Affective and anxiety disorders in patients with different rare chronic diseases: a systematic review and meta-analysis

We aimed to identify the prevalence of affective and anxiety disorders across different rare disease and identify correlates of psychopathology. We performed a systematic review and meta-analysis. We systematically searched Medline, PSYNDEX, PsycINFO for observational studies examining clinically diagnosed affective and/or anxiety disorders in adults with rare chronic diseases. Two researchers reviewed titles and abstracts independently and, for eligible studies, independently extracted data. The prevalence rates were pooled using a random intercept logistic regression model. We published a review protocol (http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018106614CRD42018106614). We identified and screened 34 402 records for eligibility and considered 39 studies in the qualitative and 37 studies in the quantitative analysis, including N = 5951 patients with 24 different rare diseases. Heterogeneity between studies was large. Prevalence rates ranged widely between studies, with pooled prevalence estimates of 13.1% (95% CI 9.6-17.7%; I2 = 87%, p < 0.001) for current and 39.3% (95% CI 31.7-47.4%; I2 = 84%, p < 0.001) for lifetime major depressive disorder, 21.2% (95% CI 15.4-28.6%; I2 = 90%, p < 0.001) for current and 46.1% (95% CI 35.8-56.8%; I2 = 90%, p < 0.001) for lifetime affective disorders, and 39.6% (95% CI 25.5-55.6%; I2 = 96%, p < 0.001) for current and 44.2% (95% CI 27.0-62.9%; I2 = 94%, p < 0.001) for lifetime anxiety disorders. Sensitivity analyses excluding studies of low quality revealed nearly the same results. We conducted the first systematic review examining affective and anxiety disorders in adults with different rare diseases and found high prevalence rates. Supporting patients in disease adjustment can be crucial for their overall health and well-being.

Coding of medically unexplained symptoms and somatoform disorders by general practitioners - an exploratory focus group study

BACKGROUND

Medically unexplained symptoms (MUS) and somatoform disorders are common in general practices, but there is evidence that general practitioners (GPs) rarely use these codes. Assuming that correct classification and coding of symptoms and diseases are important for adequate management and treatment, insights into these processes could reveal problematic areas and possible solutions. Our study aims at exploring general practitioners' views on coding and reasons for not coding MUS/somatoform disorders.

METHODS

We invited GPs to participate in six focus groups (N = 42). Patient vignettes and a semi-structured guideline were used by two moderators to facilitate the discussions. Recordings were transcribed verbatim. Two researchers analyzed the data using structuring content analysis with deductive and inductive category building.

RESULTS

Three main categories turned out to be most relevant. For category a) "benefits of coding" GPs described that coding is seen as being done for reimbursement purposes and is not necessarily linked to the content of their reference files for a specific patient. Others reported to code specific diagnoses only if longer consultations to explore psychosomatic symptoms or psychotherapy are intended to be billed. Reasons for b) "restrained coding" were attempting to protect the patient from stigma through certain diagnoses and the preference for tentative diagnoses and functional coding. Some GPs admitted to c) "code inaccurately" attributing this to insufficient knowledge of ICD-10-criteria, time constraints or using "rules of thumb" for coding.

CONCLUSIONS

There seem to be challenges in the process of coding of MUS and somatoform disorders, but GPs appear not to contest the patients' suffering and accept uncertainty (about diagnoses) as an elementary part of their work. From GPs' points of view ICD-10-coding does not appear to be a necessary requirement for treating patients and coding might be avoided to protect the patients from stigma and other negative consequences. Our findings supply a possible explanation for the commonly seen difference between routine and epidemiological data. The recent developments in the DSM-5 and the upcoming ICD-11 will supposedly change acceptance and handling of these diagnoses for GPs and patients. Either way, consequences for GPs' diagnosing and coding behavior are not yet foreseeable.

Factors influencing the length of hospital stay of patients with anorexia nervosa - results of a prospective multi-center study

BACKGROUND

The length of stay (LOS) strongly influences anorexia nervosa (AN) inpatient weight outcomes. Hence, understanding the predictors of LOS is highly relevant. However, the existing evidence is inconsistent and to draw conclusions, additional evidence is required.

