Community Behavioral Health Service Use and Criminal Recidivism of People With Mental, Substance Use, and Co-occurring Disorders

OBJECTIVE

This study assessed the relationship between community behavioral health service (CBHS) use and criminal recidivism in a broad sample of potential beneficiaries and by diagnostic group.

METHODS

Among a cohort of people on probation with any mental and/or substance use disorder (N=772), the study estimated the effect of CBHS use on rearrest with Cox proportional hazards models.

RESULTS

Service use significantly predicted reduced recidivism among people with any mental disorder (hazard rate=0.36, p=0.008), but not among those with any substance use disorder or co-occurring disorders.

CONCLUSIONS

CBHS use in a given week predicted a 64% reduced recidivism risk during the following week among people with any mental disorder. However, CBHS use had no clear relationship with recidivism among people with co-occurring disorders or any substance use disorder. CBHS use may reduce recidivism, depending on recipient and service characteristics.

Equivalency of the diagnostic accuracy of the PHQ-8 and PHQ-9: a systematic review and individual participant data meta-analysis

BACKGROUND

Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.

METHODS

We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.

RESULTS

16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (-0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).

CONCLUSIONS

PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis

OBJECTIVES

Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence.

STUDY DESIGN AND SETTING

Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status.

RESULTS

A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: -13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: -16.4%, 15.0%).

CONCLUSION

PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.

The Accuracy of the Patient Health Questionnaire-9 Algorithm for Screening to Detect Major Depression: An Individual Participant Data Meta-Analysis

BACKGROUND

Screening for major depression with the Patient Health Questionnaire-9 (PHQ-9) can be done using a cutoff or the PHQ-9 diagnostic algorithm. Many primary studies publish results for only one approach, and previous meta-analyses of the algorithm approach included only a subset of primary studies that collected data and could have published results.

OBJECTIVE

To use an individual participant data meta-analysis to evaluate the accuracy of two PHQ-9 diagnostic algorithms for detecting major depression and compare accuracy between the algorithms and the standard PHQ-9 cutoff score of ≥10.

METHODS

Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, Web of Science (January 1, 2000, to February 7, 2015). Eligible studies that classified current major depression status using a validated diagnostic interview.

RESULTS

Data were included for 54 of 72 identified eligible studies (n participants = 16,688, n cases = 2,091). Among studies that used a semi-structured interview, pooled sensitivity and specificity (95% confidence interval) were 0.57 (0.49, 0.64) and 0.95 (0.94, 0.97) for the original algorithm and 0.61 (0.54, 0.68) and 0.95 (0.93, 0.96) for a modified algorithm. Algorithm sensitivity was 0.22-0.24 lower compared to fully structured interviews and 0.06-0.07 lower compared to the Mini International Neuropsychiatric Interview. Specificity was similar across reference standards. For PHQ-9 cutoff of ≥10 compared to semi-structured interviews, sensitivity and specificity (95% confidence interval) were 0.88 (0.82-0.92) and 0.86 (0.82-0.88).

CONCLUSIONS

The cutoff score approach appears to be a better option than a PHQ-9 algorithm for detecting major depression.

Shortening self-report mental health symptom measures through optimal test assembly methods: Development and validation of the Patient Health Questionnaire-Depression-4

BACKGROUND

The objective of this study was to develop and validate a short form of the Patient Health Questionnaire-9 (PHQ-9), a self-report questionnaire for assessing depressive symptomatology, using objective criteria.

METHODS

Responses on the PHQ-9 were obtained from 7,850 English-speaking participants enrolled in 20 primary diagnostic test accuracy studies. PHQ unidimensionality was verified using confirmatory factor analysis, and an item response theory model was fit. Optimal test assembly (OTA) methods identified a maximally precise short form for each possible length between one and eight items, including and excluding the ninth item. The final short form was selected based on prespecified validity, reliability, and diagnostic accuracy criteria.

RESULTS

A four-item short form of the PHQ (PHQ-Dep-4) was selected. The PHQ-Dep-4 had a Cronbach's alpha of 0.805. Sensitivity and specificity of the PHQ-Dep-4 were 0.788 and 0.837, respectively, and were statistically equivalent to the PHQ-9 (sensitivity = 0.761, specificity = 0.866). The correlation of total scores with the full PHQ-9 was high (r = 0.919).

CONCLUSION

The PHQ-Dep-4 is a valid short form with minimal loss of information of scores when compared to the full-length PHQ-9. Although OTA methods have been used to shorten patient-reported outcome measures based on objective, prespecified criteria, further studies are required to validate this general procedure for broader use in health research. Furthermore, due to unexamined heterogeneity, there is a need to replicate the results of this study in different patient populations.

Probability of major depression diagnostic classification using semi-structured versus fully structured diagnostic interviews

BACKGROUND

Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.AimsTo evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.

METHOD

Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.

