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Evidence-based clinical guidelines for eating disorders: international comparison

Evidence-based clinical guidelines for eating disorders: international comparison REVIEW URRENT Evidence-based clinical guidelines for eating PINION disorders: international comparison a b,c,d a Anja Hilbert , Hans W. Hoek , and Ricarda Schmidt Purpose of review The current systematic review sought to compare available evidence-based clinical treatment guidelines for all specific eating disorders. Recent findings Nine evidence-based clinical treatment guidelines for eating disorders were located through a systematic search. The international comparison demonstrated notable commonalities and differences among these current clinical guidelines. Summary Evidence-based clinical guidelines represent an important step toward the dissemination and implementation of evidence-based treatments into clinical practice. Despite advances in clinical research on eating disorders, a growing body of literature demonstrates that individuals with eating disorders often do not receive an evidence-based treatment for their disorder. Regarding the dissemination and implementation of evidence-based treatments, current guidelines do endorse the main empirically validated treatment approaches with considerable agreement, but additional recommendations are largely inconsistent. An increased evidence base is critical in offering clinically useful and reliable guidance for the treatment of eating disorders. Because developing and updating clinical guidelines is time-consuming and complex, an international coordination of guideline development, for example, across the European Union, would be desirable. Keywords eating disorders, evidence-based, guideline, therapy, treatment INTRODUCTION show a long-term natural course with remission in more than 50% of cases, whereas evidence on Anorexia nervosa (AN), bulimia nervosa (BN), and the natural course of BED is scarce [7]. While AN binge-eating disorder (BED) represent the specific occurs in up to 4% of young women [7,8 ], BN and eating disorders defined in the Diagnostic and Statis- BEDhavealifetimeprevalence of1.0 and1.9%, ticalManualofMentalDisorders,5th Edition (DSM-5 respectively [9]. [1]). They are characterized – at varying degrees – by persistent disturbances in eating or weight-control behavior andshape andweightoverconcern.The central characteristic of AN is a significantly low Department of Medical Psychology and Medical Sociology, Department body weight, induced by restriction of energy in- of Psychosomatic Medicine and Psychotherapy, University of Leipzig take. The main features of BN and BED are recurrent Medical Center, Leipzig, Germany, Parnassia Psychiatric Institute, The Hague, Department of Psychiatry, University Medical Center Groningen, binge-eating episodes. Although individuals with University of Groningen, Groningen, The Netherlands and Department BN usually attempt to prevent weight gain through of Epidemiology, Columbia University, Mailman School of Public Health, inappropriate compensatory behaviors (e.g., self- New York, New York, USA induced vomiting), those with BED do not make Correspondence to Anja Hilbert, Department of Medical Psychology and recurrent use of them. All eating disorders result in Medical Sociology, Department of Psychosomatic Medicine and Psy- significant impairments in health, psychosocial chotherapy, University of Leipzig Medical Center, Philipp-Rosenthal- functioning, and quality of life [2,3]. Increased Strasse 27, 04103 Leipzig, Germany. Tel: +49 341 97 15361; fax: +49 341 97 15359; e-mail: anja.hilbert@medizin.uni-leipzig.de healthcare utilization and costs have been docu- mented [4 ,5]. With a first onset that often occurs in Curr Opin Psychiatry 2017, 30:423–437 adolescence or young adulthood [6], AN and BN DOI:10.1097/YCO.0000000000000360 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com Eating disorders across the world. Their general aim is to inform KEY POINTS clinical decision-making of healthcare professionals and patients on efficacious interventions and treat- The systematic review showed notable commonalities ment strategies. Based on a systematic search, selec- and differences among evidence-based clinical tion, and evaluation of the treatment literature, treatment guidelines for eating disorders. evidence-based treatment guidelines offer specific Regarding the dissemination and implementation of recommendations to optimize patient care [25–27]. evidence-based treatments, current guidelines endorse In one narrative review, Herpertz-Dahlmann et al. main empirically supported treatment approaches with [28] compared several evidence-based clinical guide- considerable agreement, but additional lines from four European countries (Germany, recommendations are largely inconsistent. Spain, The Netherlands, and the United Kingdom) An increased evidence base is critical in offering regarding the treatment of AN. They found corre- clinically reliable and consistent guidance for the spondence in major recommendations, but no con- treatment of eating disorders. sensus on treatment intensity/setting, as well as Because clinical guideline development is time- no consensus and lack of evidence on nutritional consuming and complex, an international coordination, rehabilitation and weight restoration. The authors for example, across the European Union, would be identified a need for European research initiatives desirable. on AN to enhance the evidence base and clinical guidance. Since this report, several new guidelines were issued (e.g., The Netherlands, the United King- Given the clinical significance of eating disorder dom, Australia); however, current comparative in- symptomatology, over the past decades sustained formation is lacking, especially for BN and BED. This effort has been placed on designing and evaluating systematic review sought to compare the available psychological and medical treatments for eating evidence-based clinical treatment guidelines for all disorders in rigorous, randomized-controlled effica- specific eating disorders to investigate the necessity && cy studies [10 ,11–14]. Despite these advances, a of future work on guidelines for translation into growing body of literature demonstrates that indi- practice. viduals with eating disorders often do not receive an evidence-based treatment for their disorder && METHOD [15 ,16]. For example, Kessler et al. [9] documented in 24 124 adults from 14 countries that only 47.4% Guideline identification of lifetime cases with BN and 38.3% of lifetime cases with BED ever received a specific treatment for their In May 2017, we systematically searched the elec- eating disorder. In a study among 5 658 women 40– tronic databases PubMed and Cochrane Database of 50 years old from the United Kingdom, only 27.4% Systematic Reviews [‘guideline AND (eating disorder of all women with a DSM-5 life-time diagnosis of an OR anorexia nervosa OR bulimia nervosa OR binge- eating disorder had sought help or received treat- eating disorder)’]; the National Guideline Clearing- ment for an eating disorder at any point in their house and the International Guideline Library life [17 ]. Multiple system factors (e.g., lack of (‘eating disorder OR anorexia nervosa OR bulimia screening for eating disorders) and personal patient nervosa OR binge-eating disorder’); the website of the Academy of Eating Disorders through which factors (e.g., lack of information) may account for && & & partners and affiliate organizations were obtained this ‘treatment gap’ [15 ,18 ,19 ]. In addition, a and contacted; and contacted other experts in the ‘research-practice gap,’ indicating a discrepancy field. Relevant clinical guidelines were required to between evidence-based treatments and actual be evidence-based; the latest version; address the treatment delivery, was identified: As an example, treatment of AN, BN, and/or BED; have a focus the majority of eating disorder therapists do not on adults; to be published in Dutch, English, or adhere to evidence-based treatment protocols but German; and have a national or international scope. rather pursue eclectic combinations of interven- tions [20,21,22 ]; findings such as this highlight the significant challenge of disseminating and Assessments and analysis implementing of evidence-based eating disorder && To compare the content of the guidelines, key rec- treatments into clinical practice [15 ,23,24]. ommendations were summarized regarding pre- As a first step toward the dissemination and defined categories. For AN, BN, and BED, these implementation of evidence-based treatments into clinical practice, evidence-based clinical guidelines categories included: first-line treatment setting, cri- for eating disorders were issued in several countries teria for hospitalization, recommended treatment 424 www.co-psychiatry.com Volume 30  Number 6  November 2017 Evidence-based clinical guidelines for eating disorders Hilbert et al. modalities including nutritional counseling, specif- earlier versions of included guidelines, four guide- ic psychological interventions, and medications. For lines were non-evidence-based, two guidelines sole- the treatment of AN, guidelines were additionally ly focused on childhood eating disorders, and one compared with respect to the following categories: guideline had a regional scope. Accordingly, nine compulsory treatment, criteria for partial hospitali- guidelines from eight countries, published between zation, criteria for discharge, recommended energy 2009 and 2017, were included in this report. intake and weight gain, feeding supplements, and Most guidelines (n¼ 7) included treatment rec- artificial feeding. ommendations for AN, BN, and BED: these were the Included guidelines were independently exam- guidelines from Australia and New Zealand [29], ined by two authors. Relevant content was extracted Germany [30], The Netherlands [31], Spain [32], into a predefined coding table using the guidelines’ the United Kingdom [33], the United States original text by one author with corrections from [34,35], and the World Federation of Societies of the second author. For comparative purposes, it was Biological Psychiatry (WFSBP; [36]). The guideline noted whether a recommendation was given (U)or from Denmark [37,38] addressed the treatment of not reported, and if possible, the guidelines’ recom- AN and BN, while the French guideline [39] focused mendations were recoded into three ratings: explicit on AN only. All guidelines are described in Table 1. recommendation in favor (þ), recommendation re- The guideline by the WFSBP provided recommen- quiring caution [(þ)], and recommendation against dations for medical treatment of eating disorders (). In addition, and if recoding was not possible, only, whereas all other guidelines addressed several the guidelines’ recommendations were reported in treatment approaches. The majority of guidelines text format. were developed by multiprofessional working groups (Australia and New Zealand, France, Germany, The Netherlands, Spain, the United King- RESULTS dom), while both the United States and WFSBP A total of 33 guidelines were identified, as depicted guidelines were developed by psychiatric groups. in the PRISMA flow chart (Fig. 1). Most guidelines Regarding the modernity of the guidelines, three had to be excluded for not meeting the language guidelines were published within the last 3 years criterion (n¼ 12). In addition, five guidelines were (Australia and New Zealand, Denmark, the United Records identified through database searching: Additional records identified PubMed, Cochrane Database, National through contacting Academy of Guideline Clearinghouse, Eating Disorders partners and International Guideline Library affiliate organizations (n = 447) Records after duplicates removed (n = 469) Records screened Records excluded (n = 469) (n = 436) Full-text articles assessed Full-text articles excluded for eligibility (n = 24) (n = 33) - language n = 12 - old versions n = 5 - non evidence-based n = 4 - child focus n = 2 - limited regional scope n Studies included in = 1 qualitative synthesis (n = 9) FIGURE 1. PRISMA flow diagram: international comparison of evidence-based clinical guidelines for eating disorders (15 June 2017). 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 425 Included Eligibility Screening Identification Eating disorders 426 www.co-psychiatry.com Volume 30  Number 6  November 2017 Table 1. Evidence-based clinical guidelines for eating disorders published between 2009 and 2017 a b c Abbreviations Full guideline name Year Country Status Scientific society Target Preparing committee Eating disorders AUS Royal Australian and New Zealand 2014 Australia and Active Royal Australian and New Specialists Multidisciplinary group of AN, BN, BED College of Psychiatrists clinical New Zealand Zealand College of healthcare academics and practice guidelines for the Psychiatrists professionals, consultation treatment of eating disorders with key stakeholders and the [29] community DEN National clinical guideline for the 2016 Denmark Active Danish Health Authority Specialists NR AN, BN treatment of anorexia nervosa – quick guide [37] National clinical guideline for the treatment of moderate and severe bulimia – quick guide [38] FR Clinical practice guidelines 2010 France Active Association Franc ¸aise pour le Specialists Multidisciplinary group AN anorexia nervosa: management Developpement des [39] Approches Spe´cialise´es des Troubles du Comportement Alimentaire, Fe´de´ration Franc ¸aise de Psychiatrie, Haute Autorite´ de la Sante´ GER S3-guideline for the assessment 2010 Germany In revision Association of the Scientific Specialists Multidisciplinary group of AN, BN, BED and therapy of eating disorders Medical Societies in Germany clinicians and researchers [30] (AWMF) with expertise in the field of eating disorders NETH Practice guideline for the treatment 2017 The To be Dutch Foundation for Quality Population Multidisciplinary group of AN, BN, BED of eating disorders [31] Netherlands published Development in Mental and specialists healthcare professionals, Healthcare health insurance representatives, patients and relatives SP Clinical practice guideline for 2009 Spain Active Catalan Agency for Health Population Multidisciplinary group of AN, BN, BED eating disorders [32] Technology Assessment and and specialists professionals involved in the Research, Ministry of Health field of eating disorders and and Consumer Affairs experts on Clinical Practice Guidelines’ methodology UK Eating disorders: recognition and 2017 United Active National Institute for Health and Specialists Multidisciplinary group AN, BN, BED treatment, full guideline [33] Kingdom Care Excellence comprised of healthcare professionals, researchers and lay members US Practice guideline for the treatment 2010, 2012 United Active, American Psychiatric Association Specialists Psychiatrists in active clinical AN, BN, BED of patients with eating disorders, States guideline practice and some who are third edition, Guideline watch watch primarily involved in research (August 