METHODS

We conducted a prospective, multi-center study including adult female inpatients with AN. Using stepwise linear regression, the following demographic and clinical variables were examined as potential predictors for LOS: admission BMI, AN-subtype, age, age of onset, living situation, partnership status, education, previous hospitalization, self-rated depression, anxiety and somatic symptoms (PHQ-9, PHQ-15, GAD-7), self-rated therapy motivation (FEVER) and eating disorder psychopathology (EDI-2 subscale scores).

RESULTS

The average LOS of the sample (n = 176) was 11.8 weeks (SD = 5.2). Longer LOS was associated with lower admission BMI (ß = -1.66; p < .001), purging AN-subtype (ß = 1.91; p = .013) and higher EDI-2 asceticism (ß = 0.12; p = .030). Furthermore, differences between treatment sites were evident.

CONCLUSIONS

BMI at admission and AN-subtype are routinely assessed variables, which are robust and clinically meaningful predictors of LOS. Health care policies might consider these variables. In light of the differences between treatment sites future research on geographical variations in mental health care seems recommended.

Cost-effectiveness of focal psychodynamic therapy and enhanced cognitive-behavioural therapy in out-patients with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortality. The treatment of AN very often is protracted; repeated hospitalizations and lost productivity generate substantial economic costs in the health care system. Therefore, this study aimed to determine the differential cost-effectiveness of out-patient focal psychodynamic psychotherapy (FPT), enhanced cognitive-behavioural therapy (CBT-E), and optimized treatment as usual (TAU-O) in the treatment of adult women with AN.

METHOD

The analysis was conducted alongside the randomized controlled Anorexia Nervosa Treatment of OutPatients (ANTOP) study. Cost-effectiveness was determined using direct costs per recovery at 22 months post-randomization (n = 156). Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated. To derive cost-effectiveness acceptability curves (CEACs) adjusted net-benefit regressions were applied assuming different values for the maximum willingness to pay (WTP) per additional recovery. Cost-utility and assumptions underlying the base case were investigated in exploratory analyses.

RESULTS

Costs of in-patient treatment and the percentage of patients who required in-patient treatment were considerably lower in both intervention groups. The unadjusted ICERs indicated FPT and CBT-E to be dominant compared with TAU-O. Moreover, FPT was dominant compared with CBT-E. CEACs showed that the probability for cost-effectiveness of FTP compared with TAU-O and CBT-E was ⩾95% if the WTP per recovery was ⩾€9825 and ⩾€24 550, respectively. Comparing CBT-E with TAU-O, the probability of being cost-effective remained <90% for all WTPs. The exploratory analyses showed similar but less pronounced trends.

CONCLUSIONS

Depending on the WTP, FPT proved cost-effective in the treatment of adult AN.

Determinants and frequency of irritable bowel syndrome in a German sample

BACKGROUND

To date there is no study that has estimated the prevalence of irritable bowel syndrome (IBS) in Germany according to the current Rome III criteria. The aim of the present study was to investigate the prevalence of IBS in a non-clinical German sample. Furthermore, we investigated the association of IBS with socio-demographic and psychological risk factors.

METHODS

Baseline data from a prospective cohort study were analysed, including the IBS Module of the Rome III Diagnostic Questionnaires and validated psychometric scales including the Patient Health Questionnaire-15 (PHQ-15), the Big Five Inventory (BFI), the Perceived Stress Questionnaire (PSQ-5), and the Whiteley-Index (WI-7). The study population was compared to the German general population to appraise its representativeness. Multivariate logistic regression analyses were performed to identify possible risk factors associated with IBS.

RESULTS

Between January 2011 and September 2012, 2419 persons participated (female 54.0 %, mean age 37.4 ± 14.9 years). According to the Rome III criteria, 401 participants (16.6 %) suffered from IBS. Five predictors were independently associated with IBS: previous traveller's diarrhoea infection (OR = 1.76; 95 % CI = 1.34 to 2.31), higher somatic symptom burden (OR = 1.15; 95 % CI = 1.07 to 1.23), increased level of hypochondriasis (OR = 2.04; 95 % CI = 1.54 to 2.70), increased vulnerability to diarrhoea under stress (OR = 3.88; 95 % CI = 3.21 to 4.68) and perceived stress (OR = 1.43; 95 % CI = 1.04 to 1.99).

