Solmi Marco, Monaco Francesco, Højlund Mikkel, Monteleone Alessio M, Trott Mike, Firth Joseph, Carfagno Marco, Eaton Melissa, De Toffol Marco, Vergine Mariantonietta, Meneguzzo Paolo, Collantoni Enrico, Gallicchio Davide, Stubbs Brendon, Girardi Anna, Busetto Paolo, Favaro Angela, Carvalho Andre F, Steinhausen Hans-Christoph, Correll Christoph U
Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada.
Regional Centre for Treatment of Eating Disorders, and On Track: Champlain First Episode Psychosis Program, Department of Mental Health, Ottawa Hospital, Ottawa, ON, Canada.
World Psychiatry. 2024 Feb;23(1):124-138. doi: 10.1002/wps.21182.
Eating disorders (EDs) are known to be associated with high mortality and often chronic and severe course, but a recent comprehensive systematic review of their outcomes is currently missing. In the present systematic review and meta-analysis, we examined cohort studies and clinical trials published between 1980 and 2021 that reported, for DSM/ICD-defined EDs, overall ED outcomes (i.e., recovery, improvement and relapse, all-cause and ED-related hospitalization, and chronicity); the same outcomes related to purging, binge eating and body weight status; as well as mortality. We included 415 studies (N=88,372, mean age: 25.7±6.9 years, females: 72.4%, mean follow-up: 38.3±76.5 months), conducted in persons with anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified feeding and eating disorders (OSFED), and/or mixed EDs, from all continents except Africa. In all EDs pooled together, overall recovery occurred in 46% of patients (95% CI: 44-49, n=283, mean follow-up: 44.9±62.8 months, no significant ED-group difference). The recovery rate was 42% at <2 years, 43% at 2 to <4 years, 54% at 4 to <6 years, 59% at 6 to <8 years, 64% at 8 to <10 years, and 67% at ≥10 years. Overall chronicity occurred in 25% of patients (95% CI: 23-29, n=170, mean follow-up: 59.3±71.2 months, no significant ED-group difference). The chronicity rate was 33% at <2 years, 40% at 2 to <4 years, 23% at 4 to <6 years, 25% at 6 to <8 years, 12% at 8 to <10 years, and 18% at ≥10 years. Mortality occurred in 0.4% of patients (95% CI: 0.2-0.7, n=214, mean follow-up: 72.2±117.7 months, no significant ED-group difference). Considering observational studies, the mortality rate was 5.2 deaths/1,000 person-years (95% CI: 4.4-6.1, n=167, mean follow-up: 88.7±120.5 months; significant difference among EDs: p<0.01, range: from 8.2 for mixed ED to 3.4 for BN). Hospitalization occurred in 26% of patients (95% CI: 18-36, n=18, mean follow-up: 43.2±41.6 months; significant difference among EDs: p<0.001, range: from 32% for AN to 4% for BN). Regarding diagnostic migration, 8% of patients with AN migrated to BN and 16% to OSFED; 2% of patients with BN migrated to AN, 5% to BED, and 19% to OSFED; 9% of patients with BED migrated to BN and 19% to OSFED; 7% of patients with OSFED migrated to AN and 10% to BN. Children/adolescents had more favorable outcomes across and within EDs than adults. Self-injurious behaviors were associated with lower recovery rates in pooled EDs. A higher socio-demographic index moderated lower recovery and higher chronicity in AN across countries. Specific treatments associated with higher recovery rates were family-based therapy, cognitive-behavioral therapy (CBT), psychodynamic therapy, and nutritional interventions for AN; self-help, CBT, dialectical behavioral therapy (DBT), psychodynamic therapy, nutritional and pharmacological treatments for BN; CBT, nutritional and pharmacological interventions, and DBT for BED; and CBT and psychodynamic therapy for OSFED. In AN, pharmacological treatment was associated with lower recovery, and waiting list with higher mortality. These results should inform future research, clinical practice and health service organization for persons with EDs.
饮食失调（EDs）已知与高死亡率相关，且病程往往呈慢性和严重性，但目前尚缺乏对其结局的近期全面系统评价。在本系统评价和荟萃分析中，我们检索了1980年至2021年间发表的队列研究和临床试验，这些研究报告了DSM/ICD定义的饮食失调的总体结局（即康复、改善和复发、全因及与饮食失调相关的住院治疗以及慢性病程）；与清除行为、暴饮暴食和体重状况相关的相同结局；以及死亡率。我们纳入了415项研究（N = 88,372，平均年龄：25.7±6.9岁，女性：72.4%，平均随访时间：38.3±76.5个月），研究对象为神经性厌食症（AN）、神经性贪食症（BN）、暴饮暴食障碍（BED）、其他特定的喂养和饮食障碍（OSFED）及/或混合性饮食失调患者，研究来自除非洲以外的各大洲。在所有合并的饮食失调类型中，46%的患者实现了总体康复（95%CI：44 - 49，n = 283，平均随访时间：44.9±62.8个月，饮食失调组间无显著差异）。康复率在<2年时为42%，2至<4年时为43%，4至<6年时为54%，6至<8年时为59%，8至<10年时为64%，≥10年时为67%。总体慢性病程出现在25%的患者中（95%CI：23 - 29，n = 170，平均随访时间：59.3±71.2个月，饮食失调组间无显著差异）。慢性病程率在<2年时为33%，2至<4年时为40%，4至<6年时为23%，6至<8年时为25%，8至<10年时为12%，≥10年时为18%。死亡率出现在0.4%的患者中（95%CI：0.2 - 0.7，n = 214，平均随访时间：72.2±117.7个月，饮食失调组间无显著差异）。在观察性研究中，死亡率为5.2例/1000人年（95%CI：4.4 - 6.1，n = 167，平均随访时间：88.7±120.5个月；饮食失调类型间存在显著差异：p<0.01，范围：从混合性饮食失调的8.2到神经性贪食症的3.4）。住院治疗出现在26%的患者中（95%CI：18 - 36，n = 18，平均随访时间：43.2±41.6个月；饮食失调类型间存在显著差异：p<0.001，范围：从神经性厌食症的32%到神经性贪食症的4%）。关于诊断转变，8%的神经性厌食症患者转变为神经性贪食症，16%转变为其他特定的喂养和饮食障碍；2%的神经性贪食症患者转变为神经性厌食症，5%转变为暴饮暴食障碍，19%转变为其他特定的喂养和饮食障碍；9%的暴饮暴食障碍患者转变为神经性贪食症，19%转变为其他特定的喂养和饮食障碍；7%的其他特定的喂养和饮食障碍患者转变为神经性厌食症，10%转变为神经性贪食症。儿童/青少年在所有饮食失调类型以及每种饮食失调类型内部的结局都比成年人更有利。自伤行为与合并的饮食失调类型中较低的康复率相关。较高的社会人口学指数在不同国家的神经性厌食症患者中调节了较低的康复率和较高的慢性病程率。与较高康复率相关的特定治疗方法包括针对神经性厌食症的家庭治疗、认知行为疗法（CBT）、心理动力疗法和营养干预；针对神经性贪食症的自助、CBT、辩证行为疗法（DBT）、心理动力疗法、营养和药物治疗；针对暴饮暴食障碍的CBT、营养和药物干预以及DBT；针对其他特定的喂养和饮食障碍的CBT和心理动力疗法。在神经性厌食症中，药物治疗与较低的康复率相关，等待名单与较高的死亡率相关。这些结果应为未来针对饮食失调患者的研究、临床实践和卫生服务组织提供参考。
