Article

Management of Eating Disorders

Evidence report/technology assessment 05/2006; 135(135):1-166.
Source: PubMed

ABSTRACT The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) systematically reviewed evidence on efficacy of treatment for anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), harms associated with treatments, factors associated with the treatment efficacy and with outcomes of these conditions, and whether treatment and outcomes for these conditions differ by sociodemographic characteristics.
We searched MEDLINE, the Cumulative Index to Nursing and Applied Health (CINAHL), PSYCHINFO, the Educational Resources Information Center (ERIC), the National Agricultural Library (AGRICOLA), and Cochrane Collaboration libraries.
We reviewed each study against a priori inclusion/exclusion criteria. For included articles, a primary reviewer abstracted data directly into evidence tables; a second senior reviewer confirmed accuracy. We included studies published from 1980 to September 2005, in all languages. Studies had to involve populations diagnosed primarily with AN, BN, or BED and report on eating, psychiatric or psychological, or biomarker outcomes.
We report on 30 treatment studies for AN, 47 for BN, 25 for BED, and 34 outcome studies for AN, 13 for BN, 7 addressing both AN and BN, and 3 for BED. The AN literature on medications was sparse and inconclusive. Some forms of family therapy are efficacious in treating adolescents. Cognitive behavioral therapy (CBT) may reduce relapse risk for adults after weight restoration. For BN, fluoxetine (60 mg/day) reduces core bulimic symptoms (binge eating and purging) and associated psychological features in the short term. Individual or group CBT decreases core behavioral symptoms and psychological features in both the short and long term. How best to treat individuals who do not respond to CBT or fluoxetine remains unknown. In BED, individual or group CBT reduces binge eating and improves abstinence rates for up to 4 months after treatment; however, CBT is not associated with weight loss. Medications may play a role in treating BED patients. Further research addressing how best to achieve both abstinence from binge eating and weight loss in overweight patients is needed. Higher levels of depression and compulsivity were associated with poorer outcomes in AN; higher mortality was associated with concurrent alcohol and substance use disorders. Only depression was consistently associated with poorer outcomes in BN; BN was not associated with an increased risk of death. Because of sparse data, we could reach no conclusions concerning BED outcomes. No or only weak evidence addresses treatment or outcomes difference for these disorders.
The literature regarding treatment efficacy and outcomes for AN, BN, and BED is of highly variable quality. In future studies, researchers must attend to issues of statistical power, research design, standardized outcome measures, and sophistication and appropriateness of statistical methodology.

