TABLE 1.
Characteristics of included studies
| Author, date, country, study design | Participants: patients | Participants: families | Intervention and comparator | Comparator | Follow‐up period | Outcome measures (patient‐completed unless specified) | Intervention refusal/drop out and outcome measure completion | Main findings |
|---|---|---|---|---|---|---|---|---|
| Dennhag et al. (2021), Sweden, Case series | 24 adolescents | 23 mothers and 22 fathers participated. Mean maternal age = 44, mean paternal age = 47. 79% of parents had a university degree. 100% of fathers and 60% of mothers worked full time. | Multi‐family therapy (MFT). | No comparison group. | At baseline and then post‐intervention at 1 year. | BMI, %EBW, eating disorder symptomatology (EDE‐Q), psychological well‐being (CGAS), familial burden (EDSIS, family). | Days of participation in the MFT by any of the parents ranged from 8 to 10 days. Overall dropouts not reported. | Patients significantly improved in self‐rated eating disorder symptoms, BMI, and global function pre‐ to post‐adjunct MFT. Parents reported a significant reduction in caregiver burden pre‐ to post‐MFT and also reported that their feelings of guilt decreased. No significant difference between the mother and father groups were found. Major associations were found between a decrease in parental burden of social isolation and adolescent recovery in BMI and daily function during treatment. For both mothers and fathers, the decrease in social isolation was strongly associated with physical treatment outcome. |
| Diagnoses: AN (38%), EDNOS (62%) | Total contact hours: Approx. 74 (10.5 days) | No incomplete outcome data reported. | ||||||
| Age, mean years: 14 | Total length: 1 year | |||||||
| Gender: 100% female | ||||||||
| Context: Outpatient child and adolescent psychiatric clinic. | ||||||||
| Mean illness duration: 2 years (range 1–4 years) | ||||||||
| Depestele et al. (2017), Belgium, Non‐randomised controlled clinical trial | 112 adolescents (MFT = 62, MPT = 50) | One or more parents per patient. Participated. Further data not reported. | Multi‐family group with patient (MFT). | Multi‐parent group without patient (MPT). Comparator matched the intervention in all other ways. | At baseline and then post‐intervention at 8–9 weeks. | Eating disorder symptomatology (EDI), family functioning (FAD, all participants), familial burden (ECI, family). | MFT: 62/72 (86%) accepted invitation. 55/62 (89%) families randomised completed intervention. Post‐intervention data completeness ranged from 60% to 71%. | ED symptomatology (drive for thinness and body dissatisfaction) significantly improved across both interventions and independently of the presence of binge/purge behaviours. No significant effects found between interventions. Negative caregiving experiences significantly decreased across both interventions independent of presence/absence of binge/purge behaviour and independent of type of reporter. Family outcome measures showed significant improvements across family functioning according to the patients and fathers, but not to the mothers, across both interventions and ED subtypes. |
| Diagnoses: AN restrictive subtype (41%), AN binge/purge subtype (23%), BN (21%), EDNOS (14%) | Total contact hours: 15 | Total contact hours: 15 | MPT: 51/79 (65%) accepted invitation. 45/51 (88%) families randomised completed intervention. Post‐intervention data completeness ranged from 50% to 77%. | |||||
| Age, mean years: 17 | Total length: 10 weeks | Total length: 10 weeks | ||||||
| Gender: 100% female | ||||||||
| Context: Admitted to inpatient facility. | ||||||||
| Dimitropoulos et al. (2015), Canada, Non‐randomised controlled clinical trial | 45 adults (MFT = 28, SFT = 17) | 72 family members (36% mothers, 32% fathers, 21% partners, 11% siblings) | Multi‐family therapy (MFT). | Single family therapy (SFT). The purpose of SFT was to identify issues that were important to the patient to discuss with their family. | At baseline and then post‐intervention at 8 weeks, follow‐up 3 months later. | BMI, eating disorder symptomatology (EDE‐Q), family functioning (FQ, family), depression (BDI, family), familial burden (SPS, EDSIS, DCCFS, family). | MFT: 24/28 (86%) families randomised completed intervention. | No statistically significant differences between MFT and SFT: both forms of therapy resulted in significantly improved family outcomes on all measures and a significant increase in BMI. Individuals in an intensive treatment who participated in both family‐based interventions experienced improvements in eating behaviours and an increase in BMI, regardless of type of family therapy received. |
