Impact of definitions on the description and prediction of bulimia nervosa outcome

How precisely can psychotherapists predict the long-term outcome of anorexia nervosa and bulimia nervosa at the end of inpatient treatment?

OBJECTIVE

To assess the ability of psychotherapists to predict the future outcome for inpatients with anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

Psychotherapists rated the prognosis of the patient's eating disorder on a five point Likert scale on several dimensions at the end of inpatient treatment. Actual outcome was assessed about 10 years after treatment. The sample comprised 1,065 patients treated for AN, and 1,192 patients treated for BN.

RESULTS

Psychotherapists' rating of their patient's prognosis was not better than chance for good outcome in AN and BN and for poor outcome in BN. Prediction of poor outcome in AN was somewhat better with approximately two thirds of correct predictions. In logistic regression analysis, psychotherapists' rating of the patients' prognosis for AN contributed to the explained variance of long-term outcome, increasing the variance explained from 7% (by conventional predictors) to 8% after including psychotherapists' prognosis. In BN, there was no significant contribution of psychotherapists' prognosis to overall prediction.

DISCUSSION

Our current knowledge of risk and protective factors for the course of eating disorders is unsatisfying. More specialized research is urgently needed.

Post-hospitalization Daycare Treatment for Adolescents With Eating Disorders

Background: There are several possible facilities for the treatment of eating disorders (EDs). Specifically, there is the issue of the use of specialized daycare and ambulatory services over inpatient settings and the place of daycare programs following inpatient treatment. Aim: We sought to examine the contribution of post-hospitalization daycare program to the treatment of adolescents hospitalized with an ED. Methods: We assessed 61 female adolescents hospitalized with an ED. All but three were diagnosed with clinical or subthreshold anorexia nervosa (AN). Three were diagnosed with bulimia nervosa. Thirty-seven patients continued with a post-hospitalization daycare program for at least 5 months, whereas 24 did not enter or were enrolled in the program for <5 months. Patients completed on admission to, and discharge from, inpatient treatment self-rating questionnaires assessing ED-related symptoms, body-related attitudes and behaviors, and depression and anxiety. Social functioning was assessed 1 year from discharge using open-ended questions. One-year ED outcome was evaluated according to the patients' body mass index (BMI) and according to composite remission criteria, assessed with a standardized semistructured interview. To be remitted from an ED, patients were required to maintain a stable weight, to have regular menstrual cycles, and not to engage in binging, purging, and restricting behaviors for at least eight consecutive weeks before their assessment. Results: BMI was within normal range at follow-up, whether completing or not completing daycare treatment, and around 75% of the patients had menstrual cycles. By contrast, when using comprehensive composite remission criteria, less than a quarter of former inpatients not entering/not completing daycare program achieved remission vs. almost a half of the completers. In addition, a greater percentage of completers continued with psychotherapy following discharge. Fifty percent of both groups showed good post-discharge social functioning. No between-group differences were found in the BMI and the scores of the self-rating questionnaires at admission to, and discharge from, inpatient treatment. Conclusion: Adolescent females with EDs can maintain a normal-range BMI from discharge to 1-year follow-up, even if not completing daycare treatment. By contrast, completion of a post-hospitalization daycare program may improve the 1-year follow-up ED-related outcome of former ED inpatients.

Identifying duration criteria for eating-disorder remission and recovery through intensive modeling of longitudinal data

OBJECTIVE

Outcome states, such as remission and recovery, include specific duration criteria for which individuals must be asymptomatic. Ideally, duration criteria provide predictive validity to outcome states by reducing symptom-return risk. However, available research is insufficient for deriving specific recommendations for remission or recovery duration criteria for eating disorders.

METHOD

We intensively modeled the relation between duration criteria length and rates of remission, recovery, and subsequent symptom return in longitudinal data from a treatment-seeking sample of women with anorexia nervosa (AN) and bulimia nervosa (BN). We hypothesized that the length of the duration criterion would be inversely associated with both rates of remission and recovery and with subsequent rates of symptom return.

RESULTS

Generalized estimating equations supported our hypotheses for all investigated eating-disorder features except for symptom return when using the Psychiatric Status Rating for AN.

