ANTOP study: when the inexperienced guide the inexperienced

Stein Frostad1, Asle Halvorsen1, Julie Lesser2, Riccardo Dalle Grave3

1Section for Eating Disorders, Department for Psychosomatic Medicine, Haukeland University Hospital, 5021 Bergen, Norway,

2Children’s Hospitals and Clinics of Minnesota & Abbott Northwestern HospitalMinneapolis, MN, USA,

3Department of Eating Disorder and Weight Disorders, Villa Garda Hospital. Via Montebaldo, 89, 37016 Garda (Vr), Italy,

We read with interest the paper by Zipfel and colleagues1 concluding that optimised treatment as usual, focal psychodynamic therapy, and a new “enhanced” form of cognitive behaviour therapy (CBT-E) have similar, somewhat modest, effects on anorexia nervosa. Since this conclusion could have important implications for the management of the disorder, it is essential that it is robust.

We are clinicians from three different eating disorder treatment centres in three different countries (Norway, US, and Italy), each using CBT-E to treat anorexia nervosa. We have found the treatment to be remarkably effective2,3, so much so it has changed our clinics’ entire practice.  We can now treat patients who were previously untreatable.

Like many new forms of cognitive behavior therapy (CBT), CBT-E is not easy to learn.  We found that training is essential and this needs to be followed by supervision from someone who knows how to implement the treatment. It is clear that this did not happen in the Zipfel et al study as both the CBT-E therapists and their supervisors had no prior experience using the new treatment. They were experienced in CBT in general but this would no more qualify them to implement CBT-E than an orthopedic surgeon would be automatically qualified to implement a novel orthopedic procedure.

Tests of a new treatment need to ensure that it is properly implemented.  This did not happen in the Zipfel et al study.  As a result there are reasons to question the internal validity of the study and the authors’ conclusions.

  1. Zipfel S, Wild B, Gross G, et al. Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial. Lancet. 2014 Jan 11;383(9912):127-37.
  2. Fairburn CG, Cooper Z, Doll HA, O’Connor ME, Palmer RL, Dalle Grave R.  Enhanced cognitive behaviour therapy for adults with anorexia nervosa: A UK-Italy study.  Behaviour Research and Therapy 2013; 51: 2-8.
  3. Dalle Grave R, Callugi S, Doll HA, Fairburn CG.  Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: An alternative to family therapy?  Behaviour Research and Therapy 2013; 51: 9-12.