiatric illness.

00:03.135 --> 00:04.865
It's an eating disorder,

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and it has very serious adverse, physical,

00:09.745 --> 00:11.985
psychological and social consequences.

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Um, in fact, it's,

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and associated with very high morbidity and mortality.

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Um, anorexia nervosa, in fact,

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has the highest mortality rate of any psychiatric disorder.

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So it's a, it's a terrible illness

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and very difficult to treat.

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Um, so we're all the time trying to improve our treatment

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so we get, can get better outcomes

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for patients and their families.

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Specialist supportive clinical management is a treatment

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that was developed in New Zealand, actually

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by a woman called Virginia Macintosh.

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And initially this treatment was used

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as a controlled treatment in another randomized controlled

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trial, an earlier trial of treatments for anorexia nervosa.

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And it's, so it's really an atheoretical treatment.

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It's basically,

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providing psychoeducation supportive counseling

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and just good clinical management, sort

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of common sense management of, somebody

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with anorexia nervosa, which is pretty complex in itself

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because people can be very unwell medically

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and psychologically with anorexia nervosa.

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So interestingly, this treatment was developed

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as a control condition, as I said.

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So in this trial, they expected that the people who,

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received specialist supportive clinical management

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or SSCM would not do as well as people

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who had the active treatment,

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but in fact, it turned out that they did just as well.

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And SSCM is, a much easier treatment to deliver,

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for therapists, especially if they're non-expert therapists.

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Um, so that's SSCM. So we included it in our trial as well.

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The Mosley model we're talking about in the trial,

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in the SWAN trial, the SWAN study.

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Um, not to be confused with the Mosley model,

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which is often, you know, thought about.

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We often think about treating young children

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with anorexia nervosa, with the MOSLEY model,

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which is family-based treatment.

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This is in fact an treatment for adults

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with anorexia nervosa.

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Um, and it's called mantra, actually that's the acronym.

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It stands for the Mosley Anorexia

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Nervosa Treatment for Adults.

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And this is a, a theoretical treatment.

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It's based on a model called the Cognitive Interpersonal

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Model of anorexia nervosa.

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Um, and so it's a talking treatment,

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and it's really, it's a big emphasis on,

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motivation on engaging the patient

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and on helping patients to understand their thinking styles,

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their emotional styles.

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And it also involves,

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support people very closely in the treatment.

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So, close others to the person with anorexia nervosa

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and focuses on helping them to respond in a way

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that might help the person rather than hinder them.

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So enhanced CBT

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or CBTE is, again,

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it's a psychological treatment, a talking treatment.

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Um, it's,

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based on cognitive behavior therapy on the original

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treatment of, for,

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bulimia niosa cognitive behavior therapy for osa,

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which was developed by Professor Christopher Fairburn at

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Oxford University in the 1980s.

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And CBT for Bili nervosa was a very successful treatment.

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Um, but it had never been applied to anorexia nervosa

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or other eating disorders.

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So, Fairburn decided to enhance his original treatment,

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and to make it so, to make it more potent

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and also to make it applicable to all eating disorders,

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not just bulimia nervosa.

03:19.105 --> 03:21.365
So it's based on a model called the,

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trans Diagnostic Model of Eating Disorders, which purports

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that there are a number of,

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significant maintaining factors that keep people,

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people stuck in the vicious cycle

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of an eating disorder regardless of their diagnosis.

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So our RCT, we, we called it the SWAN Study,

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that's an acronym for strong without anorexia nervosa,

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but it really, because we were trying to find a word

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that fit with Western Australia.

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We had the Swan River here in Black Swans.

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But anyway, so the SWAN study, is one

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of the largest randomized controlled trials to date

03:53.265 --> 03:56.805
of treatments for anorexia nervosa psychological treatments,

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because it's, it's very difficult

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to run randomized control trials

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for an illness like anorexia nervosa

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because people are very unwell.

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Um, it's actually, not a, it's not,

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not many people develop anorexia nervosa.

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So it's, you know, in our field we think it's common,

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but it's not common illness.

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Um, and people often have to drop out of treatment to go

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to hospital or they become too unwell to complete the trial.

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So these trials are very difficult and expensive to run.

