MENTAL HEALTH

Health Evidence Bulletins - Wales
Team Leader: Dr Lyn Harris

Date of completion: 6.5.98

EATING DISORDERS

This document is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation

The Statements The Evidence
4.1 General
4.1a. A comprehensive general medical as well as psychiatric assessment should be carried out at presentation and at any point where there is an unexpected change in the conditioni. i. American Psychiatric Association. Practice Guidelines. Washington DC: American Psychiatric Association, 1996
(Type V evidence - expert opinion)
4.1b. Computerized psychoeducation is a cost effective way of improving patients’ knowledge of and attitudes to anorexia nervosa, but further research is needed to assess whether it has any therapeutic effects in terms of behavioural improvementsi. i. Andrewes DG et al. Computerised psychoeducation for patients with eating disorders. Australia and New Zealand Journal of Psychiatry 1996; 30: 492-7
(Type II evidence-randomised controlled trial)
4.2 Anorexia nervosa
4.2a. Patients suffering from severe anorexia nervosa (losing weight rapidly, less than 70% of the expected BMI for their age and sex, metabolically unstable) should be treated in hospitali. i. American Psychiatric Association. Practice Guidelines Washington DC: American Psychiatric Association, 1996
(Type V evidence - expert opinion)
4.2b. Treatment should aim to restore a patient to a healthy weight, treat physical and psychiatric co-morbid conditions, address dysfunctional thoughts, feelings and beliefs, correct defects in affect and behaviour and prevent relapsei. i. American Psychiatric Association. Practice Guidelines. Washington DC: American Psychiatric Association, 1996
(Type V evidence - expert opinion)
4.2c. Patients should be restored to near normal weight as a priority early in their treatment as this will reverse many of the features of anorexia nervosa. Dietary education, advice and monitoring of food intake appear to be important components of treatment effectiveness i. i. American Psychiatric Association. Practice Guidelines. Washington DC: American Psychiatric Association, 1996
(Type V evidence - expert opinion)
4.2d. A supportive and trusting relationship between professionals, the patient and family, where relevant, can help to achieve treatment goals i. i. American Psychiatric Association. Practice Guidelines. Washington DC: American Psychiatric Association, 1996
(Type V evidence - expert opinion)
4.2e. There is preliminary evidence that younger anorexic patients (less than 18) may respond better to family therapy than to individual therapy. Patients over 18 are more likely to respond to individual eclectic psychotherapy than to family therapy i. i. Roth A, Fonagy P. What works for whom? A critical review of psychotherapy research. New York: The Guilford Press, 1996
(Type I evidence - systematic review)

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4.2f. Pharmacotherapy should not be the sole or primary treatment for anorexia nervosa i. Drug treatments of anorexia nervosa have proved disappointing. Co-morbid psychiatric conditions such as depression or obsessive-compulsive disorders should be treated appropriately, but only once the patient is no longer physically compromisedi,ii,iii. i. Crow SJ, Mitchell J. Rational therapy of eating disorders Drugs 1994; 48(3): 372-379
(Type I evidence - systematic review)
ii. American Psychiatric Association. Practice Guidelines. Washington DC: American Psychiatric Association, 1996
(Type I evidence - systematic review);
iii. Leach A. The psychopharmacotherapy of eating disorders. Psychiatric Annals
No. 25: 10 October 1995
(Type I evidence - systematic review)
4.2g. Initial results of using fluoxetine in restrictive type anorexics indicate that it is associated with significant weight gain and significant reduction in core eating disorder symptoms, depression, anxiety and obsessions and compulsions i. i. Kaye WH, Weltzinn TE, Hsu G. Relapse prevention with fluoxetine in Anorexia Nervosa: A double-blind placebo-controlled study. American Psychiatric Association, 150th Annual Meeting, San Diego: 1997
(Type II evidence - randomised controlled trial)
4.2h. Research is needed to identify which subgroup of anorexics will benefit from out-patient treatments and the relative efficacy of behavioural and cognitive behavioural therapy i,ii. i. American Psychiatric Association. Practice Guidelines. Washington DC: American Psychiatric Association, 1996
ii. Roth A, Fonagy P. What works for whom? A critical review of psychotherapy research. New York: The Guilford Press, 1996
4.3 Bulimia nervosa
4.3a. Patients with bulimia nervosa, uncomplicated by abuse of laxatives, alcohol or drugs, suicidality or major personality disorders, rarely need hospitalisation i,ii. i. American Psychiatric Association. Practice Guidelines. Washington DC: American Psychiatric Association, 1996
(Type V evidence - expert opinion)
ii. Mitchell J, Raymond N, Specker S. A review of the controlled trials of pharmacotherapy and psychotherapy in the treatment of bulimia nervosa. International Journal of Eating Disorders 1993; 14(3): 229-247
(Type V evidence - expert opinion)
4.3b. Dietary education, advice and monitoring of food intake appear to be important components of treatment effectiveness i. i. Roth A, Fonagy P. What works for whom? A review of psychotherapy research. New York: The Guilford Press, 1996
(Type V evidence - expert opinion)

