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Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa

  • Review
  • Intervention

Authors


Abstract

Background

Anorexia nervosa is a disorder with high morbidity and significant mortality. It is commonest in young adult women, in whom the incidence may be increasing. The focus of treatment has moved to an outpatient setting and a number of differing psychotherapies are presently used in treatment.

Objectives

The aim of the present review was to evaluate the evidence from randomised controlled trials for the efficacy of outpatient psychotherapies used in the treatment of older adolescents and adults with anorexia nervosa.

Search methods

CCDANCTR-Studies and CCDANCTR-References were searched on 12/2/2008. Further database searches of MEDLINE, EXTRAMED, EMBASE, PSYCLIT, CURRENT CONTENTS were carried out, hand-search of The International Journal of Eating Disorders, and the reference lists of all papers selected. Personal letters were sent to identified notable researchers who had published in the area, requesting information on trials that are unpublished or in progress. The search was updated to December 2005 (MEDLINE and CCDAN registers) and then to Feb 2008 (MEDLINE, SCOPUS, and CCDAN registers).

Selection criteria

All randomised controlled trials of adult individual outpatient therapy for anorexia nervosa, as defined by DSM-IV or similar international criteria. Quality assessment was made according to Quality Rating Scale criteria and in addition, whether the trial had examined treatment integrity.

Data collection and analysis

A range of outcome variables were selected, including physical state, severity of eating disorder attitudes and beliefs, interpersonal function, and general psychiatric symptom severity. Continuous outcome data comparisons used the standardised mean difference statistic, and binary outcome comparisons used relative risk. Reliability of data extraction and quality assessment were made with the kappa statistic. Sensitivity analyses to evaluate the effects of trial quality and subgroup analyses to explore specific questions of treatment effects from different settings, frequency and duration of therapies were planned.

Main results

Seven small trials only, two of which included children or adolescents, were identified from the search, and aggregation of data was not possible. Bias was possible due particularly to lack of blinding of outcome assessments. The results in two trials suggested that 'treatment as usual' or similar may be less efficacious than a specific psychotherapy. No specific treatment was consistently superior to any other specific approach. Dietary advice as a control arm had a 100% non-completion rate in one trial. One trial found a nonspecific therapy was favoured over two specific psychotherapies.

Authors' conclusions

No specific approach can be recommended from this review. It is unclear why 'treatment as usual' performed so poorly, or why dietary advice alone appeared so unacceptable, as the reasons for non-completion were not reported. There is an urgent need for large well-designed trials in this area.

摘要

背景

使用個別心理治療來治療門診的成人神經性厭食症患者

神經性厭食症是一種高發病率和高死亡率的疾病。常見於年輕女性,且其發生率可能逐漸升高。目前治療的重點轉到門診治療,且嘗試使用不同種類的心理治療模式。

目標

本次回顧的目的是評估從隨機對照試驗所得來的證據,有關於針對門診中患有神經性厭食症的青少年和成人病患使用心理治療的效果。

搜尋策略

搜尋策略是搜尋資料庫 MEDLINE, EXTRAMED, EMBASE, PSYCLIT, CURRENT CONTENTS, the Cochrane Depression, Anxiety and Neurosis Cochrane Group Controlled Trials Register (CCDANCTR), 尋找紙本的 The International Journal of Eating Disorders, 以及所選文章的參考文獻。寄信詢問相關領域的研究者有關未發表或正在進行的研究內容。搜尋至2005年12月(MEDLINE and CCDANCTR)。

選擇標準

選擇所有有關成人神經性厭食症的門診心理治療的隨機對照試驗,神經性厭食症是根據DSMIV或相似的國際準則來診斷。根據Quality Rating Scale criteria 來進行品質評估,而且也對研究本身是否驗證治療的完整性進行評估。

資料收集與分析

選擇相當多的結果變項,包括:身體狀況、厭食症相關的態度及信念的嚴重程度、人際功能和一般精神症狀的嚴重程度。連續變項的比較是使用標準差來統計,名義變項的比較是使用相對風險(relative risk)資料篩選的信度和品質評估都是使用 kappa 來計算。同時進行敏感度分析來評估試驗的品質,並進行次組別分析來評估在不一樣的場所、不一樣頻率、不一樣的治療時間的效果。

主要結論

只有七篇小試驗,其中兩篇是兒童或青少年,因此無法將資料整合,而且結果的評估並不是雙盲的研究,可能會產生偏誤。兩篇研究的建議是‘例行的治療’比起特定的心理治療較無效,但是也沒有特定的哪一種治療優於其他種治療。當作控制組的飲食建議在其中一個研究中有100%的不順從性。有一個研究發現一種非特定性的治療優於其他兩種特定性的心理治療。

作者結論

本文獻並沒有建議特定的治療取向,但是不清楚為什麼“例行的治療”效果這麼差,也不清楚為什麼單純‘飲食建議’很難被接受,也不清楚為什麼醫囑順從性差的原因。在這方面的領域實在是有迫切的需要進行大範圍、良好設計的研究來瞭解。

翻譯人

本摘要由彰化基督教醫院胡淑惠翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

我們並不知道在門診中患有神經性厭食症的成人患者或者年紀稍長的青少年接受心理治療是否有用。本文獻的目的是評估對門診的神經性厭食症患者進行心理治療效果的證據。雖然神經性厭食症是一個嚴重且失能的疾病,但是卻只發現7篇研究,這些研究使用不同形式的心理治療,因此很難對於這些研究所使用的心理治療有一個確定的結論。對於沒有接受心理治療的受試者(例如:在等候名單上的控制組或者只接受“例行的治療”)其結果較差。在一個研究中,所有只得到‘飲食建議’的控制組受試全部退出研究。我們極需要進行不同中心、大規模的隨機控制試驗,使用常同的心理治療來治療神經性厭食症的成人患者及年紀稍長的青少年的研究。

Plain language summary

Outpatient psychotherapy for anorexic adults

This review aimed to assess evidence about the effects of outpatient psychotherapy on older adolescents and adults with anorexia nervosa. Although anorexia nervosa is a severe and disabling disorder, only seven trials were found. The trials used different types of psychotherapy. It was not possible to make firm conclusions about the therapies tested. Participants who did not receive psychotherapy (e.g. were in a waiting-list control group or who got 'treatment as usual') did poorly. In one study, all those in the control group who got only 'dietary advice' dropped out. There is an urgent need for multi-centre, large randomized controlled trials of commonly used psychotherapies in older adolescents and adults with anorexia nervosa.

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