Ideally, treatment efficacy should be evaluated by means of randomized control trials (RCTs) (National Institute for Clinical Excellence, 2004; Wilson & Fairburn, 2002). Surprisingly, for adolescents with eating disorders, only a handful of relatively small RCTs have been completed. In the absence of the requisite empirical base, the evaluation and recommendations described in this chapter are derived from the following sources: extrapolation from evidence-based treatments for eating disorders in adults, generalizations from closely related psychological and pharmacological treatments of anxiety and mood disorders in adolescents, and consensus views of clinicians who are experienced in the treatment of eating disorders.
PSYCHOLOGICAL TREATMENTS FOR ADOLESCENTS WITH EATING DISORDERS
Psychological interventions are a mainstay of the treatment of eating disorders in adults. Despite the need for effective treatment of eating disorders in affected adolescents, there are remarkably few controlled studies of psychological interventions in this age group. There have been only five RCTs of outpatient-based psychological treatments for adolescents with anorexia nervosa (National Institute for Clinical Excellence, 2004) and no studies of adolescents with bulimia nervosa (Weisz & Hawley, 2002). The lack of research in the treatment of adolescents with eating disorders is not unique, as relatively less attention has been paid to treatment outcome studies of adolescent psychiatric disorders in general than to those of either adults (Weisz & Hawley, 2002) or younger children (Kazdin, Bass, Ayers, & Rodgers, 1990). Because symptoms of both anorexia nervosa and bulimia nervosa generally begin in adolescence (Mitchell, Hatsukami, Eckert, & Pyle, 1985; Schmidt, Hodes, & Treasure, 1992), it is difficult to explain the complete lack of research done with adolescent bulimia nervosa patients and the relatively low number of bulimia nervosa patients who present for treatment. It is possible that adolescents with anorexia nervosa are more easily identified by parents and professionals and are therefore encouraged to seek treatment, whereas adolescents with bulimia nervosa can more easily hide their behaviors, thus their disorder escapes detection.
Psychological Treatments for Adolescents with Anorexia Nervosa
Randomized Controlled Trials of Treatment of Anorexia Nervosa
Russell and colleagues, from the Maudsley Hospital in London (Russell, Szmukler, Dare, & Eisler, 1987), published the first RCT of the treatment of adolescents with anorexia nervosa. The aim of this study was to evaluate two treatment approaches, family therapy and individual treatment for the management of patients who had initially been treated in a hospital. The average duration of the patients' hospital stay was 10 weeks, and the mean weight on discharge was 88.9 ± 7.4% average body weight. Although patients are typically still symptomatic at the end of hospitalization, the next stage of treatment, is sometimes described as “relapse prevention.” This study was an evaluation of treatment at this stage.
The study did not consist of a single RCT; rather, there were four separate RCTs, each involving slightly different groups of patients. One of these groups (subgroup 1) was composed of 21 adolescents with anorexia nervosa who had a mean age of 16.6 ± 1.7 years and a mean duration of illness of 1.2 ± 0.7 years. These 21 patients were randomized to receive either 1 year of family therapy or 1 year of individual psychotherapy. The form of family therapy used has since come to be known as the “Maudsley method,” described in a recently published manual (Lock, Le Grange, Agras, & Dare, 2001). The Maudsley method, a specific form of family therapy designed for adolescent patients with anorexia nervosa, is quite unlike more generic family-based treatments. As described by Lock and colleagues (2001), this treatment has three stages: refeeding the patient, negotiating for a new pattern of relationships, and addressing adolescent issues and treatment termination.
In the initial implementation of the Maudsley treatment (Russell et al., 1987), there are two main phases. The first phase occurs after the patient and family have been engaged in therapy and focuses largely on the patient's eating and weight. Here the parents are helped to take control over the way the patient eats. In the second phase, once the patient's weight is under control, responsibility for weight management is transferred to the patient and treatment focuses on more general family and individual concerns.
The comparison individual treatment used by Russell et al. (1987) was devised specifically for this study. In content, it was based on conventional posthospitalization follow-up appointments (as practiced at the Maudsley Hospital), but the sessions were more frequent and lasted longer than usual, to match the intensity of the family treatment. The individual treatment is probably best characterized as a form of supportive psychotherapy that encourages patients to eat healthily and maintain an appropriate weight.
The results of the Russell et al. (1987) study favored the family therapy approach. At the end of treatment (1 year after discharge from the hospital), 6 out of 10 patients who received family therapy were judged to have a good outcome, as assessed via the Morgan-Russell scales (Morgan & Russell, 1975), compared with 1 out of 11 patients who received the control treatment (p < .02). Also, the family therapy patients had a better outcome in terms of weight regain (from their prehospitalization weight); the percentage weight regain in the two treatment conditions was 25.5% and 15.5%, respectively (p < .01). Similarly, the family therapy patients were better at maintaining their new higher weight, with 5 out of 10 patients keeping their weight above 85% average body weight, compared with 1 out of 11 patients who received the control individual psychotherapy (p < .05). There was also a lower dropout rate among the patients who received family therapy (1/10, vs. 7/11 in the control condition, p = .024).
A major strength of this study was that the patients were followed up 5 years after the completion of treatment (Eisler et al., 1997). At this time point, both patient groups had done well; the mean percentage of average body weight was 103.4 ± 13.2% in the group treated with family therapy and 94.4 ± 16.8% in the control group (p = ns). In terms of overall outcome on the Morgan-Russell scales, the results continued to favor the family therapy group, with 9 out of 10 patients having a good outcome, vs. 4 out of 11 patients in the control group (p = .024). This study is limited by its modest scale and the post-hospitalization design, but has had a major influence on the design of more recent investigations and on current treatment recommendations.
The later studies from the Maudsley group have focused on family therapy alone, the premise being that family therapy is “established as an effective treatment for anorexia nervosa in adolescence” (Dare & Eisler, 2002, p. 317). The next investigation (Le Grange, Eisler, Dare, & Russell, 1992) was a pilot study for a subsequent trial (Eisler et al., 2000). The goal was to compare two different ways of delivering the Maudsley method of family therapy: one involved all the family being seen together (subsequently termed “conjoint family therapy,” the original method), the other consisted of separate treatment sessions for the patient and the parents (subsequently termed “separated family therapy”). In contrast with the Russell et al. (1987) study, family therapy was provided from the outset of treatment rather than after a period of hospitalization. This study is of greater relevance to the routine management of patients with anorexia nervosa, most of whom are not admitted to a hospital.
This pilot study involved just 18 patients (mean age 15.3 ± 1.8 years; mean duration of illness 13.7 ± 8.4 months; mean percentage of average body weight 77.9 ± 7.6%). Both groups responded well, despite receiving a modest number of treatment sessions (8.9 ± 4.1 sessions over 6 months), with substantial weight regain and improvement on various measures of psychopathology. Not surprisingly, given the small sample size, there were no statistically significant differences in outcome between the two groups.
The third study in the Maudsley series (Eisler et al., 2000) followed from the Le Grange et al. (1992) pilot study. It involved a comparison of the same two family-based treatments, but on a larger scale. Forty patients were randomized to the two treatments, their mean age being 15.5 ± 1.6 years and mean duration of disorder being 12.9 ± 9.4 months. Treatment took place over 1 year and involved on average 16 sessions. The conjoint sessions lasted 1 hour, whereas the separated sessions lasted 90 minutes.