RESULTS

A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15-3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98-10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7-15) (OR = 0.96; 95% CI = 0.56-1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26-0.97).

CONCLUSIONS

The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.Declaration of interestDrs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.

The impact of system level factors on treatment timeliness: utilizing the Toyota Production System to implement direct intake scheduling in a semi-rural community mental health clinic

This study examined the effect of using the Toyota Production System (TPS) to change intake procedures on treatment timeliness within a semi-rural community mental health clinic. One hundred randomly selected cases opened the year before the change and 100 randomly selected cases opened the year after the change were reviewed. An analysis of covariance demonstrated that changing intake procedures significantly decreased the number of days consumers waited for appointments (F(1,160) = 4.9; p = .03) from an average of 11 to 8 days. The pattern of difference on treatment timeliness was significantly different between adult and child programs (F(1,160) = 4.2; p = .04), with children waiting an average of 4 days longer than adults for appointments. Findings suggest that small system level changes may elicit important changes and that TPS offers a valuable model to improve processes within community mental health settings. Results also indicate that different factors drive adult and children's treatment timeliness.

Assessing social-cognitive deficits in schizophrenia with the Mayer-Salovey-Caruso Emotional Intelligence Test

The emotion management subscale of the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) has recently been recommended by the National Institute of Mental Health Measurement and Treatment Research to Improve Cognition in Schizophrenia committee as the sole measure of social cognition for trials of cognitive enhancement in schizophrenia, yet the psychometric properties of this subscale and the larger instrument in schizophrenia patients have not been thoroughly examined. This research presents a psychometric investigation of the MSCEIT in a sample of 64 early course outpatients with schizophrenia, schizoaffective, or schizophreniform disorder. Results demonstrated that the MSCEIT possesses adequate internal consistency reliability among its branch and total scales and that patients' branch and overall test performance was significantly below normative levels. Estimates of discriminant and concurrent validity indicated that the MSCEIT diverged from measures of neurocognitive functioning and psychopathology, but was only modestly related with objective measures of functional outcome. Convergent validity estimates suggested that, contrary to expectations, the MSCEIT did not correlate with a behavioral measure of social cognition. Finally, exploratory factor analyses suggested the possibility of a shift in the latent structure of emotional intelligence in schizophrenia, compared with studies with healthy individuals. These findings support the use of the MSCEIT as a reliable and potentially valid method of assessing the emotional components of social cognition in schizophrenia, but also point to a need for additional measurement development efforts to assess broader social-cognitive domains that may exhibit stronger relations with functional outcome. Further investigation is warranted to examine the instrument's latent factor structure and convergence with other measures of social cognition.

Evidence of factorial variance of the Mayer-Salovey-Caruso Emotional Intelligence Test across schizophrenia and normative samples

The Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) is a key measure of social cognition recommended by the MATRICS committee. While the psychometric properties of the MSCEIT appear strong, previous evidence suggested its factor structure may have shifted when applied to schizophrenia patients, posing important implications for cross-group comparisons. Using multi-group confirmatory factor analysis, we explicitly tested the factorial invariance of the MSCEIT across schizophrenia (n=64) and two normative samples (n=2099 and 451). Results indicated that the factor structure of the MSCEIT was significantly different between the schizophrenia and normative samples. Implications for future research are discussed.

Screening for anxiety and depression in community mental health: the beck anxiety and depression inventories

Accurate diagnosis is key to providing quality services in community mental health. This research examined the ability of the Beck Anxiety and Depression Inventories to identify anxiety and depression in community settings. The diagnostic accuracy of these instruments was compared with the Structured Clinical Interview for DSM-IV in a sample of 288 distressed women seeking treatment for their children. Operating characteristic curves indicated the Beck Anxiety and Depression Inventories hold utility as screens for panic and major depressive disorder, respectively. Deploying these instruments as initial screens in a tiered diagnostic system may improve diagnostic accuracy in community settings.

The relationship between maternal and child symptom change in community mental health

The mental health of mothers and children are closely linked. This study examined the relationship between child and maternal symptom change during a period in which children participated in community mental health treatment. Symptom change was measured using the Child Behavior Checklist for children and the Beck Depression Inventory for Mothers. Results indicate that mothers whose children improve in community mental health treatment are significantly more likely to report a reduction in maternal depressive symptoms than mothers whose children do not improve. Implications of these findings for mental health service settings are discussed.