CONCLUSIONS

Our analyses yielded a relatively high IBS prevalence estimate, compared to studies published more than ten years ago. This might partially be explained by the fact that the time criterion of the Rome III criteria (at least 3 days/month in last 3 months) is more inclusive compared to the time criterion of the Rome II criteria (at least 12 weeks, which need not be consecutive, in the preceding 12 months).

Collaborative stepped care for somatoform disorders: A pre-post-intervention study in primary care

OBJECTIVE

The successful management of somatoform disorders in primary care is often limited due to low diagnostic accuracy, delayed referral to psychotherapy, and unstructured overuse of health care. This study aimed to investigate the feasibility of establishing a collaborative stepped health care network for somatoform disorders, and its impact on the diagnostic process and treatment recommendations in primary care.

METHOD

The Network for Somatoform and Functional Disorders (Sofu-Net) was established to connect 41 primary care physicians (PCP), 35 psychotherapists, and 8 mental health clinics. To evaluate Sofu-Net, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire, and were assessed in detail at the patient and PCP level. Discussion of psychosocial distress in the consultations, diagnostic detection rates and treatment recommendations were compared before and 12 months after establishing the network.

RESULTS

Out of the pre- (n=1645) and 12-months-post Sofu-Net patient samples (n=1756), 267 (16.2%) and 269 (15.3%) high-risk patients were identified. From these, 156 and 123 patients were interviewed and information was assessed from their PCP. Twelve months after Sofu-Net establishment, high-risk patients more frequently discussed psychosocial distress with their PCP (63.3% vs. 79.2%, p<.001). PCPs prescribed more antidepressants (3.8% vs. 25.2%, p<.001) and less benzodiazepines (21.8% vs. 6.5%, p<.001). Sofu-Net did not affect PCP's diagnostic detection rates or recommendation to initiate psychotherapy.

CONCLUSION

The study results indicate feasibility of an interdisciplinary network for somatoform disorders. Collaborative care networks for somatoform disorders have the potential to improve doctor-patient-communication and prescription behavior.

Quality of life one year post-Shiga toxin-producing Escherichia coli O104 infection--a prospective cohort study

BACKGROUND

In 2011, a major outbreak of hemolytic-uremic syndrome (HUS) and bloody diarrhea related to infections from Shiga toxin-producing Escherichia coli O104 (STEC) occurred in Germany. While previous research has focused on the medical components of this disease, we aimed to investigate the course of health-related quality of life (HrQoL) over 12 months including somatic and psychosocial risk factors. Furthermore, the influence of chronic fatigue (CF) on HrQoL was examined.

METHODS

A prospective cohort study with n = 389 patients completing self-report scales at baseline, after 6 months (participation rate: 79%) and after 12 months (participation rate: 77%). The courses of physical and mental HrQoL over the 12 month period were calculated by employing general linear mixed models.

KEY RESULTS

While the physical component score of HrQoL reached a score comparable to the general population, the mental component score remained below average 12 months after STEC infection. Female gender, prior psychiatric disorder, and prior traumatic events were risk factors for a worse HrQoL course after 12 months, while social support was identified to be protective. CF was associated with low HrQoL. In addition, the somatic symptom burden remained persistently high.

CONCLUSIONS & INFERENCES

Our results show high somatic and psychosocial burden in patients 12 months after STEC infection. We recommend considering the risk factors and protective factors of poor HrQoL early in the treatment of STEC or similar diseases. Patients who are suffering from persisting somatic symptoms, CF, and impaired HrQoL may require specific aftercare.

[Chronic pollakiuria: cystectomy or psychotherapy]

BACKGROUND

Persistent unexplained urological complaints and diseases are a common problem in clinical practice. Psychological components can play an important role in urological complaints. Neglect of these facts can lead to an insufficient or incorrect treatment. Therefore, apart from the specific medical diagnostics, a complete examination of mental and psychological functions before an invasive intervention is also required.