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Um, but anyway, we got some funding from the National Health

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and Medical Research Council to test out,

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these three treatments.

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And at the time, they were relatively new treatments.

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They've only had only really just been, developed

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and haven't been tested that much, particularly not

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with anorexia vota.

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So we compared SSCM as we said, mantra

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and CBTE, we recruited, participants

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from three different sites in Australia.

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So in Perth, Adelaide, and Sydney.

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Um, we recruited in all, 120 participants.

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Um, and they were randomized, so, you know,

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ran randomly allocated to one of the three treatments.

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And then the all participants then, attended up

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to 40 sessions of therapy for their, so the, the, the trial,

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the, the actual treatment lasted about a year.

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Um, they got slightly less sessions if they weren't

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so underweight and,

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40 sessions if they were very underweight.

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And they attended, treatment weekly

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for the 40 sessions for the 40 weeks.

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Um, one of the three treatments, with a therapist

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that was, you know, highly trained

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to deliver these treatments

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and supervised by the chief investigators at the trial,

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like myself and Tracy, way, Philippa, hay, other people from

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around Australia who were running the trial.

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And then we had, blind assessors.

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That means someone who is taking measures,

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measuring outcomes of people who doesn't know

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what treatment the person had. So there was no bias.

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And so people were assessed when they first started the

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treatment, halfway through the treatment, the end

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of treatment, and then at six months

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and 12 months follow up after treatment finished.

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So in its day, I mean, this,

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this trial was published now in 2017,

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but it was one of the largest trials to date of,

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treatments for anorexia nervosa.

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And that, and that had also a quite

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significant follow-up period.

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What we found was that in all three treatments, people

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improved significantly over time.

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Um, and these improvements were clinically significant,

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not just statistically significant.

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So, people were, doing much better in their lives

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and in main, I mean, our main two measures were body weight

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and, what we call eating disorder psychopathology.

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So all of the cognitions and the thoughts

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and the, the mindset really

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that people stay trapped in when

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they're stuck in an eating disorder.

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So patients in all three treatments improved.

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And in fact, there was no significant differences in

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outcomes between the three treatments.

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Um, apart from the fact that people who got,

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cognitive behavior therapy were slightly more likely

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to achieve a healthy weight by the end of treatment.

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And in all three treatments,

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people improved in weight in eating disorder,

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psychopathology, as well

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as in other co-occurring problems such as depression,

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anxiety, stress,

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that they were less impaired in their

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life by their eating disorder.

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And the really important thing was

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that these gains were maintained,

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during the 12 month follow up.

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So after 12 months, people were doing just as well

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as they had been doing at the end of treatment.

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Um, obviously anorexia nervosa, as I've mentioned,

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is a really, really difficult treatment to treat,

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diet, illness to treat,

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and there's, lots of challenges along the way.

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So I think we found in total overall that about 50%

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of people who entered the trial had a good outcome

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by the end of treatment in terms of body weight.

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Um, and we looked at various ways

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of defining whether someone was, what we would call,

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recovered at the end of treatment or not,

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because it's really hard to really define

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what is recovery from anorexia divo.

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I mean, some people never really fully recover according

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to a research criteria,

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but are still doing much better in their lives.

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But for research purposes, we normally define recovery as

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reaching a healthy weight and also, being just sort of,

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no worse than the normal person in the street.

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Um, on measures of like body image

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and how you feel about your body

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and eating weight and shape, et cetera.

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Um, and if you use, if you have to have both

08:35.065 --> 08:37.745
of those criteria, criteria to be called recovered,

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we don't get very good recovery rates.

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We, we are looking at like 25%.

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Um, but if you look at those individually, so we, about 50%

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of people were in the healthy weight range by the end

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of treatment that was maintained.

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But these are good outcomes actually for people

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with anorexia d vosa.

08:53.285 --> 08:56.125
Um, they're not, you know, it sounds a bit bit dismal,

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but in our minds it's, it's a really good step forward.

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And the most important thing is

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that we now have three treatments

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that we have good evidence for.

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Um, so the next question is trying to figure out,

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what treatment would work best with whom.

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Um, and we don't really know the answer to that yet.

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So in conclusion, we successfully tested, three

09:19.065 --> 09:22.285
new psychological treatments for anorexia nervosa in adults.