Once again, both groups of patients improved markedly; their percentage average body weight increased from 74.3 ± 9.8% to 87.0 ± 13.0% (p = .001), and the equivalent figures for body mass index (BMI) increased from 15.4 ± 2.0 kg/m2 to 18.5 ± 3.6 kg/m2 (p < .001). There was a substantial decrease in eating disorder features—for example, the total score on the Eating Attitudes Test (Garner & Garfinkel, 1979) decreased from 47.7 ± 25.7 to 19.7 ± 16.1 (p < .001), and there was improvement on the Morgan-Russell scales. The analysis of differences in outcome between the two treatments revealed few statistically significant findings, although the pattern of the findings suggested that separated family therapy might be more potent at addressing the specific psychopathology of eating disorders, whereas conjoint family therapy might be more effective at addressing general psychopathology, such as depressive and obsessional features. With only 20 patients per treatment condition, however, the study did not have sufficient power for comparisons of this type. Nevertheless, the findings do suggest that family meetings of the type required for conjoint family therapy may not be needed for the Maudsley method to achieve its effects.
The fourth RCT was by Robin and colleagues (Robin, Siegel, Koepke, Moye, & Tice, 1994; Robin et al., 1999). They compared “behavioral family systems therapy,” a treatment similar to the original Maudsley method, with “ego-oriented individual therapy,” a psychodynamically oriented treatment in which patients are seen individually, with occasional supportive sessions for their parents. In the latter condition there was little or no direct emphasis on changing eating habits or increasing body weight.
Thirty-seven patients were randomized to the two treatments, the mean ages of the family therapy and individual therapy groups being 14.9 years and 13.4 years, respectively (p < .05), and their baseline BMI being 15.2 ± 1.8 kg/m2 and 16.6 ± 2.1 kg/m2, respectively (p = .038). All the patients had developed anorexia nervosa within the previous 12 months. The two treatments were more intensive and multifaceted than those provided by the Maudsley group, and involved 12 to 18 months of treatment with weekly sessions for half of the treatment and sessions every other week thereafter. In addition, both groups of patients saw a dietician who prescribed a diet designed to restore body weight at a rate of 1 lb/week. Furthermore, those patients whose weight was below 75% of ideal or who had significant cardiac problems were hospitalized at the outset and received a structured refeeding program until they reached 80% of their target weight and were medically stable. This applied to 58% of the family therapy group and 28% of those receiving individual therapy (p = .099). While in the hospital, the patients also received their assigned form of psychotherapy.
The outcome of both groups was positive, both at the end of treatment and 1 year later. There was one statistically significant difference between the groups: patients in the family therapy group had a greater increase in BMI. The mean BMI posttreatment and at 1 year follow-up was 19.9 ± 1.9 kg/m2 and 20.7 ± 2.7 kg/m2 in the family therapy group, and 18.9 ± 1.9 kg/m2 and 19.8 ± 3.1 kg/m2 for those receiving individual therapy. On all other measures of outcome there were no statistically significant differences between the two groups. At the end of treatment, two thirds of the patients had reached their target weight. By the end of 1-year follow-up, 80% of those who had received family therapy had reached their target weight; there was no such increase for those who had received individual therapy. In considering these findings, it is important to note that it is not possible to attribute the changes observed specifically to the two psychotherapies received. All the patients also received extensive dietary advice, and many were hospitalized during the initial stages of treatment (especially those receiving family therapy).
The most recent of the five RCTs (Geist, Heinmaa, Stephens, Davis, & Katzman, 2000) compared two 16-week family-based interventions. The interventions occurred in the context of considerable additional treatment, including an initial period of inpatient treatment (lasting on average 6 weeks) that involved an assertive refeeding program, as well as milieu therapy, and individual and group psychotherapy. In addition, following discharge from the hospital pa tients had continuing medical and nursing contact that was designed to encourage further weight regain. A further complicating factor is that many patients and their families declined to take part in the study: 59% of the eligible patients refused, and only 29 patients entered the trial. The two treatment groups did not differ in their outcome.
Evaluation of Research on Psychological Treatments for Anorexia Nervosa
There has been little research on the treatment of adolescents with anorexia nervosa. The studies that have been conducted are small, with the largest study including just 20 patients per treatment condition. Thus the power of these studies to detect differences between treatments is minimal, and it is difficult to evaluate the findings of these studies. Three larger studies (I. Eisler, personal communication, 2003; S. G. Gowers, personal communication, 2002; J. Lock, personal communication, 2002) are currently under way, and may provide additional information about the efficacy of treatments for adolescents with anorexia nervosa.
Another limitation of this research is the quality of the assessment measures used. None of the studies has employed standardized and psychometrically sound instruments of the type routinely used in adult eating disorder treatment trials. As a result, it is difficult to gauge the true extent of the patients' improvement.
In addition, limited data are available on the longer-term effects of treatment. Such data are important, because not only is relapse into anorexia nervosa common but the eating disorder may evolve into bulimia nervosa or an eating disorder not otherwise specified (EDNOS) (Fairburn & Harrison, 2003). To assess the frequency of diagnostic migration and determine whether treatments differ in their ability to influence the long-term course of the disorder, repeated assessments are required and measures capable of characterizing any form of eating disorder must be used.
None of the studies in this area has included a delayed-treatment (“waiting list”) control condition. It is conceivable that once adolescent patients and their parents request help, changes have already begun to take place that will lead to symptomatic improvement. And even if this were not true of the majority of patients, it might be true for a significant minority. However, the serious psychological and medical morbidity of anorexia nervosa makes the employment of a waiting-list condition ethically problematic, and there has been very little discussion of what might constitute appropriate control conditions against which new interventions for anorexia nervosa should be compared.
It is widely accepted that family therapy is the treatment of choice for adolescents with anorexia nervosa (e.g., National Institute for Clinical Excellence [NICE], 2004). This is surprising given the modest evidence to support it. Only two studies have compared family therapy to another form of treatment (Robin et al., 1999; Russell et al., 1987), and the findings of the second are difficult to interpret.
The superiority of family therapy over individual therapy has not been clearly established. In the family treatment used in the Russell et al. (1987) trial, great emphasis was placed on getting patients to eat well and maintain a healthy weight; the control treatment did not have the same focus on eating and weight. The same is true of the two treatments studied in the Robin et al. (1999) trial. Thus, in both studies any differences in outcome between the family-based treatment and individual therapy could have been a result of their relative emphasis on eating and weight rather than the modality of the treatment.
The Maudsley Method
As noted earlier, research on the treatment of adolescent anorexia nervosa has concentrated on a very particular form of family therapy. Two ways of delivering this treatment have been compared (Eisler et al., 2000; Le Grange et al., 1992), but no other type of family therapy has been adequately tested. It is important that clinicians be aware of this when deciding how to treat their adolescent patients. It is of note that the Maudsley group has progressively modified their family-based treatment and now view their original method as “slightly out of date” (Dare & Eisler, 2002; p. 318). They favor treating groups of families at one time (so-called “multi-family group therapy”; Dare & Eisler, 2000), not least because this form of treatment is well received by patients and their families, and are in the process of evaluating this method.
There is a pressing need for more research on the psychological treatment of adolescents with anorexia nervosa. Family therapy is widely used but its effectiveness has not been definitively established, and individual therapy has been largely ignored. Further well-designed psychological treatment trials are needed and are feasible.
Psychological Treatments for Adolescents with Bulimia Nervosa
No RCTs of psychological treatments for adolescents with bulimia nervosa have been published. Treatments such as the Maudsley family-therapy approach are nonetheless being adapted for adolescents with bulimia nervosa (LeGrange, Lock, & Dymek, 2003). Although it cannot be assumed that effective treatments for adults with eating disorders will be as effective for adolescents, a case can be made for the feasibility of adapting evidence-based treatments for adults to adolescents.