2012) [34,35] or other academic endeavors WFSBP World Federation of Societies of 2011 - Active World Federation of Societies of Specialists Psychiatrists of WFSBP task force AN, BN, BED Biological Psychiatry (WFSBP) Biological Psychiatry on eating disorders guidelines for the pharmacological treatment of eating disorders [36] Italicized words indicate that the information was inferred from the text, where explicit information from the guideline was lacking. Not reported. AN, anorexia nervosa; BN, bulimia nervosa; BED, binge-eating disorder. Evidence-based clinical guidelines for eating disorders Hilbert et al. Kingdom) or are currently being published (The weight gain per week in inpatient and outpatient Netherlands), while the remainder were published settings, mostly ranging between 0.5–1.5 and 0.2– at least 5 years ago (France, Germany, Spain, the 0.5 kg, respectively, variation in the amount of rec- United States, WFSBP). ommended energy intake per week was apparent. Although some guidelines recommended daily en- ergy intakes of 30–40 kcal/kg (Germany, the United Comparison States) or higher (The Netherlands), others recom- The comparative results for AN, BN, and BED are mended considerably lower intakes (Spain, the Unit- summarized in Tables 2–4. ed Kingdom), particularly for severely malnourished patients at risk for refeeding syndrome. Among the Anorexia nervosa seven guidelines which specified the use of nutri- All guidelines which provided information on the tional supplements, there was a large variation of treatment setting (n¼ 7) consistently recommended recommendations regarding the type and indica- outpatient treatment as a first-line therapy setting tion for nutritional supplements. Some guidelines for patients with AN. For determining more intense specifically recommended phosphate (n¼ 6), thia- levels of care, most guidelines provided criteria for mine (n¼ 3), zinc (n¼ 2), or potassium (n¼ 2), if partial (n¼ 5) and full-time hospitalization (n¼ 7). indicated, while others made a general recommen- The degree of detail and range of hospitalization dation for mineral or vitamin supplements (n¼ 3). criteria varied between guidelines. However, the Although psychotherapy was deemed a central guidelines consistently emphasized the necessity part of treatment by all guidelines, only seven guide- to decide about hospitalization on an individual lines recommended specific psychological inter- basis taking multiple factors into account. Overall, ventions. All seven guidelines recommended hospitalization should be considered for patients family-based therapy (for greater detail, see Herpertz- who have failed at outpatient care, or who are at Dahlmann in this issue [40,41]), particularly for high risk for medical complications as determined youngerpatients. Forindividualpsychotherapy, using patient’s weight status (e.g., extremely low most guidelines recommended cognitive-behavior- body mass index), behavioral factors (e.g., decline al therapy (n¼ 6) which intervenes at the symptom in oral intake), vital signs (e.g., heart rate< 40 bpm), level and centers on the modification of dysfunc- psychiatric comorbidity (e.g., suicide risk), or envi- tional behaviors and cognitions that maintain the ronmental aspects (e.g., family support). For very disorder [42]. It was recommended as a first- malnourished patients who do not consent to treat- line psychotherapy for AN by two guidelines (The ment, most guidelines provided some information Netherlands, the United Kingdom). Lesser agree- on compulsory treatment (n¼ 7). Criteria for dis- ment was achieved for psychodynamic therapy charge from hospital were specified by the majority and interpersonal psychotherapy, which were ex- of guidelines (n¼ 7). plicitly recommended as an alternative by four and The majority of guidelines (n¼ 6) emphasized two guidelines, respectively. While psychodynamic the importance to treat patients with AN and eating therapyincludestreatmentsthatoperate on an disorders in general, respectively, by specialized pro- interpretative-supportive continuum [43], inter- fessionals and/or by professionals with substantial personal psychotherapy is a focused, goal-oriented experience in the treatment of eating disorders. treatment which seeks to treat an eating disorder Regarding specific treatment modalities, most through resolving interpersonal problems in the guidelines included recommendations for nutri- contextofwhatthe disorder presents [44,45]. tional management ranging from artificial feeding Further, the cognitive-interpersonal approach (n¼ 8) to general nutritional counseling (n¼ 6). Maudsley Anorexia Nervosa Treatment for Adults Although the extent to which information on arti- [46] and the Specialist Supportive Clinical Manage- ficial feeding was given differed among guidelines ment [47,48] were recommended as first-line (e.g., concerning refeeding practice, duration, or therapies by two guidelines (The Netherlands, indication), guidelines consistently favored oral the United Kingdom). Although the German guide- enteral nutrition over parenteral nutrition which lineonlymadeageneralrecommendationfor should only be used as a last option. Regarding psychological interventions, it recommended in- general nutritional counseling, two (Germany, the volving the patient’s family in the treatment of United Kingdom) of six guidelines explicitly stated children and adolescents. Some guidelines noted that it should be part of a multidisciplinary therapy that psychological interventions would be more approach and not used as a stand-alone treatment. effective in medically stabilized and cognitively Although there was substantial agreement across improved patients (n¼ 3) or through combining guidelines about the amount of recommended psychological and nutritional interventions (n¼ 1). 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 427 Eating disorders 428 www.co-psychiatry.com Volume 30  Number 6  November 2017 Table 2. Comparison of evidence-based clinical guidelines for anorexia nervosa regarding key recommendations Clinical guideline Recommendation AUS DEN FR GER NETH SP UK US WFSBP Treatment setting First-line treatment: þ N.R. þþ þ þ þ þ N.R. outpatient Criteria for day N.R. N.R. UU N.R. UU U N.R. hospital treatment Criteria for U N.R. UU U U U U N.R. hospitalization Criteria for dischargeUU U U N.R. UU U N.R. Information on N.R. N.R. UU U U U U N.R. compulsory treatment Treatment modalities Refeeding/nutrition Recommended energy Start at 6000 kJ N.R. N.R. Start at 30–40 kcal/kg for Start at 40–60 kcal/kg 25–30 kcal/kg or Inpatient settings : sometimes Start at 30–40 kcal/kg N.R. intake, per day (1433 kcal), severely underweight for severely total kcal <1000 lower starting intakes (e.g., (i.e., 1000–1600 kcal), increases of patients, 800– underweight patients, for severe 5–10 kcal/kg) for severely weight gain phase: up 2000 kJ (478 kcal) 1200 kcal 800–1100 kcal malnutrition, day underweight patients, to 70–100 kcal/kg, every 2–3 days supplementary intake/ supplementary hospital: stepwise increase to male patients with until adequate day necessary for 100 g intake/day necessary supplementary 20 kcal/kg within 2 days, higher energy need intake for weight weight gain/day intake of 300– about 3500–7000 extra restoration 1000 kcal calories/week Recommended weight 0.5–1.4 kg N.R. 0.5–1 kg 0.5–1 kg 0.5–1.5 kg 0.5–1 kg N.R. 0.9–1.4 kg N.R. gain per week, inpatient settings Recommended weight N.R. N.R. 0.25 kg 0.2–0.5 kg 0.25–0.5 kg N.R. N.R. 0.2–0.5 kg N.R. gain per week, outpatient settings Recommended (þ) Phosphate, N.R. (þ) Phosphate, vitamin (þ) Zinc (skin lesions), (þ) Phosphate, thiamine (þ) Oral multivitamin (þ) Multivitamin and (þ) Phosphate, magnesium, N.R. supplements thiamine (risk of and trace elements potassium chloride (risk of refeeding and/or mineral multimineral supplements, potassium, calcium, refeeding (risk of refeeding (cardiac arrhythmia), syndrome) supplements biphosphonates vitamin D, zinc syndrome) syndrome) iron (iron-deficiency anemia), thiamine, riboflavin, niacin, folic acid, phosphate Recommendations for U N.R. UU U U U U U artificial feeding Nutritional counseling N.R. N.R. þ (þ) Only in þþ (þ) Only in multidisciplinary (þ) Registered dieticians N.R. multidisciplinary therapy therapy approach approach Psychological interventions In general þ (More intense when þ Cannot treat severe þ When medically N.R. N.R. Formal psychotherapy with N.R. medically stabilized AN alone, but in stabilized and starving patients may be and cognitively conjunction with cognitively sufficiently ineffective improved from refeeding recovered from starvation) malnutrition CBT þ N.R. þ N.R. þ (First) þþ (First) þ (After weight restoration) N.R. c c c c c c c FBT þ þ þ N.R. þ þ þ þ N.R. Psychodynamic N.R. N.R. þ N.R. N.R þþ þ (Acute AN and after N.R. therapy weight restoration) IPT N.R. N.R. N.R. N.R. N.R. þ N.R. þ (After weight restoration) N.R. Other Specialist therapist-led N.R. Support therapies, N.R. MANTRA (first), SSCM Behavioral therapy MANTRA (first), SSCM (first) þ Nonverbal therapeutic N.R. manualized based systemic and (first) methods (chronic AN), approaches (first), strategic therapies, group psychotherapy adolescent focused motivational for adults (after weight therapy approaches, restoration) nonverbal approaches in conjunction Evidence-based clinical guidelines for eating disorders Hilbert et al. 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 429 Table 2 (Continued) Clinical guideline Recommendation AUS DEN FR GER NETH SP UK US WFSBP Medication In general N.R. N.R. (No specific N.R. N.R. Not as only primary Not as sole treatment N.R. N.R. medication to treat treatment AN) Antidepressants (þ) N.R. þ Depressive  Weight gain N.R. N.R N.R. þ Depressive, anxiety, or N.R. disorders, anxious þ depressive symptoms obsessive-compulsive disorders, OCD symptoms, or bulimic symptoms SSRIs – N.R. N.R. N.R. – N.R. N.R.  Weight gain N.R. þ depressive, anxiety, obsessive-compulsive, or bulimic symptoms (in combination with psychotherapy or after weight restoration) TCAs N.R. N.R. (þ) N.R. N.R. N.R. N.R. – N.R. MAOIs N.R. N.R. N.R. N.R. N.R. N.R. N.R. – N.R. Antipsychotics (þ) Obsessional N.R. (þ)  Weight gain (þ) Obsessional thinking N.R. N.R. (þ) Weight gain N.R. thinking (þ) Obsessional thinking (olanzapine) (þ) Obsessional thinking (olanzapine) (only short-term) (olanzapine, risperidone, quetiapine, chlorpromazine) Appetizers N.R. N.R. N.R. – N.R. N.R. N.R. N.R. N.R. Lithium N.R. N.R. N.R. – N.R. N.R. N.R. N.R. N.R. Estrogen N.R. N.R. (þ) N.R. N.R. (þ)(þ)(þ) N.R. Other medication N.R. N.R. N.R. N.R. N.R. N.R. N.R. þ Pro-motility agents N.R. Buproprion (þ) Antianxiety agents Other treatments N.R. þ Meal support/ N.R. N.R. N.R. N.R.  Physical therapy (transcranial  Electroconvulsive therapy N.R. eating training magnetic stimulation, (or only for severe (as adjunct) acupuncture, weight cooccuring disorders) þ Supervised training, yoga or warming physical activity therapy) (as adjunct during weight gain phase) Special issues Separate Weighing, pregnancy, Detailed information on Separate Treatment of Separate recommendations for Recommendations for acute recommendations medical artificial feeding, recommendations for comorbidities, children and adolescents, AN versus after weight for children and management different settings of children and pregnancy, medical detailed information on restoration versus adolescents and for care, weighing, specific adolescents and for management psychotherapies, carer chronic AN, refeeding severe and long- recommendations for severe and long- support, weighing, medical syndrome standing AN, treatment of core standing AN, management, treatment of refeeding symptoms progress monitoring, comorbidities, pregnancy syndrome, medical relapse prevention management Note: U recommendation given; þ explicit recommendation in favor; (þ) cautious recommendation in favor;  recommendation against; N.R., no recommendation reported; AUS, Australia and New Zealand; CBT, cognitive-behavioral therapy; DEN, Denmark; FBT, family-based therapy; FR, France; GER, Germany; IPT, interpersonal therapy; OCD, obsessive-compulsive disorder; MAOI, monoamine oxidase inhibitor; MANTRA, Maudsley Anorexia Nervosa Treatment for Adults; NETH, The Netherlands; SSCM, Specialist Supportive Clinical Management; SSRI, selective serotonin reuptake inhibitor; SP, Spain; TCAs, tricyclic antidepressants; UK, United Kingdom; US, United States; WFSBP, World Federation of Societies of Biological Psychiatry. Recommendations for weight gain and energy intake were derived from both the guideline’s text and recommendations. Information on energy intake for the UK guideline was obtained from the Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN) guideline, because the UK guideline refers to it in this respect Indicates that the recommended intervention refers to children and adolescents only. Eating disorders 430 www.co-psychiatry.com Volume 30  Number 6  November 2017 Table 3. Comparison of evidence-based clinical guidelines for bulimia nervosa regarding key recommendations Clinical guideline AUS DEN GER NETH SP UK US WFSBP Treatment setting First-line treatment: outpatient þ N.R. þ N.R. þþ þ N.R. Criteria for day hospital treatment U N.R. U N.R. N.R. UU N.R. Criteria for inpatient treatment U N.R. U N.R. UU U N.R. Treatment modalities Nutritional counseling N.R. þ (Individualized or N.R. N.R. (þ) Only with N.R. þ (As part of the treatment) N.R. standardized) psychiatrist’s approval Psychological interventions In general þ (Individual) N.R. þ N.R. N.R. N.R. N.R. N.R. CBT þ (First) þ (First, individual þ (First) þ (First, individualþþ (Individual) þ (First) N.R. or group) or group) a a a FBT N.R. þ N.R. þ N.R. þ þ N.R. Self-help þ (Guided, CBT) N.R. þ (Guided, CBT) þ (Guided, CBT)þþ (First, guided, CBT) þ N.R. Psychodynamic therapies N.R. N.R. þ N.R. N.R. N.R. þ N.R. IPT N.R. N.R. þþ þ N.R. þ N.R. Other þ Internet-based CBT N.R. N.R. N.R. N.R. N.R. þ Group psychotherapy N.R. þ Psychodynamic interventions and CBT and other psychotherapies þ Couples therapy þ Support groups (as adjunct) Medications In general þ (If psychotherapy is not N.R. N.R. N.R. Pharmacological Not as sole treatment N.R. N.R. available or as treatments other than adjunctive therapy) antidepressants are not recommended Antidepressants þ N.R. N.R. N.R. þ N.R. þ N.R. SSRIs þ (Fluoxetine) (þ) þ (Fluoxetine, in þ (Fluoxetine) þ (Fluoxetine) N.R. þ (Fluoxetine) þ (Fluoxetine, combination with fluvoxamine) psychotherapy) TCAs N.R. N.R. N.R. N.R. N.R. N.R. þ (Imipramine, desipramine) MAOIs N.R. N.R. N.R. N.R. N.R. N.R.  (Phenelzine) Anticonvulsants þ (Topiramate) N.R. N.R. N.R. N.R. N.R. (þ) (Topiramate) N.R. Lithium N.R. N.R. N.R. N.R. N.R. N.R.  N.R. Other þ Weight loss (orlistat) N.R. N.R. N.R. N.R. N.R. N.R. N.R. Other treatments þ Combined psychological N.R. N.R. N.R. N.R.  