An Alternative Treatment for Anorexia Nervosa: Systemic Family Therapy

Family-based therapy (FBT) has become a mainstay in the treatment of anorexia nervosa (AN) in adolescents, and it has substantial research support. On the other hand, FBT clearly does not work for all adolescents, so alternative treatments are certainly needed. Stewart Agras and colleagues recently reported the results of their study comparing FBT to an alternative type of treatment, systemic family therapy (JAMA Psychiatry. 2014; 71:1279). Systemic family therapy views the problems of an individual in relation to the different contexts in which this individual lives: i.e, as a partner in a couple relationship, as a family member, or as a person with particular cultural and/or religious allegiances, while also taking into account socioeconomic circumstances and political processes.

The study involved 164 male and female adolescents. All participated in 16 one-hour sessions, which were provided over the course of 9 months. Typical eating disorder outcomes were examined, as well as measures of anxiety, obsessionality, and mood.

The results with FBT and systemic family therapy did not differ, either at the end of treatment or at the end of the follow-up period. At the end of treatment, remission rates were 33.1% and 25.3% with FBT and systemic family therapy, respectively. By the end of follow-up, remission rates were 40.7% with FBT and 39.0% with systemic family therapy. An economic analysis of the trial showed that costs per remitted patient were lower with FBT, perhaps due in part to the faster weight gain that was observed in the FBT group, which may have led to shorter hospital stays. Also of note, response to treatment was influenced by obsessive-compulsive symptoms, such that higher levels of obsessive-compulsive symptoms (as measured by the Children’s Yale-Brown Obsessive Compulsive Scale were linked to better response to systemic family therapy.

The results are somewhat surprising. The researchers had hypothesized that FBT would be more effective than systemic family therapy, which seemed a reasonable hypothesis based on prior research. On the other hand, the results are very useful, as they provide an alternative treatment approach for adolescents with AN, and may indicate a particular group (those with high obsessive-compulsive symptoms) who might be particularly good candidates for systemic family therapy.