In adults, cognitive-behavioral therapy (CBT) for bulimia nervosa has been intensively evaluated in a large number of RCTs (NICE, 2004). Cognitive-behavioral therapy has been shown to be consistently superior to assignment to a waiting-list, as those receiving the latter have typically shown no improvement across a range of measures. On average, CBT has eliminated binge eating and purging in roughly 30% to 50% of patients in controlled outcome studies. The percentage reduction in binge eating and purging across all patients treated with CBT has typically been 80% or more. Dysfunctional dieting is decreased, and patients' attitudes about their body shape and weight are improved. In addition, there is usually a reduction in the level of general psychiatric symptoms and an improvement in self-esteem and social functioning.
Cognitive-behavioral therapy has been found to be equal or superior to all the treatments with which it has been compared. It has been shown to be more effective than antidepressant medication, an intensively researched treatment for bulimia nervosa that has been consistently shown to be significantly more effective than pill placebo (Hay & Bacaltchuk, 2000; NICE, 2004; Whittal, Agras, & Gould, 1999; Wilson & Fairburn, 2002). Cognitive-behavioral therapy has also proved to be more effective than several other psychological treatments, including supportive psychotherapy, supportive-expressive psychotherapy, stress management therapy, and a form of behavior therapy that did not address cognitive features of bulimia nervosa (Whittal et al., 1999; Wilson & Fairburn, 2002).
Cognitive-behavioral therapy is based on a model that emphasizes the critical role of both cognitive and behavioral factors in the maintenance of the disorder. Of primary importance is the value attached to an idealized body weight and shape, which leads women to restrict their food intake in rigid and unrealistic ways. As a result, they may become physiologically and psychologically susceptible to periodic loss of control over eating, namely binge eating. Purging and other extreme forms of weight control are then attempts to compensate for the effects of binge eating. The purging helps maintain the binge eating by reducing the patient's anxiety about potential weight gain and disrupting learned satiety that regulates food intake. In turn, the binge eating and purging cause distress and low self-esteem, thereby reciprocally fostering the conditions that lead to more dietary restraint and binge eating (Fairburn, 1997a; Fairburn, Cooper, & Shafran, 2003).
Cognitive-behavioral therapy consists of procedures for developing a regular pattern of eating that includes previously avoided foods, and more constructive skills to cope with high-risk situations for binge eating and purging; for modifying abnormal attitudes to eating, shape, and weight; and for preventing relapse at the conclusion of treatment (Fairburn, Marcus, & Wilson, 1993). Treatment is time limited, directive, and problem oriented.
Some research suggests that guided self-help programs based on the principles of CBT (Fairburn et al., 1995) can be effective with at least a subset of patients with bulimia nervosa (Thiels, Schmidt, Treasure, Garthe, & Troop, 1998). Accordingly, a stepped-care approach to the treatment of bulimia nervosa might begin with guided self-help (Wilson, Vitousek, & Loeb, 2000).
Interpersonal psychotherapy (IPT) was originally developed by Klerman, Weissman, Rounsaville, and Chevron (1984) as a short-term treatment for depression. The primary focus of IPT is to help patients identify and modify current interpersonal problems. As adapted for bulimia nervosa (Fairburn, 1997b), IPT focuses exclusively on interpersonal issues, with little or no attention directed to the modification of binge eating, purging, disturbed eating, or overconcern with body shape and weight. Specific eating problems are viewed as a means of understanding the interpersonal context that is assumed to be maintaining them.
Two major comparative outcome studies of adult bulimia nervosa patients demonstrated that at the end of treatment IPT was significantly less effective than CBT (Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; Fairburn et al., 1993). At 1-year follow-up, however, the difference between the two treatments was no longer statistically significant. In the absence of a control condition it is not possible to attribute the improvement associated with IPT to any specific treatment effect. However, in the study by Fairburn et al. (1995), both IPT and CBT fared significantly better than a suitable comparison treatment (a form of behavior therapy without the cognitive features of CBT) over the course of follow-up. Given that the behavior therapy treatment was equivalent in the amount of therapist contact and ratings of suitability and expectancy, this single study provides specific evidence of the efficacy of IPT for bulimia nervosa.
A variety of psychological treatments other than CBT or IPT are commonly used to treat bulimia nervosa (e.g., psychodynamic therapy, family therapy; Garner & Garfinkel, 1997), but none has been systematically evaluated in controlled research. None can be considered an evidence-based treatment (NICE, 2004).
Application of Cognitive-Behavioral Therapy to Adolescents with Bulimia Nervosa
It can be predicted that CBT will prove comparably effective for adolescents with bulimia nervosa, as conceptually and procedurally similar forms of CBT that were originally developed as treatments for adults with anxiety disorders and major depression have been readily adapted to adolescent populations. Cognitive-behavioral therapy has been shown to be reliably effective in the treatment of adult anxiety and mood disorders (Barlow, 2002; Hollon, Thase, & Markowitz, 2002; Nathan & Gorman, 2002). Manual-based CBT is as effective as antidepressant medication as an acute treatment of panic disorder and major depression, and has more sustained effects if medication is discontinued (Barlow, 2002). The CBT interventions that have been successfully used in treating adults have been adapted to adolescents.
Manual-based CBT for adolescents with major depression results in greater improvement and faster remission than being assigned to a waiting-list or alternative forms of psychotherapy, including family and supportive therapy, at the end of acute treatment (Curry, 2001). Cognitive-behavioral therapy has also been successfully used to prevent the onset of depression in at-risk adolescents with no prior history of depression (Clarke et al., 2001). There is also evidence of the efficacy of CBT in treating anxiety disorders (Donovan & Spence, 2001); a large RCT found CBT to be significantly more effective than a waiting-list control at post-treatment on a variety of outcome measures. Therapeutic improvement was maintained at 1-year follow-up (Kendall et al., 1997). Replications of this CBT treatment for anxiety disorders in children have shown maintenance of treatment effects for up to 6 years (Kazdin, 2003).
Although not studied as extensively as treatments for adult disorders, psychological therapies for depression and anxiety disorders in ad olescence have proven effective. The theoretical models, treatment principles, and technical interventions that comprise these therapies are similar to those that would be applied to bulimia nervosa. It should also be noted that depression and anxiety disorders are commonly comorbid with bulimia nervosa (Bulik, 2002).
Interpersonal psychotherapy for treatment of depression in adolescents.
Two controlled studies have shown that IPT is effective with adolescents with major depression (Mufson, Weissman, Moreau, & Garfinkel, 1999; Rossello & Bernal, 1999). According to Curry (2001), IPT meets criteria “for possible efficacy in treating adolescent major depression” (p. 1092). In light of these data and the frequent co-occurrence of depression and bulimia nervosa, studies of the utility of IPT for adolescents with bulimia nervosa would be of interest.
Psychological Therapy for Adolescents with Eating Disorders: General Considerations
Developmental psychologists emphasize a connection between the psychological dimensions of development and the treatment of adolescents. Weisz and Hawley (2002) focused on the following issues: motivation, cognition, and social development.
The issue here is that many adolescents in treatment are not self-referred but pressured by family into seeking help. Weisz and Hawley (2002) state that interventions programs tacitly assume motivation for treatment. They recommend that therapists assess motivation prior to starting treatment and implement specific strategies for enhancing it.
