Feasibility and effectiveness of nurses and clinical officers in implementing the WHO mhGAP intervention guide: Pilot study in Makueni County, Kenya.

OBJECTIVES: (1) To determine the feasibility and effectiveness of nurses and clinical officers in using the mental health Global Action Programme Intervention Guide (mhGAP-IG) as an intervention tool in reducing disability, improving quality of life in the clinical outcomes in patients with the mhGAP-IG priority mental disorders in a Kenyan rural setting. (2) To identify any gaps that can be contributed towards future research. METHODS: This study was conducted in 20 healthcare facilities across Makueni County in the South East of Kenya. This county had a population of approximately one million people, with no psychiatrist or clinical psychologist. We recruited 2306 participants from the healthcare facilities in the catchment areas that had previously been exposed to the community mental health awareness campaigns, while being subjected to screening for the mhGAP-IG disorders. We used the Mini-International Neuropsychiatric Interview for adults (MINI-Plus) for DSM-IV confirmatory diagnosis on those who screened positive on the mhGAP-IG. We measured disability using WHO-Disability Assessment Schedule II (DAS II), Quality of Life (QoL) using the WHO QoL-BREF, depression using Patient Health Questionnaire (PHQ-9), suicidality using The Beck Suicide Scale (BSS), psychosis using the Washington Early Recognition Center Affectivity and Psychosis (WERCAP), epilepsy using a seizure questionnaire and alcohol and substance abuse using The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). These measurements were at the baseline, followed by the training for the health professionals on using the WHO mhGAP-IG as an interventional tool. The measurements were repeated at 3 and 6 months post-intervention. RESULTS: Of the 2306 participants enrolled in the study, we followed 1718 at 3 months and 1371 at 6 months a follow-up rate of 74.5% and 59.4% respectively. All participants received psycho-education and most depending on condition also received medication. Overall, there was significant decline in disabilities, improvement in seizure control and improvement in clinical outcomes on the identified mental disorders. CONCLUSIONS: Trained, supervised and supported nurses and clinical officers can produce good outcomes using the mhGAP-IG for mental health.

Changing patterns of mental health knowledge in rural Kenya after intervention using the WHO mhGAP-Intervention Guide.

BACKGROUND: Despite the high prevalence of mental disorders, mental health literacy has been comparatively neglected. People's symptom-management strategies will be influenced by their mental health literacy. This study sought to determine the feasibility of using the World Health Organization mhGAP-Intervention Guide (IG) as an educational tool for one-on-one contact in a clinical setting to increase literacy on the specified mental disorders. METHODS: This study was conducted in 20 health facilities in Makueni County, southeast Kenya which has one of the poorest economies in Kenya. It has no psychiatrist or clinical psychologist. We recruited 3267 participants from a community that had already been exposed to community mental health services. We used Mental Health Knowledge Schedule to measure the changing patterns of mental health knowledge after a period of 3 months, following a training intervention using the WHO mhGAP-IG. RESULTS: Overall, there was a significant increase in mental health related knowledge [mean range 22.4-23.5 for both post-test and pre-test scores (p < 0.001)]. This increase varied with various socio-demographic characteristics such as sex, marital status, level of education, employment status and wealth index. CONCLUSIONS: mhGAP-IG is a feasible tool to increase mental health literacy in low-resource settings where there are no mental health specialists. Our study lends evidence that the WHO Mental Health Action Plan 2013-2020 and reduction of the treatment gap may be accelerated by the use of mhGAP-IG through improving knowledge about mental illness and potentially subsequent help seeking for early diagnosis and treatment.

Treating severe and enduring anorexia nervosa: a randomized controlled trial.

