Enhanced cognitive-behavior therapy and family-based treatment for adolescents with an eating disorder: A non-randomized effectiveness trial

Family-based treatment (FBT) is an efficacious intervention for adolescents with an eating disorder. Evaluated to a lesser degree among adolescents, enhanced cognitive-behavior therapy (CBT-E) has shown promising results.

A new study published in Psychological Medicine compared the relative effectiveness of FBT and CBT-E delivered by the Center for the Treatment of Eating Disorders (CTED) at Children’s Minnesota, MN, a pediatric specialty clinic in the USA, provides inpatient and outpatient treatment to youth and their families.

Over the course of the study period (July 2015–November 2019), 107 patients met the eligibility criteria for the study. Of those, 10 families withdrew consent, and 97 patients (83%) and their families were enrolled and offered a choice between one of two manualized treatments: FBT or CBT-E. Fifty-one (52.5%) chose FBT, and 46 (47.5%) CBT-E.

The sample was divided into a lower weight cohort [<90% median body mass index (mBMI); 38% of participants) and higher weight choort. Regardless of weight cohort, participants who selected CBT-E were older, had been ill longer, presented with higher depression and anxiety, more prior mental health treatment, and higher rates of psychosocial impairment due to eating disorder features (all ps 0.034–0.0001).

Assessments were administered at baseline, end-of-treatment (EOT), and follow-up (6 and 12 months). Treatment comprised of 20 sessions over 6 months, except for the lower weight cohort where CBT-E comprised 40 sessions over 9-12 months. Primary outcomes were slope of weight gain and change in Eating Disorder Examination (EDE) Global Score at EOT.

Regardless of weight cohort, FBT was more efficient than CBT-E in terms of the slope of weight gain from baseline to the EOT. However, this was no longer the case at either the 6- or 12-month follow-up.

Initial more gradual weight gains achieved by CBT-E compared to FBT at EOT seems due to distinct strategies used to achieve weight gain across these two treatments. In CBT-E, weight gain (when indicated) is addressed after 4 weeks of treatment, and only when patients reach the conclusion that they need to attend to their low weight. In contrast, weight gain in FBT (when indicated) is addressed at the outset, while parents are supported to drive this agenda.

However, for a substantial minority of patients in the higher weight cohort (∼22%), weight gain was not a treatment goal. Therefore, relative effectiveness was defined in terms of weight gain and/or improvement in eating disorders psychopathology. In this domain, both treatments demonstrated improvements in the EDE/Q Global Score with no significant differences across time. In terms of the secondary outcomes (controlling for baseline differences), the two treatments largely established similar gains across measures of general psychopathology and clinical impairment.

An interesting data is that choosing between FBT and CBT-E resulted in older and less well participants opting for CBT-E. Albeit speculatively, it seems that parents considered an individual therapy rather than a family-based one to be more appropriate when their offspring was older and more unwell.

In conclusion, results show that FBT and CBT-E achieved similar outcomes in the treatment of adolescents with eating disorders, making CBT-E a viable treatment for adolescents with an eating disorder.

Le Grange, D., Eckhardt, S., Dalle Grave, R., Crosby, R. D., Peterson, C. B., Keery, H., Lesser, J. Martell, C. (2020). Enhanced cognitive-behavior therapy and family-based treatment for adolescents with an eating disorder: a non-randomized effectiveness trial. Psychological Medicine, 1-11. doi:10.1017/s0033291720004407