Weisz and Hawley (2000) argue that the adolescent's developing cognitive abilities may impose limits on the utility of some therapeutic interventions. They emphasize the importance of three cognitive skills in adolescence “that are especially relevant to therapy: abstraction, consequential thinking, and hypothetical reasoning” (Holmbeck et al., 2000). They suggest that this might be especially relevant to CBT, with its explicit cognitive focus.
Developmental change in social interactions is a distinguishing feature of adolescence. Peer group and family relationships loom large in adolescent adjustment. Weisz and Hawley (2002) underscore the relevance of addressing interpersonal skills and relationship issues in adolescent treatments. They also assert that an adolescent's psychological and social adjustment and school performance can be enhanced by “authoritative parenting,” namely, “consistently enforced guidelines and limits with warmth and psychological autonomy granting” (p. 30). They suggest that the former is especially relevant to “externalizing” problem behaviors such as substance abuse, whereas the latter applies particularly to “internalizing” problems such as anxiety and depression. It can be argued that both sets of problems often characterize eating disorders, and that both limit setting and autonomy granting, a “complicated balancing act,” are required. Treatment of adolescents inescapably raises the question of how to involve parents in the therapy. Somewhat surprisingly, fewer than half the studies of empirically supported treatments identified by Weisz and Hawley addressed family relationships in therapy. Among those that did, the evidence on outcome was mixed.
Psychological Therapy for Adolescents with Bulimia Nervosa: Specific Considerations
The conceptual model of the maintenance of bulimia nervosa and the therapeutic principles and procedures of CBT appear to mesh well with the psychology of adolescence and the developmental factors summarized above. Bulimia nervosa occurs predominantly in females, and much is known about the developmental challenges (psychosocial tasks) facing adolescent girls (Striegel-Moore, 1993). Girls, far more than boys, are socially oriented. Girls' sense of personal identity is said to be interpersonally constructed, with self-esteem being strongly influenced by the perceptions of others' approval. Social approval is closely linked to physical attractiveness, and girls are socialized to evaluate themselves in terms of appearance. Striegel-Moore (1993) has argued that girls with an insecure identity who are concerned about how others view them may focus disproportionately on physical appearance as a concrete way to construct a sense of self. Bulimia nervosa is often marked by problems with social adjustment and social-self difficulties. These findings about bulimia nervosa and the psychology of adolescence for girls indicate that treatment needs to address interpersonal relationships.
Although body shape and weight concerns have been documented in prepubertal girls, it is the key developmental milestone of reaching puberty that poses biological and psychological challenges for adolescent girls. Concerns about body image are commonplace, and severe dissatisfaction with body shape and weight and pressure to be thin can drive the rigid, unhealthy dieting and negative affect (because appearance is a key evaluative dimension for females) that are proximal triggers for bulimia nervosa (Fairburn, 1997a; Stice, 2001).
Psychological Treatments for Other Adolescent Eating Disorders
As discussed previously, most adolescent patients who present for treatment do not meet the DSM-IV diagnostic criteria for anorexia nervosa or bulimia nervosa. Their eating disorder is therefore categorized as eating disorder not otherwise specified (Brewerton, 2002; Dancyger & Garfinkel, 1995; Eliot & Baker, 2001; Engelsen, 1999; Fisher et al., 1995; Muscari, 2002; Nicholls et al., 2000). Thus, treatment for adolescents must be able to accommodate a wide range of eating disorder pathology.
A recently described manual-based form of CBT provides a transdiagnostic model of eating disorders (Fairburn, Cooper, & Shafran, 2003): specific therapeutic interventions are matched to particular clinical features of the eating disorder, rather than a heterogeneous diagnostic category. The flexibility of this enhanced CBT allows different clinical features to be targeted with theory-driven and evidence-based treatment modules within the overall framework of the core CBT approach. This approach could be useful in treating adolescent patients with an eating disorder not otherwise specified.
Cognitive-behavioral therapy is the leading evidence-based therapy for bulimia nervosa among adults (NICE, 2004) and is likely to be adaptable to the treatment of adolescents. The flexibility of CBT and recent evidence for its utility in preventing relapse among adults with anorexia nervosa (see below) suggest that when suitably adapted, it may be useful for the wide spectrum of eating disturbances in adolescents. Examination of the efficacy of CBT for adolescents with bulimia nervosa is clearly warranted. Interpersonal psychotherapy has some utility in the treatment of adults with bulimia nervosa and has been successfully employed in the treatment of depression among adolescents. Thus IPT might be useful for adolescents with bulimia nervosa. Finally, the apparent success of family-based interventions for anorexia nervosa suggests that this approach may also have merit in the treatment of bulimia nervosa.
PHARMACOLOGICAL TREATMENTS FOR ADOLESCENTS WITH EATING DISORDERS
With rare exception (e.g., Biederman et al., 1985), there are no studies of the efficacy of pharmacological treatment for adolescents with eating disorders. Therefore, as is the case with psychological treatments for adolescents, information about pharmacological interventions must be adapted from the literature for adults. Recent evidence that some pharmacological treatments of clear efficacy for adults with disorders such as major depression can be successfully employed for adolescents (Varley, 2003) should encourage further research on the utility of pharmacological treatments for adolescents with eating disorders.
Pharmacological Treatments for Anorexia Nervosa
There are no empirically supported pharmacological treatments for the acute symptoms of anorexia nervosa in either adolescents or adults. As in the case of the existing psychotherapy research, however, data from pharmacological studies of adults with eating disorders may provide some guidance in developing promising therapeutic interventions.
Four placebo-controlled trials of antidepressants in the treatment of anorexia nervosa have been published (Attia, Haiman, Walsh, & Flater, 1998; Biederman et al., 1985; Halmi, Eckert, LaDu, & Cohen, 1986; Lacey & Crisp, 1980). None of the trials documented more than a slight therapeutic effect. Given the evidence of utility of antidepressant medication for conditions with substantial symptomatic overlap with anorexia nervosa, such as major depression and bulimia nervosa, the lack of any significant effect is surprising and raises the possibility that the malnutrition inherent in anorexia nervosa somehow interferes with the therapeutic action of antidepressant medication. Circumstantial evidence consistent with this hypothesis has emerged from studies of serotonin function. For example, in healthy women, dieting significantly lowers plasma levels of tryptophan, the precursor of serotonin (Andersen, Parry-Billings, Newsholme, Fairburn, & Cowen, 1990). Individuals with anorexia nervosa who are malnourished have reduced plasma tryptophan availability (Schweiger, Warnoff, Pahl, & Pirke, 1986) and reduced levels of cerebrospinal fluid 5-hydroxyindoleacetic acid (CSF 5-HIAA), the major metabolite of serotonin, which increases with weight gain (Kaye, Gwirtsman, George, Jimerson, & Ebert, 1988). Depletion of serotonin in anorexia nervosa might interfere with the effects of antidepressants in general and the selective serotonin reuptake inhibitors (SSRIs) in particular (Delgado et al., 1990).