PSYCHOSOMATICS IN UROLOGY

Illustrated by the case of a young woman with a request for a cystectomy while suffering from a chronic pollakiuria, this paper explains the importance of good interdisciplinary collaboration for evidence-based, guideline-oriented medical treatment. The patient's suffering and urge for removing the bladder was contrasted by a lack of medical indication for surgery and the principle of proportionality. The essay gives insight into the discipline of psychosomatic medicine, somotoform disorders found in urology and, especially, the symptoms of pollakiuria and overactive bladder.

CONCLUSION

The case illustrates the importance of timely and simultaneous medical and psychosocial diagnostics for the treatment outcome in patients with unspecific physical complaints. Treatment recommendations for patients with somatoform complaints in clinical practice are provided.

[Mental health of children, adolescents and young adults--part 2: burden of illness, deficits of the German health care system and efficacy and effectiveness of early intervention services]

Numerous birth-control studies, epidemiological studies, and observational studies investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use of children, adolescents and young adults is low, even lower than in adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the border of child and adolescent and adult psychiatry. Emerging studies show that these health care structures are effective and efficient. Part 2 of the present review focuses on illness burden including disability and costs, deficits of the present health care system in Germany, and efficacy and efficiency of early intervention services.

[Mental health of children, adolescents and young adults--part 1: prevalence, illness persistence, adversities, service use, treatment delay and consequences]

Numerous birth-control studies, epidemiological studies, and observational studies have investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use by children, adolescents and young adults is low, even lower than for adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for a poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the interface of child and adolescent and adult psychiatry. Emerging studies show that these health-care structures are effective and efficient. Part 1 of the present review summarises the current state of mental health in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, and treatment delay with consequences.

[Repeated measurement of memory with valenced test items: verbal memory, working memory and autobiographic memory]

A large number of questions in clinical and/or experimental neuropsychology require the multiple repetition of memory tests at relatively short intervals. Studies on the impact of the associated exercise and interference effects on the validity of the test results are rare. Moreover, hardly any neuropsychological instruments exist to date to record the memory performance with several parallel versions in which the emotional valence of the test material is also taken into consideration. The aim of the present study was to test whether a working memory test (WST, a digit-span task with neutral or negative distraction stimuli) devised by our workgroup can be used with repeated measurements. This question was also examined in parallel versions of a wordlist learning paradigm and an autobiographical memory test (AMT). Both tests contained stimuli with neutral, positive and negative valence. Twenty-four participants completed the memory testing including the working memory test and three versions of a wordlist and the AMT at intervals of a week apiece (measuring points 1. - 3.). The results reveal consistent performances across the three measuring points in the working and autobiographical memory test. The valence of the stimulus material did not influence the memory performance. In the delayed recall of the wordlist an improvement in memory performance over time was seen. The tests on working memory presented and the parallel versions for the declarative and autobiographical memory constitute informal economic instruments within the scope of the measurement repeatability designs. While the WST and AMT are appropriate for study designs with repeated measurements at relatively short intervals, longer intervals might seem more favourable for the use of wordlist learning paradigms.

Effects of cortisol on memory in women with borderline personality disorder: role of co-morbid post-traumatic stress disorder and major depression

BACKGROUND

Stress and cortisol administration are known to have impairing effects on memory retrieval in healthy humans. These effects are reported to be altered in patients with major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) but they have not yet been investigated in borderline personality disorder (BPD).

METHOD

In a placebo-controlled cross-over study, 71 women with BPD and 40 healthy controls received either placebo or 10 mg of hydrocortisone orally before undertaking a declarative memory retrieval task (word list learning) and an autobiographical memory test (AMT). A working memory test was also applied.

RESULTS

Overall, opposing effects of cortisol on memory were observed when comparing patients with controls. In controls, cortisol had impairing effects on memory retrieval whereas in BPD patients cortisol had enhancing effects on memory retrieval of words, autobiographical memory and working memory. These effects were most pronounced for specificity of autobiographical memory retrieval. Patients with BPD alone and those with co-morbid PTSD showed this effect. We also found that co-morbid MDD influenced the cortisol effects: in this subgroup (BPD + MDD) the effects of cortisol on memory were absent.

