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Kognitiivinen psykoterapia ahmimishäiriön ja bulimisten oireiden hoidossa

Näytönastekatsaukset
Hanna Ebeling
25.8.2014

Näytön aste: C

Kognitiivis-behavioraalisen psykoterapian tehosta ahminnan ja oksentelun hoidossa muihin terapioihin verrattuna on ristiriitaista tietoa.

Laajassa systemaattisessa Cochrane-katsauksessa ja meta-analyysissa «Hay PP, Bacaltchuk J, Stefano S ym. Psychological ...»1, «Psychological treatments for bulimia nervosa and binging»1 tarkasteltiin 48 satunnaistettua tutkimusta, jotka olivat kohdistuneet ahmimishäiriön hoitoon (21 tutkimusta, potilaat yli 16-vuotiaita), tarkemmin määrittelemättömän syömishäiriön hoitoon (8 tutkimusta) tai ahmimisen hoitoon (9 tutkimusta). Kahdeksassa tutkimuksessa oli verrattu kognitiivis-behavioraalista psykoterapiaa (KBT) hoitoa odottaviin potilaisiin (waiting list, WL, 29 % kontrolliryhmistä). Vertailtuihin psykoterapioihin kuului interpersoonallinen psykoterapia (IPT), dialektinen käyttäytymisterapia (DKT), hypnokäyttäytymisterapia, supportiivinen psykoterapia, käyttäytymiseen liittyvä painon hallinta ja itsehoito. Psykoterapiat toteutuivat keskimäärin 15,5 viikon ajan (vaihteluväli 6–52 viikkoa), useimmiten kerran viikossa. Käytetyt mittarit vaihtelivat: syömishäiriöoireiden itseraportoimisen (esimerkiksi EDE, EDI; EAT-26) lisäksi käytettiin osassa tutkimuksista yleistä psyykkistä oireilua mittaavia lomakkeita (esimerkiksi SCL-90, BDI, Rosenberg Self Esteem) ja haastattelua.

Tulokset: Ahmimishäiriö ja bulimiset oireet paranivat KBT:lla paremmin verrattuna WL-ryhmään; ahmimishäiriö (kahdeksan tutkimusta, N = 349) RR 0,69, 95 % luottamusväli 0,61–0,79; oireet (12 tutkimusta, N = 465) (SMD -0,94, 95 % luottamusväli -1,19 – -0,70). Samoin seitsemässä tutkimuksessa (N = 286) oli selvitetty depressio-oireiden paranemista: KBT oli parempi kuin WL (SMD -0,69, 95 % luottamusväli -1,09 – -0,30). Psykososiaalisessa interpersoonallisessa toimintakyvyssä (kaksi tutkimusta, N = 101) tai painon muutoksessa (neljä tutkimusta, N = 218) ei todettu eroa psykoterapioiden välillä.

Verrattuna muihin psykoterapioihin (N = 941) bulimisissa oireissa todettiin tilastollisesti merkitsevä ero KBT:n eduksi (SMD -0,21, 95 % luottamusväli -0,34 – -0,09). Bulimiasta toipuminen ja depressio-oireiden väheneminen oli suuntaa antavaa KBT:n eduksi, mutta ei tilastollisesti merkitsevää. Yleisten psykiatristen oireiden tai painon muutosten suhteen ei todettu merkitseviä eroja.

Verrattaessa ahmimishäiriön hoidossa muita psykoterapioita WL-ryhmään (6 tutkimusta, N = 291), psykoterapiat tehosivat: remissio RR 0,63, 95 % luottamusväli 0,48–0,83. Myös ahmimishäiriön oireisiin (7 tutkimusta, N = 325) terapioilla oli tehoa: SMD -1,14, 95 % luottamusväli -1,39 – -0,89.

  • Tutkimuksen laatu: tasokas
  • Sovellettavuus suomalaiseen väestöön: hyvä

A randomized controlled trial «Poulsen S, Lunn S, Daniel SI ym. A randomized cont...»2 was conducted with 70 patients (69 female, all >17 years) with bulimia nervosa. Of the patients 34 were randomly selected for psychoanalytic therapy (for 2 years and 72 sessions) and 36 for CBT (for 6 months and 20 sessions). The main outcome measure was Eating Disorder Examination Interview, ministered blind to treatment at baseline, after 5 months of the beginning and after 2 years.

