Mental health articles

One small RCT found limited evidence that focal analytical therapy or family therapy versus treatment as usual significantly increased the number of people recovered or improved as assessed by the Morgan Russell scale at one year. One small RCT found no significant difference in outcomes between psychotherapy and dietary counselling at one year. A second RCT comparing cognitive therapy versus dietary counselling found a 100 per cent failure to take-up/withdrawal rate with dietary counselling. Six small RCTs found no significant difference between different psychotherapies.

However, all the RCTs were small and were unlikely to have been powered to detect a clinically important difference between treatments approaches are used for people whose body mass index may be as low as 13 kg/m2. In such cases, there needs to be careful medical risk management and close cooperation between professional and lay carers. The patient’s level of motivation and their psychosocial resources can act as a buffer against the medical risks. Measuring the early response to treatment, such as a change in weight, or the arrest of weight loss and the ability to show active involvement in treatment is a good proxy measure of motivation and capacity to respond to outpatient psychotherapy. Once the decision is made that high intensity treatment (day or inpatient care) is needed, the next question is: What are the goals of this high intensity care? Traditionally the goal was weight restoration to a body mass index within the normal range (with less attention paid to goals for the other aspects of the psychopathology). This often leaves a gap between physical and psychological recovery that can be difficult to bridge. An alternative position is that admission should be long enough to ameliorate the medical risk, short of restoring weight to normal. This lessens the gap between physical and psychological recovery.

In many countries this decision is made pragmatically depending on how services are organized such as whether there is a model of shared care between community resources including carers and specialist services. Evidence from a large naturalistic study suggests that short admissions are more effective for those with a short duration of illness, i.e. adolescents, whereas long admission have a better chance of success in those with a longer duration of illness, i.e. adults.

Unnecessary hospitalization, has obvious disadvantages in terms of health care costs, schooling/career and disruption of social experiences, in addition to which there is some weak evidence that it may have a negative impact on the longterm outcome of the illness. Thus, the stage at which psychotherapy is started may need to vary depending on the clinical and demographic details of the patient. In young people, outpatient management should start after a shorter time and possibly at a lower weight than for cases with a long duration.

Tags: psychotherapy, techniques, types