Attachment security and existential distress among patients with advanced cancer.

BACKGROUND: Felt security in close relationships may affect individual adaptation responses to existential threat in severe illness. We examined the contribution of attachment security to demoralization, a state of existential distress involving perceived pointlessness and meaninglessness in advanced cancer. METHOD: A mixed cross-sectional sample of 382 patients with advanced cancer (mean age 59, 60% female) was recruited from outpatient oncology clinics. Participants completed self-report measures of attachment security, demoralization, depression, and physical symptom burden. We used multiple linear regression to analyze the association between attachment security and demoralization, controlling for demographic factors and symptom burden and tested whether attachment security moderated the association of symptom burden with demoralization. Separate analyses compared the contribution of the dimensions of attachment anxiety and attachment avoidance. RESULTS: The prevalence of clinically relevant demoralization was 35%. Demoralization was associated with lower attachment security (ß = -0.54, 95%CI: -0.62 to 0.46). This effect was empirically stronger for attachment anxiety (ß = 0.52, 95%CI: 0.44 to 0.60) compared to attachment avoidance (ß = 0.36, 95%CI: 0.27 to 0.45). Attachment security also significantly moderated the association of physical symptom burden with demoralization, such that with less attachment security, there was a stronger association between symptom burden and demoralization. CONCLUSION: Attachment security may protect from demoralization in advanced cancer. Its relative lack, particularly on the dimension of attachment anxiety, may limit adaptive capacities to deal with illness burden and to sustain morale and purpose in life. An understanding of individual differences in attachment needs can inform existential interventions for severely ill individuals.

The use of antidepressants in oncology: a review and practical tips for oncologists.

Background: The use of psychotropic drugs, namely those with an antidepressant profile (ADs), is a mandatory part of an integrated treatment of psychiatric disorders among cancer patients. We aimed to synthetize the most relevant data emerging from published studies to provide tips about the use of ADs in oncology. Design: A search was made of the major databases over the last 30 years (Embase/Medline, PsycLIT, PsycINFO, the Cochrane Library), including narrative reviews, systematic reviews and meta-analyses summarizing the results from observational studies and randomized clinical trials assessing effectiveness, safety profile, interactions, contraindications and use of ADs in oncology with regard to both psychiatric (depressive spectrum, stress-related, anxiety disorders) and cancer-related symptoms (e.g. pain, hot flashes and fatigue). Results: The weight of evidence supports the efficacy of ADs for more severe major depression in individuals with cancer and as an adjuvant treatment in cancer-related symptoms, although the methodological limitations of reported randomized controlled trials do not permit definite conclusions. Data also indicate that there should be caution in the use of ADs in cancer patients in terms of their safety profile and potential clinically significant interactions with other prescribed medications. Practical recommendations that have been made for the use of ADs in cancer patients, in the context of a multimodal approach to depression treatment, have been summarized here. Conclusions: ADs are a relatively safe and effective treatment for more severe major depression in cancer patients. However, more research is urgently needed regarding the efficacy of ADs in different cancer types and cancer settings, their interactions with anticancer agents and their additive benefit when integrated with psychosocial interventions.

Preliminary psychometrics of the Existential Distress Scale in patients with advanced cancer.

Existential distress is of clinical concern in patients with terminal illness. Although existential distress has been used to describe a broad spectrum of psychological disturbances, its narrower definition may be confined to distress that arises when the meaning and value of one's life is unclear, and is comorbid with feelings of loneliness and low self-worth. To promote further study, we developed and pilot-tested a 10-item Existential Distress Scale (EDS). Twenty-one patients with advanced cancer were recruited from a palliative care unit. Measures of existential distress, death anxiety, depression, performance status and physical symptom burden were collected. The EDS showed promising psychometric properties, including significant associations with death anxiety and depression. Thirty-eight per cent of the sample reported great or unbearable distress on at least one existential concern. The EDS may be administered to measure existential distress in patients with advanced cancer and clinicians may find the instrument useful to initiate a structured discussion about this symptom.

Impact of early palliative care on caregivers of patients with advanced cancer: cluster randomised trial.

