Clinical effectiveness, cost-effectiveness and process evaluation of group schema therapy for eating disorders: study protocol for a multicenter randomized controlled trial

BACKGROUND

Eating disorders (EDs), such as (atypical) Anorexia (AN) and Bulimia Nervosa (BN), are difficult to treat, causing socioeconomic impediments. Although enhanced cognitive behavioral therapy (CBT-E) is widely considered clinically effective, it may not be the most beneficial treatment for (atypical) AN and BN patients who do not show a rapid response after the first 4 weeks (8 sessions) of a CBT-E treatment. Alternatively, group schema therapy (GST) may be a valuable treatment for this ED population. Even though GST for EDs has yielded promising preliminary findings, the current body of evidence requires expansion. On top of that, data on cost-effectiveness is lacking. In light of these gaps, we aim to describe a protocol to examine whether GST is more (1) clinically effective and (2) cost-effective than CBT-E for (atypical) AN and BN patients, who do not show a rapid response after the first 4 weeks of treatment. Additionally, we will conduct (3) process evaluations for both treatments.

METHODS

Using a multicenter RCT design, 232 Dutch (atypical) AN and BN patients with a CBT-E referral will be recruited from five treatment centers. Clinical effectiveness and cost-effectiveness will be measured before treatment, directly after treatment, at 6 and at 12 months follow-up. In order to rate process evaluation, patient experiences and the degree to which treatments are implemented according to protocol will be measured. In order to assess the quality of life and the achievement of personalized goals, interviews will be conducted at the end of treatment. Data will be analyzed, using a regression-based approach to mixed modelling, multivariate sensitivity analyses and coding trees for qualitative data. We hypothesize GST to be superior to CBT-E in terms of clinical effectiveness and cost-effectiveness for patients who do not show a rapid response to the first 4 weeks of a CBT-E treatment.

DISCUSSION

To our knowledge, this is the first study protocol describing a multicenter RCT to explore the three aforementioned objectives. Related risks in performing the study protocol have been outlined. The expected findings may serve as a guide for healthcare stakeholders to optimize ED care trajectories.

TRIAL REGISTRATION

clinicaltrials.gov (NCT05812950).

Perspectives of underweight people with eating disorders on receiving Imagery Rescripting trauma treatment: a qualitative study of their experiences

BACKGROUND

The prognosis for underweight individuals with an eating disorder (ED) and posttraumatic stress disorder (PTSD) is worse than for their peers without these comorbid symptoms. This qualitative study explores the experiences of trauma-focused Imagery Rescripting (ImRs) therapy of underweight inpatients being treated for an ED.

OBJECTIVE

To test the feasibility and to improve ImRs by understanding the experiences and perspectives of people with an ED and PTSD who, when underweight, received ImRs as an adjunct to their inpatient ED treatment.

METHOD

To explore how underweight people with an ED experience and perceive ImRs, we used a qualitative study design involving semi-structured interviews with 12 participants. After analysis, the data were summarized and classified within a thematic framework that focused on experiences and improving the ImRs method.

RESULTS

The thematic analysis resulted in the following 6 main themes; (1) Expectations of ImRs; (2) Ability to participate in ImRs; (3) Effect of ImRs; (4) Experience of ImRs technique; (5) Conditions under which ImRs is given; (6) In depth-analysis. The results show that despite the fear of disappointment the participants appreciate addressing the PTSD and ED symptoms simultaneously. Further, results showed that it had been possible for them to attend ImRs but that the effects of ImRs were not uniformly perceived. Also, participants indicated that a caring context is important and that ImRs should not be scheduled immediately before a meal. Finally, the treatment generated hope.

CONCLUSIONS

The findings of this study demonstrated the feasibility of the integration of ImRs trauma treatment for individuals who are being treated in an ED inpatient treatment setting, and are in contrast to standard practice where the focus of inpatient treatment has been ED-symptom improvement without comprehensively addressing past traumatic experiences during an underweight phase. Trial registration International Clinical Trials Registry Platform (ICTRP) (NTR6094). Date of registration 09/23/2016. https://trialsearch.who.int/Trial2.aspx?TrialID=NTR6094.