CONCLUSIONS

The present results demonstrate beneficial effects of acute cortisol elevations on hippocampal-mediated memory processes in BPD. The absence of these effects in patients with co-morbid MDD suggests that these patients differ from other BPD patients in terms of their sensitivity to glucocorticoids (GCs).

Reliability of the emotional Stroop task: an investigation of patients with panic disorder

Despite its popularity in clinical research, the emotional Stroop task's reliability in patient groups is unknown. Given the low reliability of interference scores in healthy subjects, correlations with other variables pose a problem, especially as reliability in clinical samples is unknown. To assess reliability in panic disorder for the first time, we used the spilt-half method in two independent samples of patients and controls. As expected, only patients showed the behavioral interference effect. Reliability of interference scores (i.e. mean response latency emotional minus neutral words) was insufficiently low for patient and control samples; however, reliability scores derived from the conditions' response latencies (i.e. mean response latency emotional or neutral words) were much higher. The assumption that reliability scores in patients might differ from controls was not supported. This finding questions the use of correlations with external variables and suggests the use of response latencies instead of interference scores.

Work-related behaviour and experience pattern in nurses: impact on physical and mental health

Nursing is associated with high levels of emotional strain and heavy workloads. Changing working conditions raise the importance of investigating job satisfaction, stress and burnout and its consequences for nurses. The aim of the study was to investigate whether work-related behaviour and experience patterns are associated with mental and physical health status in nurses. A sample of 356 nurses in four German hospitals were interviewed using questionnaires regarding work-related behaviour and experience patterns, work stress, depression, anxiety and physical symptoms ('Work-related Behaviour and Experience Pattern'--AVEM and ERI). The main result of this study is that unhealthy work-related behaviour and experience patterns (i.e. the excessive ambitious type and the resigned type) are associated with reduced mental and physical health. Preventive, as well as intervention, strategies are needed that focus both on the individual as well as on working conditions.

Magersucht

Die Magersucht unterscheidet sich deutlich von anderen psychogenen Ess-Störungen: Seit mehr als dreihundert Jahren bekannt, tritt sie mit konstanter Häufigkeit auf und gehört zu den gefährlichsten Erkrankungen der betroffenen Altersstufe: Dreiviertel der Patientinnen gesunden oder bessern sich langfristig, ein Viertel hat einen chronischen Verlauf, häufig mit somatischen Komplikationen und tödlichem Ausgang. Wegen des sich oft über viele Jahre erstreckenden Gesundungsprozesses und der erheblichen Chronifizierungs- und Komplikationsrate sollte zu Beginn jeder Behandlung ein individueller Gesamtbehandlungsplan stehen, um den Therapieverlauf langfristig zu strukturieren. In Abhängigkeit von Schwere, Phase und Komorbidität sind stationäre oder ambulante Therapien indiziert. Bei kurzem Krankheitsverlauf, hinreichendem Gewicht (BMI > 15 kg/m2), guter Motivation und fehlenden Komplikationen ist eine ambulanter Psychotherapieversuch gerechtfertigt. Entsprechend der multifaktoriellen Ätiologie der Anorexia nervosa ist die stationäre Psychotherapie multimodal. Die Gewichtszunahme ist ein wichtiges erstes Therapieziel und Voraussetzung für eine konfliktzentrierte, ambulant fortzusetzende Psychotherapie. Die ambivalente Psychotherapiemotivation und die Notwendigkeit zur Symptomorientierung erfordern sowohl stationär als auch ambulant technische Modifikationen der Psychotherapie und feste Rahmenbedingungen.

