One-year use and cost of inpatient and outpatient services among female and male patients with an eating disorder: evidence from a national database of health insurance claims

Key factors that influence government policies and decision making about healthcare priorities: Lessons for the field of eating disorders

Worldwide, the demand for healthcare exceeds what individuals and governments are able to afford. Priority setting is therefore inevitable, and mental health services have often been given low priority in the decision-making process. Drawing on established economic criteria, and specifically the work of Philip Musgrove, key factors which influence government decision-making about health priorities are reviewed. These factors include the size of the health burden, the availability of cost-effective interventions to reduce the burden, whether private markets can provide the necessary treatment efficiently, whether there are "catastrophic costs" incurred in accessing treatment, whether negative externalities arise from not providing care, and if the "rule of rescue" applies. Beyond setting priorities for resource allocation, governments also become involved where there is a need for regulation to maintain quality in the delivery of healthcare. By providing field-specific examples for each factor, we illustrate how advocates in the eating disorder field may use evidence to inform government policy about resource allocation and regulation in support of individuals with an eating disorder.

Intensive treatment for adults with anorexia nervosa: The cost of weight restoration

OBJECTIVE

Weight restoration in anorexia nervosa (AN) is associated with lower relapse risk; however rate of weight gain and percent of patients achieving weight restoration (BMI ≥ 19 at discharge) vary among treatment programs. We compared both cost/pound of weight gained and cost of weight restoration in a hospital-based inpatient (IP)-partial hospitalization (PH) eating disorders program to estimates of these costs for residential treatment.

METHOD

All adult first admissions to the IP-PH program with AN (N = 314) from 2003 to 2015 were included. Cost of care was based on hospital charges, rates of weight gain, and weight restoration data. Results were compared with residential treatment costs extracted from a national insurance claims database and published weight gain data.

RESULTS

Average charge/day in the IP-PH program was $2295 for IP and $1567 for PH, yielding an average cost/pound gained of $4089 and $7050, respectively, with 70% of patients achieving weight restoration. Based on published mean weight gain data and conservative cost/day estimates, residential treatment is associated with higher cost/pound, and both higher cost and lower likelihood of weight restoration for most patients.

DISCUSSION

The key metrics used in this study are recommended for comparing the cost-effectiveness of intensive treatment programs for patients with AN.

Weight gain trajectories in hospital-based treatment of anorexia nervosa

Weight gain is a primary treatment goal for anorexia nervosa (AN); however little is known about heterogeneity in weight gain pattern during treatment. Preliminary evidence suggests weight gain trajectory is associated with treatment outcome. This study grouped patients using mixture modeling into weight gain trajectories, and compared predictors and treatment outcomes between trajectory groups. Women diagnosed with AN or subthreshold AN (N = 211) completed self-report measures at admission and six-months after discharge from an integrated inpatient (IP)-partial hospitalization (PH) behavioral specialty eating disorders program. Gowned weights were measured daily. Three distinct trajectories emerged: negative quadratic (Optimal), negative quadratic with fast weight gain (Fast), and positive linear with slower weight gain (Slow). The majority of patients were assigned to the Optimal group. Trajectory groups differed on admission, discharge, and follow-up variables. The Fast group emerged as most distinct. Women in this group were more than twice as likely to binge and or vomit regularly compared with the other two groups and were most likely to achieve weight restoration by discharge and to have more positive weight outcomes at short-term follow-up. There were no group differences in eating disorder behavioral frequencies at follow-up when adjusting for behavioral severity at admission. Weight gain trajectory may serve as a personalized in-treatment marker of outcome and could inform research on moderators and mediators of treatment response. Randomized controlled treatment studies, utilizing weight gain trajectories to determine group membership, may help identify subgroups of patients with differential responses to treatment interventions.

Cost-utility of an internet-based intervention with or without therapist support in comparison with a waiting list for individuals with eating disorder symptoms: a randomized controlled trial

OBJECTIVE

To investigate the cost-utility of the internet-based intervention "Featback" provided with different levels of therapist support, in comparison to a waiting list.

METHOD

This economic evaluation was conducted from a societal perspective and was part of a randomized controlled trial in which participants (N = 354) with self-reported ED symptoms were randomized to: (1) 8 weeks of Featback, consisting of psychoeducation and a fully automated monitoring- and feedback system, (2) Featback with low-intensity (weekly) therapist support, (3) Featback with high-intensity (three times a week) therapist support, and (4) a waiting list. Participants were assessed at baseline, postintervention, and 3-month follow-up. Cost-utility acceptability curves were constructed.

RESULTS

No significant differences between the study conditions were found regarding quality-adjusted life-years (P = 0.55) and societal costs (P = 0.45), although the mean costs per participant were lowest in the Featback condition with low-intensity therapist support (€1951), followed by Featback with high-intensity therapist support (€2032), Featback without therapist support (€2102), and the waiting list (€2582). Featback seemed to be cost-effective as compared to the waiting list. No clear preference was found for Featback with or without therapist support.

DISCUSSION

A fully automated Internet-based intervention for ED symptoms with no, low-, or high-intensity therapist support represented good value for money when compared to a waiting list. This finding may have important implications for clinical practice, as both the unguided- and guided intervention could allow for more efficient care and widespread dissemination, potentially increasing the accessibility and availability of mental health care services for individuals with ED symptoms. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1068-1076).

Cost evaluation of out-of-country care for patients with eating disorders in Ontario: a population-based study

BACKGROUND

Eating disorders, specifically anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified, represent a substantial burden to the health care system. Our goal was to estimate the economic burden of patients who received specialized inpatient care for an eating disorder out of country.

METHOD

We conducted a cost-of-illness study evaluating health care costs among patients in Ontario who received specialized inpatient care for an eating disorder out of country from 2003 to 2011, from the public third-party payer perspective. Using linked administrative databases, we estimated net costs of eating disorders for 2 patient groups: those who received specialized inpatient care both out of country and in province (n = 160), and those who received specialized inpatient care out of country only (n = 126).

RESULTS

Patients approved for specialized out-of-country inpatient care were mostly girls and young women from high-income, urban neighbourhoods. Total net costs varied annually and were higher for patients treated both out of country and in province (about $11 million before 2007, $6.5 million after) than for those treated out of country alone (about $5 million and $2 million, respectively). The main cost drivers were out-of-country care and physician services.

INTERPRETATION

Costs associated with eating disorder care represent a substantial economic burden to the Ontario health care system. Given the high costs of out-of-country care, there may be opportunity to redirect these funds to increase capacity and expertise for eating disorder treatment within Ontario.

Does family-based treatment reduce the need for hospitalization in adolescent anorexia nervosa?

OBJECTIVE

We examined the timing and number of days of hospitalization during the course of treatment, hospitalization effects on outcome, and predictors and moderators of the use of hospitalization in adolescents with anorexia nervosa (AN).