The need to adapt standardized outcomes measures for community mental health

In order to determine whether evidence-based practices are effective in community settings, the use of measurement tools that accurately capture symptoms and functioning in the community context is imperative. Without accurate measurement, researchers face the troubling possibility that tests of effective treatments may not attain positive results because of measurement error. The authors have experienced apparently serious problems with measurement validity in community mental health practice settings in which we are conducting diffusion research. Features of survey design that strengthen measurement in the university setting (where survey instruments are designed and treatments are usually tested) appear to work against us in community settings. Problems are compounded when it is necessary to measure across several domains, and thus, to employ multiple questionnaires. Here, we discuss the problems we have experienced with three common survey design strategies: (1) the use of multiple, similar items; (2) the use of reverse-coded items; and (3) the use of graded response-items. These strategies result in measures whose length and cognitive complexity may compromise their validity in community settings. Race is an especially important issue in diffusion research, as we lack even basic information concerning efficacy and effectiveness for some important evidence-based treatments. Invalid measures could seriously delay transfer and development of appropriate treatments. Careful psychometric work is badly needed, but such work is time intensive and costly. In the meantime, we encourage researchers to consider the modifications suggested here.

Limitations of the Patient Health Questionnaire in Identifying Anxiety and Depression: Many Cases Are Undetected

OBJECTIVE

To determine the concordance between the Structured Clinical Interview for DSM-IV (SCID) and the Patient Health Questionnaire (PHQ) in diagnosing anxiety and depressive disorders.

METHOD

Fifty women seeking psychiatric services for their children at two mental health centers in Western Pennsylvania were assessed for anxiety and depressive disorders using the SCID and the PHQ.

RESULTS

Twenty-five women met SCID criteria for at least one anxiety disorder, 11 (44%) of whom the PHQ failed to identify. The PHQ was particularly limited in identifying individuals with anxiety disorders other than panic disorder. Seventeen women met SCID criteria for at least one major depressive disorder, 6 (35%) of whom the PHQ failed to identify. The PHQ was particularly limited in identifying depressed individuals with dysthymia.

CONCLUSIONS

Caution should be used when screening for anxiety and depression with the PHQ. Implications for improving diagnostic accuracy in social work practice are discussed.

Why lower income mothers do not engage with the formal mental health care system: perceived barriers to care

Lower income mothers who bring their children for mental health services also have high rates of depression and anxiety, yet few seek help. Maternal and child mental health are intimately intertwined; thus, the distress of both is likely to continue if the mother's needs are unaddressed. Because mothers overcome numerous instrumental challenges to help their children, the authors identify potential perceptual barriers to mothers' help seeking. An ethnographic analysis of in-depth qualitative interviews with 127 distressed mothers suggests several critical perceptual factors. For example, mothers attributed their distress to external causes (e.g., poverty, negative life stressors), which they believed individually focused mental health services could not affect. Interviewees also anticipated negative ramifications for seeking care, including being labeled unfit mothers, and thus potentially losing custody of their children. The authors discuss the implications of these and other key themes for engaging lower income mothers and their children.

Effect of maternal mental health problems on child treatment response in community-based services

OBJECTIVE

Many mothers bringing children for community mental health treatment need mental health services themselves. Moreover, children of mothers with mental health problems enter treatment with more severe symptomatology than do other children. However, little is known about how maternal mental health problems affect children's response to treatment. This study examined the impact of maternal mental health status on the child's treatment response.

METHODS

The mental health of 272 mother-child pairs was assessed twice, when children entered treatment at three community mental health clinics and again three months later. Analysis of variance was used to examine the impact of maternal mental health status on children's rate of improvement.

RESULTS

Children of mothers with mental health problems had significantly greater behavior problems (F=34.54, p<.001) and demonstrated less improvement over time (F=4.44, p=.04) than children of mentally healthy mothers.

CONCLUSION

These findings suggest that treatment for mothers as well as children could be beneficial for this population.

Impact of maternal mental health status on child mental health treatment outcome

This study examined the effect of maternal depression and anxiety on child treatment outcome. Psychiatric assessments were conducted on 180 mother-child pairs when the child entered treatment in a community mental health center and six months later. Children whose mothers were depressed or anxious were significantly more impaired than children of mentally healthy mothers at both time points. Both groups of children improved at approximately the same rate. The findings suggest that early mental health screening of children and their mothers may be important preventive practices. Addressing the mental health needs of mothers and children simultaneously may be an effective method of reducing their mental health problems.

Depression and anxiety among mothers who bring their children to a pediatric mental health clinic

OBJECTIVE

Maternal psychiatric illness is a potent risk factor for child psychiatric disorders, but little is known about rates of psychiatric diagnoses among mothers who bring their children to pediatric mental health clinics. This study investigated rates of psychiatric disorders among mothers of children presenting for psychiatric evaluation and examined the relationship between maternal diagnosis and child psychopathology.

METHODS

Interviewers conducted structured diagnostic interviews with nonpsychotic, school-age children and their mothers (N=222) and collected self-report measures of symptoms, functioning, and social support.

RESULTS

One-hundred-thirty-five participating mothers (61 percent) met DSM-IV criteria for a current axis I disorder, most commonly depression (35 percent) and anxiety (42 percent). Children of mothers with a diagnosis met criteria for significantly more diagnoses on the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime version and had significantly higher scores on measures of internalizing and externalizing symptoms than children of mothers without a diagnosis. Two-thirds of mothers with a diagnosis were not receiving psychiatric treatment.