BACKGROUND: There are no evidence-based treatments for severe and enduring anorexia nervosa (SE-AN). This study evaluated the relative efficacy of cognitive behavioral therapy (CBT-AN) and specialist supportive clinical management (SSCM) for adults with SE-AN. METHOD: Sixty-three participants with a diagnosis of AN, who had at least a 7-year illness history, were treated in a multi-site randomized controlled trial (RCT). During 30 out-patient visits spread over 8 months, they received either CBT-AN or SSCM, both modified for SE-AN. Participants were assessed at baseline, end of treatment (EOT), and at 6- and 12-month post-treatment follow-ups. The main outcome measures were quality of life, mood disorder symptoms and social adjustment. Weight, eating disorder (ED) psychopathology, motivation for change and health-care burden were secondary outcomes. RESULTS: Thirty-one participants were randomized to CBT-AN and 32 to SSCM with a retention rate of 85% achieved at the end of the study. At EOT and follow-up, both groups showed significant improvement. There were no differences between treatment groups at EOT. At the 6-month follow-up, CBT-AN participants had higher scores on the Weissman Social Adjustment Scale (WSAS; p = 0.038) and at 12 months they had lower Eating Disorder Examination (EDE) global scores (p = 0.004) and higher readiness for recovery (p = 0.013) compared to SSCM. CONCLUSIONS: Patients with SE-AN can make meaningful improvements with both therapies. Both treatments were acceptable and high retention rates at follow-up were achieved. Between-group differences at follow-up were consistent with the nature of the treatments given.

The slippery slope: prediction of successful weight maintenance in anorexia nervosa.

BACKGROUND: Previous research has found that many patients with anorexia nervosa (AN) are unable to maintain normal weight after weight restoration. The objective of this study was to identify variables that predicted successful weight maintenance among weight-restored AN patients. METHOD: Ninety-three patients with AN treated at two sites (Toronto and New York) through in-patient or partial hospitalization achieved a minimally normal weight and were then randomly assigned to receive fluoxetine or placebo along with cognitive behavioral therapy (CBT) for 1 year. Clinical, demographic and psychometric variables were assessed after weight restoration prior to randomization and putative predictors of successful weight maintenance at 6 and 12 months were examined. RESULTS: The most powerful predictors of weight maintenance at 6 and 12 months following weight restoration were pre-randomization body mass index (BMI) and the rate of weight loss in the first 28 days following randomization. Higher BMI and lower rate of weight loss were associated with greater likelihood of maintaining a normal BMI at 6 and 12 months. An additional predictor of weight maintenance was site; patients in Toronto fared better than those in New York. CONCLUSIONS: This study found that the best predictors of weight maintenance in weight-restored AN patients over 6 and 12 months were the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately following intensive treatment. These results suggest that outcome might be improved by achieving a higher BMI during structured treatment programs and on preventing weight loss immediately following discharge from such programs.

Toward an understanding of risk factors for anorexia nervosa: a case-control study.

BACKGROUND: Prospective, longitudinal studies of risk factors for anorexia nervosa (AN) are lacking and existing cross-sectional studies are generally narrow in focus and lack methodological rigor. Building on two studies that used the Oxford Risk Factor Interview (RFI) to establish time precedence and comprehensively assess potential risk correlates for AN, the present study advances this line of research and represents the first case-control study of risk factors for AN in the USA. METHOD: The RFI was used for retrospective assessment of a broad range of risk factors, while establishing time precedence. Using a case-control design, 50 women who met DSM-IV criteria for AN were compared to those with non-eating disorder DSM-IV psychiatric disorders (n=50) and those with no psychiatric disorder (n=50). RESULTS: Women with psychiatric disorders reported higher rates of negative affectivity, maternal and paternal parenting problems, family discord, parental mood and substance disorder, and physical and sexual abuse than women with no psychiatric disorder. Women with AN specifically reported greater severity and significantly higher rates of negative affectivity, perfectionism and family discord, and higher parental demands than women with other psychiatric disorders. The role of weight and shape concerns was most salient in the year preceding onset of AN. CONCLUSIONS: Convergent data identifying common risk factors as well as those more severe in the development of AN are emerging to inform longitudinal risk factor and prevention studies for this disorder.

In search of predictors of dropout from inpatient treatment for anorexia nervosa.

OBJECTIVE: The purpose of the present study was to investigate risk factors associated with premature dropout in the treatment of anorexia nervosa (AN). METHOD: Eighty-one women who received free inpatient treatment for AN on a clinical research unit at a university-based psychiatric facility participated in this study. Demographic, lifetime, and baseline clinical characteristics as well as self-report measures of eating disorder symptomatology and associated psychopathology were assessed upon admission. RESULTS: Results indicated that AN subtype was [corrected] modestly predictive of treatment dropout. DISCUSSION: With the exception of AN subtype [corrected], successful completion of inpatient treatment may be unrelated to the severity of eating disorder symptomatology and associated psychopathology. Continued empirical research into factors that influence treatment dropout is clearly needed.

