ERAPY FOR NTS WITH Method Participants The study was carried out in four eating disorder services in the National Health Service in the United Kingdom, which are the main service providers for the populations in their respec- tive areas. Patients were referred by general practitioners. Recruitment took place between September 2000 and May 2003. Written informed consent was sought from participants and a "close other" at assessment. For patients age 16 and under, consent from a parent was sought. The research ethics committees of the participating centers approved the study. Consecutively referred patients were invited to participate if they were 13-20 years of age, met DSM-IV criteria for bulimia nervosa or eating disorder not otherwise specified, and had at least one "close other" to accompany them for "family treat- ment." Eating disorder not otherwise specified was defined as binge eating and/or purging (vomiting and abuse of laxatives or diuretics) less than twice a week or for less than 3 months or use of inappropriate compensatory behaviors without bingeing in patients with normal body weight. "Close others" included parents, other relatives, and partners. We excluded patients with a body mass index below the 10th percentile for age and sex (5), patients whose knowledge of English was insufficient to understand the treatment, and pa- tients with learning disability, severe mental illness, or substance dependence. We did not exclude patients taking antidepressants provided they had been on a stable dose for at least 4 weeks. Interventions Family Therapy. The family therapy used in this study was adapted from the Maudsley model of family therapy for anor- exia nervosa (6, 7) and detailed in a manual (Eisler et al., unpub- lished). In this model, the family is seen as a key resource in the young person's recovery. An attempt is made to engage family members and show them that they are in the best position to help the adolescent. Treatment is problem oriented, emphasizing the role of the family in promoting restoration of normal eating and providing education about the effects of bulimia. Families are en- couraged to find a way to help the patient reduce bulimic behav- iors. Finally, control over eating is handed back to the patient, and discussions of autonomy and independence take place. Patients were offered up to 13 sessions with close others and two individ- ual sessions over a 6-month period. CBT Guided Self-Care. We used a manual (8) that was previ- ously tested with adults with bulimia nervosa (4). The Flesch- Kincaid Grade Level test suggests that the manual can be read by eighth graders (ages 13-14 years). Accompanying workbooks are available for patients and close others, as well as a guide for clini- cians (9). Patients had 10 weekly sessions, three monthly follow- up sessions, and two optional sessions with a close other. The therapist's role is to motivate patients and guide them through the workbook to fit their needs. Initially treatment focuses on the function of bulimia in the person's life and builds motivation to change. Information about how bulimic symptoms are maintained is introduced, using self-monitoring of thoughts, feelings, and behaviors. Problem solving with behavioral experiments and goal setting is used to help patients alter vicious cycles of behavior. A case formulation is developed collaboratively. After 10 ses- sions the therapist writes a good-bye letter. The follow-up ses- sions focus on relapse prevention. Regular homework accom- panies the treatment. The sessions with the close other address how the other could help the patient. Therapists. Treatments were delivered by 23 experienced therapists from diverse backgrounds with training in family ther- 592 ajp.psychiatryonline.org apy and guided self-care. Therapists participated in training workshops for both therapies prior to the study and received weekly supervision. Most therapists had equal numbers of family therapy and guided self-care patients, under separate supervi- sion. Seven therapists saw only one patient because of the timing of their transfer into or out of the service. Treatment Fidelity. In family therapy, to ensure competent and uniform treatment delivery, three experienced supervisors who had previously been involved in developing or testing the Maudsley model of family therapy for anorexia nervosa used a one-way screen to provide regular "live" supervision. In guided self-care, therapists received weekly supervision by supervisors trained in motivational interviewing and CBT for bulimia nervosa. Family sessions were videotaped, and guided self-care sessions were audiotaped to allow analysis of the therapeutic process (to be reported separately). Assessments An initial clinical interview determined patients' eligibility for the study. Those who consented to participate were as- sessed by a research assistant who remained blind to the treatment assignment throughout the study. Assessments were made at 6 and 12 months for patients and close others. Patient Assessments. Body mass index (BMI; kg/m) was measured. A lifetime eating disorder history was obtained with the EATATE interview (unpublished 2000 manuscript of M.B. Anderluh et al.), a semistructured weight and eating disorder his- tory based on the Longitudinal Interval Follow-Up Evaluation (10) that includes variables from the Eating Disorder Examination (11). Although full validation of this instrument has not yet been published, preliminary analyses indicate excellent interrater reli- ability, with kappa values between 0.88 and 1.0 for first and sec- ond eating disorder diagnosis and 0.82 for the number of lifetime diagnoses. Spearman's coefficients for longitudinal assessment of symptoms are high: objective bingeing, 0.84; vomiting, 0.97; laxa- tive or diuretic abuse, 0.89; and strict dieting, 0.85. We used this interview at baseline to make DSM-IV diagnoses and at baseline, 6 months, and 12 months to assess eating disorder symptoms over the previous month. We also used it at multiple time points to assess the time course of recovery (at baseline and at 2, 4, 6, 8, and 10 months). We also used the Short Evaluation of Eating Disorders (12), a brief, valid, and reliable self-report measure assessing eating dis- order symptoms over the previous 4 weeks. We included this mea- sure to obtain information by mail or telephone on the outcome of patients who failed to attend the follow-up assessment. To assess psychiatric comorbidity at baseline, we used an adapted version of the Oxford, England, Risk Factor Interview (13) and the EATATE. Other instruments were used to assess other fac- tors, such as general psychopathology and family relationships, as well as parental outcomes, including mental health and bur- den of caring, that will be reported separately. Health Economic Assessment. The economic component used well-established methods of data collection, cost estima- tion, and analysis (14, 15). The Client Service Receipt Inventory (14, 15) documents each adolescent's use of education, health, and social care services, as well as additional expenses for them or their family that are a consequence of bulimia nervosa. Unit costs for each service were taken from nationally applicable data (16) or estimated using an equivalent methodology. Costs per case were calculated as the unit costs multiplied by the use made of service over the 3 months preceding each assessment. Randomization The randomization sequence to family therapy or guided self- care was generated by an independent statistician, using permu- Am J Psychiatry 164:4, April 2007