Physical therapy (transcranial þ Combined treatment of CBT N.R. and pharmacological magnetic stimulation, and antidepressants therapy acupuncture, weight training, þ Bright light therapy (as yoga or warming therapy) adjunct) Special issues Medical management Treatment of Treatment of Treatment of Separate recommendations for Recommendations for initial No long-term comorbidities comorbidities, comorbidities, children and adolescent with BN, versus maintenance phase evidence options for pregnancy, medical detailed information on weight loss management psychotherapies, carer support, medical management, treatment of comorbidities, pregnancy Note: U recommendation given; þ explicit recommendation in favor; (þ) cautious recommendation in favor;  recommendation against; AUS, Australia and New Zealand; CBT, cognitive-behavioral therapy; DEN, Denmark; FBT, family-based therapy; GER, Germany; IPT, interpersonal therapy; MAOI, monoamine oxidase inhibitor; N.R., no recommendation reported; NETH, The Netherlands; SP, Spain; SSRI, selective serotonin reuptake inhibitor; TCAs, tricyclic antidepressants; UK, United Kingdom; US, United States; WFSBP, World Federation of Societies of Biological Psychiatry. Indicates that the recommended intervention refers to children and adolescents only. Evidence-based clinical guidelines for eating disorders Hilbert et al. 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 431 Table 4. Comparison of evidence-based clinical guidelines for binge-eating disorder regarding key recommendations Clinical guideline AUS GER NETH SP UK US WFSBP Treatment setting First-line treatment: outpatient N.R. þþ N.R. þ N.R. N.R. Criteria for inpatient treatmentUU U N.R. U N.R. N.R. Treatment modalities Nutritional counseling N.R. N.R. N.R. (þ) (With approval N.R. þ (In the context of N.R. of psychiatrist) behavioral weight- control programs) Psychological interventions In general þ (Individual) þþ N.R. N.R. N.R. N.R. CBT þ (First) þ (First) þ (First, individualþþ (Group or individual) þ (First, individual or N.R. or group) group) FBT N.R. N.R. þ N.R. N.R. N.R. N.R. Self-help þ (Guided, CBT) þ (Guided, CBT) þ (Guided, CBT) þ (Guided or þ (First, guided, CBT) þ (Guided or unguided, N.R. unguided) CBT) Psychodynamic therapies N.R. þ N.R. N.R. N.R. N.R. N.R. IPT N.R. þþ þ N.R. þ N.R. Medications In general þ (If psychotherapy is N.R. N.R. N.R. Not as sole treatment N.R. N.R. not available or as adjunctive therapy) Antidepressants þ N.R. N.R. þ N.R. þ N.R. SSRI þþ (Off-label-use, þ Binge eating þ Binge eating N.R. þ Binge eating frequency þ (Citalopram/ short-term) frequency frequency (short-term) escitalopram, sertraline) TCAs N.R. N.R. N.R. N.R. N.R. N.R. þ (Imipramine) Anticonvulsants þ (Topiramate) N.R. N.R. N.R. N.R. þ (Topiramate, þ (Topiramate) zonisamide) Antiobesity medications þ Weight loss (orlistat) N.R. N.R. N.R. N.R. þ Binge-eating frequency N.R. (sibutramine, short-term) þ Weight loss (orlistat, sibutramine) Other treatments þ Combined N.R. N.R. N.R.  Physical therapy þ Behavioral weight- N.R. psychological and (transcranial magnetic control programs pharmacological stimulation, acupuncture, þ Orlistat plus guided self- therapy weight training, yoga or help CBT warming therapy) þ Fluoxetine plus group behavioral treatment Special issues Medical management No long-term Treatment of Treatment of Detailed information on No long-term evidence for comorbidities, comorbidities, psychotherapies, medical evidence pharmacological options for pregnancy management, treatment of treatment weight loss comorbidities, pregnancy Note: U recommendation given; þ explicit recommendation in favor; (þ) cautious recommendation in favor;  recommendation against; AUS, Australia and New Zealand; CBT, cognitive-behavioral therapy; FBT, family-based therapy; GER, Germany; IPT, interpersonal therapy; MAOI, monoamine oxidase inhibitor; N.R., no recommendation reported; NETH, The Netherlands; SSRI, selective serotonin reuptake inhibitor; SP, Spain; TCAs, tricyclic antidepressants; UK, United Kingdom; US, United States; WFSBP, World Federation of Societies of Biological Psychiatry. Indicates that the recommended intervention refers to children and adolescents only. Eating disorders Regarding the pharmacological treatment of and pregnancy attempts. Two guidelines specifically AN, five of nine guidelines provided specific recom- provided information about the treatment of physi- mendations with some notable variations. Two cal and mental comorbidities, as well as artificial guidelines made the general recommendation that feeding including refeeding syndrome. medication should not be used as the sole or primary Bulimia nervosa treatment for patients with AN (Spain, the United Kingdom) or that there is no specific medication to Among the guidelines reporting on the prioritized treat AN (France). Antidepressants were generally treatment setting of BN, all recommended outpa- recommended for those with depressive symptoms tient therapy as a first-line treatment (n¼ 5). Four by four guidelines. At the same time, the German and five guidelines provided criteria for partial and guideline cautioned against the use of antidepres- full-time hospitalization, respectively. Regarding sants for weight gain. For selective serotonin reup- specific treatment modalities, nutritional counsel- take inhibitors (SSRIs), there was one guideline ing was generally recommended by the Danish which recommended its use for treating depressive guideline, in individualized or standardized format, symptoms in conjunction with psychotherapy or while two other guidelines emphasized that nutri- after weight restoration (the United States), while tional interventions (e.g., to help develop a struc- two other guidelines made general recommenda- tured meal plan) should not be offered as stand- tions against their use, particularly in children alone therapy (Spain, the United States). and adolescents (Australia and New Zealand, The Other than the WFSBP guideline, all available Netherlands). The use of tricyclic antidepressants guidelines issued recommendations on specific psy- (TCAs) was not explicitly favored, given that there chological interventions. In agreement, five guide- was one recommendation against (the United States) lines recommended cognitive-behavioral therapy as and one cautious recommendation in favor (France). a first-line psychotherapy for patients with BN, par- The use of monoamine oxidase inhibitors (MAOIs) or ticularly in an individual format. The remaining two bupropion, an atypical antidepressant, was not rec- guidelines also made recommendations in favor of ommended by the guideline from the United States, cognitive-behavioral interventions, but prioritized the only guideline reporting on these medications. cognitive-behavioral, guided self-help treatment as Four guidelines consistently recommended the cau- a first-line treatment (the United Kingdom), or did tious use of antipsychotics for treating obsessional not provide an explicit treatment hierarchy (Spain). thinking in patients with AN, particularly olanza- Overall, among the six guidelines which recom- pine, because evidence from randomized-controlled mended self-help approaches, four highlighted the trials and regarding long-term effects were lacking. use of guided self-help based on cognitive-behavior- Conflicting results were found for weight gain, given al interventions (Australia and New Zealand, that one guideline recommended antipsychotics for Germany, The Netherlands, the United Kingdom), weight gain (the United States), whereas another that is, using structured self-help manuals supple- guideline stated that antipsychotics would not be mented with brief supportive sessions [49]. Interper- appropriate for weight gain (Germany). Promotility sonal psychotherapy was recommended as an agents and antianxiety agents were only recom- alternative to cognitive-behavioral therapy by most mended by the guideline from the United States guidelines (n¼ 4), while psychodynamic therapy for treating gastrointestinal problems and to reduce (n¼ 2) was rarely recommended. Family-based ther- anticipatory anxiety concerning food intake, respec- apy was in particular recommended for younger tively. The use of appetizers and lithium was not patients with BN (n¼ 4), and only explicitly recom- recommended by the German guideline. In addition, mended for adults by the guideline from the United four guidelines consistently stated that estrogen States. Although the German guideline recom- should not be routinely offered to patients with mended cognitive-behavioral therapy for children AN, as this would depend on the patient’s menarche and adolescents with BN, they emphasized the im- status or chronicity of AN, for example. portance of including the patient’s family into treat- Adjunctive treatment recommendations were ment. Alternative psychological interventions were, rarely made and included meal support, eating for example, the combination of psychodynamic training, and supervised physical activity, as de- and cognitive-behavioral therapies (n¼ 1), couples scribed by the Danish guideline. Physical therapies therapy (n¼ 1), or support groups (n¼ 1). (e.g., electroconvulsive therapy, transcranial mag- Among the recommendations for pharmacolog- netic stimulation) were not recommended by two ical treatment, seven out of eight guidelines consis- guidelines. Of note, four guidelines included infor- tently recommended antidepressants, specifically mation on the medical management of AN and the SSRI fluoxetine, although with some restrictions three guidelines additionally reported on pregnancy (e.g., to use antidepressants in combination with 432 www.co-psychiatry.com Volume 30  Number 6  November 2017 Evidence-based clinical guidelines for eating disorders Hilbert et al. psychotherapy). Conflicting recommendations The use of antidepressants was generally recom- were obtained for the use of TCAs such as imipra- mended by three guidelines (Australia and New mine and desipramine, which were recommended Zealand, Spain, the United States). These three by the WFSBP, while the guideline from the United guidelines and three other guidelines (Germany, States explicitly did not recommend TCAs for initial The Netherlands, WFSBP) consistently made a spe- treatment in patients with BN. Consistently, two cific recommendation in favor of SSRIs for reducing guidelines advised against the use of MAOIs (United binge-eating episodes, at least in the short-term. For States, WFSBP). The use of anticonvulsants, specifi- TCAs, only the WFSBP recommended their use, cally topiramate, was consistently recommended by particularly imipramine. For anticonvulsants, three two guidelines, while the remaining guidelines did guidelines (Australia and New Zealand, the United not report on anticonvulsants. The only guideline States, WFSBP) consistently recommended the use which made a recommendation about lithium of topiramate, while the remaining guidelines did cautioned against its use (the United States). For not report on it. Consistently, two out of two guide- patients with comorbid obesity, one guideline rec- lines reporting on antiobesity medications explicitly ommended the antiobesity medication orlistat recommended their use, specifically orlistat, for (Australia and New Zealand). weight loss in patients with BED and comorbid Of note, four guidelines included specific infor- obesity. In addition to weight loss, the antiobesity mation about the treatment of comorbidities, and medication sibutramine was recommended for three guidelines made recommendations for the reducing binge eating (the United States). Two medical management of BN. guidelines explicitly made a recommendation for pharmacological treatment in conjunction with Binge-eating disorder psychological therapies (Australia and New Zealand, Only three out of seven available guidelines explic- the United States). itly included the recommendation that outpatient Of note, three guidelines reported on the treat- treatment is the first-line treatment setting for BED ment of comorbidities, and two guidelines made (Germany, The Netherlands, the United Kingdom). recommendations for the medical management Criteria for hospitalization were provided by four of BED. guidelines (Australia and New Zealand, Germany, The Netherlands, the United Kingdom). An explicit DISCUSSION recommendation for nutritional counseling was made by the guideline from the United States, spe- The current systematic review of evidence-based cifically within the context of behavioral weight loss clinical guidelines for eating disorders revealed programs. The Spanish guideline generally recom- many consistent recommendations, but also nota- mended nutritional counseling for patients with ble differences among the guidelines. eating disorders, with a psychiatrist’s approval. For the treatment of AN, the guidelines showed All guidelines provided recommendations for a substantial agreement on the amount of recom- specific psychological interventions, except the mended weight gain, while recommended daily WFSBP guideline. Cognitive-behavioral therapy energy intakes varied considerably, which is consis- was consistently recommended by all six guidelines, tent with Herpertz-Dahlmann et al. [28], who had followed by guided (n¼ 6) or unguided (n¼ 2) narratively reviewed four European guidelines for cognitive-behavioral self-help treatment and inter- the treatment of AN. Also in line with their findings, personal psychotherapy (n¼ 4). An explicit recom- the recommendations for nutritional supplements mendation for psychodynamic therapy was made varied widely, against a background of a lack of by the German guideline only. With respect to first- evidence. More consistently, most guidelines made line psychotherapy, four guidelines recommended recommendations for specific psychological inter- cognitive-behavioral therapy, while one guideline ventions in the treatment of AN, especially for fam- favored guided cognitive-behavioral self-help treat- ily-based therapy for younger patients, because of a ment (the United Kingdom). Regarding the treat- large evidence base [40,50,51]. Most guidelines fur- ment format, guidelines varied highly, with one ther supported cognitive-behavioral therapy [52]. guideline specifically recommending individual Cognitive-behavioral therapy, the Maudsley An- psychotherapy (Australia and New Zealand), one orexia Nervosa Treatment for Adults, and the Spe- prioritizing group format (the United Kingdom), cialist Supportive Clinical Management were even and two guidelines not including any preference recommended as first-line therapies by the two (The Netherlands, the United States). Family-based current guidelines from The Netherlands and the treatment was recommended for children and ado- United Kingdom, based on recently published && && lescents with BED by the Dutch guideline only. results [53 ,54 ]. Little agreement was found for 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 433 Eating disorders psychodynamic therapy and interpersonal psycho- sparse evidence base were issued for alternative therapy as alternative treatments, because of scant treatments (e.g., a combination of psychodynamic evidence for their use [55–57]. A need for further and cognitive-behavioral therapies) and nutritional research on the psychological treatment of AN was counseling. noted for all ages [28,58]. Regarding the pharmacological treatment of Regarding pharmacotherapy