METHOD

Data used in this study were collected from 158 adolescents (ages 12 to 18 years of age) who met DSM-IVTR criteria for AN (exclusive of the amenorrhea criteria) randomized to receive either Family Based Treatment (FBT) or Systemic Family Therapy (SyFT) in a 7 site study.

RESULTS

The trajectory of hospital day use is similar in the first 5 weeks irrespective of treatment allocation. However, days of hospitalization continued to increase throughout SyFT but leveled off in FBT after ∼5 weeks of treatment. Early hospitalization was a negative predictor for improvements in percent weight change for both treatment groups (t(1)=2.6, p = 0.011). Co-morbid psychopathology predicted early hospital use in both treatments. Higher levels of eating related obsessions and depression moderated hospitalization rates suggesting that FBT reduces early hospitalization rates compared to SyFT for these subgroups.

DISCUSSION

These data support and extend findings from previous studies by identifying patterns of hospital use, and predictors and moderators of treatment effect for early hospitalization use in adolescent AN. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:891-894).

A systematic review of the health-related quality of life and economic burdens of anorexia nervosa, bulimia nervosa, and binge eating disorder

PURPOSE

To perform a systematic review of the health-related quality of life (HRQoL) and economic burdens of anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED).

METHODS

A systematic literature search of English-language studies was performed in Medline, Embase, PsycINFO, PsycARTICLES, Academic Search Complete, CINAHL Plus, Business Source Premier, and Cochrane Library. Cost data were converted to 2014 Euro.

RESULTS

Sixty-nine studies were included. Data on HRQoL were reported in 41 studies (18 for AN, 17 for BN, and 18 for BED), on healthcare utilization in 20 studies (14 for AN, 12 for BN, and 8 for BED), and on healthcare costs in 17 studies (9 for AN, 11 for BN, and only 2 for BED). Patients' HRQoL was significantly worse with AN, BN, and BED compared with healthy populations. AN, BN, and BED were associated with a high rate of hospitalization, outpatient care, and emergency department visits. However, patients rarely received specific treatment for their eating disorder. The annual healthcare costs for AN, BN, and BED were €2993 to €55,270, €888 to €18,823, and €1762 to €2902, respectively.

CONCLUSIONS

AN, BN, and BED have a serious impact on patient's HRQoL and are also associated with increased healthcare utilization and healthcare costs. The burden of BED should be examined separately from that of BN. The limited evidence suggests that further research is warranted to better understand the differences in long-term HRQoL and economic burdens of AN, BN, and BED.

Eating Disorders in the Adolescent Population:

Adolescents become vulnerable to developing eating disorders as they mature. Very little is known about the prevalence, etiology, assessment, treatment, and outcome of eating disorders among adolescents. In general, research on eating disorders continues to be plagued with design flaws. Future studies need to be prospective research based on larger, more diverse samples of adolescents that represent all developmental stages of adolescence. Consistent diagnostic criteria and definitions of treatment interventions and outcomes also need to be employed. In addition, research should address the identification of protective and risk factors that predict who will actually develop an eating disorder.

Comparison of standardized versus individualized caloric prescriptions in the nutritional rehabilitation of inpatients with anorexia nervosa

OBJECTIVE

Sparse research informs how caloric prescriptions should be advanced during nutritional rehabilitation of inpatients with anorexia nervosa (AN). This study compared the impact of a standardized caloric increase approach, in which increases occurred on a predetermined schedule, to an individualized approach, in which increases occurred only following insufficient weight gain, on rate, pattern, and cumulative amount of weight gain and other weight restoration outcomes.

METHOD

This study followed a natural experiment design comparing AN inpatients consecutively admitted before (n = 35) and after (n = 35) an institutional change from individualized to standardized caloric prescriptions. Authors examined the impact of prescription plan on weekly weight gain in the first treatment month using multilevel modeling. Within a subsample remaining inpatient through weight restoration (n = 40), multiple regressions examined the impact of caloric prescription plan on time to weight restoration, length of hospitalization, maximum caloric prescription, discharge BMI, and incidence of activity restriction and edema.

RESULTS

There were significant interactions between prescription plan and quadratic time on average weekly weight gain (p = .03) and linear time on cumulative weekly weight gain (p < .001). Under the standardized plan, patients gained in an accelerated curvilinear pattern (p = .04) and, therefore, gained cumulatively greater amounts of weight over time (p < .001). Additionally, 30% fewer patients required activity restriction under the standardized plan.

DISCUSSION

Standardized caloric prescriptions may confer advantage by facilitating accelerated early weight gain and lower incidence of bedrest without increasing the incidence of refeeding syndrome.

Healthcare costs and resource utilization of patients with binge-eating disorder and eating disorder not otherwise specified in the Department of Veterans Affairs

OBJECTIVE

The objective of this study was to compare the one-year healthcare costs and utilization of patients with binge-eating disorder (BED) to patients with eating disorder not otherwise specified without BED (EDNOS-only) and to matched patients without an eating disorder (NED).

METHODS

A natural language processing (NLP) algorithm identified adults with BED from clinical notes in the Department of Veterans Affairs (VA) electronic health record database from 2000 to 2011. Patients with EDNOS-only were identified using ICD-9 code (307.50) and those with NLP-identified BED were excluded. First diagnosis date defined the index date for both groups. Patients with NED were randomly matched 4:1, as available, to patients with BED on age, sex, BMI, depression diagnosis, and index month. Patients with cost data (2005-2011) were included. Total healthcare, inpatient, outpatient, and pharmacy costs were examined. Generalized linear models were used to compare total one-year healthcare costs while adjusting for baseline patient characteristics.

RESULTS

There were 257 BED, 743 EDNOS-only, and 823 matched NED patients identified. The mean (SD) total unadjusted one-year costs, in 2011 US dollars, were $33,716 ($38,928) for BED, $37,052 ($40,719) for EDNOS-only, and $19,548 ($35,780) for NED patients. When adjusting for patient characteristics, BED patients had one-year total healthcare costs $5,589 higher than EDNOS-only (p = 0.06) and $18,152 higher than matched NED patients (p < 0.001).

DISCUSSION

This study is the first to use NLP to identify BED patients and quantify their healthcare costs and utilization. Patients with BED had similar one-year total healthcare costs to EDNOS-only patients, but significantly higher costs than patients with NED.

Refeeding and weight restoration outcomes in anorexia nervosa: Challenging current guidelines

OBJECTIVE

Cohort study from February 2003 through May 2011 to determine weight restoration and refeeding complication outcomes for patients with anorexia nervosa (AN) treated in an integrated inpatient-partial hospital eating disorder program designed to produce rapid weight gain and weight restoration in the majority.

METHOD

Consecutive admissions (females and males, adolescents and adults; N = 361 patients, 461 admissions) at least 1.8 kg below target weight with AN or subthreshold variants were included. Main outcome measures were rates of hypophosphatemia, transfer to medicine, or death; rates of weight gain and percent achieving weight restoration.