Metabolisches Syndrom und Depression

Das Metabolische Syndrom, definiert als Symptomenkomplex aus verminderter Glucosetoleranz, zentraler Adipositas, Dyslipopoteinämie und arterieller Hypertonie, geht mit einem vermehrten Risiko für kardiovaskuläre Erkrankungen und Diabetes mellitus einher. Seit etwa 20 Jahren steigt die Häufigkeit des Metabolischen Syndroms stark an. In den USA sind derzeit 21% bis 39% der Bevölkerung betroffen; in Europa liegen die Raten noch etwas niedriger. Parallel nimmt die Häufigkeit depressiver Störungen zu, welche ihrerseits die kardiovaskuläre Mortalität um den Faktor 1,5 bis 2,5 erhöhen. Bei einer Kombination aus Metabolischem Syndrom und depressiver Störung ist mit besonders schwerwiegenden Folgen im Sinne eines Circulus Vitiosus zu rechnen: Die Depression fördert aufgrund behavioraler, pathophysiologischer, genetischer und iatrogener Wirkmechanismen die Entstehung des Metabolischen Syndrom; das Metabolische Syndrom wiederum begünstigt die Entwicklung und Aufrechterhaltung einer depressiven Symptomatik. Daher müssen bei Patienten mit beiden Krankheitsbildern unbedingt beide Störungen simultan behandelt werden. Wesentliche Bestandteile des Behandlungsplanes sind Gewichtsreduktion, körperliche Aktivität, Psychoeduktion, Einbezug der Familie, der Bezug auf subjektive Erklärungs- und Behandlungsmodelle, kognitive Techniken und der Aufbau von Problemlösekompetenzen. Neben der regelmäßigen Kontrolle von Gewicht, Blutdruck, Nüchternblutzucker, HbA1c und Lipide müssen die Risikofaktoren bzw. die Depression gegebenenfalls ergänzend medikamentös behandelt werden. Unter diesen Voraussetzungen bestehen gute Aussichten, neben dem Blutzuckerhaushalt, dem Bluthochdruck und der Adipositas auch die funktionellen Einschränkungen und das individuelle Wohlbefinden nachhaltig günstig zu beeinflussen.

Recognition of distress and psychiatric morbidity in cancer patients: a multi-method approach

BACKGROUND

This study aimed to determine the prevalence of psychiatric morbidity and distress among 189 consecutively recruited cancer patients upon admission to surgical oncology wards, and to investigate the recognition of distressed patients by medical staff.

PATIENTS AND METHODS

Assessment consisted of a diagnostic psychiatric interview (SCID, DSM-IV), patient-reported distress using a standardised questionnaire (Hospital Anxiety and Depression Scale), and physicians' and nurses' estimates of patients' distress. Twenty-eight per cent of patients were assigned a psychiatric diagnosis, with adjustment disorder predominating.

RESULTS

Surgeons accurately recognised marked distress in 77% of patients with a psychiatric disorder and nurses did so in 75%. Because of low specificity, the positive predictive value was only 39% in surgeons and 40% in nurses. However, recognition of distress translated into referral to the psychosocial liaison service for only a minor proportion of distressed patients.

CONCLUSIONS

Since a remarkable proportion of distressed patients remained unrecognised by the medical staff, only systematic screening of patients upon admission allows timely support to those who are most in need.

Osteoporosis in eating disorders: a follow-up study of patients with anorexia and bulimia nervosa

This study prospectively investigated the course of bone mineral density (BMD) in patients with anorexia nervosa (AN) and bulimia nervosa (BN) over a 3.6-yr follow-up period. From an initial sample of 47 female patients with an eating disorder (T1), 38 (n = 24 AN; n = 14 BN) were reassessed at follow-up (T2) (participation rate, 80.1%). For nonrecovered AN patients at T2, prevalence rates of osteopenia (-1.0 SD > or = T-score > -2.5 SD) and osteoporosis (T-score < or = -2.5 SD) at the lumbar spine were 54.2 and 20.8%, respectively. Due to an annual loss of lumbar spine BMD (-3.7 +/- 4.9%) in the chronic AN patients and a slight but insignificant annual increase (0.7 +/- 1.7%) for those who recovered, the difference in BMD between both outcome groups was more pronounced at follow-up (0.93 +/- 0.13 vs. 1.14 +/- 0.13 g/cm2; P < 0.01). Nonrecovered AN patients with binge eating/purging type showed a significantly reduced BMD compared with patients with the restricting type (0.87 +/- 0.13 vs. 1.02 +/- 0.08 g/cm2; P = 0.02). Both at baseline and follow-up, AN patients had increased rates of bone resorption, as measured by urinary desoxypyridinoline, compared with a control group (n = 42) (11.4 +/- 4.4 vs. 10.4 +/- 7.8, P < 0.001, vs. 5.6 +/- 2.4 and 10.4 +/- 7.8 nM/mM creatinine, P < 0.05, respectively). The subtype of AN and body mass index were best predictors for BMD at the lumbar spine at follow-up (R2 = 0.576). With one exception, all bulimic patients had BMD and markers of bone turnover within the normal range. These results suggest that patients with chronic AN, particularly of the binge eating/purging type, are at high risk for osteoporosis and may need additional therapy to prevent bone loss.

Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study

BACKGROUND

Given our poor understanding of the very long-term course of anorexia nervosa. many questions remain regarding the potential for recovery and relapse. The purpose of the present study was to investigate long-term outcome and prognosis in an anorexic sample 21 years after the initial treatment.

METHOD

A multidimensional and prospective design was used to assess outcome in 84 patients 9 years after a previous follow-up and 21 years after admission. Among the 70 living patients, the follow-up rate was 90%. Causes of death for the deceased patients were obtained through the attending physician. Predictors of a poor outcome at the 21-year follow-up were selected based on the results of a previous 12-year follow-up of these patients.

RESULTS

Fifty-one per cent of the patients were found to be fully recovered at follow-up, 21% were partially recovered and 10% still met full diagnostic criteria for anorexia nervosa. Sixteen per cent were deceased, due to causes related to anorexia nervosa. The standardized mortality rate was 9.8. The three groups also showed significant differences in psychosocial outcome. A low body mass index and a greater severity of social and psychological problems were identified as predictors of a poor outcome.

CONCLUSIONS

Recovery is still possible for anorexic patients after a period of 21 years. On the other hand, patients can relapse, becoming symptomatic again despite previously achieving recovery status. Only a few patients classified as having a poor outcome were found to seek any form of treatment, therefore, it is recommended that these patients should be monitored regularly and offered treatment whenever possible.

[Eating behavior, eating disorders and obesity]

Over the last 50 years, the nutritional and socioeconomic conditions have dramatically changed in all industrialized countries. As a consequence, there has been a sharp rise in the prevalence of obesity. Simultaneously, social and cultural pressures to maintain a thin body shape have significantly increased. This untoward situation is largely responsible for the steady increase of eating disorders, especially bulimia nervosa and binge-eating disorder, which are common disorders among normal or overweight individuals. Although the criteria for bulimia nervosa were first described in the DSM-III in 1980 (APA, 1980), recent studies have demonstrated that only about 12% of these patients are detected by their GP's. One reason for this low rate of detection may be due to the tendency of patients to conceal their illness from others. It is also possible, however, that general practitioners lack sufficient knowledge about bulimia nervosa, preventing proper identification. To help improve this situation, diagnostic guidelines and therapeutic options were summarized. Binge-eating disorder (BED), which is classified as an "eating disorder not otherwise specified" in the DSM-IV (APA, 1994), has been described as the most relevant eating disorder for overweight individuals. It has been estimated that approximately 20-30% of overweight persons seeking help at weight loss programs are classified as binge eaters. Initial results from these studies suggest that binge eaters may require a modified psychotherapeutic approach which focuses on normalizing disordered eating patterns before attempting weight loss. In addition to the importance of screening for eating disorder behaviors, overweight patients should be assessed for other comorbid conditions, such as depression and anxiety. Further, body image disturbances should be assessed during the evaluation. In the event that comorbid disorders are present, it is recommended that specific psychotherapeutic interventions which target these problems be integrated into the overall weight reduction program.

Long-term prognosis in anorexia nervosa: lessons from a 21-year follow-up study

In a prospective long-term follow-up of 84 patients 21 years after first hospitalisation for anorexia nervosa, we found that 50.6% had achieved a full recovery, 10.4% still met full diagnostic criteria for anorexia nervosa, and 15.6% had died from causes related to anorexia nervosa. Predictors of outcome included physical, social, and psychological variables.