| Diagnoses: AN restrictive subtype (44%), | Gender: 47% female | Total contact hours: 12 | Total contact hours: 10–12 | SFT: 13/17 (76%) families randomised completed intervention. | ||||
| AN binge/purge subtype (56%) | Total length: 8 weeks | Total length: 8 weeks | Analyses conducted with 31 patients (82%) and 45 family members (74%). 46% of family members completed 3‐month follow‐up assessment. | |||||
| Age, mean years: 26 | ||||||||
| Gender: 100% female | ||||||||
| Context: Inpatient and day‐treatment programme. | ||||||||
| Mean illness duration: 8 years (range 1–25 years) | ||||||||
| Eisler, Simic, Hodsoll, et al. (2016), UK, Multi‐site RCT | 167 adolescents (MFT = 85, FT‐AN = 82) | 70% came from ‘intact’ families. Further data not reported. | Multi‐family therapy for anorexia nervosa (MFT‐AN). | Family therapy for anorexia nervosa (FT‐AN). A manualised approach applied as published. | At baseline, 3 months mid‐intervention, post‐intervention at 12 months, and follow up at 18 months. | % Mean BMI, eating disorder symptomatology (Morgan/Russell global outcome scale, EDE‐Q), depression (BDI), self‐esteem (RSES), familial burden (ECI, family). | 84/359 (23%) families approached declined participation in the study. | There was a statistically significant difference rating on the Morgan/Russell global outcome scale at 12 months, in favour of MFT‐AN: The odds of a good or intermediate outcome in the MFT‐AN group was 2.55 times higher than that of FT‐AN group. Adolescents in both treatment groups gained considerable weight over the course of treatment and follow‐up, though at 12 months there were no statistically significant differences between the two trial arms for % mean BMI, eating disorder psychopathology, depression or self‐esteem. However, at 18 months there was a significant difference in % mean BMI in favour of the MFT‐AN group. |
| Diagnoses: AN (76%), EDNOS restrictive type (24%) | Total contact hours: Approx. 70 (10 days) | Total contact hours: The number and frequency of sessions is determined by clinicians, starting with weekly meetings, which are then gradually spread out to 3–4 weekly | MFT: 76/86 (88%) families randomised completed first 3 months of intervention. | |||||
| Age, mean years: 16 | Total length: 12 months | Total length: 12 months | FT‐AN: 73/83 (88%) families randomised completed first 3 months of intervention. | |||||
| Gender: 91% female | 53% of values for secondary outcome measures at follow‐up missing. | |||||||
| Ethnicity: <10% from non‐White background | ||||||||
| Context: Outpatient specialist ED services in London. | ||||||||
| Gabel et al. (2014), Canada, Case‐control | 50 adolescents (MFT + TAU = 25, matched TAU controls = 25) | Information on family members not reported. | Multiple family therapy (MFT). | TAU; medical monitoring, nutrition therapy, pharmacological treatment as needed, mental health therapy (combination of psychoeducation, and individual supportive family therapy), and inpatient admission if required. | Data acquired retrospectively. Data for weight and %IBW were collected from three time points: At assessment, prior to initiating MFT (parallel time for controls), and after completion of MFT (parallel time for controls). Both cases and controls completed psychometric self‐report measures at assessment. | %IBW, eating disorder symptomatology (EDI, EDE‐Q), depression (CDI). | N/A as retrospective audit of completers. | MFT group had a statistically significant higher percent healthy weight than TAU group. Measures of disordered eating symptoms and depression improved significantly after MFT, including significant improvements on the restraint, weight concerns and shape concerns subscales of the EDE‐Q, total EDE‐Q scores, and total depression scores. |
| Diagnoses: AN (100%) | Total contact hours: Not reported | Total contact hours: Not reported | No incomplete outcome data reported. | |||||
| Age, mean years: 14 | Total length: Not specified though typically longer than 3–6 months. | Total length: Not reported | ||||||
| Gender: 100% female | ||||||||
| Context: Multiple levels of care including inpatient, outpatient, and day hospital programmes. | ||||||||
| Gelin et al. (2015), Belgium, Case series | 82 adolescents | 70% came from ‘intact’ families. | Multiple family therapy (MFT). | No comparison group. | At baseline and then post‐intervention at 11 months. | %EBW, eating disorder symptomatology (EDI), psychological well‐being (OQ‐45). | 7 (8.5%) families dropped out during treatment. 91.5% completed intervention. | At end of treatment, approximately half of patients achieved a %EBW above 85% and half remained within the clinical range. Patients showed significant changes on all EDI dimensions except for bulimia, though very few patients endorsed bulimic symptoms at baseline. 71% of patients achieved a score below clinical significance on the OQ‐45 and significant improvements in quality of life were found on all three OQ‐45 dimensions. |