A comparison of black and white women with binge eating disorder.

OBJECTIVE: Binge eating disorder was introduced in DSM-IV as a psychiatric disorder needing further study. This community-based study describes the relationship between race and clinical functioning in black and white women with and without binge eating disorder. METHOD: A group of 150 women with binge eating disorder (52 black, 98 white) and a race-matched group of 150 healthy comparison subjects were recruited from the community. Eating and psychiatric symptoms were assessed through interviews and self-report. RESULTS: Black and white women with binge eating disorder differed significantly on numerous eating disorder features, including binge frequency, restraint, history of other eating disorders, treatment-seeking behavior, and concerns with eating, weight, and shape. Black and white healthy comparison subjects differed significantly in obesity rates. CONCLUSIONS: For both black and white women, binge eating disorder was associated with significant impairment in clinical functioning. Yet, racial differences in clinical presentation underscore the importance of considering race in psychopathology research.

Bias in binge eating disorder: how representative are recruited clinic samples?

The aim of this study was to investigate sampling bias as it affects recruited clinic samples of binge eating disorder (BED). Demographic and clinical characteristics of a recruited clinic sample were compared with a community sample. The 2 groups met the same operational definition of BED and were assessed using the same primarily interview-based methods. Ethnicity, severity of binge eating, and social maladjustment were found to increase treatment seeking among participants with BED rather than levels of psychiatric distress or comorbidity. These findings suggest that previous studies using recruited clinic samples have not biased estimates of psychiatric comorbidity in BED.

Comparison of binge eating disorder and bulimia nervosa in a community sample.

OBJECTIVE: This study examined the relationship between binge eating disorder (BED), a newly proposed eating disorder, and bulimia nervosa (BN). METHOD: Three groups recruited from the community were compared: women with BED (n = 150), women with purging BN (n = 48), and women with nonpurging BN (n = 14). RESULTS: The three groups did not differ significantly in education, weight or shape concern, and current or lifetime prevalence of nine major mental disorders. Women with BED, compared with women with purging BN, were older, less likely to have a history of anorexia nervosa, and less likely to have been treated for an eating disorder. Obesity was more commonly associated with BED than with either subtype of BN. DISCUSSION: Our results lend some support to BED as an eating disorder distinct from purging BN. More research is needed to clarify the position of nonpurging BN relative to BED and purging BN.

Subthreshold binge eating disorder.

OBJECTIVE: To examine the clinical features of subthreshold binge eating disorder (BED). METHOD: Participants were recruited directly from the community as part of an ongoing study of risk factors for BED. Forty-four women with subthreshold BED were compared with 44 women with BED and 44 healthy controls on demographic characteristics, body mass index (BMI), eating disorder symptomatology, and psychiatric distress. Diagnoses were established using the Eating Disorder Examination (EDE). Participants completed the EDE-Questionnaire, the Brief Symptom Inventory, and were measured and weighed. RESULTS: Adjusting for significant group differences in BMI, the two eating disorder groups did not differ significantly on measures of weight and shape concern, restraint, psychiatric distress, and history of seeking treatment for an eating or weight problem. DISCUSSION: Given the importance of diagnostic status for access to treatment, further evaluation of the severity criterion specified for BED is needed.

Recurrent binge eating in black American women.