Background: Early palliative care improves the quality of life (QoL) and satisfaction with care of patients with advanced cancer, but little is known about its effect on caregivers. Here, we report outcomes of caregiver satisfaction with care and QoL from a trial of early palliative care. Patients and methods: Twenty-four medical oncology clinics were cluster-randomised, stratified by tumour site (lung, gastrointestinal, genitourinary, breast and gynaecological), to early palliative care team referral, or to standard oncology care with palliative care only as needed. Caregivers of patients with advanced cancer (clinical prognosis of 6-24 months, Eastern Cooperative Oncology Group 0-2) in both trial arms completed validated measures assessing satisfaction with care (FAMCARE-19) and QoL [SF-36v2 Health Survey; Caregiver QoL-Cancer (CQoL-C)], at baseline and monthly for 4 months. We used a multilevel linear random-intercept mixed-effect model to test whether there was improvement in the intervention group relative to the control group over 3 and 4 months. Results: A total of 182 caregivers completed baseline measures (94 intervention, 88 control); 151 caregivers (77 intervention, 74 control) completed at least one follow-up assessment. Satisfaction with care improved in the palliative intervention group compared with controls over 3 months (P = 0.007) and 4 months (P = 0.02). There was no significant improvement in the intervention group compared with controls for CQoL-C (3 months: P = 0.92, 4 months: P = 0.51), Physical Component Summary of the SF-36v2 Health Survey (3 months: P = 0.83, 4 months: P = 0.20), or Mental Component Summary of the SF-36v2 Health Survey (3 months: P = 0.87, 4 months: P = 0.60). Conclusion: Early palliative care increased satisfaction with care in caregivers of patients with advanced cancer. ClinicalTrials.gov identifier: NCT01248624.

The utility of the Edmonton Symptom Assessment System in screening for anxiety and depression.

The Edmonton Symptom Assessment System (ESAS) is a common screening tool in cancer, although its validity for distress screening is unproven. Here, screening performance of the ESAS anxiety (ESAS-A) and depression (ESAS-D) items were validated against the anxiety [Generalised Anxiety Disorder-7 (GAD-7)] and depression [Patient Health Questionnaire-9 (PHQ-9)] subscales of the PHQ. A total of 1215 cancer patients completed the Distress Assessment and Response Tool (DART), a computerised distress screening instrument. Spearman's rank correlation coefficients and receiver operating characteristic curve analyses were used to evaluate the ability of ESAS-A and ESAS-D to identify moderate distress (GAD-7/PHQ-9 ≥ 10). Spearman's rank correlation coefficients comparing ESAS-A and ESAS-D with GAD-7 and PHQ-9 were 0.74 and 0.72 respectively. Areas under the receiver operating characteristic curves were 0.89 and 0.88 for anxiety and depression respectively. A cut-off of ≥3 on ESAS-A demonstrated a sensitivity of 0.91, specificity of 0.68, positive predictive value of 0.34 and negative predictive value of 0.97. A cut-off of ≥2 on the ESAS-D demonstrated a sensitivity of 0.86, specificity of 0.72, positive predictive value of 0.46 and negative predictive value of 0.95. High sensitivities of ESAS-A and ESAS-D at certain cut-offs suggest they have use in ruling-out distress. However, their low specificities indicate secondary screening is needed to rule-in anxiety or depression for case-finding.

Thyroid cancer patients' involvement in adjuvant radioactive iodine treatment decision-making and decision regret: an exploratory study.