of AN, recommen- BN, most guidelines recommended antidepressants dations varied widely – four guidelines, among for the treatment of BN, specifically the SSRI fluox- them the medically oriented WFSBP guideline, etine, albeit with several restrictions (e.g., combined made no specific recommendation for any medica- use with psychotherapy only). Fluoxetine has tion, or advocated against their sole or primary use. approval for the treatment of adults with BN in The greatest level of consistency across four out of several countries (e.g., the United States, Germany). nine guidelines was found for the careful use of However, only a few and often inconsistent antipsychotics to reduce associated obsessional recommendations were made for the use of TCAs thinking in patients with AN, but it was inconsistent and anticonvulsants, specifically topiramate, and whether or not antipsychotics should be recom- against the use of MAOIs and lithium. Again, these mended for weight gain. In addition, three guide- singular and contradictory recommendations may lines generally recommended antidepressants for mirror the overall paucity of research on pharmaco- the treatment of depressive symptoms, but a consis- logical treatments of BN [13]. tent recommendation for specific types of antide- For the treatment of BED, all guidelines provid- pressants (SSRIs, TCAs) could not be identified. ed recommendations for specific psychological Single guidelines’ recommendations emerged re- interventions (except the medically oriented garding other medications, for example, against WFSBP guideline). Cognitive-behavioral therapy the use of bupropion. Estrogen was with some con- was consistently recommended by all respective sistency recommended to be offered only upon guidelines and mostly as a first-line treatment, giv- & && specific indication (see [59 ]). Overall, these incon- en its comprehensive evidence base [10 ]. Cogni- sistent pharmacological recommendations for the tive-behavioral therapy was followed by cognitive- treatment of AN may reflect the scarce evidence base behavioral self-help treatment, with the majority of for the pharmacological treatment of this disorder guidelines recommending a guided format, a treat- [13,28,60 ]. ment with an increasing evidence base [65]. Of For the treatment of BN, all guidelines but the note, the guideline from the United Kingdom fa- medically oriented WFSBP guideline issued recom- vored guided cognitive-behavioral self-help treat- mendations on specific psychological interventions: ment as a first-line treatment, likely for economic The majority of them recommended cognitive-be- reasons, as described for BN. Interpersonal psycho- havioral therapy as a first-line treatment for BN, therapy was further recommended by the majority reflecting the treatment literature [11,52]. In con- of the guidelines, based on a small number of trast, the United Kingdom guideline recommended studies [52]. An explicit non-evidence-based offering cognitive-behavioral self-help treatment recommendation for psychodynamic therapy was first, presumably because of an emphasis on cost- made by the German guideline only [66] reflecting effectiveness [27], for which initial data are available healthcare system specificities, while family-based [61]. Interpersonal psychotherapy was recom- treatment was recommended for children and ado- mended as an alternative to cognitive-behavioral lescents with BED by the Dutch guideline only, therapy by the majority of guidelines, given its based on emerging evidence for family-based treat- slower short-term efficacy, but equivalent long-term ment of adolescents with BN [64]. A recommenda- efficacy [52]. Psychodynamic therapy was recom- tion for nutritional counseling was made by two mended by the German and guideline from the guidelines, which may reflect findings of lower United States only, despite its limited evidence base efficacy of this treatment regarding binge-eating && [62,63], possibly because of particularities in health- outcome [67 ]. care systems. Family-based therapy was recom- Regarding the pharmacological treatment of mended mostly for younger patients by half of BED, the majority of guidelines made a recommen- the guidelines, which is supported by recent clinical dation for SSRIs, which is in line with current liter- && research [64]. Most guidelines recommended self- ature [10 ], while only the WFSBP guideline help treatment, and the majority of these, especially recommended TCAs, based on studies published be- the more recent guidelines, emphasized guided cog- fore 1999. Three guidelines recommended the use of nitive-behavioral self-help treatment, documented the anticonvulsant topiramate; however, the drug’s to be efficacious in the treatment of BN [65]. A few side-effects, especially cognitive impairment, have recommendations with unclear rationale and/or been noted [68]. Regarding antiobesity medications, 434 www.co-psychiatry.com Volume 30  Number 6  November 2017 Evidence-based clinical guidelines for eating disorders Hilbert et al. two guidelines recommended orlistat for weight Another additional source for differences loss in BED and BN [69,70] and sibutramine for among guidelines may be how the evidence was binge eating in BED, the latter being withdrawn from examined, with guidelines based on meta-analyses many markets because of adverse cardiovascular (e.g., Germany, the United Kingdom), systematic events. Combined psychological and pharmaco- reviews (e.g., Australia and New Zealand, the United logical treatment was recommended by two guide- States), or unsystematic reviews of the evidence lines; however, this is not supported by current (e.g., France). The transparency with which evi- && evidence [71 ]. dence was converted into specific recommendations Overall, consistency across guidelines seemed to further varied across guidelines; several guidelines be the greatest for psychological treatments and for explicitly evaluated the strength of evidence and single medications with a larger evidence base, provided clear rationale for a specific recommenda- while for psychological and medical treatments tion (e.g., Germany, the United Kingdom, WFSBP), with a smaller evidence base, recommendations while others did not (e.g., France), leaving the em- varied considerably, and expert consensus played pirical foundation of a recommendation unclear. To a greater role. Regarding the dissemination and develop a guideline, it has been recommended to implementation of evidence-based treatments into use a systematic approach to evaluate the strength of clinical practice, the guidelines thus do endorse evidence, for example the Grading of Recommen- main empirically validated treatment approaches dations Assessment, Development, and Evaluation with considerable agreement, but beyond this, the [72], or the system of the Oxford Centre for Evi- variability is greater in what recommendations evi- dence-Based Medicine [26,73]. For some guidelines, dence-based clinical guidelines subsume. A larger only summary statements without the systematic evidence base is critical in offering clinically reliable review component were available in the review and consistent guidance in eating disorders, and languages, making the empirical background of a many important areas of future clinical research recommendation difficult to understand (e.g., have been identified for all eating disorders at dif- Denmark). Guidelines differed further in readabili- ferent ages, given the treatment gap and the re- ty, with most guidelines providing clear or even search-practice gap described at the outset of this standardized recommendations that were easily lo- && & article [15 ,22 ]. cated (e.g., Germany, the United Kingdom), while The available evidence is one reason for differ- others provided them in a more complex text format ences among guidelines. Among additional reasons, (e.g., the United States). Although these aspects are while several guidelines were issued within the past central to the quality of a guideline, it is notable that 3 years or are about to be published, the majority a systematic quality evaluation [74] of clinical eating were 5 years and older. Especially for disorders such disorder guidelines is currently lacking; this was as BED with a large recent increase in clinical re- considered to be beyond the scope of this treat- search, changes in recommendations over time are ment-oriented review but could help to systemati- to be expected. Several recommendations were non- cally identify strengths and limitations of current evidence-based and likely reflected particularities in eating disorder guidelines. healthcare systems, for example, the availability of Strengths of this study were a systematic com- outpatient, day patient, and inpatient settings or of pilation of main treatment recommendations of therapists trained in a specific intervention. The current evidence-based eating disorders guidelines. guidelines differed as well in their scope, consider- Not within the scope of this review were: general ing treatment in selected aspects (e.g., Denmark, setting-oriented recommendations (e.g., communi- France) or comprehensively (e.g., Germany, the cation with the patient, therapeutic infrastructure, United States). Some guidelines were created by organization of transitions between different levels one healthcare profession or one specialized profes- of care); methods for the identification, assessment, sional organization only (e.g., the guidelines from and diagnosis of eating disorders; and the practical the United States, WFSBP) and may thus reflect the applicability of the guidelines and their actual view of this profession only. Most guidelines, how- implementation in clinical settings. Several of ever, pursued a multiprofessional approach in these aspects warrant further investigation. One guideline development, and some of them noted further limitation is that several guidelines had the inclusion of other stakeholders as well. In fact, to be excluded from this review because of not the current literature for guideline development meeting the language requirement. For further com- advocates for broad stakeholder involvement of parative research, it would be desirable to have all relevant professions, healthcare providers, and guidelines published not only in the national lan- patients (e.g., [25–27]) for optimal acceptance guage, but also in other languages for international and implementation. reception. 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 435 Eating disorders 9. Kessler RC, Berglund PA, Chiu WT, et al. The prevalence and correlates of CONCLUSION binge eating disorder in the World Health Organization World Mental Health Surveys. Biol Psychiatr 2013; 73:904 – 914. The current systematic, international comparison 10. Brownley KA, Berkman ND, Peat CM, et al. Binge-eating disorder in adults: a demonstrated notable commonalities and differen- && systematic review and meta-analysis. Ann Intern Med 2016; 165:409 – 420. A timely meta-analysis on the efficacy of psychological and medical approaches to ces among current evidence-based clinical guide- the treatment of BED. lines for eating disorders. Currently, several 11. Hay P. A systematic review of evidence for psychological treatments in eating disorders: 2005 – 2012. Int J Eat Disord 2013; 46:462 – 469. evidence-based clinical guidelines for eating disor- 12. Kass AE, Kolko RP, Wilfley DE. Psychological treatments for eating disorders. ders are in progress (e.g., Germany, the United Curr Opin Psychiatry 2013; 26:549 – 555. 13. McElroy SL, Guerdjikova AI, Mori N, Keck PE Jr. Psychopharmacologic States). Because developing and updating clinical treatment of eating disorders: emerging findings. Curr Psychiatry Rep guidelines is time-consuming and complex, an in- 2015; 17:35. 14. Mitchell JE, Roerig J, Steffen K. Biological therapies for eating disorders. Int J ternational coordination of guideline development, Eat Disord 2013; 46:470 – 477. for example, across the European Union, would be 15. Kazdin AE, Fitzsimmons-Craft EE, Wilfley DE. Addressing critical gaps in the && treatment of eating disorders. Int J Eat Disord 2017; 50:170 – 189. desirable. Collaborative efforts would need to care- A succinct overview of important gaps in the dissemination and implementation of fully specify the goals and scope of a common evidence-based treatment into clinical practice. 16. Cooper M, Kelland H. Medication and psychotherapy in eating disorders: is ‘guideline trunc’ which should be based on an elab- there a gap between research and practice? J Eat Disord 2015; 3:45. orated, quality-assuring developmental process, 17. Micali N, Martini MG, Thomas JJ, et al. Lifetime and 12-month prevalence of & eating disorders amongst women in mid-life: a population-based study of while accounting for different cultures and national diagnoses and risk factors. BMC Med 2017; 15:12. requirements. European clinical studies on major A longitudinal study of mid-life prevalence rates of eating disorders in women in relation to psychosocial risk factors. research gaps could represent an important first step 18. Peterson CB, Becker CB, Treasure J, et al. The three-legged stool of toward this end. & evidence-based practice in eating disorder treatment: research, clinical, and patient perspectives. BMC Med 2016; 14:69. A narrative review of evidence-based practice in eating disorders. 19. Regan P, Cachelin FM, Minnick AM. Initial treatment seeking from professional Acknowledgements & healthcare providers for eating disorders: a review and synthesis of potential The authors are grateful to Jamie L. Manwaring, PhD barriers to and facilitators of ‘first contact’. Int J Eat Disord 2017; 50: 190 – 209. and Lisa Opitz, BSc for her help in editing this article. A systematic review on treatment-seeking in the eating disorders. 20. Kosmerly S, Waller G, Robinson AL. Clinician adherence to guidelines in the delivery of family-based therapy for eating disorders. Int J Eat Disord 2015; Financial support and sponsorship 48:223 – 229. 21. Von Ranson KM, Wallace LM, Stevenson A. Psychotherapies provided for A.H. and R.S. are funded by the German Federal Ministry eating disorders by community clinicians: infrequent use of evidence-based treatment. Psychother Res 2013; 23:333 – 343. of Education and Research (grant 01EO1501). 22. Waller G. Treatment protocols for eating disorders: clinicians’ attitudes, concerns, adherence and difficulties delivering evidence-based psychological interventions. Curr Psychiat Rep 2016; 18:1 – 8. Conflicts of interest A narrative review on the use of evidence-based treatment manuals in clinical practice. 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Two-year follow-up of the MOSAIC based Medicine – levels of evidence (March 2009). 2009; Available at: && trial: a multicenter randomized controlled trial comparing two psychological www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march- treatments in adult outpatients with broadly defined anorexia nervosa. Int J Eat 2009. [Accessed 22 June 2017] Disord 2016; 49:793 – 800. 74. Brouwers M, Kho ME, Browman GP, et al. AGREE II: advancing guideline Two-year follow-up data on a multicenter randomized-controlled trial of two development, reporting and evaluation in healthcare. Can Med Assoc J 2010; psychological treatments for adults with anorexia nervosa. 182:E839 – 842. 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 437 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Current Opinion in Psychiatry Pubmed Central