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    ABSTRACT: The neurotransmitter serotonin (5-HT) modulates many functions important for life, e.g., appetite and body temperature, and controls development of the neural system. Disturbed 5-HT function has been implicated in mood, anxiety and eating disorders. The serotonin transporter (SERT) controls the amount of effective 5-HT by removing it from the extracellular space. Radionuclide imaging methods single photon emission tomography (SPET) and positron emission tomography (PET) enable studies on the brain SERTs. This thesis concentrated on both methodological and clinical aspects of the brain SERT imaging using SPET. The first study compared the repeatability of automated and manual methods for definition of volumes of interest (VOIs) in SERT images. The second study investigated within-subject seasonal variation of SERT binding in healthy young adults in two brain regions, the midbrain and thalamus. The third study investigated the association of the midbrain and thalamic SERT binding with Bulimia Nervosa (BN) in female twins. The fourth study investigated the association of the midbrain and hypothalamic/thalamic SERT binding and body mass index (BMI) in monozygotic (MZ) twin pairs. Two radioligands for SERT imaging were used: [123I]ADAM (studies I-III) and [123I]nor-beta-CIT (study IV). Study subjects included young adult MZ and dizygotic (DZ) twins screened from the FinnTwin16 twin cohort (studies I-IV) and healthy young adult men recruited for study II. The first study validated the use of an automated brain template in the analyses of [123I]ADAM images and proved automated VOI definition more reproducible than manual VOI definition. The second study found no systematic within-subject variation in SERT binding between scans done in summer and winter in either of the investigated brain regions. The third study found similar SERT binding between BN women (including purging and non-purging probands), their unaffected female co-twins and other healthy women in both brain regions; in post hoc analyses, a subgroup of purging BN women had significantly higher SERT binding in the midbrain as compared to all healthy women. In the fourth study, MZ twin pairs were divided into twins with higher BMI and co-twins with lower BMI; twins with higher BMI were found to have higher SERT binding in the hypothalamus/thalamus than their leaner co-twins. Our results allow the following conclusions: 1) No systematic seasonal variation exists in the midbrain and thalamus between SERT binding in summer and winter. 2) In a population-based sample, BN does not associate with altered SERT status, but alterations are possible in purging BN women. 3) The higher SERT binding in MZ twins with higher BMIs as compared to their leaner co-twins suggests non-genetic association between acquired obesity and the brain 5-HT system, which may have implications on feeding behavior and satiety. Serotoniini (5-HT) on yksi aivojen välittäjäaineista, ja se osallistuu mm. hermoston kehityksen sekä monien elintärkeiden toimintojen, kuten ruokahalun ja ruumiinlämmön, säätelyyn. Useisiin psykiatrisiin sairauksiin, esimerkiksi masennukseen ja syömishäiriöihin, uskotaan liittyvän 5-HT-järjestelmän häiriö. Serotoniinitransportteri (SERT) on 5-HT:n kuljettajaproteiini, joka poistaa 5-HT:a solunulkoisesta tilasta ja siten säätelee vaikuttavan 5-HT:n määrää. Aivojen serotoniinitransporttereita voidaan kuvantaa käyttämällä yksifotoniemissiotomografiaa (SPET) tai positroniemissiotomografiaa (PET). Väitöskirjatyössä perehdyttiin aivojen serotoniinitransporttereiden SPET-tutkimuksiin eri näkökannoilta. Ensimmäisessä osatyössä verrattiin automatisoidun ja manuaalisen mielenkiintoalueiden rajaustavan toistettavuutta SERT-kuvien analysoinnissa. Toisessa osatyössä tutkittiin fysiologisen vuodenaikavaihtelun esiintymistä keskiaivojen ja talamuksen alueiden SERT-kertymissä tutkimalla samoja terveitä koehenkilöitä sekä kesällä että talvella. Kolmannessa osatyössä verrattiin keskiaivojen ja talamuksen alueiden SERT-kertymiä bulimia nervosaa (BN) sairastavilla naisilla, heidän terveillä kaksossisarillaan ja muilla terveillä kaksosnaisilla. Neljännessä osatyössä tutkittiin keskiaivojen ja hypotalamuksen/talamuksen alueiden SERT-kertymien ja painoindeksin yhteyttä monotsygoottisista kaksosista koostuvassa aineistossa vertaamalla suuremman painoindeksin omaavia kaksosia heidän pienemmän painoindeksin omaaviin kaksossisariinsa. Osatöissä käytettiin kahta eri SERT-kuvantamiseen soveltuvaa merkkiainetta: [123I]ADAM:ia (osatyöt I-III) ja [123I]nor-beta-CIT:ia (osatyö IV). Automatisoituun menetelmään pohjautuva [123I]ADAM-kuvien analysointimenetelmä osoittautui toistettavuudeltaan perinteistä manuaalista mielenkiintoalueiden rajaustapaa paremmaksi. Keskiaivojen ja talamuksen alueiden SERT-kertymissä ei todettu systemaattista vuodenaikaan liittyvää vaihtelua kesällä ja talvella tehtyjen kuvausten kesken. Keskiaivojen ja talamuksen SERT-kertymissä ei todettu merkittäviä eroja verrattaessa kaikkia bulimia nervosaa sairastaneita naisia, heidän terveitä kaksossisariaan ja terveitä naisia. Alaryhmäanalyyseissä vatsantyhjennys-tyyppistä bulimiaa sairastavien naisten alaryhmässä todettiin korkeampi SERT-kertymä keskiaivojen alueella kuin terveillä naisilla. Painoindeksin ja hypotalamuksen/talamuksen alueen SERT-kertymän välillä havaittiin yhteys: suuremman painoindeksin omaavilla kaksosilla todettiin korkeampi talamuksen/hypotalamuksen SERT-kertymä kuin heidän hoikemmilla kaksossisaruksillaan. Tulokset osoittavat, että automatisoitu menetelmä soveltuu aivojen [123I]ADAM-kuvien analysointiin. Keskiaivojen ja talamuksen alueiden SERT-kertymissä ei todettu merkittävää vuodenaikavaihtelua, minkä perusteella vuodenaikaa ei tarvitse huomioida sekoittavana tekijänä näiden alueiden SERT-kertymien kuvantamistutkimuksissa. Bulimia nervosaan ei väestöpohjaisessa aineistossa liity poikkeavaa SERT-kertymää keskiaivojen tai talamuksen alueilla, mutta bulimia nervosan alaryhmät saattavat erota tässä suhteessa toisistaan. 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