CONCLUSIONS

More than half the mothers who brought their children for psychiatric treatment were themselves suffering from a psychiatric disorder. Maternal psychiatric illness was, in turn, associated with greater occurrence of psychopathology among offspring, underscoring the importance of developing interventions that address the needs of both children with psychiatric disorders and their at-risk mothers.

Behavioral treatment of obesity in patients taking antipsychotic medications

OBJECTIVE

Antipsychotic medications are associated with weight gain and metabolic dysregulation, yet little is known about the management of obesity among individuals with severe and persistent mental illness. Thus we sought to evaluate the potential utility of a behavioral weight control program for this population.

METHOD

Outpatients receiving psychiatric care at a university medical center who had a body mass index (BMI; weight in kg/[height in m](2)) >or= 30 and were currently taking antipsychotic medication participated in a 12-week group behavioral weight control program. A medical chart review was conducted for each participant's body weight over the 10 months prior to beginning the program. A multiple baseline design was used to determine the impact of the intervention on BMI through 12-month posttreatment follow-up. We also assessed self-reported eating behavior, physical activity, and health-related quality of life. Data were collected from October 2000 to July 2003.

RESULTS

Among 35 patients who began the program, 29 (83%) completed treatment, with mean (+/- SD) weight loss of 5.04 (+/- 7.52) pounds (p = .001) and improvements in eating, activity, and quality of life. At 3-month posttreatment follow-up (N = 27; 77%), total mean weight loss was 7.14 (+/- 11.47) pounds (p = .003). Results of a longitudinal model based on general estimating equations indicated that, relative to the pretreatment period, BMI decreased significantly during treatment and remained stable through 12-month posttreatment follow-up.

CONCLUSION

Behavioral weight control is a promising approach to the treatment of obesity among outpatients taking antipsychotic medications, but longer and more robust interventions are needed.

Weight gain information on the Internet for people who have schizophrenia

Weight gain and chronic health problems are highly prevalent among people with schizophrenia. Basic information about diet and exercise changes would be very useful to people with schizophrenia as well as the family members and clinicians. Because people increasingly seek information from the World Wide Web, this paper reports on a survey of weight-related information on available web sites. A survey of 21 schizophrenia websites revealed that although fourteen sites (67%) included some information about weight gain and related health problems, more than half of the information was limited to site user-generated comments, and consisted of less than one paragraph of information.

Return to treatment after assessment in a community children's mental health clinic

Most people who receive mental health assessments do not follow up on needed treatment. The authors examined factors that predicted return for at least one treatment visit among 113 children who presented for treatment at a rural community mental health center, using predictors of return for adults from a previous study. Sixty-four percent of the children, compared with 46 percent of the adults, returned at least once. Time until the first appointment predicted whether patients returned for treatment. The age of the child was the only other variable that predicted initial treatment engagement. The results strongly suggest that community mental health agencies can improve treatment acceptance rates by providing rapid response to requests for treatment.

Major alternatives to the Classic Experimental Design

In summary, giving up any of the three defining features of the Classic Experimental Design has (at least) two important effects. Each concession creates a significant threat to our confidence that any improvements observed were actually attributable to the treatment we are studying. At the same time, each concession opens a door by enhancing, sometimes greatly, the feasibility of conducting work in settings that are the most true to everyday clinical practice. When the work is thoughtfully and responsibly conducted, the alternative designs can contribute to clinical knowledge in a way that is equally important to the contributions made by work that conforms to the stringent requirements of the "Classic" design. In the next article, we will discuss single-time-point designs, along with the important dictum, memorized by most everyone who has taken a course called "Introduction to Research" or "Introduction to Statistics" that correlation is not causation.

Searching for a two-factor model of marriage duration: commentary on Gottman and Levenson

Gottman and Levenson (2002) report a number of post hoc ordinary least squares regressions to "predict" the length of marriage, given that divorce has occurred. We argue that the type of statistical model they use is inappropriate for answering clinically relevant questions about the causes and timing of divorce, and present several reasons why an alternative family of models called duration models would be more appropriate. The distribution of marriage length is not bimodal, as Gottman and Levenson suggest, and their search for a two-factor model for explaining marriage length is misguided. Their regression models omit many variables known to affect marriage length, and instead use variables that were pre-screened for their predictive ability. Their final model is based on data for only 15 cases, including one unusual case that has undue influence on the results. For these and other technical reasons presented in the text, we believe that Gottman and Levenson's results are not replicable, and that they should not be used to guide interventions for couples in clinical settings.

CSF oxytocin and vasopressin levels after recovery from bulimia nervosa and anorexia nervosa, bulimic subtype

BACKGROUND

When ill, people with eating disorders have disturbances of the neuropeptides vasopressin and oxytocin.