Evidence-based clinical guidelines for eating disorders: international comparison

Current Opinion in Psychiatry , Volume 30 (6) – Jul 11, 2017

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Abstract

REVIEW URRENT Evidence-based clinical guidelines for eating PINION disorders: international comparison a b,c,d a Anja Hilbert , Hans W. Hoek , and Ricarda Schmidt Purpose of review The current systematic review sought to compare available evidence-based clinical treatment guidelines for all specific eating disorders. Recent findings Nine evidence-based clinical treatment guidelines for eating disorders were located through a systematic search. The international comparison demonstrated notable commonalities and differences among these current clinical guidelines. Summary Evidence-based clinical guidelines represent an important step toward the dissemination and implementation of evidence-based treatments into clinical practice. Despite advances in clinical research on eating disorders, a growing body of literature demonstrates that individuals with eating disorders often do not receive an evidence-based treatment for their disorder. Regarding the dissemination and implementation of evidence-based treatments, current guidelines do endorse the main empirically validated treatment approaches with considerable agreement, but additional recommendations are largely inconsistent. An increased evidence base is critical in offering clinically useful and reliable guidance for the treatment of eating disorders. Because developing and updating clinical guidelines is time-consuming and complex, an international coordination of guideline development, for example, across the European Union, would be desirable. Keywords eating disorders, evidence-based, guideline, therapy, treatment INTRODUCTION show a long-term natural course with remission in more than 50% of cases, whereas evidence on Anorexia nervosa (AN), bulimia nervosa (BN), and the natural course of BED is scarce [7]. While AN binge-eating disorder (BED) represent the specific occurs in up to 4% of young women [7,8 ], BN and eating disorders defined in the Diagnostic and Statis- BEDhavealifetimeprevalence of1.0 and1.9%, ticalManualofMentalDisorders,5th Edition (DSM-5 respectively [9]. [1]). They are characterized – at varying degrees – by persistent disturbances in eating or weight-control behavior andshape andweightoverconcern.The central characteristic of AN is a significantly low Department of Medical Psychology and Medical Sociology, Department body weight, induced by restriction of energy in- of Psychosomatic Medicine and Psychotherapy, University of Leipzig take. The main features of BN and BED are recurrent Medical Center, Leipzig, Germany, Parnassia Psychiatric Institute, The Hague, Department of Psychiatry, University Medical Center Groningen, binge-eating episodes. Although individuals with University of Groningen, Groningen, The Netherlands and Department BN usually attempt to prevent weight gain through of Epidemiology, Columbia University, Mailman School of Public Health, inappropriate compensatory behaviors (e.g., self- New York, New York, USA induced vomiting), those with BED do not make Correspondence to Anja Hilbert, Department of Medical Psychology and recurrent use of them. All eating disorders result in Medical Sociology, Department of Psychosomatic Medicine and Psy- significant impairments in health, psychosocial chotherapy, University of Leipzig Medical Center, Philipp-Rosenthal- functioning, and quality of life [2,3]. Increased Strasse 27, 04103 Leipzig, Germany. Tel: +49 341 97 15361; fax: +49 341 97 15359; e-mail: anja.hilbert@medizin.uni-leipzig.de healthcare utilization and costs have been docu- mented [4 ,5]. With a first onset that often occurs in Curr Opin Psychiatry 2017, 30:423–437 adolescence or young adulthood [6], AN and BN DOI:10.1097/YCO.0000000000000360 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com Eating disorders across the world. Their general aim is to inform KEY POINTS clinical decision-making of healthcare professionals and patients on efficacious interventions and treat- The systematic review showed notable commonalities ment strategies. Based on a systematic search, selec- and differences among evidence-based clinical tion, and evaluation of the treatment literature, treatment guidelines for eating disorders. evidence-based treatment guidelines offer specific Regarding the dissemination and implementation of recommendations to optimize patient care [25–27]. evidence-based treatments, current guidelines endorse In one narrative review, Herpertz-Dahlmann et al. main empirically supported treatment approaches with [28] compared several evidence-based clinical guide- considerable agreement, but additional lines from four European countries (Germany, recommendations are largely inconsistent. Spain, The Netherlands, and the United Kingdom) An increased evidence base is critical in offering regarding the treatment of AN. They found corre- clinically reliable and consistent guidance for the spondence in major recommendations, but no con- treatment of eating disorders. sensus on treatment intensity/setting, as well as Because clinical guideline development is time- no consensus and lack of evidence on nutritional consuming and complex, an international coordination, rehabilitation and weight restoration. The authors for example, across the European Union, would be identified a need for European research initiatives desirable. on AN to enhance the evidence base and clinical guidance. Since this report, several new guidelines were issued (e.g., The Netherlands, the United King- Given the clinical significance of eating disorder dom, Australia); however, current comparative in- symptomatology, over the past decades sustained formation is lacking, especially for BN and BED. This effort has been placed on designing and evaluating systematic review sought to compare the available psychological and medical treatments for eating evidence-based clinical treatment guidelines for all disorders in rigorous, randomized-controlled effica- specific eating disorders to investigate the necessity && cy studies [10 ,11–14]. Despite these advances, a of future work on guidelines for translation into growing body of literature demonstrates that indi- practice. viduals with eating disorders often do not receive an evidence-based treatment for their disorder && METHOD [15 ,16]. For example, Kessler et al. [9] documented in 24 124 adults from 14 countries that only 47.4% Guideline identification of lifetime cases with BN and 38.3% of lifetime cases with BED ever received a specific treatment for their In May 2017, we systematically searched the elec- eating disorder. In a study among 5 658 women 40– tronic databases PubMed and Cochrane Database of 50 years old from the United Kingdom, only 27.4% Systematic Reviews [‘guideline AND (eating disorder of all women with a DSM-5 life-time diagnosis of an OR anorexia nervosa OR bulimia nervosa OR binge- eating disorder had sought help or received treat- eating disorder)’]; the National Guideline Clearing- ment for an eating disorder at any point in their house and the International Guideline Library life [17 ]. Multiple system factors (e.g., lack of (‘eating disorder OR anorexia nervosa OR bulimia screening for eating disorders) and personal patient nervosa OR binge-eating disorder’); the website of the Academy of Eating Disorders through which factors (e.g., lack of information) may account for && & & partners and affiliate organizations were obtained this ‘treatment gap’ [15 ,18 ,19 ]. In addition, a and contacted; and contacted other experts in the ‘research-practice gap,’ indicating a discrepancy field. Relevant clinical guidelines were required to between evidence-based treatments and actual be evidence-based; the latest version; address the treatment delivery, was identified: As an example, treatment of AN, BN, and/or BED; have a focus the majority of eating disorder therapists do not on adults; to be published in Dutch, English, or adhere to evidence-based treatment protocols but German; and have a national or international scope. rather pursue eclectic combinations of interven- tions [20,21,22 ]; findings such as this highlight the significant challenge of disseminating and Assessments and analysis implementing of evidence-based eating disorder && To compare the content of the guidelines, key rec- treatments into clinical practice [15 ,23,24]. ommendations were summarized regarding pre- As a first step toward the dissemination and defined categories. For AN, BN, and BED, these implementation of evidence-based treatments into clinical practice, evidence-based clinical guidelines categories included: first-line treatment setting, cri- for eating disorders were issued in several countries teria for hospitalization, recommended treatment 424 www.co-psychiatry.com Volume 30  Number 6  November 2017 Evidence-based clinical guidelines for eating disorders Hilbert et al. modalities including nutritional counseling, specif- earlier versions of included guidelines, four guide- ic psychological interventions, and medications. For lines were non-evidence-based, two guidelines sole- the treatment of AN, guidelines were additionally ly focused on childhood eating disorders, and one compared with respect to the following categories: guideline had a regional scope. Accordingly, nine compulsory treatment, criteria for partial hospitali- guidelines from eight countries, published between zation, criteria for discharge, recommended energy 2009 and 2017, were included in this report. intake and weight gain, feeding supplements, and Most guidelines (n¼ 7) included treatment rec- artificial feeding. ommendations for AN, BN, and BED: these were the Included guidelines were independently exam- guidelines from Australia and New Zealand [29], ined by two authors. Relevant content was extracted Germany [30], The Netherlands [31], Spain [32], into a predefined coding table using the guidelines’ the United Kingdom [33], the United States original text by one author with corrections from [34,35], and the World Federation of Societies of the second author. For comparative purposes, it was Biological Psychiatry (WFSBP; [36]). The guideline noted whether a recommendation was given (U)or from Denmark [37,38] addressed the treatment of not reported, and if possible, the guidelines’ recom- AN and BN, while the French guideline [39] focused mendations were recoded into three ratings: explicit on AN only. All guidelines are described in Table 1. recommendation in favor (þ), recommendation re- The guideline by the WFSBP provided recommen- quiring caution [(þ)], and recommendation against dations for medical treatment of eating disorders (). In addition, and if recoding was not possible, only, whereas all other guidelines addressed several the guidelines’ recommendations were reported in treatment approaches. The majority of guidelines text format. were developed by multiprofessional working groups (Australia and New Zealand, France, Germany, The Netherlands, Spain, the United King- RESULTS dom), while both the United States and WFSBP A total of 33 guidelines were identified, as depicted guidelines were developed by psychiatric groups. in the PRISMA flow chart (Fig. 1). Most guidelines Regarding the modernity of the guidelines, three had to be excluded for not meeting the language guidelines were published within the last 3 years criterion (n¼ 12). In addition, five guidelines were (Australia and New Zealand, Denmark, the United Records identified through database searching: Additional records identified PubMed, Cochrane Database, National through contacting Academy of Guideline Clearinghouse, Eating Disorders partners and International Guideline Library affiliate organizations (n = 447) Records after duplicates removed (n = 469) Records screened Records excluded (n = 469) (n = 436) Full-text articles assessed Full-text articles excluded for eligibility (n = 24) (n = 33) - language n = 12 - old versions n = 5 - non evidence-based n = 4 - child focus n = 2 - limited regional scope n Studies included in = 1 qualitative synthesis (n = 9) FIGURE 1. PRISMA flow diagram: international comparison of evidence-based clinical guidelines for eating disorders (15 June 2017). 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 425 Included Eligibility Screening Identification Eating disorders 426 www.co-psychiatry.com Volume 30  Number 6  November 2017 Table 1. Evidence-based clinical guidelines for eating disorders published between 2009 and 2017 a b c Abbreviations Full guideline name Year Country Status Scientific society Target Preparing committee Eating disorders AUS Royal Australian and New Zealand 2014 Australia and Active Royal Australian and New Specialists Multidisciplinary group of AN, BN, BED College of Psychiatrists clinical New Zealand Zealand College of healthcare academics and practice guidelines for the Psychiatrists professionals, consultation treatment of eating disorders with key stakeholders and the [29] community DEN National clinical guideline for the 2016 Denmark Active Danish Health Authority Specialists NR AN, BN treatment of anorexia nervosa – quick guide [37] National clinical guideline for the treatment of moderate and severe bulimia – quick guide [38] FR Clinical practice guidelines 2010 France Active Association Franc ¸aise pour le Specialists Multidisciplinary group AN anorexia nervosa: management Developpement des [39] Approches Spe´cialise´es des Troubles du Comportement Alimentaire, Fe´de´ration Franc ¸aise de Psychiatrie, Haute Autorite´ de la Sante´ GER S3-guideline for the assessment 2010 Germany In revision Association of the Scientific Specialists Multidisciplinary group of AN, BN, BED and therapy of eating disorders Medical Societies in Germany clinicians and researchers [30] (AWMF) with expertise in the field of eating disorders NETH Practice guideline for the treatment 2017 The To be Dutch Foundation for Quality Population Multidisciplinary group of AN, BN, BED of eating disorders [31] Netherlands published Development in Mental and specialists healthcare professionals, Healthcare health insurance representatives, patients and relatives SP Clinical practice guideline for 2009 Spain Active Catalan Agency for Health Population Multidisciplinary group of AN, BN, BED eating disorders [32] Technology Assessment and and specialists professionals involved in the Research, Ministry of Health field of eating disorders and and Consumer Affairs experts on Clinical Practice Guidelines’ methodology UK Eating disorders: recognition and 2017 United Active National Institute for Health and Specialists Multidisciplinary group AN, BN, BED treatment, full guideline [33] Kingdom Care Excellence comprised of healthcare