RESULTS

Hypophosphatemia was present in 7.9% of cases at admission and in 18.5% at some point during treatment. Hypophosphatemia was mild to moderate. Lower admission body mass index (BMI), but not rate of weight gain, predicted hypophosphatemia [OR = 0.65; p < .00001 (95% CI 0.57-0.76)]. Five patients (1.1%) were transferred to medicine or surgery, none because of refeeding. There were no deaths. Mean inpatient weight gain was 1.98 kg/week; mean partial hospital weight gain was 1.36 kg/week. By program discharge, 71.8% of adults reached a BMI of 19, 58.5% a BMI of 20. For adolescents, 80.4% came within 2 kg of their target weight; 76.1% came within 1 kg.

DISCUSSION

Refeeding patients with AN using a hospital-based, behavioral protocol may be accomplished safely and more rapidly than generally recognized, weight restoring most patients by discharge. Helpful elements may include the program's integrated, step-down structure; multidisciplinary team approach emphasizing group therapy to effect behavior change; and close medical monitoring for those with BMI < 15.

Self-stigma of seeking treatment and being male predict an increased likelihood of having an undiagnosed eating disorder

OBJECTIVE

To examine whether self-stigma of seeking psychological help and being male would be associated with an increased likelihood of having an undiagnosed eating disorder.

METHOD

A multi-national sample of 360 individuals with diagnosed eating disorders and 125 individuals with undiagnosed eating disorders were recruited. Logistic regression was used to identify variables affecting the likelihood of having an undiagnosed eating disorder, including sex, self-stigma of seeking psychological help, and perceived stigma of having a mental illness, controlling for a broad range of covariates.

RESULTS

Being male and reporting greater self-stigma of seeking psychological help was independently associated with an increased likelihood of being undiagnosed. Further, the association between self-stigma of seeking psychological help and increased likelihood of being undiagnosed was significantly stronger for males than for females.

DISCUSSION

Perceived stigma associated with help-seeking may be a salient barrier to treatment for eating disorders-particularly among male sufferers.

Cost analysis of inpatient treatment of anorexia nervosa in adolescents: hospital and caregiver perspectives

BACKGROUND

Admission to hospital is the treatment of choice for anorexia nervosa in adolescent patients who are medically unstable; however, stays are often prolonged and frequently disrupt normal adolescent development, family functioning, school and work productivity. We sought to determine the costs of inpatient treatment in this population from a hospital and caregiver perspective, and to identify determinants of such costs.

METHODS

We used micro-costing methods for this cohort study involving all adolescent patients (age 12-18 yr) admitted for treatment of anorexia nervosa at a tertiary care child and adolescent eating disorder program in Toronto, between Sept. 1, 2011, and Mar. 31, 2013. We used hospital administrative data and Canadian census data to calculate hospital and caregiver costs.

RESULTS

We included 73 adolescents in our cohort for cost-analysis. We determined a mean total hospital cost in 2013 Canadian dollars of $51 349 (standard deviation [SD] $26 598) and a mean total societal cost of $54 932 (SD $27 864) per admission, based on a mean length of stay of 37.9 days (SD 19.7 d). We found patient body mass index (BMI) to be the only significant negative predictor of hospital cost (p < 0.001). For every unit increase in BMI, we saw a 15.7% decrease in hospital cost. In addition, we found higher BMI (p < 0.001) and younger age (p < 0.05) to be significant negative predictors of caregiver costs.

INTERPRETATION

The economic burden of inpatient treatment for adolescents with anorexia nervosa on hospitals and caregivers is substantial, especially among younger patients and those with lower BMI. Recognizing the symptoms of eating disorders early may preclude the need for admission to hospital altogether or result in admissions at higher BMIs, thereby potentially reducing these costs.

A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents

BACKGROUND

Anorexia nervosa (AN) is a serious disorder incurring high costs due to hospitalization. International treatments vary, with prolonged hospitalizations in Europe and shorter hospitalizations in the USA. Uncontrolled studies suggest that longer initial hospitalizations that normalize weight produce better outcomes and fewer admissions than shorter hospitalizations with lower discharge weights. This study aimed to compare the effectiveness of hospitalization for weight restoration (WR) to medical stabilization (MS) in adolescent AN.

METHOD

We performed a randomized controlled trial (RCT) with 82 adolescents, aged 12-18 years, with a DSM-IV diagnosis of AN and medical instability, admitted to two pediatric units in Australia. Participants were randomized to shorter hospitalization for MS or longer hospitalization for WR to 90% expected body weight (EBW) for gender, age and height, both followed by 20 sessions of out-patient, manualized family-based treatment (FBT).

RESULTS

The primary outcome was the number of hospital days, following initial admission, at the 12-month follow-up. Secondary outcomes were the total number of hospital days used up to 12 months and full remission, defined as healthy weight (>95% EBW) and a global Eating Disorder Examination (EDE) score within 1 standard deviation (s.d.) of published means. There was no significant difference between groups in hospital days following initial admission. There were significantly more total hospital days used and post-protocol FBT sessions in the WR group. There were no moderators of primary outcome but participants with higher eating psychopathology and compulsive features reported better clinical outcomes in the MS group.

CONCLUSIONS

Outcomes are similar with hospitalizations for MS or WR when combined with FBT. Cost savings would result from combining shorter hospitalization with FBT.

Determinants of direct and indirect costs in anorexia nervosa

OBJECTIVE

To estimate direct and indirect costs of anorexia nervosa (AN), and to identify cost determinants.

METHODS

In a subsample (n = 225) of the ANTOP trial (Anorexia Nervosa Treatment of OutPatients) health care utilization and productivity losses were assessed at baseline for the previous 3 months and monetarily valued. Included were females aged 18 years and older diagnosed with AN or subsyndromal AN, and a body mass index (BMI) between 15 and 18.5 kg/m(2) . To account for missing data multiple imputation was employed. Cost determinants were derived from generalized linear models with gamma distribution and log link function.

RESULTS

Mean 3-months costs per patient amounted to €5,866 (SE = €576). The largest share of costs (€3,374) resulted from hospitalizations. Determinants of direct costs were analyzed separately for those with hospitalizations for AN, and those without. In the group only treated as outpatients, participants with binge/purge subtype, and those diseased for more than 6 years had higher costs. Moreover, costs were increased in patients with a comorbid mental disorder. In the group with hospitalizations, direct costs increased with BMI. BMI was measured at the end of the observation period, indicating that longer duration of treatment yielded higher weight gain. Indirect costs were not significantly associated with any disease-related characteristic.

DISCUSSION

Costs resulting from health care utilization and productivity loss are substantial, although the sample studied had not received sufficient treatment. Future research should analyze the development of costs over time.

What can we learn from the history of male anorexia nervosa?