CONTEXT: Recurrent binge eating is a core diagnostic feature of bulimia nervosa and binge eating disorder, and in samples of white women has been associated with obesity and psychiatric symptoms. Eating disorders have been believed to occur primarily among white women; in fact, the limited preliminary data available suggest that black women may be as likely as white women to report binge eating. OBJECTIVE: To examine race differences in prevalence of behavioral symptoms of eating disorders and clinically significant recurrent binge eating. DESIGN: Community survey. SETTING: General community in Connecticut and Boston, Mass. PARTICIPANTS: A community sample of 1628 black women and 5741 white women (mean age, 29.7 years) participated in a telephone survey designed to ascertain the presence, during the preceding 3 months, of binge eating and extreme weight control behaviors (vomiting, laxative or diuretic abuse, or fasting). MAIN OUTCOME MEASURE: Interviewer-based phone assessment of recurrent binge eating and behavioral symptoms of eating disorders. RESULTS: Black women were as likely as white women to report binge eating or vomiting during the preceding 3 months, and were more likely to report fasting and the abuse of laxatives or diuretics. Recurrent binge eating was more common among black women than among white women. In both race groups, recurrent binge eating was associated with elevated body weight and increased psychiatric symptoms. CONCLUSION: Results suggest that recurrent binge eating is a significant problem among black and white women. Health professionals need to be ready to respond to this health risk behavior.

Natural course of a community sample of women with binge eating disorder.

OBJECTIVE: A community sample of women with binge eating disorder (BED) was followed for a period of 6 months, in order to examine the natural course of the disorder. METHOD: Baseline, 3-, and 6-month assessments were conducted. The following variables were examined: eating disorder symptomatology, importance of weight or shape, psychopathology, social adjustment, childhood sexual abuse, childhood obesity, parental obesity, and parental psychopathology. RESULTS: After the 3-month follow-up, 10 of the original sample of 31 participants dropped out of the study; drop-outs were more likely to have reported a history of sexual abuse. Of the 21 remaining participants, 11 continued to suffer from full-syndrome BED at 6-month follow-up, while the remaining 10 appeared to be in partial remission. There were no significant baseline predictors of outcome. CONCLUSION: It appears that for some women with BED, the eating disorder improves with a decrease in binge eating and importance of weight or shape. For others, the eating disorder symptoms remain constant.

Long-term course of anorexia nervosa: response, relapse, remission, and recovery.

There is no predictable or normative long-term course associated with anorexia nervosa. Some Individuals achieve complete recovery; others are ravaged by a chronic disorder; and some die from it. Predicting course and outcome of anorexia nervosa is complicated by the intrinsic complexity of the disorder; a lack of shared terminology in studying the disorder; and a paucity of controlled clinical treatment studies. This manuscript provides a review of the current state of knowledge based on the long-term studies and discusses ways in which methodological issues limit our ability to generalize more confidently regarding the course and outcome of anorexia nervosa. In order to advance the field, we need to bridge the gap between treatment outcome studies and naturalistic follow-up studies. Further we need to devine more carefully and consistently the milestones of initial treatment response, relapse, remission, and recovery. Building on previous works, criteria for each of these terms are proposed. Based on existing studies, a discussion of treatment outcome and prognostic factors is provided. Finally, clinical recommendations are provided for the clinician who is responsible for the long-term care of an individual with anorexia nervosa.

Inflammatory large bowel disease in immunodeficient rats naturally and experimentally infected with Helicobacter bilis.

Proliferative and ulcerative typhlitis, colitis, and proctitis were found incidentally in a breeding colony of male athymic nude (Cr:NIH-rnu) rats. Within the crypts of the large intestine, modified Steiner's silver stain revealed spiral organisms that were identified by culture, polymerase chain reaction, and sequencing to be Helicobacter bilis. The large bowel disease was reproduced in H. bilis-free male athymic nude rats that were injected intraperitoneally with a culture of H. bilis from the affected colony. The organism was isolated from the feces and cecum of the experimentally infected rats. H. bilis should be considered a potential pathogen in immunocompromised rats. The infection in immunocompromised rats may serve as an animal model for inflammatory large bowel disease.

Medication and psychotherapy in the treatment of bulimia nervosa.