professionals, researchers and lay members US Practice guideline for the treatment 2010, 2012 United Active, American Psychiatric Association Specialists Psychiatrists in active clinical AN, BN, BED of patients with eating disorders, States guideline practice and some who are third edition, Guideline watch watch primarily involved in research (August 2012) [34,35] or other academic endeavors WFSBP World Federation of Societies of 2011 - Active World Federation of Societies of Specialists Psychiatrists of WFSBP task force AN, BN, BED Biological Psychiatry (WFSBP) Biological Psychiatry on eating disorders guidelines for the pharmacological treatment of eating disorders [36] Italicized words indicate that the information was inferred from the text, where explicit information from the guideline was lacking. Not reported. AN, anorexia nervosa; BN, bulimia nervosa; BED, binge-eating disorder. Evidence-based clinical guidelines for eating disorders Hilbert et al. Kingdom) or are currently being published (The weight gain per week in inpatient and outpatient Netherlands), while the remainder were published settings, mostly ranging between 0.5–1.5 and 0.2– at least 5 years ago (France, Germany, Spain, the 0.5 kg, respectively, variation in the amount of rec- United States, WFSBP). ommended energy intake per week was apparent. Although some guidelines recommended daily en- ergy intakes of 30–40 kcal/kg (Germany, the United Comparison States) or higher (The Netherlands), others recom- The comparative results for AN, BN, and BED are mended considerably lower intakes (Spain, the Unit- summarized in Tables 2–4. ed Kingdom), particularly for severely malnourished patients at risk for refeeding syndrome. Among the Anorexia nervosa seven guidelines which specified the use of nutri- All guidelines which provided information on the tional supplements, there was a large variation of treatment setting (n¼ 7) consistently recommended recommendations regarding the type and indica- outpatient treatment as a first-line therapy setting tion for nutritional supplements. Some guidelines for patients with AN. For determining more intense specifically recommended phosphate (n¼ 6), thia- levels of care, most guidelines provided criteria for mine (n¼ 3), zinc (n¼ 2), or potassium (n¼ 2), if partial (n¼ 5) and full-time hospitalization (n¼ 7). indicated, while others made a general recommen- The degree of detail and range of hospitalization dation for mineral or vitamin supplements (n¼ 3). criteria varied between guidelines. However, the Although psychotherapy was deemed a central guidelines consistently emphasized the necessity part of treatment by all guidelines, only seven guide- to decide about hospitalization on an individual lines recommended specific psychological inter- basis taking multiple factors into account. Overall, ventions. All seven guidelines recommended hospitalization should be considered for patients family-based therapy (for greater detail, see Herpertz- who have failed at outpatient care, or who are at Dahlmann in this issue [40,41]), particularly for high risk for medical complications as determined youngerpatients. Forindividualpsychotherapy, using patient’s weight status (e.g., extremely low most guidelines recommended cognitive-behavior- body mass index), behavioral factors (e.g., decline al therapy (n¼ 6) which intervenes at the symptom in oral intake), vital signs (e.g., heart rate< 40 bpm), level and centers on the modification of dysfunc- psychiatric comorbidity (e.g., suicide risk), or envi- tional behaviors and cognitions that maintain the ronmental aspects (e.g., family support). For very disorder [42]. It was recommended as a first- malnourished patients who do not consent to treat- line psychotherapy for AN by two guidelines (The ment, most guidelines provided some information Netherlands, the United Kingdom). Lesser agree- on compulsory treatment (n¼ 7). Criteria for dis- ment was achieved for psychodynamic therapy charge from hospital were specified by the majority and interpersonal psychotherapy, which were ex- of guidelines (n¼ 7). plicitly recommended as an alternative by four and The majority of guidelines (n¼ 6) emphasized two guidelines, respectively. While psychodynamic the importance to treat patients with AN and eating therapyincludestreatmentsthatoperate on an disorders in general, respectively, by specialized pro- interpretative-supportive continuum [43], inter- fessionals and/or by professionals with substantial personal psychotherapy is a focused, goal-oriented experience in the treatment of eating disorders. treatment which seeks to treat an eating disorder Regarding specific treatment modalities, most through resolving interpersonal problems in the guidelines included recommendations for nutri- contextofwhatthe disorder presents [44,45]. tional management ranging from artificial feeding Further, the cognitive-interpersonal approach (n¼ 8) to general nutritional counseling (n¼ 6). Maudsley Anorexia Nervosa Treatment for Adults Although the extent to which information on arti- [46] and the Specialist Supportive Clinical Manage- ficial feeding was given differed among guidelines ment [47,48] were recommended as first-line (e.g., concerning refeeding practice, duration, or therapies by two guidelines (The Netherlands, indication), guidelines consistently favored oral the United Kingdom). Although the German guide- enteral nutrition over parenteral nutrition which lineonlymadeageneralrecommendationfor should only be used as a last option. Regarding psychological interventions, it recommended in- general nutritional counseling, two (Germany, the volving the patient’s family in the treatment of United Kingdom) of six guidelines explicitly stated children and adolescents. Some guidelines noted that it should be part of a multidisciplinary therapy that psychological interventions would be more approach and not used as a stand-alone treatment. effective in medically stabilized and cognitively Although there was substantial agreement across improved patients (n¼ 3) or through combining guidelines about the amount of recommended psychological and nutritional interventions (n¼ 1). 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 427 Eating disorders 428 www.co-psychiatry.com Volume 30  Number 6  November 2017 Table 2. Comparison of evidence-based clinical guidelines for anorexia nervosa regarding key recommendations Clinical guideline Recommendation AUS DEN FR GER NETH SP UK US WFSBP Treatment setting First-line treatment: þ N.R. þþ þ þ þ þ N.R. outpatient Criteria for day N.R. N.R. UU N.R. UU U N.R. hospital treatment Criteria for U N.R. UU U U U U N.R. hospitalization Criteria for dischargeUU U U N.R. UU U N.R. Information on N.R. N.R. UU U U U U N.R. compulsory treatment Treatment modalities Refeeding/nutrition Recommended energy Start at 6000 kJ N.R. N.R. Start at 30–40 kcal/kg for Start at 40–60 kcal/kg 25–30 kcal/kg or Inpatient settings : sometimes Start at 30–40 kcal/kg N.R. intake, per day (1433 kcal), severely underweight for severely total kcal <1000 lower starting intakes (e.g., (i.e., 1000–1600 kcal), increases of patients, 800– underweight patients, for severe 5–10 kcal/kg) for severely weight gain phase: up 2000 kJ (478 kcal) 1200 kcal 800–1100 kcal malnutrition, day underweight patients, to 70–100 kcal/kg, every 2–3 days supplementary intake/ supplementary hospital: stepwise increase to male patients with until adequate day necessary for 100 g intake/day necessary supplementary 20 kcal/kg within 2 days, higher energy need intake for weight weight gain/day intake of 300– about 3500–7000 extra restoration 1000 kcal calories/week Recommended weight 0.5–1.4 kg N.R. 0.5–1 kg 0.5–1 kg 0.5–1.5 kg 0.5–1 kg N.R. 0.9–1.4 kg N.R. gain per week, inpatient settings Recommended weight N.R. N.R. 0.25 kg 0.2–0.5 kg 0.25–0.5 kg N.R. N.R. 0.2–0.5 kg N.R. gain per week, outpatient settings Recommended (þ) Phosphate, N.R. (þ) Phosphate, vitamin (þ) Zinc (skin lesions), (þ) Phosphate, thiamine (þ) Oral multivitamin (þ) Multivitamin and (þ) Phosphate, magnesium, N.R. supplements thiamine (risk of and trace elements potassium chloride (risk of refeeding and/or mineral multimineral supplements, potassium, calcium, refeeding (risk of refeeding (cardiac arrhythmia), syndrome) supplements biphosphonates vitamin D, zinc syndrome) syndrome) iron (iron-deficiency anemia), thiamine, riboflavin, niacin, folic acid, phosphate Recommendations for U N.R. UU U U U U U artificial feeding Nutritional counseling N.R. N.R. þ (þ) Only in þþ (þ) Only in multidisciplinary (þ) Registered dieticians N.R. multidisciplinary therapy therapy approach approach Psychological interventions In general þ (More intense when þ Cannot treat severe þ When medically N.R. N.R. Formal psychotherapy with N.R. medically stabilized AN alone, but in stabilized and starving patients may be and cognitively conjunction with cognitively sufficiently ineffective improved from refeeding recovered from starvation) malnutrition CBT þ N.R. þ N.R. þ (First) þþ (First) þ (After weight restoration) N.R. c c c c c c c FBT þ þ þ N.R. þ þ þ þ N.R. Psychodynamic N.R. N.R. þ N.R. N.R þþ þ (Acute AN and after N.R. therapy weight restoration) IPT N.R. N.R. N.R. N.R. N.R. þ N.R. þ (After weight restoration) N.R. Other Specialist therapist-led N.R. Support therapies, N.R. MANTRA (first), SSCM Behavioral therapy MANTRA (first), SSCM (first) þ Nonverbal therapeutic N.R. manualized based systemic and (first) methods (chronic AN), approaches (first), strategic therapies, group psychotherapy adolescent focused motivational for adults (after weight therapy approaches, restoration) nonverbal approaches in conjunction Evidence-based clinical guidelines for eating disorders Hilbert et al. 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 429 Table 2 (Continued) Clinical guideline Recommendation AUS DEN FR GER NETH SP UK US WFSBP Medication In general N.R. N.R. (No specific N.R. N.R. Not as only primary Not as sole treatment N.R. N.R. medication to treat treatment AN) Antidepressants (þ) N.R. þ Depressive  Weight gain N.R. N.R N.R. þ Depressive, anxiety, or N.R. disorders, anxious þ depressive symptoms obsessive-compulsive disorders, OCD symptoms, or bulimic symptoms SSRIs – N.R. N.R. N.R. – N.R. N.R.  Weight gain N.R. þ depressive, anxiety, obsessive-compulsive, or bulimic symptoms (in combination with psychotherapy or after weight restoration) TCAs N.R. N.R. (þ) N.R. N.R. N.R. N.R. – N.R. MAOIs N.R. N.R. N.R. N.R. N.R. N.R. N.R. – N.R. Antipsychotics (þ) Obsessional N.R. (þ)  Weight gain (þ) Obsessional thinking N.R. N.R. (þ) Weight gain N.R. thinking (þ) Obsessional thinking (olanzapine) (þ) Obsessional thinking (olanzapine) (only short-term) (olanzapine, risperidone, quetiapine, chlorpromazine) Appetizers N.R. N.R. N.R. – N.R. N.R. N.R. N.R. N.R. Lithium N.R. N.R. N.R. – N.R. N.R. N.R. N.R. N.R. Estrogen N.R. N.R. (þ) N.R. N.R. (þ)(þ)(þ) N.R. Other medication N.R. N.R. N.R. N.R. N.R. N.R. N.R. þ Pro-motility agents N.R. Buproprion (þ) Antianxiety agents Other treatments N.R. þ Meal support/ N.R. N.R. N.R. N.R.  Physical therapy (transcranial  Electroconvulsive therapy N.R. eating training magnetic stimulation, (or only for severe (as adjunct) acupuncture, weight cooccuring disorders) þ Supervised training, yoga or warming physical activity therapy) (as adjunct during weight gain phase) Special issues Separate Weighing, pregnancy, Detailed information on Separate Treatment of Separate recommendations for Recommendations for acute recommendations medical artificial feeding, recommendations for comorbidities, children and adolescents, AN versus after weight for children and management different settings of children and pregnancy, medical detailed information on restoration versus adolescents and for care, weighing, specific adolescents and for management psychotherapies, carer chronic AN, refeeding severe and long- recommendations for severe and long- support, weighing, medical syndrome standing AN, treatment of core standing AN, management, treatment of refeeding symptoms progress monitoring, comorbidities, pregnancy syndrome, medical relapse prevention management Note: U recommendation given; þ explicit recommendation in favor; (þ) cautious recommendation in favor;  recommendation against; N.R., no recommendation reported; AUS, Australia and New Zealand; CBT, cognitive-behavioral therapy; DEN, Denmark; FBT, family-based therapy; FR, France; GER, Germany; IPT, interpersonal therapy; OCD, obsessive-compulsive disorder; MAOI, monoamine oxidase inhibitor; MANTRA, Maudsley Anorexia Nervosa Treatment for Adults; NETH, The Netherlands; SSCM, Specialist Supportive Clinical Management; SSRI, selective serotonin reuptake inhibitor; SP, Spain; TCAs, tricyclic antidepressants; UK, United Kingdom; US, United States; WFSBP, World Federation of Societies of Biological Psychiatry. Recommendations for weight gain and energy intake were derived from both the guideline’s text and recommendations. Information on energy intake for the UK guideline was obtained from the Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN) guideline, because the UK guideline refers to it in this respect Indicates that the recommended intervention refers to children and adolescents only. Eating disorders 430 www.co-psychiatry.com Volume 30  Number 6  November 2017 Table 3. Comparison of evidence-based clinical guidelines for bulimia nervosa regarding key recommendations Clinical guideline AUS DEN GER NETH SP UK US WFSBP Treatment setting First-line treatment: outpatient þ N.R. þ N.R. þþ þ N.R. Criteria for day hospital treatment U N.R. U N.R. N.R. UU N.R. Criteria for inpatient treatment U N.R. U N.R. UU U N.R. Treatment modalities Nutritional counseling N.R. þ (Individualized or N.R. N.R. (þ) Only with N.R. þ (As part of the treatment) N.R. standardized) psychiatrist’s approval Psychological interventions In general þ (Individual) N.R. þ N.R. N.R. N.R. N.R. N.R. CBT þ (First) þ (First, individual þ (First) þ (First, individualþþ (Individual) þ (First) N.R. or group) or group) a a a FBT N.R. þ N.R. þ N.R. þ þ N.R. Self-help þ (Guided, CBT) N.R. þ (Guided, CBT) þ (Guided, CBT)þþ (First, guided, CBT) þ N.R. Psychodynamic therapies N.R. N.R. þ N.R. N.R. N.R. þ N.R. IPT N.R. N.R. þþ þ N.R. þ N.R. Other þ Internet-based CBT N.R. N.R. N.R. N.R. N.R. þ Group psychotherapy N.R. þ Psychodynamic interventions and CBT and other psychotherapies þ Couples therapy þ Support groups (as adjunct) Medications In general þ (If psychotherapy is not N.R. N.R. N.R. Pharmacological Not as sole treatment N.R. N.R. available or as treatments other than adjunctive therapy) antidepressants are not recommended Antidepressants þ N.R. N.R. N.R. þ N.R. þ N.R. SSRIs þ (Fluoxetine) (þ) þ (Fluoxetine, in þ (Fluoxetine) þ (Fluoxetine) N.R. þ (Fluoxetine) þ (Fluoxetine, combination with fluvoxamine) psychotherapy) TCAs N.R. N.R. N.R. N.R. N.R. N.R. þ (Imipramine, desipramine) MAOIs N.R. N.R. N.R. N.R. N.R. N.R.  (Phenelzine) Anticonvulsants þ (Topiramate) N.R. N.R. N.R. N.R. N.R. (þ) (Topiramate) N.R. Lithium N.R. N.R. N.R. N.R. N.R. N.R.  