Researchers evaluate therapies for anorexia nervosa

Therapists and eating disorders specialists at Washington University School of Medicine in St. Louis are joining investigators at a handful of sites around North America to evaluate anorexia nervosa treatments. Only 25 percent of anorexia patients recover completely, and the goal of this study is to improve those odds.

Anorexia nervosa has one of the highest mortality rates of any mental illness, and only 25 percent of anorexia patients completely recover. Denise Wilfley, professor of psychiatry, is searching for ways to improve outcomes for anorexia patients.

Funded by the National Institute of Mental Health (NIMH), the study will look at therapeutic approaches that involve families and also test whether antidepressant medication can enhance the results. The researchers will compare two types of family therapy. Participants will come to 16 one-hour family therapy sessions over a nine-month period. In addition, half of the patients with anorexia nervosa will receive the drug fluoxetine (Prozac). The rest will take an inactive placebo.

“We’re examining whether one type of family therapy is superior to another and whether or not there is an added benefit from medication, both in terms of initial improvements and long-term health,” says Denise E. Wilfley, Ph.D., professor of psychiatry, medicine, pediatrics and psychology and principal investigator at the Washington University study site. “Anorexia nervosa is the eating disorder that we’ve been aware of the longest, but very few large-scale studies have been conducted, so it’s virtually impossible to provide good evidence-based recommendations for care.”

Anorexia nervosa is associated with serious medical complications, including cardiovascular, dermatological, gastrointestinal and osteoporosis problems.

“Many teenagers with anorexia nervosa also do poorly in school because starvation interferes with their cognitive function as well as multiple other systems in the body,” Wilfley says. “This disorder affects both physical and psychological health, and it has among the highest suicide rates of any psychiatric illness. In fact, while anorexia nervosa is rare it has the highest death rate of any mental disorder.”

The investigators will recruit 240 anorexia patients and their families at six sites in North America, making this the largest NIH-funded treatment study of the disorder. Some 40 patient families will receive treatment at Washington University School of Medicine.

The families will be divided into four groups: Behavioral Family Therapy (BFT), an intervention that focuses on changing the affected child’s eating behavior; BFT and the antidepressant drug fluoxetine; Systems Family Therapy (SFT), an intervention that explores family issues that may influence the development of the eating disorder; and SFT plus fluoxetine for the affected adolescent.

The researchers are seeking families with a child between the ages of 12 and 18 who has anorexia nervosa. Adolescents of both genders with the disorder are eligible for the study because although anorexia nervosa is more commonly diagnosed in females, 10 percent of anorexia nervosa patients are male.

Families who qualify will be randomly assigned to one of the four study groups. Those in the BFT groups primarily will be taught what the medical literature calls “re-feeding.” Dorothy Van Buren, Ph.D., research assistant professor of psychiatry, will be involved in BFT therapy. She says among the unique aspects of the treatment is the session at which the counselor observes a family meal.

“We observe how effective they are at being able to encourage their child to eat an adequate amount,” she says. “That gives us information about how best to coach the family, what their strengths are and some areas they might need to work on.”

Van Buren describes BFT as encouraging and structuring the family situation so that eating is expected. Often, she says, parents are so fearful of anorexia nervosa that they stop expecting their child to eat normally, and as the child becomes sicker, the expectations get lower as the family accommodates the eating disorder.

“The behavioral therapy is designed to help families find ways to break that cycle,” she says.

Families randomly selected for the SFT treatment also will come in for family therapy sessions, but those sessions have a different philosophical approach, according to Robinson Welch, Ph.D., assistant professor of psychiatry.

“We assume families have a ‘set point’ where they function best, and we intervene via a series of questions and reflections to help them make changes in the ways they operate,” Welch explains. “Whereas the behavioral approach provides something like a map for the family, the systems approach is like holding up a mirror. The therapist helps the family reflect on how they are different and how the family dynamic may have changed as a result of anorexia nervosa. Going through that process, we hope they will be able to self-correct.”

Both behavioral and systems family therapy have been demonstrated to be effective treatments for anorexia nervosa, but there has been little research about which approach works best. There also is some evidence that antidepressant drugs like fluoxetine may help this patient population.

“Fluoxetine could help anorexia nervosa patients deal more effectively with the anxiety and the depressive features of the disorder,” Wilfley explains. “Controlling those symptoms could make therapy more effective. That’s important because when patients do recover, there still is a 40 percent relapse rate.”

Divorced and nontraditional families are welcome to participate, and all family members living in a household are expected to participate in behavioral or systems family therapy sessions. Screenings, family treatment, medication and medical monitoring are provided at no cost. For more information or to volunteer for the study, call project coordinator Nichole Cecil at (314) 286-0076.

Washington University School of Medicine’s 2,100 employed and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children’s hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked fourth in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children’s hospitals, the School of Medicine is linked to BJC HealthCare.