Treating PTSD with Imagery Rescripting in underweight eating disorder patients: a multiple baseline case series study

BACKGROUND

Eating disorder patients with posttraumatic stress disorder have worse treatment results regarding their eating disorder than patients without posttraumatic stress disorder. Many eating disorder patients with co-morbid posttraumatic stress disorder symptoms are not treated for posttraumatic stress disorder symptoms during an underweight state. We propose that treatment of posttraumatic stress disorder is possible for underweight patients and that their trauma symptoms decrease with the use of Imagery Rescripting. We also investigated whether treatment of trauma influences eating disorder pathology in general and the process of weight gain specifically.

METHOD

Ten patients in clinical treatment (BMI 14-16.5) participated. A multiple baseline design was used, with baseline varying from 6 to 10 weeks, a 6-week treatment phase, a 3-week follow-up period and a 3-month follow-up measurement. Data were analysed with mixed regression.

RESULTS

Evidence was found that Imagery Rescripting had strong positive effects on posttraumatic stress disorder symptoms without interfering with eating disorder treatment. Positive effects were also found on a range of secondary emotional and cognitive measures.

CONCLUSION

Imagery Rescripting of traumatic memories is a possible and safe intervention for underweight eating disorder patients. It also had positive clinical effects. Trial registration Netherlands trial register (NTR) Trial NL5906 (NTR6094). Date of registration 09/23/2016. https://www.trialregister.nl/trial/5906 .

Evaluation of the cognitive behavioural theory of eating disorders: A network analysis investigation

OBJECTIVE

One of the prevailing theories of eating disorders (ED) is the transdiagnostic cognitive behavioural theory of eating disorders, which suggests that certain ED symptoms, such as over-valuation of eating, shape, and weight, may be more central than others. In the present study, network analyses were used to evaluate these assumptions in a patient sample.

METHODS

Participants were 336 individuals receiving treatment at an expert center for ED in the Netherlands. Eating disorder symptoms were used to create transdiagnostic and diagnosis-specific networks and assess symptom centrality and density of the networks.

RESULTS

Networks for patients with bulimia nervosa and binge eating disorder confirmed that over-valuation of shape, weight, and eating is the most central symptom in the network. A transdiagnostic network of ED symptoms and separate networks for patients with anorexia nervosa and bulimia nervosa showed that strict dieting was an additional central ED symptom. An exploratory analysis revealed that, although eating disorder symptoms decreased, there were no differences in density of the eating disorder networks before and after treatment with cognitive behavioural therapy.

DISCUSSION

In conclusion, the current study confirmed that over-valuation of shape, weight, and eating is a central symptom across eating disorders, in agreement with the transdiagnostic cognitive behavioural model of eating disorders. Specifically targeting this symptom in treatment could lead to other symptoms improving as a result.

[Trauma and anorexia nervosa: the association between trauma characteristics, PTSD and the duration of the eating disorder]

Research into the prevalence of various traumatic events in anorexia nervosa (AN) is sparse, with the findings from these studies varying. In addition, the number and age at which traumatic events occurred was not consistently included in previous studies.<br/> AIM: To study the prevalence of different types of traumatic events, whether they occurred in early childhood or not, the number of different events and their associations with PTSD symptoms, and the duration of the eating disorder among clinically admitted patients with AN.<br/> METHOD: In the admission department of an eating disorder clinic, 60 female patients with AN completed questionnaires about traumatic events and symptoms of PTSD during the first week of admission.<br/> RESULTS: Although physical violence during early childhood and traumatic sexual events in later childhood and adulthood were the most commonly reported, there was a variety of types of traumatic events that were frequently reported. In addition, patients who had experienced traumatic events at a young age and / or multiple types of traumatic events had a longer-lasting eating disorder.<br/> CONCLUSION: A thorough inventory of trauma in patients with eating disorders seems important, as this could play a role in maintaining an eating disorder.

Home-based alcohol prevention program for parents and children: A randomized controlled trial

Objective To evaluate the effectiveness of a home-based alcohol prevention program to delay initiation of alcohol use in children. Methods In 2011, a total of 1349 sixth-grade children (M=12.15, SD=0.47) and their mothers who could read and write Dutch were recruited from primary schools in the northern part of the Netherlands. They participated in a cluster randomized controlled trial with two conditions; (1) intervention group (5 modules which families received by mail every 4weeks over 5months), (2) control group (a factsheet information brochure). An independent statistician allocated the schools to the conditions (allocation ratio (1:1)). Participants and data-analyst were blind to randomization. The primary outcome was alcohol initiation. Results Of the participants, 680 were randomized to the intervention and 669 to the control condition. In the intervention condition (N=540) 5.4% of the children drank alcohol compared to 7.1% in the control condition (N=601). The difference was not significant (OR=.99, 95% CI=.96-1.02, p=52). Conclusion The present study showed no effects of 'In control: No alcohol!' on alcohol initiation. A critical evaluation of program design and content, and future studies in different target groups, are suggested. The trial is registered at trialregister.nl, number NTR2474.

