Evaluating the real-world effectiveness of cognitive-behavior therapy efficacy research on eating disorders: a case study from a community-based clinical setting.

OBJECTIVE: There is a growing consensus that there is a need to test the real-world effectiveness of eating disorder therapies that show promise in efficacy research. This article provides a narrative account of an NIMH-funded study that attempted to apply efficacy findings from CBT research to an Intensive Outpatient Program (IOP) at the largest community-based eating disorder program in the United States. METHOD: We describe the study as originally envisioned as well as the various challenges that the researchers and the IOP staff encountered in implementing this study. RESULTS: The different training, assumptions, and "ways of knowing" of the research team and the treatment staff in regard to the nature of eating disorders and their treatment created multiple challenges for both groups during the study period. We describe valuable lessons learned about how to-and how not to-implement effectiveness designs in clinical settings that are relatively unfamiliar with empirically-based research findings. DISCUSSION: It is hoped that our experience in attempting to apply efficacy-based research findings on eating disorders treatment in a community-based clinical setting will prove helpful to other researchers and service providers engaging in such translational research.

Does attrition during follow-up bias outcome data in studies of eating disorders?

Attrition is a pervasive problem in eating disorders research. This study examined whether those who do and do not respond to follow-up assessments differ before or during treatment. Participants (N=268) receiving residential eating disorders treatment were categorized according to those who did ("responders," n=152) and did not ("non-responders," n=116) complete a one-month follow-up assessment. Among participants diagnosed with bulimia nervosa (n=136), responders exhibited significantly higher scores than non-responders at intake on restraint, weight concern, eating concerns, body dissatisfaction, drive for thinness, and depressive symptoms, and had significantly less improvement in eating concerns during treatment. Among participants with anorexia nervosa (n=132), there were no significant differences between responders and non-responders at intake or in treatment improvement. Research on bulimia nervosa treatment based on responders to follow-up assessments may underestimate the amount of improvement that patients experience.

Role of parenting and maltreatment histories in unipolar and bipolar mood disorders: mediation by cognitive vulnerability to depression.

In this article, we review empirical research on the role of individuals' parenting and maltreatment histories as developmental antecedents for symptoms and diagnosable episodes of unipolar and bipolar spectrum disorders. Our review is focused on the following three overarching questions: (1) Do negative parenting and a history of maltreatment contribute risk to symptoms or diagnosable episodes of unipolar and bipolar disorders? (2) Are the associations of negative parenting and maltreatment histories with bipolar disorders similar to those for unipolar depression? and (3) Are the associations between negative parenting and maltreatment histories and unipolar and bipolar symptoms or disorders mediated by cognitive vulnerability to depression? We begin by discussing the methodological requirements for demonstrating a psychosocial risk factor and the methodological issues that plague the parenting and maltreatment literatures. Next, we review the extant studies on the role of parenting histories in unipolar and bipolar disorders. We consider the specificity and possible moderators of the parenting-mood disorder relationship, as well as cognitive vulnerability to depression as a mediator of this relationship. Then, we review studies on the association of maltreatment histories with unipolar and bipolar disorders and the role of cognitive vulnerability to depression as a mediator of this association. We conclude with an assessment of the state of the parenting and maltreatment literatures in unipolar and bipolar disorder with regard to our guiding questions.

The psychosocial context of bipolar disorder: environmental, cognitive, and developmental risk factors.

In this article, we review empirical research on the role of individuals' current environmental contexts, cognitive styles, and developmental histories as risk factors for the onset, course, and expression of bipolar spectrum disorders. Our review is focused on the following over arching question: Do psychosocial factors truly contribute risk to the onset, course, or expression of bipolar disorders? As a secondary issue, we also address whether the psychosocial risks for bipolar disorders are similar to those for unipolar depression. We begin by discussing the methodological requirements for demonstrating a psychosocial risk factor and the challenges posed by bipolar spectrum disorders for psychosocial risk research. Next, we review the extant studies on the role of recent life events and supportive and non-supportive social interactions (current environment) in bipolar disorders, as well as psychosocial treatments designed to remediate these current environmental factors. We then review the role of cognitive styles featured as vulnerabilities in theories of unipolar depression as risk factors for bipolar disorder alone and in combination with life events, including studies of cognitive-behavioral therapies for bipolar disorder. Finally, we review studies of parenting and maltreatment histories in bipolar disorders. We conclude with an assessment of the state of the psychosocial risk factors literature in bipolar disorder with regard to our guiding questions.