09:22.825 --> 09:25.965
We found that all three treatments, led

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to significant improvements that were improvements

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that in the real world were meaningful for people over time.

09:32.265 --> 09:35.525
And that, once treatment finished about a year,

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after about a year, those,

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those gains were maintained really well, at, you know,

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up to a year, at up to a year follow up.

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We're currently doing even more longer term follow ups

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to find out after eight to 10 years

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where the people are still, you know, doing well

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after, after the trial.

09:52.785 --> 09:55.375
Um, so the good news,

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one good news point is that people got better.

09:57.635 --> 10:00.055
Um, about half the people in the trial got

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better, significantly better.

10:01.595 --> 10:04.575
Um, the other point to note is that, you know,

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all three treatments, were helpful.

10:07.915 --> 10:09.575
Um, and there was no difference

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between the three treatments.

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So now we have, good evidence

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for three different treatments for people

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with anorexia nervosa, which we have never had before.

10:18.675 --> 10:19.775
Um, so there's a bit, there's

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more choice out there for people.

10:21.435 --> 10:23.895
Um, and I guess the next step is to try

10:23.895 --> 10:26.095
and find out, as I mentioned earlier,

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can we match people to these treatments so that,

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can we find out that some people

10:31.045 --> 10:32.855
with certain characteristics do better with mantra

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or some people do better with CBTE

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or do some people do better with SSEM?

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And, you know, that's a very difficult question

10:40.315 --> 10:41.815
to answer,

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because you need very large sample sizes

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to be able to sort that out.

10:46.075 --> 10:49.375
But we're trying to find more creative ways now using,

10:49.825 --> 10:51.935
mixed method, mixed research methods to try

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and sort that question out.

10:55.395 --> 10:56.495
Um, and the,

10:56.495 --> 10:59.135
and the other thing about future research is,

11:00.105 --> 11:02.525
we need a lot of it in the field of anorexia nervosa

11:02.525 --> 11:04.325
because we don't really have good treatments.

11:05.265 --> 11:07.245
Um, well, we have pretty good

11:07.245 --> 11:08.565
treatments for half the people.

11:09.545 --> 11:13.245
Um, but firstly, you know, half the people

11:13.265 --> 11:15.365
who enter treatment may will, will not do well.

11:16.105 --> 11:19.025
And, even people

11:19.025 --> 11:21.905
who enter treatment about half will drop out of treatment.

11:21.905 --> 11:24.985
So our completion rate for this trial was about 60%,

11:25.675 --> 11:29.385
which is very good in terms of, an for anorexia.

11:29.565 --> 11:33.185
So normally at least half people drop out of treatment,

11:33.185 --> 11:36.195
because it's very difficult for, for the patient,

11:36.245 --> 11:38.115
their family, and, and the therapist of course.

11:38.855 --> 11:42.115
Um, and so we, we need much more research to try

11:42.275 --> 11:45.125
and find, better treatments if we can,

11:45.125 --> 11:46.965
whether they be psychopharmacological

11:47.105 --> 11:49.485
or psychological or behavioral.

11:50.225 --> 11:53.845
Um, that's, there are still lots of things in the pipeline,

11:54.465 --> 11:56.885
but you know, it's a, it's a very,

11:57.355 --> 11:59.405
it's a horrible illness to have,

11:59.705 --> 12:04.005
and very, very hard on patients and on their families

12:04.005 --> 12:04.845
and loved ones as well.

00:00 - Anorexia nervosa is a serious psychiatric illness. It's an eating disorder, and it has very serious adverse, physical, psychological and social consequences. in fact, it's, and associated with very high morbidity and mortality.

00:18 - anorexia nervosa, in fact, has the highest mortality rate of any psychiatric disorder. So it's a, it's a terrible illness and very difficult to treat. so we're all the time trying to improve our treatment so we get, can get better outcomes for patients and their families. Specialist supportive clinical management is a treatment that was developed in New Zealand, actually by a woman called Virginia Macintosh.

