Post-Acute Interventions for the Treatment of Anorexia Nervosa

Presenter:

Matthew V. Rudorfer, M.D. and Mary Rooney, Ph.D.
Division of Services and Intervention Research

Goal:

This concept seeks applications for projects to evaluate preliminary effectiveness of interventions targeting sustained and enhanced clinical response following acute treatment for anorexia nervosa (AN). In this pilot research phase, trials should be designed to evaluate the feasibility, tolerability, acceptability, safety, and target engagement, as well as potential effectiveness, with a deployment-focused approach to facilitate approaches that are scalable to community settings.

Rationale:

It can be startling to appreciate that the mental disorder with the highest mortality is anorexia nervosa (AN). Data continue to show a mortality rate of approximately 5% per decade for those with AN, outpacing other eating disorders by several orders of magnitude. While most of these premature deaths result from physical complications of the disease, one-in-five of them are due to suicide. Meanwhile, treatment options are limited and primarily focused on acute intervention. Although no medication with an indication for the treatment of AN has been approved by the Food and Drug Administration, evidence-based short-term interventions for AN do exist and are widely used in many specialty clinics. These include individual and family-based psychotherapy and medical and behavioral approaches to restore healthy body weight. Yet even the most promising of these interventions result in remission rates that hover around 50%. A recent meta-analysis found evidence-based psychosocial interventions to be superior to comparison treatments at imparting change in weight-based outcomes at the end of acute treatment, but these changes tended to fade at 6- and 12-month follow-up time points. In terms of impact on psychological symptoms, evidence-based treatments conferred no advantage over comparator interventions either at end-of-treatment or follow-up. These findings highlight the pressing need for enhanced interventions for the treatment of AN.

Seeking to build upon what progress has been made to date, this concept encourages research that focuses on interventions – psychosocial, pharmacological, or somatic – delivered during the post-acute treatment period. At that time, individuals with AN who have achieved weight restoration may be more physically capable of engaging in interventions targeting psychological symptoms, have greater insight, and present a more favorable benefit: risk ratio for pharmacotherapy or neurostimulation than when they were in a malnourished state on initial presentation.

Potential intervention approaches resulting from this program of research could include, but are not limited to:

• Interventions that support the maintenance of treatment gains and emphasize relapse prevention during high-risk periods in the post-acute treatment phase (e.g., developmental and environmental transitions such as leaving home and progressing to living independently);
• Augmentations and adaptations targeting residual symptoms, functional impairments, and comorbidities that persist beyond the acute intervention period;
• Adaptations addressing mechanisms of response that may mediate reductions in psychological symptoms associated with AN and sustained weight restoration.