DISCUSSION

We recommend that 6 months be used for remission definitions applied to binge eating, purging, and BN symptom composite measures, whereas no duration criteria be used for low weight and AN symptom composites. We further recommend that 6 months be used for recovery definitions applied to BN symptom composites and AN symptom composites, whereas 18 months be used for individual symptoms of binge eating, purging, and low weight. The adoption of these duration criteria into comprehensive definitions of remission and recovery will increase their predictive validity, which in turn, maximizes their utility.

Predictors of long-term recovery in anorexia nervosa and bulimia nervosa: Data from a 22-year longitudinal study

OBJECTIVE

The objective of this study was to investigate predictors of long-term recovery from eating disorders 22 years after entry into a longitudinal study.

METHOD

One hundred and seventy-six of the 228 surviving participants (77.2%) were re-interviewed 20-25 years after study entry using the Longitudinal Interval Follow-up Evaluation to assess ED recovery. The sample consisted of 100 women diagnosed with anorexia nervosa (AN) and 76 with bulimia nervosa (BN) at study entry.

RESULTS

A comorbid diagnosis of major depression at the start of the study strongly predicted having a diagnosis of AN-Restricting type at the 22-year assessment. A higher body mass index (BMI) at study intake decreased the odds of being diagnosed with AN-Binge Purge type, relative to being recovered, 22 years later. The only predictor that increased the likelihood of having a diagnosis of BN at the 22-year assessment was the length of time during the study when the diagnostic criteria for BN were met.

CONCLUSIONS

Together, these results indicate that the presence and persistence of binge eating and purging behaviors were poor prognostic indicators and that comorbidity with depression is particularly pernicious in AN. Treatment providers might pay particular attention to these issues in an effort to positively influence recovery over the long-term.

Predictors of short-term outcome variables in hospitalised female adolescents with eating disorders

OBJECTIVE

Research in eating disorders (EDs) suggests that outcome variables other than that of the ED per se, such as the presence of comorbid disorders and overall functioning at follow-up, may influence the ED condition at that time. We sought to assess the factors potentially predicting these different outcome variables.

METHODS

Eighty-eight female adolescent in-patients with an ED were assessed on admission, discharge, and around one-year post-discharge using clinical interviews and self-rating questionnaires assessing ED and other relevant symptoms.

RESULTS

The mean body mass index (BMI) of patients with anorexia nervosa increased from admission to discharge and was maintained at follow-up. Twenty-eight patients were remitted at follow-up, whereas 48 and 12 patients had intermediate and poor ED-related outcome, respectively. Follow-up BMI was correlated with baseline BMI. Good ED-related outcome at follow-up according to accepted criteria was associated with more lifetime suicide attempts and more severe baseline ED symptomatology. Elevated psychiatric comorbidity at follow-up was associated with elevated baseline anxiety and with re-hospitalisation during the post-discharge follow-up period. Better academic/occupational functioning and social functioning at follow-up were associated with less lifetime suicide attempts, less re-hospitalisation and lower baseline anxiety.

CONCLUSIONS

In EDs, diverse factors may predict different outcome variables.

The recovery index: A novel approach to measuring recovery and predicting remission in major depressive disorder

BACKGROUND

Clinicians view "recovery" as the reduction in severity of symptoms over time, whereas patients view it as the restoration of premorbid functioning level and quality of life (QOL). The main purpose of this study is to incorporate patient-reported measures of functioning and QOL into the assessment of patient outcomes in MDD and to use this data to define recovery.

METHOD

Using the STAR*D study of patients diagnosed with MDD, this present analysis grades patients' MDD severity, functioning level, and QOL at exit from each level of the study, as well as at follow-up. Using Item Response Theory, we combined patient data from functioning and QOL measures (WSAS, Q-LES-Q) in order to form a single latent dimension named the Recovery Index.

RESULTS

Recovery Index - a latent measure assessing impact of illness on functioning and QOL - is able to predict remission of MDD in patients who participated in the STAR*D study.

CONCLUSIONS

By incorporating functioning and quality of life, the Recovery index creates a new dimension towards measuring restoration of health, in order to move beyond basic symptom measurement.

What does remission tell us about women with eating disorders? Investigating applications of various remission definitions and their associations with quality of life

OBJECTIVE

To compare remission rates, determine level of agreement and identify quality of life (QoL) distinctions across a broad spectrum of remission definitions among patients with eating disorders (ED).