METHODS

To avoid the confounding effects of the ill state, we studied women who were recovered (more than 1 year, normal weight, and regular menstrual cycles, no bingeing or purging) from bulimia nervosa (rBN) or binge eating/purging-type anorexia nervosa (rAN-BN), and matched healthy control women.

RESULTS

Vasopressin was elevated in rAN-BN and showed a trend towards elevation in rBN. In rBN, elevated cerebrospinal fluid vasopressin may be related to having a lifetime history of major depression. In comparison, cerebrospinal fluid oxytocin was normal in recovered subjects, but elevated levels in some rBN might be related to birth control pill use.

CONCLUSIONS

These data confirm and extend the possibility that elevated cerebrospinal fluid vasopressin may be related to the pathophysiology of eating disorders, and/or a lifetime history of major depression.

Binge antecedents in obese women with and without binge eating disorder

In this study, women with binge eating disorder (BED; n = 41) and weight- and age-matched comparison women without BED (NBED; n = 38) monitored their eating for 6 days, using handheld computers to measure mood, appetite, and setting at all eating episodes and comparison noneating episodes. Poor mood, low alertness, feelings of poor eating control, and craving sweets all preceded binge episodes for the BED group. An unanticipated finding was the frequent report of binge episodes in the comparison group; only feelings of poor eating control and craving sweets predicted binge episodes in this group. Binge eating NBED women tended to experience worse mood, less control, and more craving than other NBED women, contributing to evidence of the close relationship of binge eating and decrements in emotional and appetitive functioning.

Initial treatment engagement in a rural community mental health center

The charts of patients who received an initial assessment at a rural mental health center were reviewed to identify patient, system, and clinical characteristics that predicted return to the center for at least one treatment visit in the following three months. Among 112 patients, the overall rate of return was 46 percent. Patients who were seen for assessment within one week of their initial request for services were significantly more likely to return, as were those who had lower scores on the Global Assessment of Functioning scale. Patients referred for assessment by agencies of social control were the least likely to return for treatment.

Anger attacks: correlates and significance of an underrecognized symptom

BACKGROUND

Anger attacks over provocations described as trivial by the individual are an underrecognized symptom associated with aggressive acts. They are usually followed by guilt and regret. Anger attacks among mothers are an important problem because they are often directed at the woman's spouse and/or children. This study examines the prevalence and correlates of anger attacks in a psychiatric clinic for women who are either pregnant or up to 18 months postpartum.

METHOD

Fifty consecutive consenting patients were assessed at initial presentation with the Structured Clinical Interview for DSM-IV Axis I Disorders, a modified Anger Attacks Questionnaire, self-reports of psychiatric symptoms and psychosocial variables, and clinician ratings.

RESULTS

Thirty (60%) of 50 patients reported anger attacks. Of those with anger attacks, 76.7% worried about them, and 73.3% had tried to prevent them. Compared with women without anger attacks, those with anger attacks were significantly more likely to report higher state and trait anger (p < .001), have a diagnosis of unipolar depression (p < .01), report more aggression directed at immediate family, and avoid their children. Both groups displayed little angry affect in the interview, thus appearing similar at assessment.

CONCLUSION

Anger attacks in response to children and spouse were common in this group of women and were associated with subjective distress. Because those with and without anger attacks appear similar at interview, inquiring about the presence of anger attacks is important to ensure that they become a focus of treatment.

How many donuts is a "binge"? Women with BED eat more but do not have more restrictive standards than weight-matched non-BED women

Theories of disordered eating suggest that binge eating may occur as a response to violations of unrealistically restrictive dietary standards, but there are few direct comparisons of the dietary standards of binge eaters and nonbinge eaters. In this study, we asked obese women with Binge Eating Disorder (BED) and weight- and age-matched women without BED to report the minimum amount of each of eight foods they considered a "binge" and "out of control" to determine whether binge eaters had stricter dietary standards than women without BED. Women with BED did not consider smaller amounts of food a "binge" or "out of control" than did women without BED; however, binge eaters did report that their "typical" and "largest-ever" servings of each of the eight foods were larger than those reported by nonbinge eaters. This suggests that for this group of eating- disordered women, eating behaviors may be a more important intervention target than overly restrictive dietary standards.

The effect of perceived control over eating on the life satisfaction of women and men: results from a community sample

OBJECTIVE

To test whether overweight, or perception of lack of control over eating, or both, contributed to the level of life satisfaction for women and men in a random sample of community-dwelling adults.

METHOD

This study examined the effects of body mass index (BMI) and perceived control over eating on life satisfaction for women and men in a community-based sample of 1,069 women and 963 men.

RESULTS

For women, both lack of perceived eating control and higher BMI were associated with less life satisfaction, and lack of control over eating was the more important predictor. For men, only lack of perceived eating control was associated with less life satisfaction. Furthermore, for both women and men, the contribution of eating control to life satisfaction was unaffected by BMI, that is, the life satisfaction of heavier people was not more affected by perceived control over eating than was the life satisfaction of lighter people.