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4.3c. Individual and group psychotherapies have been shown to improve binge/purge symptomsi,ii,iii.
A review is currently in preparationiv.
See also statement 4.3d.
i. American Psychiatric Association. Practice Guidelines. Washington DC: American Psychiatric Association, 1996
(Type I evidence - systematic review)
ii. Roth A, Fonagy P. What works for whom? A review of psychotherapy research. New York: The Guilford Press, 1996
(Type I evidence - systematic review)
iii. Mitchell J, Raymond N, Specker, S. A review of the controlled trials of pharmacotherapy and psychotherapy in the treatment of bulimia nervosa. International Journal of Eating Disorders 1993; 14(3): 229-247
(Type I evidence - systematic review)
iv. Anonymous. Binge eating disorder, purging and non-purging bulimia nervosa and related EDNOS syndromes: Is psychotherapy effective? [Protocol]. Cochrane Database of Systematic Reviews. Cochrane Library 1998 Issue 2. In preparation.
4.3d. Cognitive Behavioural Therapy appears to be the most effective treatment for reducing binge/purging episodes. Behavioural therapy, short term psychotherapy, family therapy and fluoxetine are all equally effective i.
See also statement 4.3c.
i. Whitbread J, McGown A.The treatment of bulimia nervosa. What is effective? A meta-analysis. International Journal of Clinical Psychology 1994; 21: 32-44
(Type I evidence - systematic review)
4.3e. Exposure and response prevention strategies alone seem to be of little benefiti. i. Roth A, Fonagy P. What works for whom? A critical review of psychotherapy research. New York: The Guilford Press, 1996
(Type I evidence - systematic review)
4.3f. More research is required to define the optimal number of therapy sessions required to achieve a response and the length of time for which treatment should continue i. i. Hartmann A, Herzog T, Drinkmann A. Psychotherapy of bulimia nervosa: what is effective? A meta-analysis. Journal of Psychosomatic Research 1992; 36(2): 159-167
4.3g. Out-patient group therapies are effective in some patients but more work needs to be done to establish the profile of these patientsi. i. Fettes PA, Peters JM. A meta-analysis of group treatments for bulimia nervosa. International Journal of Eating Disorders 1992; 11(2): 97-110
(Type I evidence - systematic review)

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4.3h. Antidepressant therapy can reduce the binge/purge symptomatology of bulimia nervosa independent of concurrent depressioni,ii,iii,iv,v.
No particular antidepressant is more effective than the others but fluoxetine carries fewer side-effects and is said to
reduce cravings.
A Cochrane review is in preparation vi.
i. American Psychiatric Association. Practice Guidelines. Washington DC: American Psychiatric Association, 1996
(Type I evidence - systematic review)
ii. Mitchell J, Raymond N, Specker S. A Review of the controlled trials of pharmacotherapy and psychotherapy in the treatment of bulimia nervosa. International Journal of Eating Disorders 1993; 14(3): 229-247
(Type I evidence - systematic review)
iii. Goldstein D, Wilso M et al. Long-term fluoxetine treatment of bulimia nervosa. British Journal of Psychiatry 1995; 166: 660-666
(Type I evidence - systematic review)
iv. Leach A. The Psychopharmacotherapy of Eating Disorders. Psychiatric Annals 10 October 1995, p. 25
(Type I evidence - systematic review)
v. Wood A. Pharmacotherapy of bulimia nervosa-experience with fluoxetine. International Clinical Psychopharmacology. 1993
(Type II evidence - randomised controlled trial)
vi. Bacaltchuk J, Hay P. Antidepressants for people with bulimia nervosa. Cochrane Database of Systematic Reviews. Cochrane Library. 1998 Issue 2. Review in preparation.
4.3i. There is no evidence that the addition of an antidepressant to cognitive behavioural therapy (CBT) increases the effectiveness of CBT alonei. i. Mitchell J, Raymond N, Specker S. A Review of the controlled trials of pharmacotherapy and psychotherapy in the treatment of bulimia nervosa. International Journal of Eating Disorders 1993; 14(3): 229-247
(Type I evidence - systematic review)
4.3j. More research needs to be done to establish if the full therapeutic dose of antidepressants in the treatment of depression is needed in the treatment of bulimia nervosai. More research is needed on the effectiveness of long term maintenance therapy with antidepressantsi. i. Mitchell J, Raymond N, Specker S. A Review of the controlled trials of pharmacotherapy and psychotherapy in the treatment of bulimia nervosa. International Journal of Eating Disorders 1993; 14(3): 229-247
4.3k. Consideration needs to be given to research methodologies particularly to extending the range of outcome measures wider than just binge/purge symptoms. i,ii. i. Mitchell J, Raymond N, Specker S. A Review of the controlled trials of pharmacotherapy and psychotherapy in the treatment of bulimia nervosa. International Journal of Eating Disorders 1993; 14(3): 229-247
ii. Wolfe, B. Dimensions of response to antidepressant agents in bulimia nervosa: A review. Archives of Psychiatric Nursing 1995; 9(3): 111-121

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk