Review of: Couturier J et al, J Eating Disorders 2020;8:4

Good guidelines can optimize clinical practice. The APA last published eating disorder guidelines in 2012. In 2020, a group of Canadian psychiatrists published new practice guidelines for eating disorder treatment. Let’s take a look.

This systematic and comprehensive literature review screened thousands of abstracts to find several dozen articles and prioritized randomized controlled trials (RCTs). The diverse 24-member research team included parents and patient representatives and looked at various psychotherapies: family-based cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), medications (primarily atypical antipsychotics and SSRIs), and site of treatment.

Of the studies reviewed, many suffered from significant potential bias and many showed no significant effect of treatment. But there was some strong research. For example, one study compared CBT with psychodynamic therapy for 81 girls with anorexia nervosa. The two treatments were comparable, each yielding remission rates of about 33% after an average of 37 weeks of treatment.

After synthesizing all the study results, the researchers arrived at two main recommendations: First, family-based treatment is clearly effective for both anorexia nervosa and bulimia nervosa, and second, less restrictive treatment environments (eg, family-based or day treatment) are more effective than lengthy hospitalizations. The following five modalities were also recommended, but with less confidence: multi-family therapy, CBT, adolescent-focused psychotherapy, yoga, and olanzapine or aripiprazole with anorexia nervosa “if monitored carefully.”

Why weren’t SSRIs recommended? After all, the 2012 APA guidelines found grade A evidence for numerous antidepressants in bulimia nervosa (36 RCTs) and binge eating disorder (26 RCTs) with adults. The answer is that these Canadian researchers excluded studies with subjects over age 18, eliminating the great majority of medication RCTs in eating disorders.

CCPR’s Take
Don’t rely on medications to be game changers for children and adolescents with eating disorders. This exhaustive review of the literature on child and adolescent eating disorder treatment guides us to favor evidence-based psychotherapies in the least restrictive environments (Editor’s note: To review the guidelines for eating disorders, see the Couturier et al study at www.tinyurl.com/3whtlsxa).