OBJECTIVE: Two treatments for bulimia nervosa have emerged as having established efficacy: cognitive-behavioral therapy and antidepressant medication. This study sought to address 1) how the efficacy of a psychodynamically oriented supportive psychotherapy compared to that of cognitive-behavioral therapy; 2) whether a two-stage medication intervention, in which a second antidepressant (fluoxetine) was employed if the first (desipramine) was either ineffective or poorly tolerated, added to the benefit of psychological treatment; and 3) if the combination of medication and psychological treatment was superior to a course of medication alone. METHOD: A total of 120 women with bulimia nervosa participated in a randomized, placebo-controlled trial. RESULTS: Cognitive-behavioral therapy was superior to supportive psychotherapy in reducing behavioral symptoms of bulimia nervosa (binge eating and vomiting). Patients receiving medication in combination with psychological treatment experienced greater improvement in binge eating and depression than did patients receiving placebo and psychological treatment. In addition, cognitive-behavioral therapy plus medication was superior to medication alone, but supportive psychotherapy plus medication was not. CONCLUSIONS: At present, cognitive-behavioral therapy is the psychological treatment of choice for bulimia nervosa. A two-stage medication intervention using fluoxetine adds modestly to the benefit of psychological treatment.

Eating disturbance and body image: a comparison of a community sample of adult black and white women.

OBJECTIVE: This study examined racial differences in eating disorder symptomatology in a community-based sample of middle-aged adult Black and White women and investigated predictors of body image dissatisfaction in these two different racial groups, since most research has focused on young adult White women. METHOD: Subjects (538 Black and White women) completed the Eating Disorder Inventory and measures of social pressures about thinness and negative attitudes about overweight. RESULTS: Black and White women reported comparable levels of eating disturbance. However, after controlling for degree of overweight, White women had significantly greater rates of body dissatisfaction than Black women. Nonetheless, both racial groups reported considerable body image dissatisfaction and similar factors were found to predict body dissatisfaction for Black and White women. DISCUSSION: Our data and other recent data indicate that eating disturbance occurs across a much broader age, race, and socioeconomic distribution than previously suspected. Research implications are discussed.

Ethnicity and eating disorders: implications for incidence and treatment.

The focus of this article is the role of ethnicity in the development and treatment of eating disorders. We describe briefly the clinical features of the major eating disorders. Using extant data, we discuss the frequency of eating disturbances and eating disorders in the population and specifically among minority groups. Finally, we address the significance of race in the treatment of eating disorders.

Drive for thinness in black and white preadolescent girls.

This study examined racial differences in drive for thinness, a motivational variable implicated in the etiology of eating disorders. Subjects included 613 black and white preadolescent girls from one of three National Heart, Lung, and Blood Institute (NHLBI) Growth and Health Study centers. Instruments included the Drive for Thinness Scale, a Criticism about Weight scale, the Self-Perception Profile for Children, a Sexual Maturation index, and 3-day food diaries. Black girls reported significantly greater drive for thinness than white girls. Drive for thinness was significantly associated with adiposity in both groups; additional predictors included criticism about weight for black girls and dissatisfaction with physical appearance for white girls. Correlations between drive for thinness and nutrient intakes were not significant. The finding of a greater drive for thinness among young black girls is provocative, given the higher prevalence of obesity and the lower prevalence of anorexia nervosa among black women. Longitudinal follow-up will examine the significance of drive for thinness in the development of weight and eating disorders in this cohort.

Diagnostic assay for Helicobacter hepaticus based on nucleotide sequence of its 16S rRNA gene.

Conserved primers were used to PCR amplify 95% of the Helicobacter hepaticus 16S rRNA gene. Its sequence was determined and aligned to those of related bacteria, enabling the selection of primers to highly diverged regions of the 16S rRNA gene and an oligonucleotide probe for the development of a PCR-liquid hybridization assay. This assay was shown to be both sensitive and specific for H. hepaticus 16S rRNA gene sequences.

The relationship between weight and psychological functioning among adolescent girls.

This study investigated whether Body Mass Index (BMI) was associated with various aspects of psychological functioning in a sample of largely Caucasian adolescent girls. Three hundred sixty-five adolescent girls ranging from ages 14 through 19 were assessed for general psychological functioning utilizing the Symptom Checklist-90-Revised (SCL-90-R), and functioning specific to eating, shape and weight utilizing the Eating Disorders Inventory (EDI). Excess weight was associated with higher scores on the Bulimia, Body Dissatisfaction and Drive for Thinness subscales of the EDI. Excess weight was not, however, associated with general psychopathology or any of the subscales of the SCL-90-R. The results suggest that excess weight may carry risk for pathology specifically related to eating, shape and weight in adolescent girls, but not for general forms of psychopathology.