| Diagnoses: AN restrictive subtype (84%), AN binge/purge subtype (11%), BN (5%). | Total contact hours: Approx. 147 h (21 days) | Missing data ranged from 6% to 26% across outcome measures. | ||||||
| Age, mean years: 16 | Total length: 11 months | |||||||
| Gender: 98% female | ||||||||
| Context: Adolescent ED outpatient treatment centre. | ||||||||
| Illness duration: 74% < 1 year | ||||||||
| Hollesen et al. (2013), Denmark, Case series | 20 adolescents | Information on family members not reported. | Multiple family therapy (MFT). | No comparison group. | At baseline and then post‐intervention at 12 months. | BMI, eating disorder symptomatology (EDI, EDE‐Q), emotional and interpersonal difficulties (IIP, SASB‐Intrex). | 1/32 (3%) families offered MFT dropped out of treatment. 97% completed intervention. | After MFT treatment, 13 patients (65%) were free of ED diagnosis. Significant improvement was found in BMI, restriction, eating concern, weight concern and amount of exercise after the MFT groups. Results from the EDI showed significant improvement with high effect sizes regarding drive for thinness and interoceptive awareness. Post‐treatment, patients reported less interpersonal problems on most IIP dimensions, but differences were not of statistical significance. No results regarding patients' relations to their parents reached statistical significance. |
| Diagnoses: AN restrictive subtype (25%), AN binge/purge subtype (15%), EDNOS (60%) | Total contact hours: Approx. 84 (12 days) | 11/32 (34%) families offered MFT did not complete outcome measures and were therefore excluded from analyses. | ||||||
| Age, mean years: 15 | Total length: 12 months | |||||||
| Gender: 100% female | ||||||||
| Context: Outpatient specialist ED service in Western Denmark. | ||||||||
| Marzola et al. (2015), USA, Retrospective cohort study | 74 adolescents (M‐IFT = 54, S‐IFT = 20) | Information on family members not reported. | Intensive family therapy – Multiple families (M‐IFT). | Intensive family therapy – Single family (S‐IFT). | At baseline and then a mean of 30 months after the intervention. | %IBW, eating disorder symptomatology (EDE‐Q completed by patients and parents). Semi‐structured interview adapted from EDE‐Q. | All families (100%) completed full treatment. | At follow‐up, mean %IBW of the overall sample significantly increased, with a very large effect size. A significant increase in %IBW emerged in both diagnosis subgroups but no differences between S‐IFT and M‐IFT groups emerged. |
| Diagnoses: AN (60%), EDNOS, restricting type (40%) | Total contact hours: 40 | Total contact hours: 40 | 74/92 (80.5%) completed outcome measures for follow‐up study at 30 months. | |||||
| Age, mean years: 15 | Total length: 5 days | Total length: 5 days | ||||||
| Mean illness duration: 2 years | ||||||||
| Gender: 92% female | ||||||||
| Ethnicity: 92% Caucasian | ||||||||
| Context: Treatment completed between Nov 2006 and Jun 2013 at services linked with University of California, San Diego. | ||||||||
| Mehl et al. (2013), Czech Republic, Case series | 15 adolescents and young adults | Information on family members not reported. | Multi‐family therapy (MFT). | No comparison group. | At baseline and then post‐intervention at 12 months. | BMI, self‐esteem (RSES), psychological well‐being (SOS‐10). | 2 families (13%) dropped out (1 patient and 1 entire family). 87% completed intervention. | Patients experienced significant improvements in quality of life after MFT, though a significant reduction in self‐esteem. Patients' BMIs significantly improved during MFT, which the authors argue may explain the decrease in self‐esteem. |
| Diagnoses: Not specified | Total contact hours: Approx. 64 (8 days) | All 15 patients (100%) completing intervention completed outcome measures. | ||||||
| Age, mean years: 18 | Total length: 12 months | |||||||
| Gender: Not specified | ||||||||
| Context: Outpatient and inpatient specialist clinic in Prague. All patients lived at home with their families. | ||||||||