The eating disorders literature has focussed on females and little is known of the male experience. The overall image this has generated suggests a young woman in conflict with socio-cultural pressures which associate thinness with beauty. Historical studies have examined anorexia nervosa from an entirely female focus while ignoring how diagnostic categories have shaped approaches to the male body. This paper will track the case of the male with anorexia nervosa through changing theories of causation and treatment approaches, from when the condition first emerged in 1873 to the present. In doing so, we gain a valuable new insight into how anorexia nervosa has been historically gendered and the far-reaching implications this has had for diagnosis and treatment of the male sufferer. Similarities between the sexes helped to establish male anorexia as a distinct category. However, this shifted focus away from important differences, which have yet unexplored implications in the assessment, diagnosis and management of disordered eating. Throughout history, there has been constant pressure to give a precise definition to anorexia nervosa, despite being fraught with medical uncertainties. This has resulted in inevitably harmful generalisations rooted in the dominant epidemiology. This paper reveals that anorexia nervosa is a truly global phenomenon which cannot be adequately constructed through exclusive studies of the female. There is consequently a pressing need to address the dearth of research examining eating disorders in males.

Randomized controlled pilot trial of a novel dissonance-based group treatment for eating disorders

The authors conducted a pilot trial of a new dissonance-based group eating disorder treatment designed to be a cost-effective front-line transdiagnostic treatment that could be more widely disseminated than extant individual or family treatments that are more expensive and difficult to deliver. Young women with a DSM-5 eating disorder (N = 72) were randomized to an 8-week dissonance-based Counter Attitudinal Therapy group treatment or a usual care control condition, completing diagnostic interviews and questionnaires at pre, post, and 2-month follow-up. Intent-to-treat analyses revealed that intervention participants showed greater reductions in outcomes than usual care controls in a multivariate multilevel model (χ(2)[6] = 34.1, p < .001), producing large effects for thin-ideal internalization (d = .79), body dissatisfaction (d = 1.14), and blinded interview-assessed eating disorder symptoms (d = .95), and medium effects for dissonance regarding perpetuating the thin ideal (d = .65) and negative affect (d = .55). Midway through this pilot we refined engagement procedures, which was associated with increased effect sizes (e.g., the d for eating disorder symptoms increased from .51 to 2.30). This new group treatment produced large reductions in eating disorder symptoms, which is encouraging because it requires about 1/20th the therapist time necessary for extant individual and family treatments, and has the potential to provide a cost-effective and efficacious approach to reaching the majority of individuals with eating disorders who do not presently received treatment.

The economic burden of eating disorders and related mental health comorbidities: An exploratory analysis using the U.S. Medical Expenditures Panel Survey

Background

Very little is known about the economic burden of eating disorders (ED) and related mental health comorbidities.

Methods

Using 5 years of data from the U.S. Medical Expenditures Panel Survey, we estimated the difference in annual health care costs, employment status, and earned income (2011 US$) between individuals with current ED compared to those without ED. We further estimated the contribution of mental health comorbidities to these disparities in health care costs, employment and earnings.

Results

Individuals with ED had greater annual health care costs ($1869, p = 0.012), lower but borderline significant employment rates (OR = 0.67, 95% CIs [0.41, 1.09]), and lower but not statistically significant earnings among those who were employed ($2093, p = 0.48), compared to individuals without ED. Among individuals with ED, the presence of mental health comorbidities was associated with higher but not statistically significant health care costs ($1993, p = 0.17), lower borderline significant odds of employment (OR = 0.41, 95% CIs [0.14, 1.20]), and significantly lower earnings ($19,374, p < 0.01).

Conclusions

Treatment and prevention of ED may have broader economic benefits in terms of heath care savings and gains in work productivity than previously recognized. This exploratory study justifies large scale evaluations of the societal economic impact of eating disorders and comorbidities.

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Eating disorders were associated with greater health care costs.

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Eating disorders were associated with lower rates of employment and earnings.

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Mental health comorbidities contributed substantially to these disparities.

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Treatment and prevention of ED may have broad economic benefits to society.

Marital conflict in early childhood and adolescent disordered eating: emotional insecurity about the marital relationship as an explanatory mechanism

Disordered eating behaviors, including frequent dieting, unhealthy weight control behaviors (e.g., vomiting and skipping meals for weight loss) and binge eating are prevalent among adolescents. While negative, conflict-ridden family environments have long been implicated as problematic and a contributing factor to the development of disordered eating, few studies have examined the influence of marital conflict exposure in childhood to understand the development of these behaviors in adolescence. The current study investigates the impact of marital conflict, children's emotional insecurity about the marital relationship, and disordered eating behaviors in early adolescence in a prospective, longitudinal study of a community sample of 236 families in Midwest and Northeast regions of the U.S. Full structural mediation analyses utilizing robust latent constructs of marital conflict and emotional insecurity about the marital relationship, support children's emotional insecurity as an explanatory mechanism for the influence of marital conflict on adolescent disordered eating behaviors. Findings are discussed with important implications for the long-term impact of marital conflict and the development of disordered eating in adolescence.

Predicting clinical outcome using brain activation associated with set-shifting and central coherence skills in Anorexia Nervosa

BACKGROUND

Patients with Anorexia Nervosa (AN) have neuropsychological deficits in Set-Shifting (SS) and central coherence (CC) consistent with an inflexible thinking style and overly detailed processing style, respectively. This study investigates brain activation during SS and CC tasks in patients with AN and tests whether this activation is a biomarker that predicts response to treatment.

METHODS

FMRI data were collected from 21 females with AN while performing an SS task (the Wisconsin Card Sort) and a CC task (embedded figures), and used to predict outcome following 16 weeks of treatment (either 16 weeks of cognitive behavioral therapy or 8 weeks cognitive remediation therapy followed by 8 weeks of cognitive behavioral therapy).

RESULTS

Significant activation during the SS task included bilateral dorsolateral and ventrolateral prefrontal cortex and left anterior middle frontal gyrus. Higher scores on the neuropsychological test of SS (measured outside the scanner at baseline) were correlated with greater DLPFC and VLPFC/insula activation. Improvements in SS following treatment were significantly predicted by a combination of low VLPFC/insula and high anterior middle frontal activation (R squared = .68, p = .001). For the CC task, visual and parietal cortical areas were activated, but were not significantly correlated with neuropsychological measures of CC and did not predict outcome.

CONCLUSION

Cognitive flexibility requires the support of several prefrontal cortex resources. As previous studies suggest that the VLPFC is important for selecting context-appropriate responses, patients who have difficulties with this skill may benefit the most from cognitive therapy with or without cognitive remediation therapy. The ability to sustain inhibition of an unwanted response, subserved by the anterior middle frontal gyrus, is a cognitive feature that predicts favorable outcome to cognitive treatment. CC deficits may not be an effective predictor of clinical outcome.

The cost-effectiveness of school-based eating disorder screening

OBJECTIVES

We aimed to assess the value of school-based eating disorder (ED) screening for a hypothetical cohort of US public school students.

METHODS

We used a decision-analytic microsimulation model to model the effectiveness (life-years with ED and quality-adjusted life-years [QALYs]), total direct costs, and cost-effectiveness (cost per QALY gained) of screening relative to current practice.