The Co-Development of Parenting Stress and Childhood Internalizing and Externalizing Problems

Although the detrimental influence of parenting stress on child problem behavior is well established, it remains unknown how these constructs affect each other over time. In accordance with a transactional model, this study investigates how the development of internalizing and externalizing problems is related to the development of parenting stress in children aged 4-9. Mothers of 1582 children participated in three one-year interval data waves. Internalizing and externalizing problems as well as parenting stress were assessed by maternal self-report. Interrelated development of parenting with internalizing and externalizing problems was examined using Latent Growth Modeling. Directionality of effects was further investigated by using cross-lagged models. Parenting stress and externalizing problems showed a decrease over time, whereas internalizing problems remained stable. Initial levels of parenting stress were related to initial levels of both internalizing and externalizing problems. Decreases in parenting stress were related to larger decreases in externalizing problems and to the (stable) course of internalizing problems. Some evidence for reciprocity was found such that externalizing problems were associated with parenting stress and vice versa over time, specifically for boys. Our findings support the transactional model in explaining psychopathology.

Intergenerational transmission of drinking motives and how they relate to young adults' alcohol use

AIMS

This study examined whether parental drinking motives are associated with young adults' drinking motives, and their association with young adults' drinking behaviors.

METHODS

The sample consisted of 290 18-year-old and 289 20-year-old drinking young adults and their parents.

RESULTS

For the younger group, stronger maternal coping motives were related to stronger social and enhancement motives, while stronger paternal coping motives were associated with stronger young adult coping motives. For the older group, stronger maternal coping motives were related to stronger social motives and stronger paternal enhancement motives were associated with stronger overall young adult drinking motives. For the younger group, both enhancement and conformity motives were predictive of their alcohol use. For the older group, only higher social motives were predictive of higher alcohol use. Both groups' higher coping and enhancement motives were associated with more drinking problems.

CONCLUSIONS

While, concerning content, there are some differences due to parent gender and adolescent age, stronger parental drinking motives are indeed associated with stronger adolescent drinking motives, which in turn are quite consistently related to more adolescent alcohol use and alcohol-related problems.

The mediating role of alcohol-related memory associations on the relation between perceived parental drinking and the onset of adolescents' alcohol use

AIMS

The aim of the current study was to examine the mediating role of alcohol-related memory associations in the relation between perceived parental drinking and the onset of adolescents' alcohol use. Gender and grade were also included in the analyses.

DESIGN

We tested a mediation model within a structural path modelling framework using longitudinal data (two waves).

SETTING AND PARTICIPANTS

The sample consisted of 608 Canadian adolescents (42.9% boys), who did not have any alcohol experiences at the first measurement. The adolescents were recruited from all grades 7-9 classes in a large school district in western Canada.

MEASUREMENTS

Alcohol-related memory associations were tested with the Word Association Test. We used adolescent self-reports of alcohol use and parental drinking.

FINDINGS

Results clearly showed a mediation effect of alcohol-related memory associations [estimate = 0.023, 95% confidence interval (CI): 0.002-0.044). That is, parental drinking as perceived by the adolescent was related positively to alcohol-related memory associations, which in turn predicted adolescents' alcohol use a year later. Gender and grade were related to alcohol-related memory associations. That is, boys and adolescents of higher grades had more memory associations.

CONCLUSIONS

Children appear to form memory associations related to alcohol before they ever drink alcohol themselves, and these associations appear to mediate the link between their perceptions of their parents' drinking and their own initial alcohol use.

Alcohol-specific parenting, adolescent alcohol use and the mediating effect of adolescent alcohol-related cognitions

OBJECTIVES

Previous research indicated that alcohol-specific parenting is an important precursor of adolescent alcohol use, but failed to define the underlying mechanism. Based on social cognitive theory, alcohol-related cognitions such as alcohol refusal self-efficacy and alcohol-related expectancies were hypothesised to mediate this link.

DESIGN

A cross-sectional survey included 1349 mothers and their sixth grade (11-12 years old) adolescent offspring. Structural equation modelling was employed to test the association between alcohol-specific parenting and adolescent alcohol use, mediated by adolescent alcohol-related cognitions.

