Neurosciences Department and Neuroscience Centre, University of Padua, Padua, Italy.
Discipline of Psychology, Flinders University, Adelaide, SA, Australia.
Lancet Psychiatry. 2021 Mar;8(3):215-224. doi: 10.1016/S2215-0366(20)30566-6. Epub 2021 Feb 15.
No consistent first-option psychological interventions for adult outpatients with anorexia nervosa emerges from guidelines. We aimed to compare stand-alone psychological interventions for adult outpatients with anorexia nervosa with a specific focus on body-mass index, eating disorder symptoms, and all-cause dropout rate.
In this systematic review and network meta-analysis, we assessed randomised controlled trials about stand-alone pharmacological or non-pharmacological treatments of adult outpatients with anorexia nervosa, defined according to standardised criteria, with data for at least two timepoints relating to either body-mass index or global eating disorder psychopathology. We searched Cochrane CENTRAL, CINAHL, MEDLINE, and PsychINFO for published and unpublished literature from inception until March 20, 2020. The primary outcomes were the change in body mass index and clinical symptoms, and the secondary outcome was all-cause dropout rate, which were all assessed for treatment as usual, cognitive behavioural therapy (CBT), Maudsley anorexia treatment for adults, family-based treatment, psychodynamic-oriented psychotherapies, a form of CBT targeting compulsive exercise, and cognitive remediation therapy followed by CBT. Global and local inconsistencies for the network meta-analysis were measured, and CINeMA was used to assess the confidence in evidence for primary outcomes. The protocol is registered in PROSPERO (CRD42017064429).
Of 14 003 studies assessed for their title and abstract, 16 (0·1%) randomised controlled trials for psychological treatments were included in the systematic review, of which 13 (0·1%) contributed to the network meta-analysis, with 1047 patients in total (of whom 1020 [97·4%] were female). None of the interventions outperformed treatment as usual in our primary outcomes, but the all-cause dropout rate was lower for CBT than for psychodynamic-oriented psychotherapies (OR 0·54, 95% CI 0·31-0·93). Heterogeneity or inconsistency emerged only for a few comparisons. Confidence in the evidence was low to very low.
Compared with treatment as usual, specific psychological treatments for adult outpatients with anorexia nervosa can be associated with modest improvements in terms of clinical course and quality of life, but no reliable evidence supports clear superiority or inferiority of the specific treatments that are recommended by clinical guidelines internationally. Our analysis is based on the best data from existing clinical studies, but these findings should not be seen as definitive or universally applicable. There is an urgent need to fund new research to develop and improve therapies for adults with anorexia nervosa. Meanwhile, to better understand the effects of available treatments, participant-level data should be made freely accessible to researchers to eventually identify whether specific subgroups of patients are more likely to respond to specific treatments.
Flinders University, National Institute for Health Research Oxford Health Biomedical Research Centre.
针对成人门诊厌食症患者，指南中没有明确的首选心理干预措施。我们旨在比较针对成人门诊厌食症患者的单一心理干预措施，特别关注体重指数、饮食障碍症状和全因辍学率。
在这项系统评价和网络荟萃分析中，我们评估了根据标准化标准定义的成人门诊厌食症患者的单独药理学或非药理学治疗的随机对照试验，这些试验的数据至少有两个时间点与体重指数或整体饮食障碍心理病理学相关。我们检索了 Cochrane 中心、CINAHL、MEDLINE 和 PsychINFO，以获取截至 2020 年 3 月 20 日发表和未发表的文献。主要结局是体重指数和临床症状的变化，次要结局是全因辍学率，这些结局均针对常规治疗、认知行为疗法（CBT）、Maudsley 成人厌食症治疗、家庭为基础的治疗、精神动力学导向的心理治疗、针对强迫性运动的 CBT 形式以及认知矫正治疗后进行 CBT 进行评估。测量了网络荟萃分析的全局和局部不一致性，并使用 CINeMA 评估了主要结局的证据可信度。该方案已在 PROSPERO（CRD42017064429）中注册。
在评估标题和摘要的 14003 项研究中，纳入了 16 项（0.1%）针对心理治疗的随机对照试验进行系统评价，其中 13 项（0.1%）纳入了网络荟萃分析，共有 1047 名患者（其中 1020 名[97.4%]为女性）。在我们的主要结局中，没有一种干预措施比常规治疗表现更好，但 CBT 的全因辍学率低于精神动力学导向的心理治疗（OR 0.54，95%CI 0.31-0.93）。只有少数比较出现了异质性或不一致性。证据可信度低至非常低。
与常规治疗相比，针对成人门诊厌食症患者的特定心理治疗可能与临床病程和生活质量的适度改善相关，但没有可靠的证据支持国际临床指南推荐的特定治疗具有明显的优势或劣势。我们的分析基于现有临床研究的最佳数据，但这些发现不应被视为定论或普遍适用。迫切需要为成人厌食症患者的治疗开发和改进疗法提供资金。同时，为了更好地了解现有治疗方法的效果，应向研究人员免费提供参与者水平的数据，以便最终确定是否特定亚组的患者更有可能对特定治疗方法产生反应。
弗林德斯大学、英国牛津大学国家卫生研究院健康生物医学研究中心。