METHODS

Women (N=195; 94 AN, 24 BN, and 77 EDNOS) from inpatient and partial hospital ED programs participated in a study of treatment outcomes. Remission rates were evaluated with percentages, kappa coefficients identified level of agreement and Mann-Whitney-Wilcoxon tests with Bonferroni corrections determined differences in quality of life between remitted and not remitted patients by remission definition.

RESULTS

Depending on remission definition used, the percent of remitted patients varied from 13.2% to 40.5% for AN, 15.0% to 47.6% for BN and 24.2% to 53.1% for EDNOS. Several definitions demonstrated "very good" agreement across diagnoses. Remission was associated with higher quality of life in psychological, physical/cognitive, financial and work/school domains on a disease-specific measure, and in mental but not physical functioning on a generic measure.

CONCLUSIONS

Remission rates vary widely depending on the definition used; several definitions show strong agreement. Remission is associated with quality of life, and often approximates scores for women who do not have an eating disorder. The ED field would benefit from adopting uniform criteria, which would allow for more accurate comparison of remission rates across therapeutic interventions, treatment modalities and facilities. We recommend using the Bardone-Cone criteria because it includes assessment of psychological functioning, was found to be applicable across diagnoses, demonstrated good agreement, and was able to distinguish quality of life differences between remitted and not remitted patients.

Defining recovery in adult bulimia nervosa

To examine how different definitions of recovery lead to varying rates of recovery, maintenance of recovery, and relapse in bulimia nervosa (BN), end-of-treatment (EOT) and follow-up data were obtained from 96 adults with BN. Combining behavioral, physical, and psychological criteria led to recovery rates between 15.5% and 34.4% at EOT, though relapse was approximately 50%. Combining these criteria and requiring abstinence from binge eating and purging when defining recovery may lead to lower recovery rates than those found in previous studies; however, a strength of this definition is that individuals who meet this criteria have no remaining disordered behaviors or symptoms.

When have eating disordered patients recovered and what do the DSM-IV criteria tell about recovery?

Lack of consensus about criteria for recovery from eating disorders results in greatly varying percentages of recovered patients. Outcome studies not only use different criteria for recovery, but also quite different instruments, rendering their results incomparable. The same problem occurs among studies of predictors for recovery from eating disorders. Without consensus on criteria for recovery, it is not clear which goals of treatment are important to realize full recovery. In order to develop larger consensus on criteria for recovery, this study critically analyzes the most important outcome scores and the criteria for recovery deduced from the DSM-IV.

An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents

The authors examined the natural history of threshold, subthreshold, and partial eating disorders in a community sample of 496 adolescent girls who completed annual diagnostic interviews over an 8-year period. Lifetime prevalence by age 20 years was 0.6% and 0.6% for threshold and subthreshold anorexia nervosa (AN), 1.6% and 6.1% for threshold and subthreshold bulimia nervosa (BN), 1.0% and 4.6% for threshold and subthreshold binge-eating disorder (BED), and 4.4% for purging disorder (PD). Overall, 12% of adolescents experienced some form of eating disorder. Subthreshold BN and BED and threshold PD were associated with elevated treatment, impairment, and distress. Peak age of onset was 17-18 years for BN and BED and 18-20 years for PD. Average episode duration in months was 3.9 for BN and BED and 5.1 for PD. One-year recovery rates ranged from 91% to 96%. Relapse rates were 41% for BN, 33% for BED, and 5% for PD. For BN and BED, subthreshold cases often progressed to threshold cases and diagnostic crossover was most likely for these disorders. Results suggest that subthreshold eating disorders are more prevalent than threshold eating disorders and are associated with marked impairment.

Temporal patterns of recovery across eating disorder subtypes

OBJECTIVE

To compare patterns of recovery in individuals with index episodes of anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

Using Kaplan-Meier methods and Cox proportional hazards models, comparisons were conducted that were conditional on duration of eating disorder from onset and included a conservative recovery criterion of 3 asymptomatic years. Data collection was retrospective and from two of the international Price Foundation genetic studies on 901 individuals with eating disorders.

