Outcome in patients with eating disorders: a 5-year study.

BACKGROUND: Eating disorders are disabling, unpredictable, and difficult to treat. We did a prospective 5-year investigation of a representative sample of patients with eating disorders. Our aim was to identify predictors of outcome and to assess effects of available treatments. METHODS: We prospectively investigated 95 patients with anorexia nervosa, 88 with bulimia nervosa, and 37 with eating disorders not otherwise specified (EDNOS), who sought treatment in Adelaide, South Australia. We divided patients into those who had, and had not, received treatment in specialist units and reached a safe body weight. Individuals were then further classified dependent on intensity of any treatment received. We assessed clinical symptoms, body-related attitudes, and psychosocial function. FINDINGS: 216 (98%) patients were available for follow-up after 5 years. Three patients with anorexia nervosa and two with EDNOS died. 65 (74%) bulimic, 29 (78%) EDNOS, and 53 (56%) anorexic patients had no diagnosable eating disorder. A small proportion of patients in every group had poor Morgan-Russell-Hayward scores at outcome. Final outcome was predicted by extent and intensity, but not duration, of initial symptoms in patients with anorexia nervosa, and by initial body-related attitudes and impaired psychosocial functioning in bulimia patients. We were unable to predict EDNOS outcome. Treatment did not affect outcome for any group. INTERPRETATION: Deaths in the study confirm the serious nature of eating disorders. However, our results suggest that the efficacy of existing interventions is questionable.

Eating disorders revisited. II: Bulimia nervosa and related syndromes.

Bulimia nervosa and related syndromes are common, and occur in up to 5% of women who attend general practitioners. Young women in First World countries, particularly those who "diet", are at increased risk. Behaviours, such as binge eating and induced vomiting, are typically kept well hidden. Only a minority of those with these disorders present for treatment. General practitioners play a key role in primary and secondary prevention. Effective treatments include psychotherapies that focus on the patient's attitudes and relationships, not just the binge eating behaviour. About 50% of patients make a complete recovery, but the long term outcome is unknown.

Eating disorders revisited. I: Anorexia nervosa.

Anorexia nervosa is a serious psychiatric illness with a high morbidity and a significant lifetime mortality. Recurring themes in such patients centre on issues of self-worth and control. Treatment is difficult and prolonged, and may require hospitalisation. Therapy focuses on altering the misperceptions that patients have of themselves, both psychologically and physically. A multi-disciplinary team based in a specialised unit provides the treatment of choice, but if this is not available, a consistent, supportive relationship with an individual therapist familiar with the condition will be beneficial. Successful outcome should be based not simply on body weight but also on the resolution of anorexic thinking.

Telepsychiatry in South Australia.

Telemedicine has evolved to become an integral part of the South Australian Rural and Remote Mental Health Service. The resulting telemedicine service is one of only a few telepsychiatry services around the world that is firmly embedded in normal clinical practice and can be regarded as sustainable. The telepsychiatry service has been operational in Adelaide since January 1994 and more than 2000 clinical consultations have been performed since that time. In contrast to other telepsychiatry systems internationally, more than 80% of the usage of the South Australian system has been for clinical purposes. The benefits and limitations of telepsychiatry are reviewed, as are factors that have affected the success of the project.

Telepsychiatry: 'tele' yes, but what about the 'psychiatry'?

To investigate what is lost or gained in a psychiatric evaluation when it takes place via telepsychiatry we compared the interrater reliability between two psychiatrists interviewing 63 subjects in an observer/interviewer split configuration in telepsychiatry and same-room settings. The measures used were the BPRS and interviewer ratings from a semi-structured interview. Patients also rated their experience. There were some clear differences between the telepsychiatry and same-room evaluations. Despite these variations, diagnoses were as reliably made by telepsychiatry. Patient acceptance of telepsychiatry was high.

Decision making in clinically depressed patients. A transcultural social psychological study.

One of the most important cognitive deficits in depression is said to be the patient's inability to make decisions. A research design involving a cross-cultural comparison between Australian and Japanese normal controls (N = 309 and N = 743, respectively) and clinically depressed patients (N = 59 and N = 45, respectively) was used to examine the influence of culture on illness and decision-making behavior, and whether deficits in decision making may be related to culture. It was found that depression had a greater effect on decision making in Australian patients than in Japanese patients. While many differences were found between Australian and Japanese nondepressed students, few differences were found between Australian and Japanese depressed patients. Thus, there appears to be an important interactional effect of culture and depression on decision making. The theoretical and clinical implications of the results are discussed.

Problems of subject inclusion in psychiatric research: observations from research with psychiatric inpatients.

In a recent study of psychiatric disturbance and decision making behaviour, it was observed that a significant number of psychiatric inpatients experienced difficulties in addressing themselves to the experimental tasks at hand. Despite the large number of studies that have used psychiatric inpatients as subjects, little, if any mention has been made of these difficulties. The following report describes the difficulties that have been observed in the above research project, and examines their possible implications for clinical assessment, research, and for clinical investigations and evaluation of treatment regimes (e.g. effectiveness of particular drug therapies), which use psychiatric inpatient populations as subject sources.

Sleep difficulties, pain and other correlates.