Atypical Antipsychotic Medications
Almost 50 years ago, experience with chlorpromazine, the first antipsychotic medication in clinical use, led to substantial enthusiasm about its potential role in the treatment of anorexia nervosa. With greater experience, however, the enthusiasm waned, and two small, placebo-controlled trials of antipsychotic medication found little evidence of efficacy (Vandereycken, 1984; Vandereycken & Pierloot, 1982). The recent introduction of the atypical antipsychotic drugs, a number of which are associated with considerable weight gain, has prompted reconsideration of this class of medication as a treatment for acute anorexia nervosa. Several case reports and open studies have described improvement associated with olanzapine treatment of children, adolescents, and adults with anorexia nervosa (Boachie, Goldfield, & Spettigue, 2003; Hansen, 1999; Jensen & Mejlhede, 2000; La Via, Gray, & Kaye, 2000; Mehler et al., 2001; Powers, Santana, & Bannon, 2002). By contrast, one open study reported no appreciable weight gain with olanzapine among patients treated on a specialized inpatient unit (Gaskill, Treat, McCabe, Marcus, 2001). In the absence of randomized placebo-controlled trials, no conclusion about the role of atypical antipsychotic medications in the treatment of anorexia nervosa in either adults or adolescents is possible. This is nonetheless a potentially promising area for new research.
Zinc deficiency is associated with weight loss, a decrease in appetite, changes in taste perception, amenorrhea, and depression, all symptoms described by patients with anorexia nervosa. This observation, coupled with reports of zinc deficiency associated with anorexia nervosa, has prompted several controlled trials of zinc supplementation. While one controlled trial in adults found zinc to be associated with an increased rate of weight gain (Birmingham, Goldner, & Bakan, 1994), two other trials among adolescents found no effect (Katz et al., 1987; Lask, Fosson, Rolfe, & Thomas, 1993). The role of zinc supplementation as a treatment for anorexia nervosa is uncertain.
The benefits of lithium in the treatment of bipolar (manic-depressive) disorder among adults are very well established, and, like many antipsychotic medications, the use of lithium is associated with weight gain. These considerations prompted a single controlled trial of lithium among inpatients with anorexia nervosa, which provided little support for the utility of this agent (Gross, Ebert, Faden, Goldberg, Nee, & Kaye, 1981).
The pharmacokinetics and pharmacodynamics of psychotropic drugs in children and adolescents are not well studied. Some biological factors inherent to adolescents may affect the metab-olism and efficacy of psychiatric medications, such as immature neurotransmitter systems, rapid hepatic metabolism, and shifting hormonal levels in adolescents (Hazell, O'Connell, Heathcote, Robertson, & Henry, 1995). Dramatic shifts in weight, especially weight loss, can also occur much more rapidly in adolescents than in adults with eating disorders. As a result, there may be differences in the metabolism and/or the effects of medications in adolescents with eating disorders, which could necessitate adjustments in dosage and medication response.
The safety of psychotropic medications should be considered when prescribing medications for patients with an eating disorder, especially when patients are medically unstable. Tricyclic antidepressants (TCAs) and mood stabilizers, which tend to be less frequently used today than in the past, have potential for serious side effects. In particular, although a clear causal link has not been documented, TCAs have been associated with sudden death among adolescents without eating disorders (Geller, Reising, Leonard, Riddle, & Walsh, 1999), and the cardiac abnormalities associated with anorexia nervosa, in theory, should increase the risks of tricyclic use in this population. Careful medical and psychiatric monitoring is required when prescribing psychotropic drugs to adolescents with eating disorders. As with adults, adolescent patients with eating disorders are prone to develop other behavioral problems, such as substance abuse, which may increase the risk of side effects. In addition, in sexually active adolescents, ensuring adequate birth control is important to prevent the potential harmful effects of medications during pregnancy (Kotler & Walsh, 2000). Finally, concerns have recently been raised about the potential for some SSRIs to increase suicidal ideation among adolescents (Dalrymple, 2003; Harris, 2003; United Kingdom Department of Health, 2003; United States Food and Drug Administration, 2004). The potential for SSRIs to increase the risk of suicide among adolescents is controversial, but suggests a need for close monitoring of suicidal ideation when such treatment is initiated.
Finally, as noted in the discussion of psychotherapeutic approaches, the motivation of adolescents for treatment is quite variable, and a lack of motivation may compromise patients' compliance with following treatment recommendations, including taking psychotropic drugs as prescribed. For adolescents, compliance may be increased by family psychoeducation and parental involvement with treatment.
Pharmacological Treatments for Bulimia Nervosa
Virtually every class of antidepressant medication has been studied in placebo-controlled, double-blind trials for adult patients with bulimia nervosa. Antidepressant medications, including both TCAs and SSRIs, appear to have approximately equal efficacy in the acute treatment of bulimia nervosa; however, SSRI antidepressants are generally better tolerated and have fewer side effects (Zhu & Walsh, 2002), thus they are the first pharmacological treatment of choice for adults with bulimia nervosa. Specifically, the SSRI fluoxetine is the only drug approved by the U.S. Food and Drug Administration for the treatment of bulimia nervosa. It is most effective at a dose of 60 mg/day, significantly higher than the standard dose used to treat major depression. A recent open trial suggests that fluoxetine at this dose is well tolerated and may be useful for adolescents with bulimia nervosa (Kotler, Devlin, Davies, & Walsh, 2003). Newer selective noradrenergic/serotonergic reuptake inhibitors such as venlafaxine have not been systematically studied in treatment of bulimia nervosa.
Although wide variability exists across studies, the rates of reduction in binge eating and vomiting with antidepressant treatment have ranged between 50% and 75% in controlled trials. A comprehensive review of the overall effectiveness of such studies (Agras, 1997) found a median reduction in binge eating and vomiting of about 70% and complete abstinence in about 30% of subjects. The mechanism of action of an tidepressant medications in bulimia nervosa may be different from that in depression, as the response to antidepressant drugs in bulimia nervosa is independent of mood state; nondepressed bulimia nervosa patients respond equally as well as depressed bulimia nervosa patients to these drugs (Hughes, Wells, & Cunningham, 1986; Walsh, Hadigan, Devlin, Gladis, & Roose, 1991). Many patients with eating disorders are reluctant to use medication and a significant number of patients who initiate medication terminate treatment prematurely. In addition, despite convincing empirical evidence of efficacy in treating bulimia nervosa with antidepressant medications, residual symptoms persist in the majority of subjects treated with a single antidepressant medication (Nakash-Eisikovits, Dierberger, & Westen, 2002).
Several studies have examined the effectiveness of a combination of antidepressant pharmacotherapy with psychotherapy, usually CBT, for adults with bulimia nervosa. A meta-analysis of controlled trials using combined treatments for bulimia nervosa (Nakash-Eisikovits et al., 2002) demonstrated that combined treatments are superior to medication alone, but the advantage of combined treatments over psychotherapy alone is small.
Experience with several novel pharmacological agents may hold promise for the development of other medications for bulimia nervosa. Both the antiobesity agent sibutramine and the anticonvulsant topiramate may be beneficial for the treatment of binge eating in adults (Appolinario et al., 2002; McElroy et al., 2003). The serotonin antagonist ondansetron, which is used for the treatment of chemotherapy-induced nausea and vomiting, has been found to be of use in the treatment of adults with refractory bulimia nervosa (Faris et al., 2000). However, much work will be required to extend these preliminary findings to the treatment of adolescents.
Despite the widespread use of psychotropic medications for adolescents with eating disorders, there is little empirical information about the utility and safety of such interventions. Reports that atypical antipsychotic medications may be useful for adolescents with anorexia nervosa are encouraging but need to be examined in controlled trials. Antidepressant medications have been shown to be useful in the treatment of adults with bulimia nervosa, but studies are needed to assess their utility and safety for adolescents with bulimia nervosa.