N.R. Other þ Weight loss (orlistat) N.R. N.R. N.R. N.R. N.R. N.R. N.R. Other treatments þ Combined psychological N.R. N.R. N.R. N.R.  Physical therapy (transcranial þ Combined treatment of CBT N.R. and pharmacological magnetic stimulation, and antidepressants therapy acupuncture, weight training, þ Bright light therapy (as yoga or warming therapy) adjunct) Special issues Medical management Treatment of Treatment of Treatment of Separate recommendations for Recommendations for initial No long-term comorbidities comorbidities, comorbidities, children and adolescent with BN, versus maintenance phase evidence options for pregnancy, medical detailed information on weight loss management psychotherapies, carer support, medical management, treatment of comorbidities, pregnancy Note: U recommendation given; þ explicit recommendation in favor; (þ) cautious recommendation in favor;  recommendation against; AUS, Australia and New Zealand; CBT, cognitive-behavioral therapy; DEN, Denmark; FBT, family-based therapy; GER, Germany; IPT, interpersonal therapy; MAOI, monoamine oxidase inhibitor; N.R., no recommendation reported; NETH, The Netherlands; SP, Spain; SSRI, selective serotonin reuptake inhibitor; TCAs, tricyclic antidepressants; UK, United Kingdom; US, United States; WFSBP, World Federation of Societies of Biological Psychiatry. Indicates that the recommended intervention refers to children and adolescents only. Evidence-based clinical guidelines for eating disorders Hilbert et al. 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 431 Table 4. Comparison of evidence-based clinical guidelines for binge-eating disorder regarding key recommendations Clinical guideline AUS GER NETH SP UK US WFSBP Treatment setting First-line treatment: outpatient N.R. þþ N.R. þ N.R. N.R. Criteria for inpatient treatmentUU U N.R. U N.R. N.R. Treatment modalities Nutritional counseling N.R. N.R. N.R. (þ) (With approval N.R. þ (In the context of N.R. of psychiatrist) behavioral weight- control programs) Psychological interventions In general þ (Individual) þþ N.R. N.R. N.R. N.R. CBT þ (First) þ (First) þ (First, individualþþ (Group or individual) þ (First, individual or N.R. or group) group) FBT N.R. N.R. þ N.R. N.R. N.R. N.R. Self-help þ (Guided, CBT) þ (Guided, CBT) þ (Guided, CBT) þ (Guided or þ (First, guided, CBT) þ (Guided or unguided, N.R. unguided) CBT) Psychodynamic therapies N.R. þ N.R. N.R. N.R. N.R. N.R. IPT N.R. þþ þ N.R. þ N.R. Medications In general þ (If psychotherapy is N.R. N.R. N.R. Not as sole treatment N.R. N.R. not available or as adjunctive therapy) Antidepressants þ N.R. N.R. þ N.R. þ N.R. SSRI þþ (Off-label-use, þ Binge eating þ Binge eating N.R. þ Binge eating frequency þ (Citalopram/ short-term) frequency frequency (short-term) escitalopram, sertraline) TCAs N.R. N.R. N.R. N.R. N.R. N.R. þ (Imipramine) Anticonvulsants þ (Topiramate) N.R. N.R. N.R. N.R. þ (Topiramate, þ (Topiramate) zonisamide) Antiobesity medications þ Weight loss (orlistat) N.R. N.R. N.R. N.R. þ Binge-eating frequency N.R. (sibutramine, short-term) þ Weight loss (orlistat, sibutramine) Other treatments þ Combined N.R. N.R. N.R.  Physical therapy þ Behavioral weight- N.R. psychological and (transcranial magnetic control programs pharmacological stimulation, acupuncture, þ Orlistat plus guided self- therapy weight training, yoga or help CBT warming therapy) þ Fluoxetine plus group behavioral treatment Special issues Medical management No long-term Treatment of Treatment of Detailed information on No long-term evidence for comorbidities, comorbidities, psychotherapies, medical evidence pharmacological options for pregnancy management, treatment of treatment weight loss comorbidities, pregnancy Note: U recommendation given; þ explicit recommendation in favor; (þ) cautious recommendation in favor;  recommendation against; AUS, Australia and New Zealand; CBT, cognitive-behavioral therapy; FBT, family-based therapy; GER, Germany; IPT, interpersonal therapy; MAOI, monoamine oxidase inhibitor; N.R., no recommendation reported; NETH, The Netherlands; SSRI, selective serotonin reuptake inhibitor; SP, Spain; TCAs, tricyclic antidepressants; UK, United Kingdom; US, United States; WFSBP, World Federation of Societies of Biological Psychiatry. Indicates that the recommended intervention refers to children and adolescents only. Eating disorders Regarding the pharmacological treatment of and pregnancy attempts. Two guidelines specifically AN, five of nine guidelines provided specific recom- provided information about the treatment of physi- mendations with some notable variations. Two cal and mental comorbidities, as well as artificial guidelines made the general recommendation that feeding including refeeding syndrome. medication should not be used as the sole or primary Bulimia nervosa treatment for patients with AN (Spain, the United Kingdom) or that there is no specific medication to Among the guidelines reporting on the prioritized treat AN (France). Antidepressants were generally treatment setting of BN, all recommended outpa- recommended for those with depressive symptoms tient therapy as a first-line treatment (n¼ 5). Four by four guidelines. At the same time, the German and five guidelines provided criteria for partial and guideline cautioned against the use of antidepres- full-time hospitalization, respectively. Regarding sants for weight gain. For selective serotonin reup- specific treatment modalities, nutritional counsel- take inhibitors (SSRIs), there was one guideline ing was generally recommended by the Danish which recommended its use for treating depressive guideline, in individualized or standardized format, symptoms in conjunction with psychotherapy or while two other guidelines emphasized that nutri- after weight restoration (the United States), while tional interventions (e.g., to help develop a struc- two other guidelines made general recommenda- tured meal plan) should not be offered as stand- tions against their use, particularly in children alone therapy (Spain, the United States). and adolescents (Australia and New Zealand, The Other than the WFSBP guideline, all available Netherlands). The use of tricyclic antidepressants guidelines issued recommendations on specific psy- (TCAs) was not explicitly favored, given that there chological interventions. In agreement, five guide- was one recommendation against (the United States) lines recommended cognitive-behavioral therapy as and one cautious recommendation in favor (France). a first-line psychotherapy for patients with BN, par- The use of monoamine oxidase inhibitors (MAOIs) or ticularly in an individual format. The remaining two bupropion, an atypical antidepressant, was not rec- guidelines also made recommendations in favor of ommended by the guideline from the United States, cognitive-behavioral interventions, but prioritized the only guideline reporting on these medications. cognitive-behavioral, guided self-help treatment as Four guidelines consistently recommended the cau- a first-line treatment (the United Kingdom), or did tious use of antipsychotics for treating obsessional not provide an explicit treatment hierarchy (Spain). thinking in patients with AN, particularly olanza- Overall, among the six guidelines which recom- pine, because evidence from randomized-controlled mended self-help approaches, four highlighted the trials and regarding long-term effects were lacking. use of guided self-help based on cognitive-behavior- Conflicting results were found for weight gain, given al interventions (Australia and New Zealand, that one guideline recommended antipsychotics for Germany, The Netherlands, the United Kingdom), weight gain (the United States), whereas another that is, using structured self-help manuals supple- guideline stated that antipsychotics would not be mented with brief supportive sessions [49]. Interper- appropriate for weight gain (Germany). Promotility sonal psychotherapy was recommended as an agents and antianxiety agents were only recom- alternative to cognitive-behavioral therapy by most mended by the guideline from the United States guidelines (n¼ 4), while psychodynamic therapy for treating gastrointestinal problems and to reduce (n¼ 2) was rarely recommended. Family-based ther- anticipatory anxiety concerning food intake, respec- apy was in particular recommended for younger tively. The use of appetizers and lithium was not patients with BN (n¼ 4), and only explicitly recom- recommended by the German guideline. In addition, mended for adults by the guideline from the United four guidelines consistently stated that estrogen States. Although the German guideline recom- should not be routinely offered to patients with mended cognitive-behavioral therapy for children AN, as this would depend on the patient’s menarche and adolescents with BN, they emphasized the im- status or chronicity of AN, for example. portance of including the patient’s family into treat- Adjunctive treatment recommendations were ment. Alternative psychological interventions were, rarely made and included meal support, eating for example, the combination of psychodynamic training, and supervised physical activity, as de- and cognitive-behavioral therapies (n¼ 1), couples scribed by the Danish guideline. Physical therapies therapy (n¼ 1), or support groups (n¼ 1). (e.g., electroconvulsive therapy, transcranial mag- Among the recommendations for pharmacolog- netic stimulation) were not recommended by two ical treatment, seven out of eight guidelines consis- guidelines. Of note, four guidelines included infor- tently recommended antidepressants, specifically mation on the medical management of AN and the SSRI fluoxetine, although with some restrictions three guidelines additionally reported on pregnancy (e.g., to use antidepressants in combination with 432 www.co-psychiatry.com Volume 30  Number 6  November 2017 Evidence-based clinical guidelines for eating disorders Hilbert et al. psychotherapy). Conflicting recommendations The use of antidepressants was generally recom- were obtained for the use of TCAs such as imipra- mended by three guidelines (Australia and New mine and desipramine, which were recommended Zealand, Spain, the United States). These three by the WFSBP, while the guideline from the United guidelines and three other guidelines (Germany, States explicitly did not recommend TCAs for initial The Netherlands, WFSBP) consistently made a spe- treatment in patients with BN. Consistently, two cific recommendation in favor of SSRIs for reducing guidelines advised against the use of MAOIs (United binge-eating episodes, at least in the short-term. For States, WFSBP). The use of anticonvulsants, specifi- TCAs, only the WFSBP recommended their use, cally topiramate, was consistently recommended by particularly imipramine. For anticonvulsants, three two guidelines, while the remaining guidelines did guidelines (Australia and New Zealand, the United not report on anticonvulsants. The only guideline States, WFSBP) consistently recommended the use which made a recommendation about lithium of topiramate, while the remaining guidelines did cautioned against its use (the United States). For not report on it. Consistently, two out of two guide- patients with comorbid obesity, one guideline rec- lines reporting on antiobesity medications explicitly ommended the antiobesity medication orlistat recommended their use, specifically orlistat, for (Australia and New Zealand). weight loss in patients with BED and comorbid Of note, four guidelines included specific infor- obesity. In addition to weight loss, the antiobesity mation about the treatment of comorbidities, and medication sibutramine was recommended for three guidelines made recommendations for the reducing binge eating (the United States). Two medical management of BN. guidelines explicitly made a recommendation for pharmacological treatment in conjunction with Binge-eating disorder psychological therapies (Australia and New Zealand, Only three out of seven available guidelines explic- the United States). itly included the recommendation that outpatient Of note, three guidelines reported on the treat- treatment is the first-line treatment setting for BED ment of comorbidities, and two guidelines made (Germany, The Netherlands, the United Kingdom). recommendations for the medical management Criteria for hospitalization were provided by four of BED. guidelines (Australia and New Zealand, Germany, The Netherlands, the United Kingdom). An explicit DISCUSSION recommendation for nutritional counseling was made by the guideline from the United States, spe- The current systematic review of evidence-based cifically within the context of behavioral weight loss clinical guidelines for eating disorders revealed programs. The Spanish guideline generally recom- many consistent recommendations, but also nota- mended nutritional counseling for patients with ble differences among the guidelines. eating disorders, with a psychiatrist’s approval. For the treatment of AN, the guidelines showed All guidelines provided recommendations for a substantial agreement on the amount of recom- specific psychological interventions, except the mended weight gain, while recommended daily WFSBP guideline. Cognitive-behavioral therapy energy intakes varied considerably, which is consis- was consistently recommended by all six guidelines, tent with Herpertz-Dahlmann et al. [28], who had followed by guided (n¼ 6) or unguided (n¼ 2) narratively reviewed four European guidelines for cognitive-behavioral self-help treatment and inter- the treatment of AN. Also in line with their findings, personal psychotherapy (n¼ 4). An explicit recom- the recommendations for nutritional supplements mendation for psychodynamic therapy was made varied widely, against a background of a lack of by the German guideline only. With respect to first- evidence. More consistently, most guidelines made line psychotherapy, four guidelines recommended recommendations for specific psychological inter- cognitive-behavioral therapy, while one guideline ventions in the treatment of AN, especially for fam- favored guided cognitive-behavioral self-help treat- ily-based therapy for younger patients, because of a ment (the United Kingdom). Regarding the treat- large evidence base [40,50,51]. Most guidelines fur- ment format, guidelines varied highly, with one ther supported cognitive-behavioral therapy [52]. guideline specifically recommending individual Cognitive-behavioral therapy, the Maudsley An- psychotherapy (Australia and New Zealand), one orexia Nervosa Treatment for Adults, and the Spe- prioritizing group format (the United Kingdom), cialist Supportive Clinical Management were even and two guidelines not including any preference recommended as first-line therapies by the two (The Netherlands, the United States). Family-based current guidelines from The Netherlands and the treatment was recommended for children and ado- United Kingdom, based on recently published && && lescents with BED by the Dutch guideline only. results [53 ,54 ]. Little agreement was found for 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 433 Eating disorders psychodynamic therapy and interpersonal psycho- sparse evidence base were issued for alternative