RESULTS

The screening strategy cost $2260 (95% confidence interval [CI] = $1892, $2668) per student and resulted in a per capita gain of 0.25 fewer life-years with ED (95% CI = 0.21, 0.30) and 0.04 QALYs (95% CI = 0.03, 0.05) relative to current practice. The base case cost-effectiveness of the intervention was $9041 per life-year with ED avoided (95% CI = $6617, $12,344) and $56,500 per QALY gained (95% CI = $38,805, $71,250).

CONCLUSIONS

At willingness-to-pay thresholds of $50,000 and $100,000 per QALY gained, school-based ED screening is 41% and 100% likely to be cost-effective, respectively. The cost-effectiveness of ED screening is comparable to many other accepted pediatric health interventions, including hypertension screening.

Mental health services use and management of eating disorders in an Italian Department of Mental Health

OBJECTIVE

To investigate the clinical characteristics of patients with eating disorders referred to Community Mental Health Centers (CMHCs) in the Department of Mental Health of Bologna, Italy, and to evaluate the number and type of interventions delivered.

METHODS

Adult patients with eating disorders who had a first contact with CMHCs between January 1, 2007 and December 31, 2012 were extracted from Bologna Local Health Authority database. Moreover, the hospital discharge records of patients were linked to the mental health information system of Bologna.

RESULTS

Among the 276 patients with eating disorders identified, 59 (21.4%) were diagnosed as anorexia nervosa, 77 (27.9%) as bulimia nervosa and 140 (50.7%) as eating disorders not otherwise specified. The mean age of the sample was 37.3 (SD = 13.4), with no significant differences among the three diagnostic groups. The number of CMHCs outpatients increased each year from 2007 to 2011 and decreased in 2012. The proportion of new patients by year comprised about 50% of the total of patients. Psychotherapy accounted for about 10% of the interventions. Day-hospital and hospital admissions concerned 6.1 and 11.6% of the sample.

CONCLUSIONS

CMHCs are part of the system of care outlined by the Regional policies for eating disorders and are responsible for providing the first level of outpatient care to adults. To date, there is the need to extend our monitoring across the whole system of care, to assess the implementation of specific and effective strategies to decrease the age of access of patients and to improve the quality of care delivered with the inclusion of evidence-based treatments in the process of care.

Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa (ANDI): a multicentre, randomised, open-label, non-inferiority trial

BACKGROUND

In-patient treatment (IP) is the treatment setting of choice for moderately-to-severely ill adolescents with anorexia nervosa, but it is costly, and the risks of relapse and readmissions are high. Day patient treatment (DP) is less expensive and might avoid problems of relapse and readmission by easing the transition from hospital to home. We investigated the safety and efficacy of DP after short inpatient care compared with continued IP.

METHODS

For this multicentre, randomised, open-label, non-inferiority trial, we enrolled female patients (aged 11-18 years) with anorexia nervosa from six centres in Germany. Patients were eligible if they had a body-mass index (BMI) below the tenth percentile and it was their first admission to hospital for anorexia nervosa. We used a computer-generated randomisation sequence to randomly assign patients to continued IP or DP after 3 weeks of inpatient care (1:1; stratified for age and BMI at admission). The treatment programme and treatment intensity in both study groups were identical. The primary outcome was the increase in BMI between the time of admission and a 12-month follow-up adjusted for age and duration of illness (non-inferiority margin of 0·75 kg/m(2)). Analysis was done by modified intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Number Register, number ISRCTN67783402, and the Deutsches Register Klinischer Studien, number DRKS00000101.

FINDINGS

Between Feb 2, 2007, to April 27, 2010, we screened 660 patients for eligibility, 172 of whom we randomly allocated to treatment: 85 to IP and 87 to DP. DP was non-inferior to IP with respect to the primary outcome, BMI at the 12-month follow-up (mean difference 0·46 kg/m(2) in favour of DP (95% CI, -0·11 to 1·02; pnon-inferiority<0·0001). The number of treatment-related serious adverse events was similar in both study groups (eight in the IP group, seven in the DP group). Three serious adverse events in the IP group and two in the DP group were related to suicidal ideation; one patient in the DP attempted suicide 3 months after she was discharged.

INTERPRETATION

DP after short inpatient care in adolescent patients with non-chronic anorexia nervosa seems no less effective than IP for weight restoration and maintenance during the first year after admission. Thus, DP might be a safe and less costly alternative to IP. Our results justify the broad implementation of this approach.

FUNDING

German Ministry for Education and Research.

Health-related quality of life among adolescents with eating disorders

OBJECTIVE

Health-related quality of life (HRQoL) is an emerging area of research in eating disorders (EDs) that has not been examined in adolescents in detail. The aim of the current study is to investigate HRQoL in an adolescent ED sample, examining the impact of ED symptoms on HRQoL.

METHODS

Sixty-seven treatment-seeking adolescents (57 females) with anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder not otherwise specified (EDNOS) completed self-report measures of HRQoL and ED symptoms.

RESULTS

Participants reported poorer HRQoL in mental health domains than in physical health domains. Disordered attitudes, binge eating, and compensatory behaviors were associated with poorer mental health HRQoL, and body dissatisfaction was associated with poorer physical health HRQoL.

CONCLUSION

The current study assessed HRQoL among adolescents with EDs, finding several consistencies with the literature on adults with EDs. Future research should compare adolescents and adults with EDs on HRQoL.

Is outpatient cognitive remediation therapy feasible to use in randomized clinical trials for anorexia nervosa?

OBJECTIVE

There are limited data supporting specific treatments for adults with anorexia nervosa (AN). Randomized clinical trials (RCTs) for adults with AN are characterized by high attrition limiting the feasibility of conducting and interpreting existing studies. High dropout rates may be related to the inflexible and obsessional cognitive style of patients with AN. This study evaluated the feasibility of using cognitive remediation therapy (CRT) to reduce attrition in RCTs for AN.

METHOD

Forty-six participants (mean age of 22.7 years and mean duration of AN of 6.4 years) were randomized to receive eight sessions of either CRT or cognitive behavioral therapy (CBT) over 2 months followed by 16 sessions of CBT for 4 months.

RESULTS

During the 2-month CRT vs. CBT treatment, rates of attrition were lower in CRT (13%) compared with that of CBT (33%). There were greater improvements in cognitive inefficiencies in the CRT compared with that of the CBT group at the end of 2 months. There were no differences in other outcomes.

DISCUSSION

These results suggest that CRT is acceptable and feasible for use in RCTs for outpatient treatment of AN. CRT may reduce attrition in the short term. Adequately powered future studies are needed to examine CRT as an outpatient treatment for AN.

Prevalence, comorbidities and outpatient treatment of anorexia and bulimia nervosa in German children and adolescents

OBJECTIVE

This study aimed at investigating the prevalence, psychiatric comorbidity and outpatient treatment in a sample of German children and adolescents with eating disorders (EDs).