Combined Treatments for Anorexia Nervosa and Bulimia Nervosa
Virtually all of the studies of acute pharmacological treatment for anorexia nervosa have been conducted in settings such as hospitals where patients receive psychological treatment in addition to medication. There have been no controlled trials examining the combination of psychological and pharmacological treatment for anorexia nervosa. Given the dearth of evidence that medication is useful in the treatment of anorexia nervosa, it is not possible to draw any conclusions about the potential utility of combined treatments.
For adults with bulimia nervosa, studies suggest that the addition of antidepressant medication to psychotherapy leads to a small but detectable increase in improvement of bulimic symptoms (Walsh et al., 1997). There have been no controlled studies of combined treatments in adolescents with bulimia nervosa.
PREVENTION OF RELAPSE WITH PSYCHOLOGICAL TREATMENTS
Relapse prevention, as initially formulated by Marlatt and colleagues, was conceptualized as a maintenance therapy for individuals who had completed initial treatment and had achieved a certain measure of symptomatic recovery (Brownell, Marlatt, Lichtenstein, & Wilson, 1986; Marlatt & Gordon, 1985). The prevention of relapse among anorexia nervosa and bulimia nervosa patients is an essential goal and an integral step in the course of recovery. Standardized definitions of relapse, or uniform goals of relapse pre vention interventions, have not been established, however. By definition, relapse occurs with a resurgence of symptoms or deterioration of condition subsequent to attaining a clinically significant degree of improvement. Because the operationalized definitions of initial treatment response have varied from study to study, empirical estimates of relapse are difficult to interpret. Moreover, follow-up studies often fail to differentiate reports of chronicity and relapse. Given these limitations and variations in terminology, current estimates of relapse are imprecise, and caution must be used when comparing across studies.
With anorexia nervosa, the definition of relapse usually involves weight loss coupled with a clinical deterioration following a successful response to treatment. In the past decade, attention to relapse and relapse prevention initiatives has increased, with a focus on the need for continuing care following initial improvements in weight and psychological and behavioral symptoms. However, without operationalized and consistent terminology for assessing treatment response and relapse in research studies, it is difficult to develop standardized clinical guidelines for preventing relapse. For bulimia nervosa, binge eating and purging are the core behavioral components that define treatment response and relapse; however, treatment response and recovery can include many other dimensions of functioning, including a range of attitudinal and psychological variables. As with anorexia nervosa, the field does not have accepted standards for defining response and relapse in bulimia nervosa, and reports of response and relapse vary considerably across studies. In addition, much of the available data have been obtained from studies of adults and may not strictly apply to adolescents.
Relapse Rates and Relapse Prevention for Anorexia Nervosa
Data from outpatient trials of psychological treatments for anorexia nervosa report that an overwhelming percentage of individuals, between 60% and 70%, fail to achieve full recovery or even a good response to treatment (Dare, Eisler, Russell, Treasure, & Dodge, 2001; McIntosh et al., 2002). In some cases, high rates of attrition among anorexia nervosa outpatients result in an inability to analyze treatment response (e.g., Serfaty, Turkington, Heap, Ledsham, & Jolley, 1999). Treatment of anorexia nervosa with the Maudsley family therapy has resulted in more success, with approximately 75% of adolescents achieving full recovery by the end of treatment (Lock et al., 2001). Follow-up data of outpatients treated solely with the Maudsley therapy have not been published, thus the rates of maintenance and relapse for individuals who participate in this type of therapy are unknown.
In most types of outpatient anorexia nervosa treatment, a large percentage of patients fail to achieve a good response to treatment. Thus it is extremely difficult to report relapse rates following outpatient treatment, and there are virtually no data on relapse prevention strategies for those individuals who do achieve a significant response to outpatient treatment. As a result, it is somewhat premature to discuss relapse prevention for individuals with anorexia nervosa treated on an outpatient basis, as the first-line intervention for reducing relapse for these patients is to improve initial response rates.
The data indicate that most hospitalized an-orexia nervosa patients respond to treatment (Anderson, Bowers, & Evans, 1997; Attia et al., 1998; Baran, Weltzin, & Kaye, 1995), despite the greater severity of illness seen in hospitalized patients. However, follow-up studies indicate that the posthospitalization period is fraught with difficulty, with a significant resurgence of symptoms and relapse rates generally ranging from 30% to 50% (for review see Pike, 1998); some rates run as high as 70% (Lay, Jennen-Steinmetz, Reinhard, Schmidt, 2002). In addition to symptomatic relapse, it is not uncommon for individuals with AN-R subtype to develop binge eating following hospitalization. The reported median latency is 24 months for adolescents (Strober, Freeman, & Morrell, 1997).
Posthospitalization relapse rates are significant for both adolescent and adult patients. In a study of 95 patients between the ages of 12 to almost 18 years old, Strober and colleagues (1997) reported that nearly 30% of patients who successfully completed their inpatient program relapsed following discharge, with a mean time to relapse of 15 months and a median of 11 months. In an older sample (mean age = 20 ± 5.4 years), Eckert and colleagues reported that 42% of women who achieved weight normalization in the hospital relapsed within 1 year of discharge, but if weight normalization was maintained for 1 year, the risk of subsequent weight loss declined dramatically (Eckert, Halmi, Marchi, Grove & Crosby, 1995).
Psychological Treatments Aimed at Relapse Prevention following Hospitalization for Anorexia Nervosa
As discussed above, the Maudsley approach to family therapy for anorexia nervosa was originally designed as a posthospitalization treatment, delivered over the course of 1 year following inpatient treatment. The findings from the initial study of this treatment (Russell et al., 1987) reported that family treatment was more effective than individual supportive therapy for individuals whose onset of anorexia nervosa was at 18 years or younger and whose illness had a duration of less than 3 years. Treatment gains in this group were largely maintained at a 5-year follow-up assessment (Eisler et al., 1997), suggesting that changes effected by family therapy serve to prevent relapse and enhance long-term efficacy for this group of patients with anorexia nervosa.
A version of CBT treatment has been designed to treat anorexia nervosa patients in the year following the successful completion of inpatient treatment. Consistent with the fundamental components of CBT for eating disorders (Fairburn et al., 1993; Garner, Vitousek, & Pike, 1997; Pike, Devlin, & Loeb, 2003), this intervention focuses on the cognitive and behavioral processes involved in the overvaluation of weight and shape, dysregulation of eating behavior, and deficits in self-esteem and self-schemata that are thought to be at the core of maintaining the eating disorder. Initially, treatment focuses on specific cognitive distortions and behavioral dysfunction pertaining to eating and weight that increase the risk of relapse. As treatment progresses, schema-based approaches are used to address a range of issues that extend beyond the specific domains of eating and weight but remain fundamental to the individual's self-schema, self-esteem, and eating disorder. On the basis of a sample of 33 patients, a survival analysis demonstrated a statistically significant advantage of CBT over the comparison treatment of nutritional counseling (log-rank statistic = 8.39, p < .004). According to Morgan-Russell outcome criteria, 44.4% of the CBT group met criteria for good outcome, compared to 6.7% of the nutritional counseling group (c2 = 5.89; p <.02), and 16.7% of the CBT group met criteria for full recovery, compared to none in the nutritional counseling group (c2 = 2.75, p < .097) (Pike, Walsh, Vitousek, Wilson, & Bauer, 2003). These data provide preliminary support for CBT in preventing relapse and promoting recovery following inpatient hospitalization for adult women with anorexia nervosa.