00:44 - And initially this treatment was used as a controlled treatment in another randomized controlled trial, an earlier trial of treatments for anorexia nervosa. And it's, so it's really an atheoretical treatment. It's basically, providing psychoeducation supportive counseling and just good clinical management, sort of common sense management of, somebody with anorexia nervosa, which is pretty complex in itself because people can be very unwell medically

01:09 - and psychologically with anorexia nervosa. So interestingly, this treatment was developed as a control condition, as I said. So in this trial, they expected that the people who, received specialist supportive clinical management or SSCM would not do as well as people who had the active treatment, but in fact, it turned out that they did just as well. And SSCM is, a much easier treatment to deliver, for therapists, especially if they're non-expert therapists.

01:36 - so that's SSCM. So we included it in our trial as well. The Mosley model we're talking about in the trial, in the SWAN trial, the SWAN study. not to be confused with the Mosley model, which is often, you know, thought about. We often think about treating young children with anorexia nervosa, with the MOSLEY model, which is family-based treatment. This is in fact an treatment for adults with anorexia nervosa.

01:57 - and it's called mantra, actually that's the acronym. It stands for the Mosley Anorexia Nervosa Treatment for Adults. And this is a, a theoretical treatment. It's based on a model called the Cognitive Interpersonal Model of anorexia nervosa. and so it's a talking treatment, and it's really, it's a big emphasis on, motivation on engaging the patient and on helping patients to understand their thinking styles,

02:24 - their emotional styles. And it also involves, support people very closely in the treatment. So, close others to the person with anorexia nervosa and focuses on helping them to respond in a way that might help the person rather than hinder them. So enhanced CBT or CBTE is, again, it's a psychological treatment, a talking treatment. it's,

02:46 - based on cognitive behavior therapy on the original treatment of, for, bulimia niosa cognitive behavior therapy for osa, which was developed by Professor Christopher Fairburn at Oxford University in the 1980s. And CBT for Bili nervosa was a very successful treatment. but it had never been applied to anorexia nervosa or other eating disorders. So, Fairburn decided to enhance his original treatment, and to make it so, to make it more potent

03:14 - and also to make it applicable to all eating disorders, not just bulimia nervosa. So it's based on a model called the, trans Diagnostic Model of Eating Disorders, which purports that there are a number of, significant maintaining factors that keep people, people stuck in the vicious cycle of an eating disorder regardless of their diagnosis. So our RCT, we, we called it the SWAN Study, that's an acronym for strong without anorexia nervosa,

03:43 - but it really, because we were trying to find a word that fit with Western Australia. We had the Swan River here in Black Swans. But anyway, so the SWAN study, is one of the largest randomized controlled trials to date of treatments for anorexia nervosa psychological treatments, because it's, it's very difficult to run randomized control trials for an illness like anorexia nervosa because people are very unwell.

04:05 - it's actually, not a, it's not, not many people develop anorexia nervosa. So it's, you know, in our field we think it's common, but it's not common illness. and people often have to drop out of treatment to go to hospital or they become too unwell to complete the trial. So these trials are very difficult and expensive to run. but anyway, we got some funding from the National Health and Medical Research Council to test out, these three treatments.

04:32 - And at the time, they were relatively new treatments. They've only had only really just been, developed and haven't been tested that much, particularly not with anorexia vota. So we compared SSCM as we said, mantra and CBTE, we recruited, participants from three different sites in Australia. So in Perth, Adelaide, and Sydney. we recruited in all, 120 participants. and they were randomized, so, you know,

05:03 - ran randomly allocated to one of the three treatments. And then the all participants then, attended up to 40 sessions of therapy for their, so the, the, the trial, the, the actual treatment lasted about a year. they got slightly less sessions if they weren't so underweight and, 40 sessions if they were very underweight. And they attended, treatment weekly for the 40 sessions for the 40 weeks. one of the three treatments, with a therapist

05:33 - that was, you know, highly trained to deliver these treatments and supervised by the chief investigators at the trial, like myself and Tracy, way, Philippa, hay, other people from around Australia who were running the trial. And then we had, blind assessors. That means someone who is taking measures, measuring outcomes of people who doesn't know what treatment the person had. So there was no bias. And so people were assessed when they first started the

06:00 - treatment, halfway through the treatment, the end of treatment, and then at six months and 12 months follow up after treatment finished. So in its day, I mean, this, this trial was published now in 2017, but it was one of the largest trials to date of, treatments for anorexia nervosa. And that, and that had also a quite significant follow-up period. What we found was that in all three treatments, people

06:26 - improved significantly over time. and these improvements were clinically significant, not just statistically significant. So, people were, doing much better in their lives and in main, I mean, our main two measures were body weight and, what we call eating disorder psychopathology. So all of the cognitions and the thoughts and the, the mindset really that people stay trapped in when they're stuck in an eating disorder.