RESULTS

Using Kaplan-Meier methods, 11% of those with index AN and 10% of those with index BN met recovery criteria at 10 years. At 15 years, 16% of those with index AN and 25% of those with index BN met recovery criteria. In a Cox proportional hazards model the index BN group had three times the rate of recovery at 10-14 years (p=0.01) than the index AN group.

CONCLUSIONS

Initially the probability of recovery was greater for those with index AN, but as the duration of the eating disorder lengthened those with BN had higher probabilities of recovery. Replication of these results with prospective data using similarly stringent recovery criteria and methods is required to confirm trends.

Negative self-image and outcome in eating disorders: results at 3-year follow-up

INTRODUCTION

Negative self-image has been hypothesised to be of aetiological significance in eating disorders; however, its relationship to outcome remains unclear. The present study examined the relationship between self-image and follow-up status in a heterogeneous sample of eating disorder patients (N=246).

METHODS

Patients were assessed at intake and after 36 months. Self-image was measured using SASB, and a general outcome measure was calculated comprising eating disorder symptoms, occupational status, interpersonal relationships and general psychopathology.

RESULTS

SASB self-hate was the most important variable for predicting poor outcome, followed by occupational status, interpersonal relationships, eating disorder symptoms, SASB self-emancipation and general psychiatric symptoms. Together these variables predicted 23% of the variance in outcome.

DISCUSSION

High levels of self-hate may increase the risk of poor outcome in eating disorders by adversely affecting interpersonal relationships and making it difficult for patients to engage in treatment.

Outcomes of eating disorders: a systematic review of the literature

OBJECTIVE

The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center systematically reviewed evidence on factors associated with outcomes among individuals with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) and whether outcomes differed by sociodemographic characteristics.

METHOD

We searched electronic databases including MEDLINE and reviewed studies published from 1980 to September, 2005, in all languages against a priori inclusion/exclusion criteria and focused on eating, psychiatric or psychological, or biomarker outcomes.

RESULTS

At followup, individuals with AN were more likely than comparisons to be depressed, have Asperger's syndrome and autism spectrum disorders, and suffer from anxiety disorders including obsessive-compulsive disorders. Mortality risk was significantly higher than what would be expected in the population and the risk of suicide was particularly pronounced. The only consistent factor across studies relating to worse BN outcomes was depression. A substantial proportion of individuals continue to suffer from eating disorders over time but BN was not associated with increased mortality risk. Data were insufficient to draw conclusions concerning factors associated with BED outcomes. Across disorders, little to no data were available to compare results based on sociodemographic characteristics.

CONCLUSION

The strength of the bodies of literature was moderate for factors associated with AN and BN outcomes and weak for BED.

Social and health adjustment of bulimic women 7-9 years following therapy

OBJECTIVE

To examine the long-term social adaptation and long-term follow-up of bulimic women after therapy.

METHOD

Eighty women with bulimia nervosa were investigated 7-9 years after the beginning of either conflict-oriented in-patient therapy or systemic out-patient therapy. Data was gathered through interviews and patient questionnaires.

RESULTS

At the time of follow-up, 28.9% still had DSM-III-R bulimia, 10.1% suffered from subthreshold bulimia or anorexia (EDNOS), 61.2% did not suffer from any DSM-III-R eating disorder. Compared with statistics on the normal population, the social adaptation of the women was quite good with regard to work, household and living conditions. Some dimensions representing probable aetiological factors (i.e. restrictions of intake, feelings of ineffectiveness) showed a delayed reaction to therapy.

CONCLUSION

Long-term outcome of bulimia nervosa may be expected to be moderately good. During therapy, greater attention should be paid to characteristics of the disorder less responsive to treatment.

Review of studies evaluating psychotherapy in bulimia nervosa: The influence of research methods

The purpose of the study was to test if design and research methods of studies predict outcome results of bulimia nervosa. Fifty-seven articles on outcome of bulimia nervosa were found through MEDLINE and PSYCHINFO databases and 25 were included in the statistical analysis. Percentages of patients with a good outcome ranged from 24% to 74% with a mean of 51.1%. The variables best predicting outcome were time to follow-up and number of symptoms evaluated in definition of good outcome whereas dropout, design of studies, treatments, and sample characteristics did not predict significantly. The implications of these findings are discussed.