A multiple regression analysis was used with variables relevant to sleeping problems from a large community health survey in South Australia. The variables that were found to be most strongly correlated with sleep problems were, in order of importance, pain, anxiety, age, somatic health and annual household income, all of which accounted for 22% of the variance. Weight problems, depression and sex of the respondent were not so important in this analysis. Arthritis, which often increases with age, appeared to be most strongly associated with pain, explaining in part why sleeping problems increase with age. Anxiety, pain and poor somatic health were most strongly associated with lying awake at night or sleeping badly, and anxiety and pain were most strongly correlated with taking longer to get to sleep. Poor somatic health and anxiety were most strongly associated with waking early, and age and pain were the most important variables in taking tablets to aid sleep.

The attitude of parents to the use of computer-assisted interviewing in a child psychiatry service.

Before undergoing interview, parents reported that a computer-assisted interview would lack the friendly and personal approach of one conducted by a clinician but, after completing the interview, parents showed more acceptance of the procedure. Computer-assisted interviewing has the potential to play an important role in the collection of clinically relevant information from both parents and children referred to child psychiatry services.

The prevalence of emotional and behaviour disorders and patterns of service utilisation in children and adolescents.

This study compared the prevalence of emotional and behavioural disorders in children attending schools of different socio-economic class. In addition, the study compared the rate of service utilization by children with and without disorders. Using cutoff scores recommended for use with Australian children, the prevalence of disorders in schools of different socio-economic class ranged from 2.3 +/- 2.2 to 13.9 +/- 5.3 per 100 children, with the highest prevalence being found in the lower socio-economic class schools. Although few children with disorders had been seen in a mental health clinic, advice had been sought from other services with regard to 66% of these children. This high rate of service utilization by children with disorders highlights the key role that general practitioners, school guidance officers and hospital services could play in facilitating the early identification and management of children with emotional and behavioural disorders.

Psychobiological aspects of asthma and the consequent research implications.

Recent research suggests that anxiety disorders are more common in asthmatic patients than in the population as a whole. There are a variety of biologic, psychologic, and social factors that suggest that the disorder of asthma may in itself be anxiogenic and that simply having asthma may give patients an increased vulnerability toward the development of anxiety disorders. These issues are reviewed and emphasis is placed on the need for further research into the apparent biologic areas of overlap between psychiatric disorders and asthma. It is hypothesized that a "lactate challenge test" may be used in asthmatics to see if they are predisposed to panic and suggested that a therapeutic trial of tricyclic antidepressants in anxious asthmatics is indicated. Research into the psychobiologic aspects of asthma is likely to clarify the role of "emotional" factors in asthma and may well have significant implications for the management of this disorder.

A factor analytic study of clinical competence in undergraduate psychiatry.

This study used factor analysis to define the components of clinical competence of medical students during their undergraduate psychiatric training. Four factors were defined; factor 1 related to cognitive and psychological problem-solving; factor 2 tapped the interpersonal and observational skills students showed with patients; factor 3 was characterized by knowledge in the examination setting, and factor 4 related to students' capacity to demonstrate their ability in an interpersonal setting. These are similar to the component skills of clinical competence demonstrated by students in other areas of the medical curriculum. They also correspond to the skills which Walton (1986) has suggested should be focused upon in undergraduate psychiatric education.

Early childhood development: a comparative study of beliefs held by adolescents, medical students and mothers.

This study examined beliefs about the normal development of preschool children held by adolescents, medical students and mothers. A consistent pattern was identified, with adolescents estimating that young children can do the least, medical students' estimations lying between those of adolescents and mothers, and mothers estimating that the children can do the most. In addition, medical students were found to change their beliefs during the time that they participated in their paediatric teaching programme. It is suggested that paediatricians and other child health professionals take into account the varying beliefs held by different groups in the community when providing advice or teaching about early child development.

A study of depression in two cultures: a transcultural study with Japanese and Australian clinically depressed patients.

Recently there has emerged a growing interest in transcultural aspects of depressive disorders. Unlike earlier studies, recent research has concentrated on using standardized assessment and evaluation procedures in an effort to reduce "differences" associated with research techniques. The following paper reports a study which, using the WHO developed Standardized Assessment of Depressive Disorders (WHO/SADD) schedule, examines the nature of depressive symptomatology in Australian and Japanese clinically depressed patients. While results supported the presence of a "symptom core" common to both cultures, some unexpected findings in relation to "feelings of guilt" and "severity of depression" were noted.

Prenatal and adult presymptomatic testing for Huntington's disease.

The discovery of a fragment of DNA that is linked closely to the Huntington's-disease autosomal locus offers the opportunity for the presymptomatic diagnosis of this dominantly-inherited neurodegenerative disorder. Presymptomatic testing will present individuals and society with difficult choices and responsibilities. A pilot adult presymptomatic test programme is under way for SA families. Presymptomatic testing requires intensive counselling both before and after the test. A form of prenatal test, which is applicable to a significant proportion of couples with one partner at risk of Huntington's disease, is available also. As this form of prenatal test does not change the risk status of the parent, less extensive counselling is required and testing is available nationally through the SA programme. It is anticipated that other states will develop their own diagnostic programmes in the near future. This article explains the basis for the test, its accuracy and the importance of obtaining DNA from key individuals in pedigrees of Huntington's disease.

Psychological predictors of disease course in rheumatoid arthritis.

A three year prospective study of 30 patients with established rheumatoid arthritis demonstrated that symptoms of depression and anxiety predicted a good outcome whilst externalized hostility predicted a poorer outcome. A multiple regression analysis further showed that patients who denied the emotional significance of their illness faired worse. Psychological variables accounted for 32% of the variance of outcome.