METHOD

Data of a large German statutory health insurance company were analysed and outpatients aged between 10 and 21 years with an ED diagnosis in 2009 were identified.

RESULTS

Of 248,558 insured children and adolescents, 1,404 patients (79.9 % females, mean age: 16.7; SD: 3.3 years) matched the inclusion criteria. The large majority of patients with anorexia nervosa (AN) and bulimia nervosa (BN) were females (94.7 and 92.7 %), on which we focus in the following analyses. The prevalence in females was 0.28 % (AN) and 0.20 % (BN). Psychiatric comorbidity was diagnosed in 59.8 % (AN) and 64.1 % (BN) of patients, respectively. Most patients were treated with psychotherapy (AN: 75.7 %, BN: 78.5 %), 16.4 % (AN) and 20.2 % (BN) of our patients received pharmacotherapy with either antidepressants or antipsychotics. 23.5 % (AN) and 21.1 % (BN) received no treatment with psychotherapy, antidepressants or antipsychotics.

DISCUSSION

This naturalistic study suggests that in young ED outpatients, EDs seem to be underdiagnosed and treatment does not necessarily comply with current guidelines. Therefore, dissemination of state-of-the-art knowledge on diagnosis and treatment in children and adolescents with EDs constitutes an important educational goal.

The MOSAIC study - comparison of the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) with Specialist Supportive Clinical Management (SSCM) in outpatients with anorexia nervosa or eating disorder not otherwise specified, anorexia nervosa type: study protocol for a randomized controlled trial

BACKGROUND

Anorexia nervosa (AN) is a biologically based serious mental disorder with high levels of mortality and disability, physical and psychological morbidity and impaired quality of life. AN is one of the leading causes of disease burden in terms of years of life lost through death or disability in young women. Psychotherapeutic interventions are the treatment of choice for AN, but the results of psychotherapy depend critically on the stage of the illness. The treatment response in adults with a chronic form of the illness is poor and drop-out from treatment is high. Despite the seriousness of the disorder the evidence-base for psychological treatment of adults with AN is extremely limited and there is no leading treatment. There is therefore an urgent need to develop more effective treatments for adults with AN. The aim of the Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC) is to evaluate the efficacy and cost effectiveness of two outpatient treatments for adults with AN, Specialist Supportive Clinical Management (SSCM) and the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA).

METHODS/DESIGN

138 patients meeting the inclusion criteria are randomly assigned to one of the two treatment groups (MANTRA or SSCM). All participants receive 20 once-weekly individual therapy sessions (with 10 extra weekly sessions for those who are severely ill) and four follow-up sessions with monthly spacing thereafter. There is also optional access to a dietician and extra sessions involving a family member or a close other. Body weight, eating disorder- related symptoms, neurocognitive and psychosocial measures, and service use data are measured during the course of treatment and across a one year follow up period. The primary outcome measure is body mass index (BMI) taken at twelve months after randomization.

DISCUSSION

This multi-center study provides a large sample size, broad inclusion criteria and a follow-up period. However, the study has to contend with difficulties directly related to running a large multi-center randomized controlled trial and the psychopathology of AN. These issues are discussed.

Health Belief Model deterrents of social support seeking among people coping with eating disorders

BACKGROUND

Eating disorders have the highest mortality rates of any psychiatric diagnosis (Sullivan, 1995). Understanding what prevents people from seeking or accessing that which can help them manage these disorders is critical to improving eating disorder outcomes. This study identifies specific barriers and deterrents individuals living with eating disorders perceive when deciding if and when they will seek eating disorder-specific social support.

METHODS

34 men and women living with eating disorders were recruited and interviewed regarding their experiences with managing their disorders, including reasons why they may forego seeking social support to help cope with these conditions.

RESULTS

Participant-reported reasons as to why they would forego seeking social support for the management of their eating disorders were framed against the five main constructs of the Health Belief Model. These include (a) perceived susceptibility to a health threat, (b) perceived severity of the health threat, (c) perceived benefit of protective health behaviors, (d) perceived self-efficacy with these protective behaviors, and (e) perceived barriers to performing these behaviors.

LIMITATIONS

It could be argued that since this study does not focus solely on one type of eating disorder, such as anorexia or bulimia, the barriers to social support may differ depending upon the characteristics inherent to the specific disorders.

CONCLUSIONS

Findings can be used to inform and improve therapeutic interventions to produce better long-term outcomes among people struggling with eating disorders.

Anorexia nervosa

We first discuss current diagnostic issues concerning the classification of anorexia nervosa (AN) by reference to the proposed criteria of the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). We strongly welcome the changes in the latest revision of DSM-5 (update April 2012), which in our opinion partially solve the previously delineated classification problems. Nevertheless, we still miss a standard or reference(s) for the weight criterion including the delineation between a healthy and unhealthy underweight, a better operationalization of observable behaviors including symptoms of disordered eating, readily accessible cognitions and a better allowance for cross-cultural aspects in the proposed DSM-5 classification of AN. In the second part, we review the treatment recommendations of the NICE guidelines for AN, which overall are characterized by a lack of evidence. Nevertheless, NICE recommended an outpatient treatment setting based on one randomized controlled trial with many methodological limitations. A review of the current literature shows that (a) the optimal treatment setting (inpatient vs. outpatient treatment) still is a subject of debate, and (b) the evaluation of treatment costs in AN plays an important role within this discussion. In contrast to the German Guidelines for the Treatment of Eating Disorders, NICE does not offer any specific criteria for the clinician with regard to determining the adequate treatment setting.

Sex differences in biopsychosocial correlates of binge eating disorder: a study of treatment-seeking obese adults in primary care setting

OBJECTIVE

Although community-based studies suggest equivalent levels of physical and psychological impairment by binge eating disorder (BED) in men and women, men with BED are still underrepresented in clinical studies. This study aimed to provide a comprehensive analysis of sex differences in biopsychosocial correlates of treatment-seeking obese patients with BED in primary care.

METHOD

One hundred-ninety obese adults (26% men) were recruited in primary care settings for a treatment study for obesity and BED.

RESULTS

Very few significant sex differences were found in the developmental history and in current levels of eating disorder features, as well as psychosocial factors. Women reported significantly earlier age at onset of overweight and dieting and greater frequency of dieting. Men reported more frequent strenuous exercise. Men were more likely than women to meet criteria for metabolic syndrome; men were more likely to show clinically elevated levels of triglycerides, blood pressure, and fasting glucose levels.

CONCLUSION

Despite few sex differences in behavioral and psychosocial factors, metabolic problems associated with obesity were more common among treatment-seeking obese men with BED than women. The findings highlight the importance of including men in clinical studies of BED and active screening of BED in obese men at primary care settings.