Relapse Rates and Relapse Prevention for Bulimia Nervosa
Naturalistic follow-up studies, which do not control for specific treatment effects, estimate a relapse rate of approximately 30% for patients with bulimia nervosa (Herzog et al., 1999; Keel & Mitchell, 1997). None of the published clinical trials evaluating psychological treatments for the acute symptoms of bulimia nervosa specifically focused on relapse prevention for this disorder; instead, relapse prevention was typically an integrated component of the initial intervention. Follow-up data on CBT and IPT, two evidence-based treatments for bulimia nervosa, indicate that the two psychotherapies do not differ in rates of relapse at 1-year follow-up. Some studies suggest that therapeutic changes are well maintained for most individuals who respond well to initial CBT or IPT treatment, with the most enduring recovery being reported by individuals who achieve complete remission of binge eating and purging by the end of treatment (Agras et al., 2000, Fairburn et al., 1995). However, another study has indicated that as many as 30% of individuals who are abstinent from binge eating and purging at the end of CBT treatment report some resurgence of symptoms during 1-year follow-up (Halmi et al., 2002). It is unclear whether these patients should be classified as “relapsed,” on the basis of the severity of their symptoms. A similar rate of 30% relapse has been reported among individuals who had responded to an eating disorders day program (Olmsted, Kaplan, & Rockert, 1994).
A significant fraction of individuals who receive CBT or IPT fail to achieve full remission of binge eating and purging at the end of treatment. Data suggest that the risk of relapse is greater for this group than for those who achieve complete abstinence of binge eating and purging (Halmi et al., 2002). Therefore, treatment interventions for bulimia nervosa should be targeted not only at those individuals who fail to respond to initial treatment but also those who have a significant but incomplete response to treatment. Maintenance and relapse prevention treatments should promote further recovery and also mitigate against lapses and relapse for these individuals.
The data on relapse rates for anorexia nervosa suggest that the risk of posthospitalization relapse is approximately 30%–50% for adolescents as well as for adults. Long-term outcome studies of anorexia nervosa indicate that early onset of anorexia nervosa and early intervention (i.e., short duration of illness at time of presentation for treatment) may be associated with a better long-term prognosis; it is likely, however, that the journey to recovery will include periods of relapse, as documented by Strober et al. (1997). Family therapy has been shown to be effective in preventing relapse among adolescent anorexia nervosa patients. It is important to note that the family therapy data are strongest for a very specific group of patients, i.e., those who develop anorexia nervosa before 18 years of age and who have a very short duration of illness (less than 3 years). Cognitive-behavioral therapy has support for relapse prevention among adult patients, but there are no data on the efficacy of this treatment for adolescents.
Clinical trials have not specifically targeted adolescents with bulimia nervosa and data for the adolescent patients in these trials have generally not been sufficient to analyze separately. Given that bulimia nervosa typically begins in adolescence, initiatives aimed at getting individuals into treatment earlier in the course of their disorder may result in improved outcome and reduced risk for relapse. Currently, LeGrange, Lock, and Dymek (2003) are adapting the Maudsley family therapy approach for anorexia nervosa to the treatment of adolescent bulimia nervosa. Although this treatment is not specifically a relapse prevention intervention, it aims to assist patients in achieving significant and lasting recovery. Empirical data on the clinical efficacy of treatments for adolescents with bulimia nervosa, both in the short term and in preventing relapse in the longer term, are needed to help inform evidence-based clinical practice.
RELAPSE PREVENTION WITH PHARMACOLOGICAL TREATMENTS
As described above, trials evaluating antidepressant medications for underweight patients with anorexia nervosa have failed to show a difference between active medication and placebo for the treatment of eating disorders or mood symptoms. Antidepressant medications may lack efficacy in anorexia nervosa because of the neurochemical disturbances associated with low body weight (Attia et al., 1998). Despite their apparent lack of utility for underweight patients, antidepressant medications may be useful in the prevention of relapse after weight gain.
One placebo-controlled study has addressed this issue (Kaye et al., 2001). Following inpatient hospitalization, patients were randomized to receive either fluoxetine or placebo in a double-blind fashion. Some patients also received psychological treatment, which was not standardized. Fluoxetine-treated patients were more likely to complete the trial (63% completed) than were patients receiving placebo (16% completed, p = .0001). Patients who completed the trial tended to experience more weight gain and psychological improvement than patients who did not complete the trial. The average age of the patient sample was 22.5 years old, and it is not clear whether any adolescent patients were included.
In the last 15 years, more than a dozen RCTs have demonstrated that antidepressant medications are effective in the treatment of adult bulimia nervosa patients (Zhu & Walsh, 2002). Although antidepressant medications have been shown to reduce bulimic symptoms in the short term, the role of continued pharmacological treatment in sustaining clinical improvement over time is unclear. Several controlled trials have examined the efficacy of antidepressant medications in preventing relapse among bulimia nervosa patients.
Some studies have evaluated continuing treatment with pharmacotherapy to prevent relapse after an initial positive response to medication (Pyle et al., 1990; Romano, Halmi, Sarkar, Koke, & Lee, 2002; Walsh et al., 1991), and an additional study randomized patients to receive either medication or placebo for relapse prevention after receiving a course of inpatient treatment (Fichter, Kruger, Rief, Holland, & Dohne, 1996). A consistent finding across studies has been the significant rate of symptomatic relapse despite continued pharmacological treatment. There is also an indication that TCAs, specifically imipramine and desipramine, and the SSRI fluoxetine may diminish the rate of relapse for patients maintained on antidepressant medications, compared to patients maintained on placebo. These studies suggest that, despite a significant rate of relapse on antidepressant medications, the rate of relapse is greater when medication is discontinued after a few months (Romano et al., 2002). Although the studies evaluating pharmacotherapy as a means to prevent relapse have generated similar results, there have been a relatively limited number of studies in this area, with modest sample sizes and large dropout rates across trials.
All four controlled trials evaluating pharmacotherapy to prevent relapse enrolled only adult bulimia nervosa patients. Therefore, it is unclear whether the results of these studies are applicable to an adolescent population, or if there are special considerations for using antidepressant medications with younger patients for the prevention of relapse.
Pharmacological interventions may be useful in the prevention of relapse of anorexia nervosa following initial treatment. However, replication of the Kaye et al. (2001) results is necessary before firm conclusions can be drawn about the benefits of antidepressant medications for adults with anorexia nervosa. If such a benefit is established for adults, it will be important to extend studies to an adolescent population. Clearly, for some adult patients with bulimia nervosa who initially respond to medication, symptomatic relapse occurs despite continued pharmacotherapy. Therefore, continued treatment with medication after an initial positive response cannot guarantee against relapse. The data from placebo-controlled studies do suggest that when bulimia nervosa patients respond to a medication and are maintained on that medication, they experience lower rates of relapse than those of patients who are switched to placebo (Pyle et al., 1990; Romano et al., 2002; Walsh et al., 1991). Therefore, continuation of an effective pharmacological intervention may reduce the rate of relapse but does not ensure against the return of bulimic symptoms. The question remains as to the optimal length of time to maintain a patient on medication to prevent symptomatic relapse. Additionally, given the absence of data in adolescent samples, it is not known if the pattern of results from the controlled studies of pharmacotherapy for relapse prevention apply to a younger population.
The previous discussion has focused on the specific efficacy of psychological and pharmacological treatments. There are a number of other questions that need to be addressed when evaluating the treatment of eating disorders in adolescents: When is the best time to begin treatment? What is the optimal treatment setting? Do adolescents with eating disorders need specialized services? Finally, who should provide the treatment?
When Should Treatment Begin?
