Evaluating the Psychological Component of Interventions for Anorexia Nervosa in Female Athletes: A Mixed Methods Systematic Review

Objective: Female athletes are a distinct high-risk population for Anorexia nervosa. Current clinical guidelines and psychological treatments are based predominantly on general population evidence, and review evidence is needed to support guideline development. The purpose of this review is to evaluate the psychological components of interventions for anorexia nervosa in adult female athletes, and to integrate quantitative effectiveness data with qualitative athlete experiences to identify factors that moderate treatment outcomes. Methods: This review was conducted as a convergent sequential mixed-methods systematic review in accordance with PRISMA 2020 and JBI guidelines (PROSPERO: CRD420251073240). Five databases were searched up to April 2026. Studies were eligible if they involved adult female athletes (≥18 years) with a clinical diagnosis of AN and included a psychological intervention component. The quantitative findings were synthesised narratively using the SWiM framework and certainty was assessed using GRADE. The qualitative findings underwent JBI meta-aggregation and certainty was assessed using CERQual. Results were then integrated. Results: Thirteen studies were included. A total population of 168 athletes were identified (137 female, 17 male, 12 unknown). Most of the studies were conducted in the USA and most utilised Cognitive Behavioural Therapy as a key component. From the quantitative results, the certainty was very low all outcome domains (eating disorder psychopathology, weight restoration, return to sport). Although the potential for meaningful recovery was identified. Although recovery was likely to be achieved when the environment, culture and support from the multi-disciplinary team was in place. Three themes from the qualitative synthesis provide insight to this. Conclusions: Standard psychological treatments may be insufficient for female athletes with AN without meaningful athlete-specific adaptation. Psychological interventions may be most effective when they incorporate sport-specific cultural competence, performance-framed cognitive restructuring, structured coach integration, and return-to-sport as an explicit therapeutic goal. This study has provided evidence that future research must prioritise athlete-adapted RCTs with sport-specific outcome measures to build the evidence base for this underserved population.