MAIN OUTCOME MEASURES

Adolescent alcohol use, drinking refusal self-efficacy and alcohol expectancies.

RESULTS

The associations between frequency of communication, maternal alcohol use and adolescent alcohol use were mediated by negative alcohol-related expectancies. The associations between quality of communication, rules and disclosure and adolescent alcohol use were mediated by self-efficacy.

CONCLUSIONS

The present study provides a first indication that the underlying mechanism of the association between the most important alcohol-specific parenting practices and adolescent alcohol use can be contributed to the mediating effect of alcohol-refusal self-efficacy.

Parental alcohol-specific rules and alcohol use from early adolescence to young adulthood

BACKGROUND

  Several studies stress the importance of alcohol-specific rules during adolescence to prevent them from drinking early and heavily. However, most studies have short follow-up periods and do not cover the relevant developmental period in which direct parental control diminishes and adolescent alcohol use increases. The current study aimed to provide a developmental perspective on the link between alcohol-specific rules and alcohol use from early adolescence until early adulthood in the Netherlands.

METHODS

  The sample consisted of 428 Dutch families including fathers, mothers and adolescents from 2 age groups (13 and 15 years old) at Time 1 (T1), who have been surveyed annually for 6 years. To address the effect of alcohol-specific rules on adolescent alcohol use over time, a latent growth curve analytic approach with time-varying covariates was employed.

RESULTS

  Over time, adolescent alcohol use increased, whereas alcohol-specific rules decreased. Most importantly, however, the lagged paths of alcohol-specific rules consistently predicted subsequent alcohol use across the 6 assessments for both younger and older siblings. Thus, strict alcohol-specific rules at a certain point in time were related to a lower intensity of adolescent alcohol use a year later.

CONCLUSIONS

  Although parents turn somewhat less strict in alcohol-specific rules over time, and adolescent alcohol use increases over time, the specific rules parents set remain important in restraining the alcohol use of their adolescent offspring. Thus, parents should and can feel confident about their parenting capabilities, and they should maintain being strict to prevent their offspring from drinking.

Results of the 'in control: no alcohol!' pilot study

More than 50% of Dutch 12-year olds already started drinking. Since it is known that delaying the onset of alcohol use results in a lower risk of alcohol-related problems, the recently developed 'In control: No alcohol!' prevention program is targeted at elementary school children and their mothers. In this pilot study, the success of program implementation and impact of the program on quality of alcohol-specific communication, rules and monitoring were evaluated, using a randomized controlled design. A total of 108 children (11-12 years) and their mothers participated in the prevention program, while the control group consisted of 105 dyads. Families participating in the experimental condition showed an increase in frequency of alcohol-specific communication and 75% of the dyads reported that they took part in at least 3 of 5 magazines, suggesting implementation was successful. The program led to an increase in quality of communication but only for those dyads in which mothers' alcohol use was above average. The program led parents to set up a non-drinking contract with their children and to monitor their children more closely. Results are promising but need to be replicated in a larger longitudinal study.

Parental alcohol use, alcohol-related problems, and alcohol-specific attitudes, alcohol-specific communication, and adolescent excessive alcohol use and alcohol-related problems: An indirect path model

Alcohol-specific parent-child communication has often been studied in relation to regular alcohol use of adolescents. However, it might be as important to focus on adolescent problematic alcohol use. In addition, the way parents communicate with their children about alcohol might depend on their own (problematic) drinking behaviors. Therefore, the current study examined the direct effects of parental alcohol use, alcohol-related problems, and parental alcohol-specific attitudes on adolescent excessive drinking and alcohol-related problems later in life. It also looked at indirect effects via alcohol-specific communication. The sample consisted of 428 Dutch families including fathers, mothers and adolescents from two age groups (13 and 15 years old) at T1, who have been surveyed annually for 5 years. We tested the model with structural equation modeling (SEM). The results showed that parental alcohol-related problems were positively associated with communication about alcohol, which in turn was related with less excessive adolescent drinking and alcohol-related problems. Lenient parental attitudes about alcohol and parental alcohol-related problems were directly related to more excessive drinking and alcohol-related problems in adolescents. In conclusion, alcohol-specific communication intervenes in the relationship between parental alcohol-related problems and adolescent excessive drinking and alcohol-related problems. This indicates that in family alcohol interventions targeted at youth alcohol use, parental alcohol-related problems should be taken into account.