PURPOSE: We explored regret in thyroid cancer patients, relating to the decision to accept or reject adjuvant radioactive iodine treatment. METHODS: We studied patients with a recent diagnosis of early stage papillary thyroid carcinoma, in whom treatment decisions on adjuvant radioactive iodine had been finalized. Participants completed a Decision Regret Scale questionnaire. We asked the participants to identify who made the final decision about radioactive iodine treatment. We explored the relationship between decision regret and a) degree of patient involvement in decision-making and b) receipt of radioactive iodine treatment. RESULTS: We included 44 individuals, more than half of whom received adjuvant radioactive iodine treatment (26/44). Decision regret was generally low (mean 22.1, standard deviation [SD] 13.0). Participants reported that the final treatment decision was made by the following: patient and doctor (52.3%, 23/44), completely the patient (27.3%, 12/44), or completely the physician (20.5%, 9/44). Decision regret significantly differed according to who made the final decision: the patient (mean 19.0, SD 11.3), patient and doctor (mean 19.5, SD 7.4), and the doctor (mean 32.9, SD 20.37) (F = 4.569; degrees of freedom = 2, 41; p = 0.016). There was no significant difference in decision regret between patients who received radioactive iodine and those who did not (mean difference -2.5; 95% confidence interval -10.6, 5.6; p = 0.540). CONCLUSION: Thyroid cancer patients who reported being involved in the final treatment decision on adjuvant radioactive iodine had less regret than those who did not.

How can we meet the information needs of patients with early stage papillary thyroid cancer considering radioactive iodine remnant ablation?

In patients with early stage papillary thyroid carcinoma (PTC) who have had a thyroidectomy, the decision must be made to accept or reject radioactive iodine remnant ablation (RRA). Counselling patients about this decision can be challenging, given the medical evidence uncertainties and the complexity of related information. Although physicians are the primary source of medical information for patients considering RRA, some patients have a desire for supplemental information from sources such as the internet. Yet, thyroid cancer resources on the internet are of variable quality, and some may not be applicable to the individual case. We have developed a computerized educational tool [called a decision aid (DA)], directed to patients with early stage papillary thyroid cancer, and intended as an adjunct to physician counselling, to relay evidence-based medical information on disease prognosis and the choice to accept or reject RRA. DAs are tools used to inform patients about available treatment options and have been utilized in oncologic decision-making. We tested our web-based DA in fifty patients with early stage PTC and found that it improved medical knowledge. Furthermore, participants found the technical usability of the tool acceptable. We are currently conducting a randomized controlled trial comparing the use of the DA plus usual care to usual care alone to confirm the educational benefit of the website and examine its impact on the decision-making process. In the future, DAs may play an expanded role as an adjunct to physician counselling in the care of patients with thyroid cancer.

Clinician-patient communication: evidence-based recommendations to guide practice in cancer.

GOALS OF WORK: To develop recommendations for effective communication between cancer health care providers and patients based on a systematic review of methods of clinician-patient communication that may affect patient outcomes associated with distress at critical points in the course of cancer care. MATERIALS AND METHODS: A systematic review of the literature was conducted, and evidence-based recommendations were formulated to guide clinician-patient communication in cancer care. A formal external review was conducted to validate the relevance of these recommendations. MAIN RESULTS: Recommendations for communication in cancer care are presented, based on guidelines from the Australian National Breast Cancer Centre and the Australian National Cancer Control Initiative,an updated systematic review of the research evidence, and a consensus by the Clinician-Patient Communications Working Panel of the Program in Evidence-Based Care of Cancer Care Ontario. The recommendations were sent to 110 Ontario practitioners for external review: 33 responded (30% response rate). Most of these respondents (87%) agreed with the draft recommendations and approved of their use as a practice guideline (90%). A condensed version of the recommendations, including 10 key points, was also created. CONCLUSIONS: There is evidence to support general clinician-patient communication approaches, although the preferences of cancer patients regarding such communication exhibit individual and cultural variability. Recommendations are provided, based on evidence, the consensus of an expert panel, and feedback from a survey of external practitioners. Evidence evaluating the role of decision aids and strategies to facilitate better communication is inconsistent, although such tools may be of value for some patients.

Treatment of depression in cancer patients.