Results: After 5 months 15 (42 %) of the patients receiving CBT and 2 (6 %) of patients receiving psychoanalytic psychotherapy had stopped binging and purging; (OR=13.40, 95 % CI 2,45-73,42; p<0,01). At 2 years 44 % of the patients in CBT and 15 % of patients in psychoanalytic psychotherapy had stopped binging and purging; (OR=4,34, 95 % CI=1,33-14,21; p=0,02). At two years substantial improvements in eating disorder features and general psychopathology were observed, but in general these chances took place more rapidly in CBT.

  • Tutkimuksen laatu: tasokas
  • Sovellettavuus suomalaiseen väestöön: hyvä

In a randomized study «Agras WS, Walsh T, Fairburn CG ym. A multicenter c...»3 220 patients (mean age 28,1+7,2 years) meeting DSM-III-R criteria for bulimia nervosa were allocated to 19 sessions of either CBT or IPT conducted over a 20-week period (on an outpatient basis) and evaluated for 1 year after treatment in a multisite study. Each session was 50 minutes in length and occurred twice weekly for the first 2 weeks, weekly for the next 12 weeks, and then at 2-week intervals for the last 6 weeks. Exclusion factors included associated severe physical or psychiatric conditions, eg, psychosis, current anorexia nervosa, current psychotherapeutic treatment of any type, all psychotropic medication, and pregnancy, as well as previous treatment by CBT or IPT.

Assessments included general psychopathology, specific eating disordered symptoms and psychopathology, measures of self-esteem, interpersonal functioning, and the perceived adequacy of therapy. General psychopathology was measured pretreatment by the Structured Clinical Interview for the DSM-III-R, SCID; the Hopkins Symptom Checklist–90-Revised, SCL-90-R, administered before and after treatment, the global severity index was used as the measure derived from this questionnaire. Eating disorder specific symptoms were assesses before and after treatment using the Eating Disorder Examination (EDE) (including frequency of objective binge eating, purging (episodes of self-induced vomiting and laxative and diuretic use), and concerns about weight and shape, and dietary restraint). These measures were assessed over the previous 28 days. The Inventory of Interpersonal Problems 17 and the self-report form of the social adjustment scale 18 and the Rosenberg Self-esteem Scale 19 were used before and after treatment. Adequacy of therapy was assessed from audiotaped therapy sessions by ratings were made on a Likert scale ranging from 1 to 7, using the following dimensions: supportive encouragement, conveyance of expertise, communication style, therapeutic involvement, warmth, rapport, empathy, and formality.

Trained interviewers (blind to the treatment allocation) assessed participants before and after treatment, and at the 4-, 8-, and 12-month follow-up. Participants also completed questionnaires at these times.

Results: Cognitive-behavioral therapy was significantly superior to IPT at the end of treatment in the percentage of participants recovered (29 % [n=32] vs 6 % [n=7]), the percentage remitted (48 % [n=53] vs 28 % [n=31]), and the percentage meeting community norms for eating attitudes and behaviors (41 % [n=45] vs 27 % [n=30]). For treatment completers, the percentage recovered was 45 % (n=29) for CBT and 8 % (n=5) for IPT. However, at follow-up, there were no significant differences between the 2 treatments: 26 (40 %) CBT completers had recovered at follow-up compared with 17 (27 %) IPT completers. At the end of treatment, binge eating was reduced by 86 % for patients given CBT and by 51 % for those given IPT (F1,122=6.5, P=0,01) (ES=0,49); purging was reduced by 84 % for the CBT group and by 50 % for the IPT group (F1,122=22.1, P=0,001) (ES=0,83). There were no significant differences between treatments at any point on any other measure. During follow-up, 19 participants (29 %) treated with CBT and 17 (27 %) treated with IPT sought further treatment for their eating disorder.

  • Tutkimuksen laatu: tasokas
  • Sovellettavuus suomalaiseen väestöön: hyvä

Kirjallisuutta

  1. Hay PP, Bacaltchuk J, Stefano S ym. Psychological treatments for bulimia nervosa and binging. Cochrane Database Syst Rev 2009;(4):CD000562 «PMID: 19821271»PubMed
  2. Poulsen S, Lunn S, Daniel SI ym. A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa. Am J Psychiatry 2014;171:109-16 «PMID: 24275909»PubMed
  3. Agras WS, Walsh T, Fairburn CG ym. A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Arch Gen Psychiatry 2000;57:459-66 «PMID: 10807486»PubMed