therapy as alternative treatments, because of scant treatments (e.g., a combination of psychodynamic evidence for their use [55–57]. A need for further and cognitive-behavioral therapies) and nutritional research on the psychological treatment of AN was counseling. noted for all ages [28,58]. Regarding the pharmacological treatment of Regarding pharmacotherapy of AN, recommen- BN, most guidelines recommended antidepressants dations varied widely – four guidelines, among for the treatment of BN, specifically the SSRI fluox- them the medically oriented WFSBP guideline, etine, albeit with several restrictions (e.g., combined made no specific recommendation for any medica- use with psychotherapy only). Fluoxetine has tion, or advocated against their sole or primary use. approval for the treatment of adults with BN in The greatest level of consistency across four out of several countries (e.g., the United States, Germany). nine guidelines was found for the careful use of However, only a few and often inconsistent antipsychotics to reduce associated obsessional recommendations were made for the use of TCAs thinking in patients with AN, but it was inconsistent and anticonvulsants, specifically topiramate, and whether or not antipsychotics should be recom- against the use of MAOIs and lithium. Again, these mended for weight gain. In addition, three guide- singular and contradictory recommendations may lines generally recommended antidepressants for mirror the overall paucity of research on pharmaco- the treatment of depressive symptoms, but a consis- logical treatments of BN [13]. tent recommendation for specific types of antide- For the treatment of BED, all guidelines provid- pressants (SSRIs, TCAs) could not be identified. ed recommendations for specific psychological Single guidelines’ recommendations emerged re- interventions (except the medically oriented garding other medications, for example, against WFSBP guideline). Cognitive-behavioral therapy the use of bupropion. Estrogen was with some con- was consistently recommended by all respective sistency recommended to be offered only upon guidelines and mostly as a first-line treatment, giv- & && specific indication (see [59 ]). Overall, these incon- en its comprehensive evidence base [10 ]. Cogni- sistent pharmacological recommendations for the tive-behavioral therapy was followed by cognitive- treatment of AN may reflect the scarce evidence base behavioral self-help treatment, with the majority of for the pharmacological treatment of this disorder guidelines recommending a guided format, a treat- [13,28,60 ]. ment with an increasing evidence base [65]. Of For the treatment of BN, all guidelines but the note, the guideline from the United Kingdom fa- medically oriented WFSBP guideline issued recom- vored guided cognitive-behavioral self-help treat- mendations on specific psychological interventions: ment as a first-line treatment, likely for economic The majority of them recommended cognitive-be- reasons, as described for BN. Interpersonal psycho- havioral therapy as a first-line treatment for BN, therapy was further recommended by the majority reflecting the treatment literature [11,52]. In con- of the guidelines, based on a small number of trast, the United Kingdom guideline recommended studies [52]. An explicit non-evidence-based offering cognitive-behavioral self-help treatment recommendation for psychodynamic therapy was first, presumably because of an emphasis on cost- made by the German guideline only [66] reflecting effectiveness [27], for which initial data are available healthcare system specificities, while family-based [61]. Interpersonal psychotherapy was recom- treatment was recommended for children and ado- mended as an alternative to cognitive-behavioral lescents with BED by the Dutch guideline only, therapy by the majority of guidelines, given its based on emerging evidence for family-based treat- slower short-term efficacy, but equivalent long-term ment of adolescents with BN [64]. A recommenda- efficacy [52]. Psychodynamic therapy was recom- tion for nutritional counseling was made by two mended by the German and guideline from the guidelines, which may reflect findings of lower United States only, despite its limited evidence base efficacy of this treatment regarding binge-eating && [62,63], possibly because of particularities in health- outcome [67 ]. care systems. Family-based therapy was recom- Regarding the pharmacological treatment of mended mostly for younger patients by half of BED, the majority of guidelines made a recommen- the guidelines, which is supported by recent clinical dation for SSRIs, which is in line with current liter- && research [64]. Most guidelines recommended self- ature [10 ], while only the WFSBP guideline help treatment, and the majority of these, especially recommended TCAs, based on studies published be- the more recent guidelines, emphasized guided cog- fore 1999. Three guidelines recommended the use of nitive-behavioral self-help treatment, documented the anticonvulsant topiramate; however, the drug’s to be efficacious in the treatment of BN [65]. A few side-effects, especially cognitive impairment, have recommendations with unclear rationale and/or been noted [68]. Regarding antiobesity medications, 434 www.co-psychiatry.com Volume 30  Number 6  November 2017 Evidence-based clinical guidelines for eating disorders Hilbert et al. two guidelines recommended orlistat for weight Another additional source for differences loss in BED and BN [69,70] and sibutramine for among guidelines may be how the evidence was binge eating in BED, the latter being withdrawn from examined, with guidelines based on meta-analyses many markets because of adverse cardiovascular (e.g., Germany, the United Kingdom), systematic events. Combined psychological and pharmaco- reviews (e.g., Australia and New Zealand, the United logical treatment was recommended by two guide- States), or unsystematic reviews of the evidence lines; however, this is not supported by current (e.g., France). The transparency with which evi- && evidence [71 ]. dence was converted into specific recommendations Overall, consistency across guidelines seemed to further varied across guidelines; several guidelines be the greatest for psychological treatments and for explicitly evaluated the strength of evidence and single medications with a larger evidence base, provided clear rationale for a specific recommenda- while for psychological and medical treatments tion (e.g., Germany, the United Kingdom, WFSBP), with a smaller evidence base, recommendations while others did not (e.g., France), leaving the em- varied considerably, and expert consensus played pirical foundation of a recommendation unclear. To a greater role. Regarding the dissemination and develop a guideline, it has been recommended to implementation of evidence-based treatments into use a systematic approach to evaluate the strength of clinical practice, the guidelines thus do endorse evidence, for example the Grading of Recommen- main empirically validated treatment approaches dations Assessment, Development, and Evaluation with considerable agreement, but beyond this, the [72], or the system of the Oxford Centre for Evi- variability is greater in what recommendations evi- dence-Based Medicine [26,73]. For some guidelines, dence-based clinical guidelines subsume. A larger only summary statements without the systematic evidence base is critical in offering clinically reliable review component were available in the review and consistent guidance in eating disorders, and languages, making the empirical background of a many important areas of future clinical research recommendation difficult to understand (e.g., have been identified for all eating disorders at dif- Denmark). Guidelines differed further in readabili- ferent ages, given the treatment gap and the re- ty, with most guidelines providing clear or even search-practice gap described at the outset of this standardized recommendations that were easily lo- && & article [15 ,22 ]. cated (e.g., Germany, the United Kingdom), while The available evidence is one reason for differ- others provided them in a more complex text format ences among guidelines. Among additional reasons, (e.g., the United States). Although these aspects are while several guidelines were issued within the past central to the quality of a guideline, it is notable that 3 years or are about to be published, the majority a systematic quality evaluation [74] of clinical eating were 5 years and older. Especially for disorders such disorder guidelines is currently lacking; this was as BED with a large recent increase in clinical re- considered to be beyond the scope of this treat- search, changes in recommendations over time are ment-oriented review but could help to systemati- to be expected. Several recommendations were non- cally identify strengths and limitations of current evidence-based and likely reflected particularities in eating disorder guidelines. healthcare systems, for example, the availability of Strengths of this study were a systematic com- outpatient, day patient, and inpatient settings or of pilation of main treatment recommendations of therapists trained in a specific intervention. The current evidence-based eating disorders guidelines. guidelines differed as well in their scope, consider- Not within the scope of this review were: general ing treatment in selected aspects (e.g., Denmark, setting-oriented recommendations (e.g., communi- France) or comprehensively (e.g., Germany, the cation with the patient, therapeutic infrastructure, United States). Some guidelines were created by organization of transitions between different levels one healthcare profession or one specialized profes- of care); methods for the identification, assessment, sional organization only (e.g., the guidelines from and diagnosis of eating disorders; and the practical the United States, WFSBP) and may thus reflect the applicability of the guidelines and their actual view of this profession only. Most guidelines, how- implementation in clinical settings. Several of ever, pursued a multiprofessional approach in these aspects warrant further investigation. One guideline development, and some of them noted further limitation is that several guidelines had the inclusion of other stakeholders as well. In fact, to be excluded from this review because of not the current literature for guideline development meeting the language requirement. For further com- advocates for broad stakeholder involvement of parative research, it would be desirable to have all relevant professions, healthcare providers, and guidelines published not only in the national lan- patients (e.g., [25–27]) for optimal acceptance guage, but also in other languages for international and implementation. reception. 0951-7367 Copyright  2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 435 Eating disorders 9. Kessler RC, Berglund PA, Chiu WT, et al. The prevalence and correlates of CONCLUSION binge eating disorder in the World Health Organization World Mental Health Surveys. Biol Psychiatr 2013; 73:904 – 914. The current systematic, international comparison 10. Brownley KA, Berkman ND, Peat CM, et al. Binge-eating disorder in adults: a demonstrated notable commonalities and differen- && systematic review and meta-analysis. Ann Intern Med 2016; 165:409 – 420. A timely meta-analysis on the efficacy of psychological and medical approaches to ces among current evidence-based clinical guide- the treatment of BED. lines for eating disorders. Currently, several 11. Hay P. A systematic review of evidence for psychological treatments in eating disorders: 2005 – 2012. Int J Eat Disord 2013; 46:462 – 469. evidence-based clinical guidelines for eating disor- 12. Kass AE, Kolko RP, Wilfley DE. Psychological treatments for eating disorders. ders are in progress (e.g., Germany, the United Curr Opin Psychiatry 2013; 26:549 – 555. 13. McElroy SL, Guerdjikova AI, Mori N, Keck PE Jr. Psychopharmacologic States). Because developing and updating clinical treatment of eating disorders: emerging findings. Curr Psychiatry Rep guidelines is time-consuming and complex, an in- 2015; 17:35. 14. Mitchell JE, Roerig J, Steffen K. Biological therapies for eating disorders. Int J ternational coordination of guideline development, Eat Disord 2013; 46:470 – 477. for example, across the European Union, would be 15. Kazdin AE, Fitzsimmons-Craft EE, Wilfley DE. Addressing critical gaps in the && treatment of eating disorders. Int J Eat Disord 2017; 50:170 – 189. desirable. Collaborative efforts would need to care- A succinct overview of important gaps in the dissemination and implementation of fully specify the goals and scope of a common evidence-based treatment into clinical practice. 16. Cooper M, Kelland H. Medication and psychotherapy in eating disorders: is ‘guideline trunc’ which should be based on an elab- there a gap between research and practice? J Eat Disord 2015; 3:45. orated, quality-assuring developmental process, 17. Micali N, Martini MG, Thomas JJ, et al. Lifetime and 12-month prevalence of & eating disorders amongst women in mid-life: a population-based study of while accounting for different cultures and national diagnoses and risk factors. BMC Med 2017; 15:12. requirements. European clinical studies on major A longitudinal study of mid-life prevalence rates of eating disorders in women in relation to psychosocial risk factors. research gaps could represent an important first step 18. Peterson CB, Becker CB, Treasure J, et al. The three-legged stool of toward this end. & evidence-based practice in eating disorder treatment: research, clinical, and patient perspectives. BMC Med 2016; 14:69. A narrative review of evidence-based practice in eating disorders. 19. Regan P, Cachelin FM, Minnick AM. Initial treatment seeking from professional Acknowledgements & healthcare providers for eating disorders: a review and synthesis of potential The authors are grateful to Jamie L. Manwaring, PhD barriers to and facilitators of ‘first contact’. Int J Eat Disord 2017; 50: 190 – 209. and Lisa Opitz, BSc for her help in editing this article. A systematic review on treatment-seeking in the eating disorders. 20. Kosmerly S, Waller G, Robinson AL. Clinician adherence to guidelines in the delivery of family-based therapy for eating disorders. Int J Eat Disord 2015; Financial support and sponsorship 48:223 – 229. 21. Von Ranson KM, Wallace LM, Stevenson A. Psychotherapies provided for A.H. and R.S. are funded by the German Federal Ministry eating disorders by community clinicians: infrequent use of evidence-based treatment. Psychother Res 2013; 23:333 – 343. of Education and Research (grant 01EO1501). 22. Waller G. Treatment protocols for eating disorders: clinicians’ attitudes, concerns, adherence and difficulties delivering evidence-based psychological interventions. Curr Psychiat Rep 2016; 18:1 – 8. Conflicts of interest A narrative review on the use of evidence-based treatment manuals in clinical practice. 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Published: Jul 11, 2017

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