06:51 - So patients in all three treatments improved. And in fact, there was no significant differences in outcomes between the three treatments. apart from the fact that people who got, cognitive behavior therapy were slightly more likely to achieve a healthy weight by the end of treatment. And in all three treatments, people improved in weight in eating disorder, psychopathology, as well as in other co-occurring problems such as depression,

07:16 - anxiety, stress, that they were less impaired in their life by their eating disorder. And the really important thing was that these gains were maintained, during the 12 month follow up. So after 12 months, people were doing just as well as they had been doing at the end of treatment. obviously anorexia nervosa, as I've mentioned, is a really, really difficult treatment to treat,

07:41 - diet, illness to treat, and there's, lots of challenges along the way. So I think we found in total overall that about 50% of people who entered the trial had a good outcome by the end of treatment in terms of body weight. and we looked at various ways of defining whether someone was, what we would call, recovered at the end of treatment or not, because it's really hard to really define what is recovery from anorexia divo.

08:09 - I mean, some people never really fully recover according to a research criteria, but are still doing much better in their lives. But for research purposes, we normally define recovery as reaching a healthy weight and also, being just sort of, no worse than the normal person in the street. on measures of like body image and how you feel about your body and eating weight and shape, et cetera. and if you use, if you have to have both

08:35 - of those criteria, criteria to be called recovered, we don't get very good recovery rates. We, we are looking at like 25%. but if you look at those individually, so we, about 50% of people were in the healthy weight range by the end of treatment that was maintained. But these are good outcomes actually for people with anorexia d vosa. they're not, you know, it sounds a bit bit dismal, but in our minds it's, it's a really good step forward.

08:59 - And the most important thing is that we now have three treatments that we have good evidence for. so the next question is trying to figure out, what treatment would work best with whom. and we don't really know the answer to that yet. So in conclusion, we successfully tested, three new psychological treatments for anorexia nervosa in adults. We found that all three treatments, led to significant improvements that were improvements

09:28 - that in the real world were meaningful for people over time. And that, once treatment finished about a year, after about a year, those, those gains were maintained really well, at, you know, up to a year, at up to a year follow up. We're currently doing even more longer term follow ups to find out after eight to 10 years where the people are still, you know, doing well after, after the trial. so the good news,

09:55 - one good news point is that people got better. about half the people in the trial got better, significantly better. the other point to note is that, you know, all three treatments, were helpful. and there was no difference between the three treatments. So now we have, good evidence for three different treatments for people with anorexia nervosa, which we have never had before.

10:18 - so there's a bit, there's more choice out there for people. and I guess the next step is to try and find out, as I mentioned earlier, can we match people to these treatments so that, can we find out that some people with certain characteristics do better with mantra or some people do better with CBTE or do some people do better with SSEM? And, you know, that's a very difficult question

10:40 - to answer, because you need very large sample sizes to be able to sort that out. But we're trying to find more creative ways now using, mixed method, mixed research methods to try and sort that question out. and the, and the other thing about future research is, we need a lot of it in the field of anorexia nervosa because we don't really have good treatments.

11:05 - well, we have pretty good treatments for half the people. but firstly, you know, half the people who enter treatment may will, will not do well. And, even people who enter treatment about half will drop out of treatment. So our completion rate for this trial was about 60%, which is very good in terms of, an for anorexia. So normally at least half people drop out of treatment, because it's very difficult for, for the patient,

11:36 - their family, and, and the therapist of course. and so we, we need much more research to try and find, better treatments if we can, whether they be psychopharmacological or psychological or behavioral. that's, there are still lots of things in the pipeline, but you know, it's a, it's a very, it's a horrible illness to have, and very, very hard on patients and on their families and loved ones as well.

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