Hospitalização integral para tratamento dos transtornos alimentares: a experiência de um serviço especializado

OBJETIVO: Descrever as características da hospitalização integral para o tratamento de transtornos alimentares em um serviço especializado de Ribeirão Preto, SP. MÉTODOS: Foram revisados todos os prontuários dos pacientes em seguimento pelo serviço, de 1982 até 2011, especialmente aqueles que tiveram indicação de internação integral. Foram coletados dados sociodemográficos e referentes ao diagnóstico. RESULTADOS: No período referido, 186 pacientes receberam atendimento pelo serviço e, desses, 44,6% (n = 83) foram internados para tratamento. Ao longo do tempo, houve redução na relação atendimento/internação, passando de 77,7% para 36,2% dos casos. A média de internações foi de 1,9 ± 3,9 vezes, e 73,5% (n = 61) dos pacientes foram hospitalizados apenas uma vez. A duração média da internação, independentemente do número de hospitalizações, foi de 70,6 ± 115,9 dias (variação de 3 a 804 dias). A predominância foi do sexo feminino, raça branca, solteira, sem filhos e com idade média de 23,3 ± 10,8 anos. O diagnóstico predominante foi de anorexia nervosa (85,5%), sobretudo em seu tipo restritivo (54,2%). As indicações mais frequentes para internação foram para realização de terapia nutricional (50,9%), seguida da investigação do quadro clínico (30,1%) e por causa de depressão e/ou ideação suicida (10,9%). CONCLUSÃO: A hospitalização integral é uma modalidade terapêutica necessária para o tratamento desses quadros, e sua frequência foi considerada significativa, porém diminuiu ao longo do tempo. Esse resultado pode ser explicado pela tendência de desospitalização a partir da reforma psiquiátrica, do diagnóstico e tratamento mais precoces e da experiência adquirida pelos profissionais do serviço ao longo dos anos.

Introduction of DRG-based reimbursement in inpatient psychosomatics--an examination of cost homogeneity and cost predictors in the treatment of patients with eating disorders

OBJECTIVE

Various western countries are focusing on the introduction of reimbursement based on diagnosis-related groups (DRG) in inpatient mental health. The aim of this study was to analyze if psychosomatic inpatients treated for eating disorders could be reimbursed by a common per diem rate.

METHODS

Inclusion criteria for patient selection (n=256) were (1) a main diagnosis of anorexia nervosa (AN), bulimia nervosa (BN) or eating disorder-related obesity (OB), (2) minimum length of hospital stay of 2 days, (3) and treatment at Charité Universitaetsmedizin Berlin, Germany during the years 2006-2009. Cost calculation was executed from the hospital's perspective, mainly using micro-costing. Generalized linear models with Gamma error distribution and log link function were estimated with per diem costs as dependent variable, clinical and patient variables as well as treatment year as independent variables.

RESULTS

Mean costs/case for AN amounted to 5,251€, 95% CI [4407-6095], for BN to 3,265€, 95% CI [2921-3610] and for OB to 3,722€, 95% CI [4407-6095]. Mean costs/day over all patients amounted to 208€, 95% CI [198-218]. The diagnosis AN predicted higher costs in comparison to OB (p=.0009). A co-morbid personality disorder (p=.0442), every one-unit increase in BMI in OB patients (p=.0256), every one-unit decrease in BMI in AN patients (p=.0002) and every additional life year in BN patients (p=.0455) predicted increased costs.

CONCLUSION

We see a need for refinements to take into account considerable variations in treatment costs between patients with eating disorders due to diagnosis, BMI, co-morbid personality disorder and age.

Case-control study of disturbed eating behaviors and related psychographic characteristics in young adults with and without diet-related chronic health conditions

Young adults with diet-related chronic health conditions (DRCHCs; i.e., type 1 diabetes, celiac disease, cystic fibrosis, inflammatory bowel diseases, irritable bowel syndrome) face challenges complying with dietary restrictions required to effectively manage their health condition. These restrictions could put them at risk for disturbed eating. The purpose of this study was to determine if young adults with and without DRCHCs differed with regard to disturbed eating behaviors and related psychographics characteristics (i.e., body image attributes, mental disorders, intrapersonal characteristics and sociocultural environment [i.e., media and family]). Each DRCHC participant (cases=166) was matched to 4 healthy participants (controls=664) based on gender and BMI (±0.50 BMI units). Conditional logistic regression analyses indicate cases were twice as likely to have been diagnosed by a healthcare provider with an eating disorder (p=0.08, OR=1.99, CI(90) [1.03-3.83]). Cases were significantly more likely to use Inappropriate Compensatory Behaviors to manage their weight, i.e., excessive exercise (p=0.04, OR=1.41, CI(95) [1.02-1.94]) and misuse medication (p=0.04, OR=1.14, CI(95) [1.00-1.29]) than controls. Depression and anxiety were significantly higher, and health status was significantly poorer in cases compared with controls. DRCHC participants were less likely to report feeling body image pressures from the media, placed a greater value on their health, used social diversion, and recalled a greater emphasis being placed on their mothers' weights and mealtimes being less structured than control participants. Findings indicate that nutrition and other healthcare professionals should incorporate screening DRCHC patients for disturbed eating behaviors and eating disorders in their standards of care.

The effectiveness of a brief eating disorder training programme in medical settings

Objective:

To investigate the longitudinal effectiveness of a brief eating disorder training on primary care providers’ self-perceived knowledge, skills and attitudes regarding eating disorder screening and intervention.

Method:

We trained 45 primary care providers (including nurses, nurse practitioners and physicians) practicing in 10 medical sites and measured their self-perceived knowledge, skills and attitudes on eating disorder screening and intervention using a 23-item questionnaire prior to, 1 week and 6 months after the training.

Results:

The eating disorder knowledge score and eating disorder skill level score showed pretest to posttest gains that were associated with large effect sizes ( d = 1.25 and 1.31, respectively). The significance and magnitude of effects carried over through the 6-month follow-up evaluation. Unlike the eating disorder knowledge and skill scores, there was no significant improvement in eating disorder attitudes from pretest to posttest or from pretest to the 6-month follow-up.

Discussion:

Findings show support for the effectiveness of a brief eating disorder training on primary care providers’ reported knowledge and skills for addressing eating disorders in their practice. These results underscore the importance of providing information to primary care providers on how they can more adequately screen and intervene with eating disorders, as part of primary care to their patients.

Cost-of-illness studies and cost-effectiveness analyses in eating disorders: a systematic review

OBJECTIVE

To review cost-of-illness studies (COIs) and cost-effectiveness analyses (CEAs) of eating disorders (EDs) and to describe their methodological quality.

METHOD

A systematic literature search was done. Search results passed through a selection process, included studies were classified as COIs, CEAs, or "other cost studies" (OCS). Costs were inflated and converted to 2008 US$ purchasing power parities (PPP). Quality criteria were developed and applied to each study.

RESULTS

Five COI, two CEA, and eleven "OCS" were reviewed. Most studies focused on anorexia nervosa and bulimia nervosa. Annual costs per patient ranged from 1,288 to 8,042 US$-PPP. All interventions, investigated in CEA, were more effective and less costly than the alternative treatments.