Ideally, patients should be identified at the earliest possible point in the course of the disorder, and treatment should begin as soon as the adolescent, the parent(s), or other professional(s) recognizes a clinically significant eating problem. As implied in the previous section, treatment should frequently be initiated before symptoms have become sufficiently severe to meet full diagnostic criteria for anorexia nervosa or bulimia nervosa. Among the factors to be considered in initiating treatment are the intensity, severity, and duration of symptoms, and the motivation of the adolescent and the family for treatment.
Where Should Adolescents Be Treated?
A fundamental and noncontroversial tenet is that treatment should occur in the least restrictive setting in which effective treatment can be provided. A primary real-world consideration is the availability of treatment settings to which the adolescent has access. Larger cities are more likely to have university-based programs, with a full spectrum of treatment options such as outpatient clinics, intensive outpatient and partial hospitalization programs, and inpatient hospitalization. Although referral to more intensive treatment settings, such as residential facilities or inpatient units, may be resisted by adolescents or their parents because of the distance from home, the disruption of family life or schooling, or financial burden, this option may be necessary if other types of treatment are not effective. Treatment options in smaller towns or rural areas are often limited to therapists with varying degrees of interest and expertise in treating adolescents with eating disorders. The skills and interests of the adolescent's treatment providers help to determine where an adolescent will be treated, as some primary care physicians may not feel comfortable monitoring the physical health of adolescents with eating disorders, and some therapists may limit their practice to adults. In these situations, adolescents who might otherwise be treated in their home community may need to be referred to a specialty program. It is best if an appropriate treatment team or program is available locally, allowing an adolescent to live at home and engage in outpatient therapy while also remaining in school and continuing to develop important peer relationships. The challenge for the provider is to determine the balance between ideal treatment and available treatment.
Even when services are available, there are very limited data to guide the practitioner in determining the most appropriate type and duration of clinical services for anorexia nervosa. A recent study suggests that more expensive, intensive inpatient treatment early in the course of anorexia nervosa is associated with reduced relapse and long-term personal, social, and financial costs (Striegel-Moore, Leslie, Petrill, Garvin, & Rosenheck, 2000). For adults with bulimia nervosa, an initial brief and less intensive treatment, followed by more intensive and specialized care for nonresponders within a stepped-care framework, as noted above, might be effective (Garner & Needleman, 1997; Wilson et al., 2000).
Currently, there are no agreed-upon specific treatment protocols for adolescents with eating disorders to guide practitioners in matching the treatment setting and intensity to the patient's clinical status. Instead, adolescents tend to begin in outpatient treatment settings, with visits to medical and mental health services, then progress to more intensive treatment approaches if they do not have a positive response to treatment.
One aspect of treatment that is unique to adolescents is the involvement and authority of the family in the treatment process. The development of a therapeutic relationship between care providers and parents can be critical to success, but also challenging if parents deny the existence of a problem or blame the adolescent for the problem. Conversely, if the care providers attribute blame or fault to the parents, it will be difficult to foster a collaborative relationship with the parents.
Who Should Provide the Treatment?
Especially for anorexia nervosa, treatment often begins with a specialist in adolescent medicine because of the physical symptoms associated with weight loss (e.g., amenorrhea, fatigue, cold intolerance, weakness, fainting). Adolescents with anorexia nervosa tend to be more willing to be evaluated for these “medical problems” than for any associated psychological symptoms. In addition to addressing the presenting medical symptoms, primary care providers can suggest the need for additional mental health services. By focusing on the signs and symptoms that precipitated a medical evaluation and emphasizing healthy meal planning and completion, the primary care provider can shift the focus away from the presence of an eating disorder and toward the behaviors needed to improve health, thereby enhancing motivation for treatment. In the case of continuing medical instability or significant eating problems, adolescent patients can be referred for additional specialist services. Appropriately trained health-care professionals can usually treat bulimia nervosa on an outpatient basis, but some patients with bulimia nervosa need to be monitored for potential medical complications.
In the United Kingdom, the National Institute for Clinical Excellence has completed a comprehensive and rigorous evaluation of the literature on eating disorders. A guideline that makes recommendations for the identification, treatment, and management of anorexia nervosa, bulimia nervosa, and atypical eating disorders (including binge eating disorder) was published in January 2004 (NICE, 2004). The guidelines contains specific recommendations regarding the treatment of adolescents with anorexia nervosa and bulimia nervosa (see http://www.nice.org.uk/).
Although not based on empirical studies addressing the appropriate timing, location, and provider of treatment for adolescents with eating disorders, several professional organizations have developed guidelines for the treatment of anorexia nervosa and bulimia nervosa.
The American Psychiatric Association (APA) published its first practice guideline for the treatment of patients with eating disorders in 1993, with a revision in 2000. In this guideline, presentation of the disorder in the younger child and older adult were described, but the specific treatment needs of adolescents were not addressed. A strength of this guideline is the advice provided to practitioners on the medical management of anorexia nervosa. The choice of a treatment site and the potential collaborative arrangements among different health care professionals are similarly addressed. The APA practice guideline notes that bulimia nervosa patients rarely require hospitalization. Family therapy is said to be especially useful for adolescents, according to the Russell et al. (1987) study (see our analysis of this research above, under Psychological Treatments for Adolescents with Anorexia Nervosa).
In 2003, the Society for Adolescent Medicine (SAM) published guidelines that are similar to the 2000 APA recommendations (Golden et al., 2003) with five major positions on the treatment of adolescents with eating disorders:
1. Diagnosis should be considered in the context of normal adolescent growth and development, because adolescents, especially younger ones, may have significant health risks associated with dysfunctional weight control practices, even though they do not meet full DSM-IV criteria.
2. Treatment should be initiated at lower symptom levels than for adults.
3. Nutritional management should reflect the patient's age, pubertal stage, and physical activity level.
4. Family-based treatment should be considered an important part of treatment for most adolescents, and mental health services should address the psychopathologic patterns of eating disorders, developmental tasks of adolescence, and possible comorbid psychiatric conditions.
5. The assessment and treatment of adolescents is best accomplished by a treatment team that is knowledgeable about normal adolescent physical and psychological growth and development. Hospitalization would be necessary in the presence of severe malnutrition, physiologic instability, severe mental health disturbance, or failure of outpatient treatment.
The American Academy of Pediatrics (AAP) also published a statement about the treatment of adolescents with eating disorders in 2003, noting the potential role for primary care providers in the identification and treatment of these disorders (Rome et al., 2003). The AAP emphasized the unique position of primary care pediatricians in detecting the onset of eating disorders and stopping their progression at the earliest stages of the illness as part of routine, preventive health care. Additionally, because of their existing relationship with a patient, primary care providers already have an established trusting relationship with the patient and the family, and usually have the necessary knowledge and skills to monitor health. The AAP policy statement also advocated rapid and aggressive treatment of eating disorders, and noted that hospitalization might be required in the case of emerging medical or psychiatric needs or failure to respond to intensive outpatient treatment.
There are no scientific studies to indicate the optimal treatment for adolescents, in terms of when treatment should begin, where that treatment should be delivered, or who should provide the treatment. The consensus view is that therapy should begin as soon as possible after a clinically significant eating problem has been identified, with the treatment provider, parents, and patient working to individualize treatment. The setting for the treatment is partially determined by availability, but the severity and duration of illness, especially with regard to medical complications, must also be considered. The optimal professional to treat an adolescent with an eating disorder is again determined in part by availability. Eating disorders can be effectively managed by a variety of different professionals, including physicians (psychiatrists, primary care providers, or adolescent medicine specialists), psychologists, social workers, and nutritionists who are familiar with efficacious treatment of eating disorders.