title: Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial.
abstract: BACKGROUND
  Psychotherapy is the treatment of choice for patients with anorexia nervosa, although evidence of efficacy is weak. The Anorexia Nervosa Treatment of OutPatients (ANTOP) study aimed to assess the efficacy and safety of two manual-based outpatient treatments for anorexia nervosa--focal psychodynamic therapy and enhanced cognitive behaviour therapy--versus optimised treatment as usual.
  
  
  METHODS
  The ANTOP study is a multicentre, randomised controlled efficacy trial in adults with anorexia nervosa. We recruited patients from ten university hospitals in Germany. Participants were randomly allocated to 10 months of treatment with either focal psychodynamic therapy, enhanced cognitive behaviour therapy, or optimised treatment as usual (including outpatient psychotherapy and structured care from a family doctor). The primary outcome was weight gain, measured as increased body-mass index (BMI) at the end of treatment. A key secondary outcome was rate of recovery (based on a combination of weight gain and eating disorder-specific psychopathology). Analysis was by intention to treat. This trial is registered at http://isrctn.org, number ISRCTN72809357.
  
  
  RESULTS
  Of 727 adults screened for inclusion, 242 underwent randomisation: 80 to focal psychodynamic therapy, 80 to enhanced cognitive behaviour therapy, and 82 to optimised treatment as usual. At the end of treatment, 54 patients (22%) were lost to follow-up, and at 12-month follow-up a total of 73 (30%) had dropped out. At the end of treatment, BMI had increased in all study groups (focal psychodynamic therapy 0·73 kg/m(2), enhanced cognitive behaviour therapy 0·93 kg/m(2), optimised treatment as usual 0·69 kg/m(2)); no differences were noted between groups (mean difference between focal psychodynamic therapy and enhanced cognitive behaviour therapy -0·45, 95% CI -0·96 to 0·07; focal psychodynamic therapy vs optimised treatment as usual -0·14, -0·68 to 0·39; enhanced cognitive behaviour therapy vs optimised treatment as usual -0·30, -0·22 to 0·83). At 12-month follow-up, the mean gain in BMI had risen further (1·64 kg/m(2), 1·30 kg/m(2), and 1·22 kg/m(2), respectively), but no differences between groups were recorded (0·10, -0·56 to 0·76; 0·25, -0·45 to 0·95; 0·15, -0·54 to 0·83, respectively). No serious adverse events attributable to weight loss or trial participation were recorded.
  
  
  CONCLUSIONS
  Optimised treatment as usual, combining psychotherapy and structured care from a family doctor, should be regarded as solid baseline treatment for adult outpatients with anorexia nervosa. Focal psychodynamic therapy proved advantageous in terms of recovery at 12-month follow-up, and enhanced cognitive behaviour therapy was more effective with respect to speed of weight gain and improvements in eating disorder psychopathology. Long-term outcome data will be helpful to further adapt and improve these novel manual-based treatment approaches.
  
  
  BACKGROUND
  German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF), German Eating Disorders Diagnostic and Treatment Network (EDNET).
authors.affiliation: Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany. Electronic address: stephan.zipfel@med.uni-tuebingen.de.
authors.forename: Stephan
authors.initials: S
authors.lastname: Zipfel
authors.affiliation: Center for Psychosocial Medicine, Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Beate
authors.initials: B
authors.lastname: Wild
authors.affiliation: Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.
authors.forename: Gaby
authors.initials: G
authors.lastname: Groß
authors.affiliation: Center for Psychosocial Medicine, Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Hans-Christoph
authors.initials: HC
authors.lastname: Friederich
authors.affiliation: Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Teufel
authors.affiliation: Center for Psychosocial Medicine, Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Dieter
authors.initials: D
authors.lastname: Schellberg
authors.affiliation: Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.
authors.forename: Katrin E
authors.initials: KE
authors.lastname: Giel
authors.affiliation: Department of Psychosomatic Medicine and Psychotherapy, University Hospital Erlangen, Erlangen, Germany.
authors.forename: Martina
authors.initials: M
authors.lastname: de Zwaan
authors.affiliation: Clinic for Psychosomatic Medicine and Psychotherapy, University of Technology Munich, Munich, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Dinkel
authors.affiliation: Clinic for Psychosomatic Medicine and Psychotherapy, LWL University Hospital of the Ruhr, University of Bochum, Bochum, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Herpertz
authors.affiliation: Clinic for Psychosomatic Medicine and Psychotherapy, University Hospital Münster, Münster, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Burgmer
authors.affiliation: Institute and Outpatient Clinic for Psychosomatic Medicine and Psychotherapy, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Bernd
authors.initials: B
authors.lastname: Löwe
authors.affiliation: Clinic for Psychosomatic Medicine and Psychotherapy, LVR Hospital Essen, University of Duisburg-Essen, Essen, Germany.
authors.forename: Sefik
authors.initials: S
authors.lastname: Tagay
authors.affiliation: Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Ulm, Ulm, Germany.
authors.forename: Jörn
authors.initials: J
authors.lastname: von Wietersheim
authors.affiliation: Department of Psychosomatic Medicine and Psychotherapy, University Hospital Freiburg, Freiburg, Germany.
authors.forename: Almut
authors.initials: A
authors.lastname: Zeeck
authors.affiliation: Coordination Center for Clinical Trials (KKS), Marburg, Germany.
authors.forename: Carmen
authors.initials: C
authors.lastname: Schade-Brittinger
authors.affiliation: Center for Psychosocial Medicine, Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Henning
authors.initials: H
authors.lastname: Schauenburg
authors.affiliation: Center for Psychosocial Medicine, Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Herzog
mesh_terms: D000328:Adult; D000553:Ambulatory Care; D000856:Anorexia Nervosa / Q000628:therapy*; D015928:Cognitive Behavioral Therapy; D005260:Female; D006801:Humans; D018579:Patient Selection; D011613:Psychotherapy / Q000379:methods*; D016896:Treatment Outcome