CBT-E and FBT for Adolescents With an Eating Disorder

Family-based treatment (FBT) is an efficacious intervention for adolescents with an eating disorder. Evaluated to a lesser degree among adolescents, enhanced cognitive-behavior therapy (CBT-E) has shown promising results. However, no previous study has directed compared the effectiveness of the two treatments.

A new study published in Psychological Medicine compared the relative effectiveness of FBT and CBT-E delivered by the Center for the Treatment of Eating Disorders (CTED) at Children’s Minnesota, MN, a pediatric specialty clinic that provides inpatient and outpatient treatment to youth and their families.

Over the course of the study period (July 2015 to November 2019), 107 patients met the eligibility criteria for the study. Of those, 10 families withdrew consent, and 97 patients (83 percent) and their families were enrolled and offered a choice between one of two manualized treatments: FBT or CBT-E.

Fifty-one (52.5 percent) participants/families chose FBT, and 46 (47.5 percent) chose CBT-E. The sample was divided into a lower weight cohort ([<90 percent median body mass index (mBMI)]; 38 percent of participants) and a higher weight cohort. Regardless of the weight cohort, participants who selected CBT-E were older, on average, had been ill longer, and presented with higher depression and anxiety, more prior mental health treatment, and higher rates of psychosocial impairment due to eating disorder features.

Assessments were administered at baseline, end-of-treatment, and 6- and 12-month follow-up. Treatment comprised of 20 sessions over 6 months, except for the lower weight cohort where CBT-E comprised 40 sessions over 9-12 months.

Regardless of weight cohort, FBT was shown to be more efficient than CBT-E in terms of the slope of weight gain from baseline to the end of treatment. However, this was no longer the case at either the 6- or 12-month follow-up. In fact, at 12 months follow-up, the percentage of mBMI among the lower weight cohort was 96.2 in FBT and 96.4 in CBT-E.

Initial more gradual weight gains achieved by CBT-E compared to FBT at end of treatment seems due to distinct strategies used to achieve weight gain across these two treatments. In CBT-E, weight gain (when indicated) is addressed after 4 weeks of treatment, and only when patients reach the conclusion that they need to attend to their low weight. In contrast, weight gain in FBT (when indicated) is addressed at the outset, while parents are supported to drive this agenda.

However, since for a substantial minority of patients in the higher weight cohort (∼22 percent), weight gain was not a treatment goal, the effectiveness of the two treatments was also assessed as defined in terms of improvement in eating disorders psychopathology. In this domain, both treatments demonstrated improvements in the eating disorder psychopathology with no significant differences across time. Moreover, the two treatments largely established similar gains across measures of general psychopathology and clinical impairment.

An interesting data point is that the choice to choose between FBT and CBT-E resulted in older and less well participants opting for CBT-E. This led to the speculation that parents considered individual therapy rather than a family-based one to be more appropriate when their offspring was older and more unwell.

In conclusion, results show that FBT and CBT-E achieved similar outcomes in the treatment of adolescents with eating disorders, making CBT-E a viable treatment for adolescents with an eating disorder.