DISCUSSION

These findings suggest that psychological issues related to eating and weight can affect global aspects of well-being.

Alterations in serotonin activity and psychiatric symptoms after recovery from bulimia nervosa

BACKGROUND

Women with bulimia nervosa (BN) have disturbances of mood and behavior and alterations of monoamine activity when they are bingeing and purging. It is not known whether these alterations are secondary to pathological eating behavior or traits that could contribute to the pathogenesis of BN.

METHODS

To avoid the confounding effects of pathological eating behavior, we studied 30 women after long-term recovery (>1 year with no bingeing or purging, normal weight, and regular menstrual cycles) from BN. Subjects were compared with 31 healthy volunteer women. We assessed psychiatric diagnoses and symptoms to determine whether there was any persistent disturbance of behavior after recovery. We measured cerebrospinal fluid (CSF) levels of the major metabolites of serotonin (5-hydroxyindoleacetic acid [5-HIAA]), dopamine (homovanillic acid [HVA]), and norepinephrine (3-methoxy-4-hydroxyphenylglycol [MHPG]) as well as hormonal and behavioral response to m-chlorophenylpiperazine (m-CPP), a serotonin-specific agent.

RESULTS

Women who were recovered from BN had mild to moderate negative moods and obsessions with perfectionism and exactness and exaggerated core eating disorder symptoms compared with healthy volunteer women. Recovered BN women had increased levels of CSF 5-HIAA compared with control women (117 +/- 33 vs 73 +/- 15 pmol/mL; P< or =.001) but normal CSF HVA and MHPG concentrations. Recovered BN women had an anxious and disorganized behavioral response to m-CPP but a normal hormonal response.

CONCLUSIONS

Persistent serotonergic and behavioral abnormalities after recovery raise the possibility that these psychobiological alterations might be trait-related and contribute to the pathogenesis of BN.

A controlled family study of anorexia nervosa and bulimia nervosa: psychiatric disorders in first-degree relatives and effects of proband comorbidity

BACKGROUND

We used contemporary family-epidemiological methods to examine patterns of comorbidity and familial aggregation of psychiatric disorders for anorexia and bulimia nervosa.

METHODS

Direct interviews and blind best-estimate diagnostic procedures were used with diagnostically "pure" groups of probands with eating disorders and a matched control group. Lifetime prevalence rates of eating disorders, mood disorders, substance use disorders, anxiety disorders, and selected personality disorders were determined in female probands with restricting anorexia nervosa (n=26) or bulimia nervosa (n=47), control women (n=44), and first-degree biological relatives (n=460).

RESULTS

Relatives of anorexic and bulimic probands had increased risk of clinically subthreshold forms of an eating disorder, major depressive disorder, and obsessive-compulsive disorder. Familial aggregation of major depressive disorder and obsessive-compulsive disorder was independent of that of anorexia nervosa and bulimia nervosa. These relatives also had increased risk of other anxiety disorders, but the mode of familial transmission was not clear-cut. The risk of substance dependence was elevated among relatives of bulimic probands compared with relatives of anorexic probands, and familial aggregation was independent of that of bulimia nervosa. The risk of obsessive-compulsive personality disorder was elevated only among relatives of anorexic probands, and there was evidence that these 2 disorders may have shared familial risk factors.

CONCLUSIONS

There may be a common familial vulnerability for anorexia nervosa and bulimia nervosa. Major depressive disorder, obsessive-compulsive disorder, and substance dependence are not likely to share a common cause with eating disorders. However, obsessional personality traits may be a specific familial risk factor for anorexia nervosa.

Psychiatric disorders in women with bulimia nervosa and their first-degree relatives: effects of comorbid substance dependence

OBJECTIVE

Women with bulimia nervosa (BN) and comorbid substance dependence often display impulsive behaviors. We assessed Axis I and II psychiatric diagnoses in their first-degree relatives in order to understand the etiological factors that may contribute to this subtype of BN.

METHOD

We used contemporary family-epidemiological methodology to compare the lifetime prevalence of psychiatric disorders among 47 women with BN and 44 non-eating-disordered community control women, and their first-degree relatives (177 and 190, respectively). BN probands were stratified by the presence (n = 20) or absence (n = 27) of a lifetime history of alcohol and/or drug dependence.

RESULTS

Social phobia, conduct disorder, and clusters B and C personality disorders were significantly more prevalent among BN probands with substance dependence than among BN probands without substance dependence or control women probands. Substance use disorders, social phobia, panic disorder, and cluster B personality disorders were significantly more prevalent among the relatives of BN probands with substance dependence than the relatives of the other two groups.

DISCUSSION

Women with BN and substance dependence have problems with social anxiety, antisocial behavior, and a variety of personality disturbances, and come from families where there are problems with substance use disorders, anxiety, impulsivity, and affective instability. These data raise the possibility that a familial vulnerability for impulsivity and affective instability may contribute to the development of substance dependence in a subgroup of women with BN.