DISCUSSION

The number of publications investigating costs in EDs has increased recently. However, no COI provided a comprehensive estimate of costs, and the comparability of CEA was limited. Nonetheless, the results indicate that the costs arising from EDs are substantial.

Inpatient costs and predictors of costs in the psychosomatic treatment of anorexia nervosa

OBJECTIVE

In German inpatient psychosomatics per diem lump sums will be introduced as reimbursement rates by 2013. It was the aim to calculate total inpatient costs per case for the psychosomatic treatment of patients with anorexia nervosa and to identify cost predictors.

METHOD

The sample comprised of 127 inpatients. Cost calculation was executed from the hospital's perspective, mainly using microcosting. Medical records provided data on patient characteristics and individual resource use. Two generalized linear models with gamma distribution and log link function were estimated to determine cost predictors by means of demographic data, comorbidities, and body-mass-index at admission.

RESULTS

Inpatient costs amounted to 4,647 €/6,831 US$ per case (standard deviation 3,714 €/5,460 US$).The admission BMI and "Disorders of Adult Personality and Behavior" were significant cost predictors (p < 0.05).

DISCUSSION

The formation of patient groups within the diagnosis anorexia nervosa should be oriented towards the determined cost predictors.

Why men should be included in research on binge eating: results from a comparison of psychosocial impairment in men and women

OBJECTIVE

Prevalence of binge eating has been shown to be as common in men as in women, yet few studies have included men. Men are especially underrepresented in treatment studies, raising the question of whether men who binge eat experience less distress or impairment than women. This study compared demographic and clinical correlates of binge eating in a large employee sample of men and women.

METHOD

Cross-sectional data from 21,743 men and 24,608 women who participated in a health risk self assessment screening were used. Group differences in obesity, hypertension, dyslipidemia, Type 2 diabetes, depression, stress, sleep, sick days, work impairment, and nonwork activity impairment were tested using chi-square tests (categorical variables) and independent sample t-tests (continuous variables).

RESULTS

Effect size estimates indicate that men (n = 1,630) and women (n = 2,754) who binge eat experience comparable levels of clinical impairment. They also report substantially greater impairment when compared with men and women who do not binge eat.

DISCUSSION

The underrepresentation of men in treatment-seeking samples does not appear to reflect lower levels of impairment in men versus women. Efforts are needed to raise awareness of the clinical significance of binge eating in men so that this group can receive appropriate screening and treatment services.

Weight suppression as a predictor of weight gain and response to intensive behavioral treatment in patients with anorexia nervosa

Previous studies have documented that weight suppression (a person's highest adult weight minus current weight) predicts weight gain and disordered eating symptoms during treatment of bulimia spectrum disorders, but no research has examined weight suppression in individuals with anorexia nervosa (AN). Thus, this study sought to characterize weight suppression in a large sample of patients with AN (N = 185), and to evaluate whether weight suppression at admission for intensive behavioral treatment predicts weight gain and clinical outcomes at discharge. Weight suppression varied from 0 kg to 78 kg (M [SD] = 17.1 [10.8] kg) in AN patients. Higher levels of weight suppression predicted greater total weight gain, a faster rate of weight gain, and bulimic symptoms during intensive treatment even after controlling for body mass index on admission, length and type of intensive treatment received, restricting versus binge-eating/purging AN subtype, and other predictors of study outcomes. These findings converge with previous research documenting the clinical significance of weight suppression in the treatment of eating disorders. Future work is needed to replicate the current findings, and examine whether weight suppression predicts the course of AN following discharge from intensive treatment.

The clinical utility of personality subtypes in patients with anorexia nervosa

OBJECTIVE

Elucidation of clinically relevant subtypes has been proposed as a means of advancing treatment research, but classifying anorexia nervosa (AN) patients into restricting and binge-eating/purging types has demonstrated limited predictive validity. This study aimed to evaluate whether an approach to classifying eating disorder patients on the basis of comorbid personality psychopathology has utility in predicting treatment response and readmission in patients with AN.

METHOD

Data were collected from 154 AN patients (M [SD] age = 25.6[9.4] years; 95.5% female; 96.8% Caucasian) at admission, discharge, and 3 months postdischarge from intensive treatment. Latent profile analysis of personality traits assessed at admission was performed to classify participants into personality subtypes, which were then used to predict outcomes at discharge and risk of readmission.

RESULTS

The best fitting model identified 3 personality subtypes (undercontrolled, overcontrolled, low psychopathology) that contributed significantly to multivariate models predicting study outcomes. Undercontrolled patients were more likely to have a poor outcome at discharge than overcontrolled (OR = 3.56, p = .01) and low psychopathology patients (OR = 11.23, p < .001). Undercontrolled patients also had a greater risk of discharge against medical advice (HR = 2.08, p = .02) and readmission than overcontrolled patients (HR = 3.76, p = .009). Binge-eating/purging versus restricting subtypes did not predict discharge against medical advice or readmission in the multivariate models.

CONCLUSIONS

Findings support the clinical utility of personality subtypes in AN. Future work is needed to identify mechanisms that explain diminished treatment response in undercontrolled patients and to develop interventions for this high-risk group.

Treating Anorexia Nervosa in the Couple Context

Anorexia nervosa is a serious mental illness that affects women and men of all ages. Despite the gravity of its chronic morbidity, risk of premature death, and societal burden, the evidence base for its treatment-especially in adults-is weak. Guided by the finding that family-based interventions confer benefit in the treatment of anorexia nervosa in adolescents, we developed a cognitive-behavioral couple-based intervention for adults with anorexia nervosa who are in committed relationships that engages both the patient and her/his partner in the treatment process. This article describes the theoretical rationale behind the development of Uniting Couples in the treatment of Anorexia nervosa (UCAN), practical considerations in delivering the intervention, and includes reflections from the developers on the challenges of working with couples in which one member suffers from anorexia nervosa. Finally, we discuss future applications of a couple-based approach to the treatment of adults with eating disorders.

Socio-demographic and clinical characteristics of individuals with diagnoses of eating disorder in a university hospital in Istanbul

OBJECTIVE

This paper reports the first-ever description of a clinical eating disorder population from Turkey. The aim of this study was to examine the socio-demographic and clinical characteristics of individuals with diagnosis of eating disorders (IDED) referred to a university psychiatry clinic in Istanbul between 2003 and 2009.

METHOD

The diagnoses and subtype of 111 IDEDs, the referral type to the hospital, setting of treatment, and state of involuntary hospitalization were evaluated by interview and semi-structured questionnaire.

RESULTS

The clinical sample included 64 individuals with anorexia nervosa (AN), 38 with bulimia nervosa (BN), and 9 with eating disorder not otherwise specified (EDNOS), including only one male. Younger individuals and those with a lower BMI were significantly more likely to be family referred and hospitalized involuntarily.

DISCUSSION

The overall socio-demographic features of the sample are generally consistent with data collected in other communities. However, aspects of the clinical features, referral types of eating disorders and subtypes exhibit some characteristics peculiar to our sample.