[Quality of life, depression and coping behavior in patients awaiting heart transplant]

From a medical perspective, heart transplantation is now an established procedure for the treatment of patients with terminal heart failure. For the patient involved, it presents itself as a situation of great psychological distress, particularly during the waiting period. In the last few years, this situation has grown worse due to the decline in the number of donor organs and the resulting longer waiting period. The aim of this study was to systematically evaluate this phase of the transplantation procedure in a follow-up study. 52 patients could be assessed in follow-up. Although the patients had already differed from the healthy control group in the areas of depression, quality of life, and physical complaints (p < 0.001) at the beginning of the study, there was a significant increase of depression and a further decline in the reported quality of life in the course of the study. The patients presented themselves as having a low internal and a significantly increased external and fatalistic locus of control. The study stresses the necessity for supportive psychotherapeutic therapy in these patients.

[A comparative study of minimal invasive harvesting of vena saphena magna segments]

From July 1997 to February 1998 we performed either minimally invasive or endoscopic saphenous vein harvesting in 55 patients and compared the results with those of 46 patients after conventional saphenous vein harvesting. Minimally invasive and endoscopical vein harvesting can be safely performed after a longer learning curve. Patients after minimally invasive and endoscopical saphenous vein harvesting showed fewer wound healing problems and better cosmetic results than after conventional vein harvesting.

Psychological distress in patients awaiting heart transplantation

Heart transplantation has become an established procedure for the treatment of terminal heart failure. However, due to a shortage of donor organs, the waiting period for a donor organ is increasing. Cross-sectional and retrospective studies have indicated that there is tremendous psychological distress during this waiting period. The aim of this study was to assess this phase systematically and longitudinally. At the beginning of their waiting period, 62 patients at the Heidelberg Transplantation Centre were examined with regard to their physical complaints, quality of life, and level of depression. Four months later the remaining 42 patients were re-examined. The sample showed a significant increase (p<0.001) in subjective physical symptoms and an impairment in social activities (p<0.05) and everyday life (p<0.05), and a significant increase in depression (p<0.001), despite the relatively short time period. These results show the necessity of supportive psychotherapy for patients undergoing heart transplantation.

[Emotional status of patients on the waiting list for heart transplantation]

Although heart transplantation is by now considered an established procedure in patients with terminal heart failure, there has been a stagnation or even a decline in the number of transplantations performed due to the decreased willingness of the public to provide organs. As a consequence of this development patients have to wait for a donor organ for a much larger time. The aim of this study was to examine patients especially during this very stressful period. From July 1995 to February 1997, 62 patients who had been continuously added to the waiting list were examined regarding their quality of life and emotional state. Completely assessed were 53 patients (participation rate: 85%). As compared to a healthy control group, patients with terminal heart failure on the waiting list reported their quality of life in the physical as well as the psychological area as significantly lower (p < 0.001). The areas of depression (p < 0.001) and anxiety (p < 0.001) also showed a significant difference. There was an obvious correlation (p < 0.01) between the key symptom of terminal heart failure-- dyspnoea--and the measured level of depression. This served to support the notion that there is a connection between the psychological and the somatic state in these severely ill patients. These results point to the necessity of supportive psychotherapeutic treatment during this very stressful time.

[Validation of the FKB-20 as scale for the detection of body image distortions in psychosomatic patients]

The study examines the validity of a body image questionnaire (FKB-20) assessing body image disturbances in a clinical sample (n = 405 outpatients of a psychosomatic clinic) and two non-clinical samples (n = 141 medical students and n = 208 sports students). The criterion group was constituted by 98 patients of the clinical sample with diagnosed body image disturbances (anorexia, transsexualism, hypochondriac symptoms). The validity coefficients were 0.56-0.65. The sensitivity of the questionnaire was 82-90%, the specificity 90-97%, and the total mistake rate was 8-10%. The FKB-20 proves to have good validity and can be used for the diagnosis of body image disturbances.