Relationship of depression, anxiety, and obsessionality to state of illness in anorexia nervosa

OBJECTIVE

Depression, anxiety, and obsessionality frequently are present in underweight, malnourished patients with anorexia nervosa. It is less certain if these symptoms persist after recovery. Thus, we assessed these symptoms in anorexic women at three states of illness (underweight, short-term weight restored, and long-term weight restored) in comparison to a group of healthy women.

METHOD

We used standardized self- and trained rater instruments to assess depression (Hamilton Depression Rating Scale and Beck Depression Inventory), anxiety (Spielberger State-Trait Anxiety Inventory and Hamilton Anxiety Rating Scale), and obsessions and compulsions (Yale-Brown Obsessive Compulsive Scale).

RESULTS

A similar pattern was found for all symptoms. That is; scores for depression, anxiety, and obsessionality were most elevated in the underweight state. These symptoms improved with weight restoration. However, milder but significantly elevated symptoms persisted in long-term weight-restored anorexic women compared to healthy control women.

DISCUSSION

These data suggest that malnutrition intensifies the severity of depression, anxiety, and obsessionality in anorexia nervosa. However, the fact that mild to moderate symptoms persisted after long-term weight restoration raises the possibility that such behaviors are related to the pathogenesis of this illness.

Weight changes in caregivers of Alzheimer's care recipients: psychobehavioral predictors

Relationships of changes in body mass index (BMI) were examined with changes in psychobehavioral variables in spouse caregivers of individuals with Alzheimer's disease (n = 81) and matched spouses of controls (n = 86). Men caregivers had significantly greater BMI and obesity than men controls at both times. Over 15-18 months, women caregivers gained significantly more weight than did women controls. A trend for greater obesity occurred in women caregivers than in women controls at follow-up. Although weight gain was not related to psychobehavioral variables in controls, in men caregivers decreased perceived control and increased fat intake explained significant variance in weight gain. In women caregivers, increased anger control and increased calories explained weight gain. Such caregivers may be at risk for health problems.

A double-blind, placebo-controlled trial of the effect of fluoxetine on dietary intake in overweight women with and without binge-eating disorder

This study examined mechanisms by which fluoxetine may reduce energy consumption and body weight. Women with binge-eating disorder (BED; n = 38) and age- and weight-matched women without BED (n = 32) monitored their dietary intake and concurrently recorded mood variables on a hand-held computer for 6 d of baseline and for 6 d after being randomly assigned to receive placebo or fluoxetine (60 mg). Fluoxetine reduced eating more than did the placebo on days 4-6 of treatment. The frequency of episodes was not affected, suggesting that fluoxetine affects satiety, not hunger. Fluoxetine did not preferentially reduce carbohydrate intake, did not affect snack consumption as compared with meal consumption, and did not affect negative-mood eating more than positive-mood eating, nor did fluoxetine affect subjects' mood ratings. Benefits of fluoxetine were of approximately equal magnitude for women with and without BED. However, women who reported higher energy consumption at baseline were more responsive to fluoxetine than were women who reported lower energy consumption at baseline, and binge-eating status was associated with greater energy consumption at all time points, including baseline. Fluoxetine affects dietary intake within 4 d of its consumption, and if future research shows that this remains true on repeated applications, this drug may be useful for short periods when difficulty with overeating is anticipated, such as during vacations.

Bulimia nervosa and substance dependence: association and family transmission

Alcohol and drug use disorders are common among women with bulimia nervosa (BN) and their family members. However, it is not known whether there is a familial relationship between BN and substance use disorders. We compared 47 women with BN and 44 non-eating-disordered community control women, and their first-degree relatives (177 and 190, respectively). BN probands were stratified by the presence (43%) or absence (57%) of lifetime alcohol and/or drug dependence. The first-degree relatives of substance-dependent BN probands had significantly higher lifetime rates of alcohol/drug dependence (38%), compared with relatives of nonsubstance-dependent BN probands (10%) or relatives of community controls (18%). These data suggest that BN and substance dependence are transmitted independently in families.

Weight changes in caregivers of Alzheimer's care recipients: psychobehavioral predictors

Relationships of changes in body mass index (BMI) were examined with changes in psychobehavioral variables in spouse caregivers of individuals with Alzheimer's disease (n = 81) and matched spouses of controls (n = 86). Men caregivers had significantly greater BMI and obesity than men controls at both times. Over 15-18 months, women caregivers gained significantly more weight than did women controls. A trend for greater obesity occurred in women caregivers than in women controls at follow-up. Although weight gain was not related to psychobehavioral variables in controls, in men caregivers decreased perceived control and increased fat intake explained significant variance in weight gain. In women caregivers, increased anger control and increased calories explained weight gain. Such caregivers may be at risk for health problems.