| Salaminiou et al. (2017), UK, Case series | 30 adolescents | 29 mothers, 22 fathers. 73% came from ‘intact’ families. | Intensive multi‐family therapy (MFT). | No comparison group. | At baseline, 3 months into the intervention, and 6 months into the intervention. | % Mean BMI, eating disorder symptomatology (Morgan/Russell global outcome scale, EDI‐II), self‐esteem (RSES), depression (BDI‐II patients and family members). | 2 families (7%) discontinued intervention. 93% completed intervention. | Patients' weight, eating disorders' psychopathology, mood and self‐esteem significantly improved over the 6 months of the study. At 3 months, half the patients were classified as having reached an intermediate or good outcome on the Morgan/Russell global outcome scale. At 6 months, just over one‐third of patients were classified as having a poor outcome but the remaining could be classified as partially remitted. Parents' self‐rating of mood improved over the course of the 6 months: The improvement was significant for the mothers but not for the fathers, though scores were in the normal range before treatment. |
| Diagnoses: AN (90%), EDNOS, restricting type (3%) | Total contact hours: Approx. 77 (9–11 days) | 26/30 (87%) patients and families completed outcome measures. | ||||||
| Age, mean years: 15 | Total length: 9 months | |||||||
| Gender: 90% female | ||||||||
| Mean illness duration: 12 months | ||||||||
| Context: Outpatient specialist ED services in London. | ||||||||
| Skarbø and Balmbra (2020), Norway, Case series | 68 young adults | 198 family members have participated: 65 mothers, 56 fathers, 59 siblings, 12 partners, 6 other relatives. | Multifamily therapy (MFT). | No comparison group. | At baseline and then post‐intervention at 12 months. | BMI | 5 (7%) families dropped out before completing intervention. 93% completed intervention. | BMI significantly increased over the course of treatment for those who were underweight at the start. |
| Diagnoses: AN (76.5%), BN (23.5%) | Total contact hours: Approx. 91 (13 days) | No outcome measures completed. 55/68 (81%) had post‐intervention BMI data. | ||||||
| Age, mean years: 21 | Total length: 12 months | |||||||
| Gender: 100% female | ||||||||
| Context: Outpatient setting | ||||||||
| Stewart et al. (2021), UK, Case series | 50 adolescents | Information on family members not reported. | Multi‐family therapy for bulimia nervosa (MFT‐BN). | No comparison group. | At baseline and then post‐intervention at 4 months. | Eating disorder symptomatology (EDE‐Q), anxiety (RCADS child, RCADS family, HADS family), depression ((RCADS child, RCADS family, HADS family), emotional and interpersonal difficulties (DERS), familial burden (ECI, family) | N/A as retrospective audit of completers. | Adolescents reported significant reductions in eating disorder symptoms including shape concern, weight concern, and frequency of binge/purge episodes. Adolescents also reported significant improvements in anxiety and depression and significant reductions in emotion regulation difficulties. Parents did not report significant changes in their child's depression or anxiety though did report significant reductions in their own depression symptoms and significant reductions in negative caregiving experiences. |
| Diagnoses: BN (100%) | Total contact hours: 28 | 28/50 (56%) of patients completed pre‐ and post‐EDE‐Q assessments. | ||||||
| Age, mean years: 16 | Total length: 4 months | |||||||
| Gender: 98% female | ||||||||
| Context: Outpatient specialist ED service in London, treatment completed between Sep 2009 and Dec 2018. | ||||||||
| Tantillo et al. (2019), USA, Case series | 10 young adults | Information on family members not reported. | Reconnecting for recovery (R4R) multifamily therapy group for anorexia nervosa (MFTG). | No comparison group. | At baseline, post‐intervention at 26 weeks, and 6‐month follow‐up. | BMI, eating disorder symptomatology (EDE‐Q), emotional and interpersonal difficulties (DERS). | No premature drop‐outs reported, all families (100%) attended ≥13 sessions. | There were clinically and statistically significant improvements in ED symptomatology and emotion regulation difficulties from baseline to end of treatment. This trajectory of improvement in these measures further continued at the 6‐month follow‐up. BMI increased though changes were modest. |
| Diagnoses: OSFED (including atypical AN) (60%), AN (40%) | Total contact hours: 24 | No incomplete outcome data reported. | ||||||
| Age, mean years: 23 | Total length: 26 weeks | |||||||
| Gender: 100% female | ||||||||
| Mean illness duration: 8 years | ||||||||
| Context: Recruited from the community in New York state. 70% lived at home with family. | ||||||||