Nocturnal eating in binge eating disorder and matched-weight controls

OBJECTIVE

To examine the association of nocturnal eating (getting up out of bed to eat) with overweight, binge eating, and negative mood or anxiety.

METHOD

Forty overweight women diagnosed with binge eating disorder (BED) and 39 overweight controls monitored their nocturnal eating for an average of eight nights.

RESULTS

Seven instances of nocturnal eating were recorded by 6 patients, all of whom were binge eaters. Foods consumed nocturnally tended to be selected from those favored for binge episodes, and reported control over nocturnal eating was low. Patients reported tiredness, but not poor mood or anxiety, at the nocturnal eating episodes.

DISCUSSION

In this sample, nocturnal eating was associated more with eating disorder than overweight. This report should provide the basis of future work to determine whether nocturnal eating should be evaluated and treated among eating disordered or overweight groups of patients.

Binge eating onset in obese patients with binge eating disorder

In this study we examined whether obese women with binge eating disorder (BED) reporting earlier onset binge eating differed from those with later onset binge eating on salient clinical parameters. Subjects were 112 women who sought treatment for BED. Subjects with early (< or = age 18) and later onset (> age 18) did not differ in age, weight, body mass index, or severity of binge eating. Participants were interviewed using the Eating Disorder Examination (EDE) and the Structured Clinical Interview for DSM-III-R, and completed a weight and diet history questionnaire. Early-onset binge eaters were more likely than those with later-onset to binge-eat before dieting, to have early onset of obesity and dieting, to have longer binge-free periods, and more paternal obesity and binge eating. Early-onset binge eaters also reported more eating-disorders psychopathology, and they were more likely to report a lifetime history of bulimia nervosa and DSM-III-R mood disorder. These data suggest that there are marked differences among BED patients presenting for treatment. Further research is needed to determine whether these differences reflect a different etiology or have implications for treatment.

Diagnosis of binge eating disorder: discrepancies between a questionnaire and clinical interview

Binge eating is a common problem among obese individuals, and a simple, accurate way to identify obese binge eaters is needed. This study measured the concordance of the Binge Eating Scale (BES) and the Eating Disorder Examination (EDE). Women seeking obesity treatment (N = 126) were identified as binge eaters or nonbinge eaters using the BES, and then interviewed by clinicians blind to BES score using the EDE, a semistructured interview considered to be the "gold standard" for eating disorder diagnosis. The BES accurately identified nonbinge eaters; 39 of 42 (92.9%) BES-identified nonbinge eaters were confirmed by the EDE. However, the BES did not accurately identify binge eaters; only 43 of the 83 (51.8%) BES-identified binge eaters were confirmed by the EDE. Reasons for the discrepancy between the BES and the EDE in the identification of binge eaters were explored, and modifications to the BES that might improve its accuracy were considered.

Behavioural and psychosocial aspects of obesity and its treatment

This chapter emphasized new directions being pursued in the behavioural treatment of obesity. Behavioural weight-loss programmes are being strengthened by their increased emphasis on low fat intake and exercise, by more direct intervention on behavioural antecedents and consequences of eating, by the use of very low calorie diets (VLCDs) and by the adoption of a chronic disease model and the concomitant lengthening of treatment programmes. With these approaches, initial weight losses of 10-20 kg can be achieved, and maintenance of weight losses of 5-10 kg can be expected. Treatments may also be strengthened by the identification of subgroups of the obese. Recently, progress has been made in this area with the description of a subgroup of the obese who have severe problems with binge eating. Binge eating disorder has been proposed as a new diagnostic category for DSM-IV. From 20 to 45% of the obese who present for treatment suffer from such problems. Obese binge eaters have worse mood and more psychopathology than obese people who do not binge eat, and are more likely to drop out of behavioural weight-control treatments. Although binge eaters may regain weight faster than non-binge eaters, both short- and long-term weight loss of binge eaters and non-binge eaters appear quite similar. Treatments have been identified that show promise in ameliorating binge eating for these patients, but these treatments have not produced weight loss. Although there has recently been concern about the possible negative effects of dieting on mood state, participation in behavioural weight-loss programmes is not associated with worsening mood in obese patients. No psychological variables have distinguished obese from non-obese individuals. Nonetheless, there is substantial prejudice against the obese. Awareness of this prejudice can lead to more sensitive and appropriate treatments for the problem of obesity.

Stress-induced eating

Stress is widely thought to lead to overeating. Studies of stress-induced eating have tested two models. One has tested whether stress increases eating in all exposed organisms and has been tested primarily with animals and physical stressors. The other has tested individual differences in vulnerability to stress-induced eating and has tested only human subjects and psychological stressors. The most consistent set of findings shows that "restrained" eating predicts vulnerability among women; we conclude that for the stressors studied to date, the individual-difference model has received stronger support. Because the question motivating much of this research is whether stress-induced eating causes obesity, future research should assess the effect of stress on weight-change more directly.