| Whitney et al. (2012), UK, Single‐site RCT | 48 adults (FDW = 25, IFW = 23) | 119 family members/carers: FDW = 65, IFW = 54. Across groups 39 mothers, 36 fathers, 44 significant others. | Family day workshops (FDW). | Individual family work (IFW). | Patient assessments completed on admission to unit, at discharge, and 3‐year follow‐up. Family members assessments completed at baseline, 6‐month follow up, and 3‐year follow‐up. | BMI, eating disorder symptomatology (SEED), emotional and interpersonal problems (IIP), psychological well‐being (GHQ‐12, family), family functioning (LEE, family), familial burden (ECI, family). | 22/25 (88%) of families in FDW group received intervention. 23/25 (92%) patients completed primary outcomes; 17/25 (68%) completed secondary outcomes. 44/67 (66%) of carers completed long‐term assessments.20/23 (87%) of families in IFW group received intervention. 21/23 (91%) patients completed primary outcomes; 16/23 (70%) completed secondary outcomes. 38/58 (66%) of carers completed long‐term assessments. | Patients had significant and persistent improvements in their BMI, and carers had a reduction in their stress level; however, no clinically significant differences between the two forms of intervention were found in the outcomes of either patient or carer. |
| Diagnoses: AN (100%) | Total contact hours: Approx. 21 | Total contact hours: 18 | ||||||
| Age, mean years: Not reported | Total length: 3 days | Total length: Variable, 1–2‐h sessions provided weekly or fortnightly, plus three follow‐up sessions. | ||||||
| Gender: 98% female | ||||||||
| Median illness duration: 5–10 years | ||||||||
| Context: Specialist inpatient ED units in London. | ||||||||
| Wierenga et al. (2018), USA, Case series | 55 adults | 73 family members/carers: Parents: 36 mothers, 17 fathers, 20 other family members or significant others. 39 (53%) patients were accompanied by 1 support, 14 (19%) patients by 2 supports, and 2 (3%) patients by three supports. | Neurobiologically‐informed 5‐day multi‐family treatment for AN. | No comparison group. | At baseline, post‐intervention at 5 days, and 3‐month follow‐up. | BMI, %IBW, eating disorder symptomatology (EDE‐Q, patients and family members), family functioning (FAD), anxiety (STAI). | 1 family (2%) did not complete treatment as higher level of intervention was required. 98% completed intervention. | BMI significantly increased after the 5‐day intervention, but it is noted the change may not be clinically meaningful. Patients reported significant reductions in eating disorder symptomatology and state anxiety as well as improvements in family functioning. Data from family members and supports who completed pre‐ and post‐treatment measures (reflecting 50 patients) showed significant improvements in observed ED symptomatology and family functioning. Post‐treatment, 10% of patients were classified as fully remitted, 21% as partially remitted, and 69% reported a poor outcome. At follow‐up, 62% of patients achieved either full remission or partial remission, while 38% reported a poor outcome. |
| Diagnoses: AN restrictive subtype (52%), AN binge/purge subtype (24%) EDNOS restrictive subtype (4%), AN partial remission (20%) | Total contact hours: 40 | 50/54 (93%) of patients completed post‐treatment assessments. 27/54 (50%) patients completed follow‐up assessments. | ||||||
| Age, mean years: 25 | Total length: 5 days | 31% of supports completed follow‐up assessments. | ||||||
| Gender: 100% female | ||||||||
| Mean illness duration: 9 years | ||||||||
| Context: Recruited via clinic websites of ED clinics in CA and OH. |
Note: %EBW, percentage expected body weight; %IBW, percentage ideal body weight; AN, anorexia nervosa; BDI, Beck Depression Inventory; BMI, body mass index; BN, bulimia nervosa; CDI, children's depression inventory; CGAS, children's global assessment scale; DCCFS, devaluation of consumers and consumer families questionnaire; DERS, difficulties in emotion regulation scale; ECI, experience of caregiving inventory; ED, eating disorder; EDE‐Q, eating disorder examination questionnaire; EDI, Eating Disorder Inventory; EDNOS, eating disorder not otherwise specified; EDSIS, eating disorder impact scale; FAD, family assessment device; FQ, family questionnaire; GHQ‐12, general health questionnaire 12; HADS, hospital anxiety and depression scale; IIP, inventory of interpersonal problems; LEE, perceived level of expressed emotion; OQ‐45, outcome questionnaire 45; OSFED, other specified feeding or eating disorder; RCADS, revised children's anxiety and depression scale; RSES, Rosenberg's self‐esteem scale; SASB‐Intrex, structural analysis of social behaviour; SEED, short evaluation of eating disorders; SOS‐10, Schwartz outcome scale 10; SPS, social provisions scale; STAI, Spielberger state‐trait anxiety inventory (STAI); TAU, treatment as usual.