QUESTION: What is the efficacy of pharmacologic and non-pharmacologic treatments for major depression and other depressive disorders in cancer populations? PERSPECTIVES: Depression occurs at an increased rate in medically ill populations, including patients with cancer. In the general population, depression has been shown to be responsive to structured forms of psychotherapy and to pharmacologic interventions. The Supportive Care Guidelines Group conducted a systematic review of the evidence for the effectiveness of those therapies in patients with depression and cancer and developed the present clinical practice guideline based on that review and on expert consensus. OUTCOMES: Outcomes of interest included symptomatic response to treatment, discontinuation rate of treatment, adverse effects, and quality of life. METHODOLOGY: Clinical recommendations were developed by the Supportive Care Guidelines Group based on a systematic review of the published literature through June 2005, feedback obtained from Ontario health care providers on the draft recommendations, the Report Approval Panel (rap) of Cancer Care Ontario's Program in Evidence-Based Care, and expert consensus. RESULTS: The systematic review of the literature included eleven trials (seven of pharmacologic agents and four of non-pharmacologic interventions). Feedback received from 44 responding health care providers and the rap on the draft recommendations was addressed and documented in the guideline. Among providers, 82% agreed with the draft recommendations as stated, 68% agreed that the report should be approved as a practice guideline, and 73% indicated that they would be likely to use the guideline in their own practice. PRACTICE GUIDELINE: These recommendations apply to adult cancer patients with a diagnosis of major depression or other non-bipolar depressive disorders. They do not address the treatment of non-syndromal depressive symptoms, for which specific antidepressant treatment is not usually indicated. The guideline is intended both for oncology health professionals and for mental health professionals engaged in the treatment of cancer patients. Expert consensus was central to the development of the guideline recommendations because of limited evidence in cancer patients. RECOMMENDATIONS: Treatment of pain and other reversible physical symptoms should be instituted before or with initiation of specific antidepressant treatment. Antidepressant medications should be considered for the treatment of moderate-to-severe major depression in cancer patients. Current evidence does not support the relative superiority of one pharmacologic treatment over another, nor the superiority of pharmacologic treatment over psychosocial interventions. The choice of an antidepressant should be informed by individual medication and patient factors: the side effect profiles of the medication, tolerability of treatment (including the potential for interaction with other current medications), response to prior treatment, and patient preference. Cancer patients diagnosed with major depression may benefit from a combined modality approach that includes both psychosocial and pharmacologic interventions. Psychosocial treatment approaches that may be of value include those that provide information and support and those that address any combination of emotional, cognitive, and behavioural factors. QUALIFYING STATEMENTS: Referral to a mental health specialist is appropriate when the diagnosis of depression is unclear, when the syndrome is severe, when patients do not respond to treatment, or when other complicating factors that may affect the choice of treatment are present. Although care has been taken in the preparation of the information contained in this guideline, any person seeking to apply or to consult the guideline is expected to use independent medical judgment in the context of individual clinical circumstances or to seek out the supervision of a qualified clinician.

Natural history and predictors of disturbed eating behaviour in girls with Type 1 diabetes.

AIM: To determine the natural history and psychosocial predictors of disturbed eating behaviour in girls with Type 1 diabetes (T1D) over a 1-year period. METHODS: One hundred and six girls with T1D, 9-13 years of age at Time 1, completed a Children's Eating Disorder Examination (cEDE) interview at Time 1 and again 1 year later (Time 2). Potential Time 1 predictors of Time 2 disturbed eating behaviour were body mass index (BMI), self-esteem, depressive symptoms, attachment to parents, and parental eating attitudes. Glycated haemoglobin (HbA(1c)) was measured. RESULTS: Disturbed eating behaviour was reported by 14% (15/106) of girls at Time 1, and 17% (18/106) at Time 2, and persisted in 8/15 girls over 1 year. Lower self-esteem, higher BMI and more disturbed maternal eating attitudes at Time 1 accounted for 35% of the variance in Time 2 cEDE score, while higher BMI and more disturbed attachment to one's mother predicted new-onset disturbed eating behaviour at Time 2. Glycaemic control was not associated with or predicted by disturbed eating behaviour. CONCLUSIONS: There was only moderate stability in disturbed eating behaviour status over a 1-year period. In this preliminary study, disturbed eating behaviour was associated with and, to a lesser degree, predicted by physical, psychological and family factors. Although the long-term clinical course of the mild disturbances identified is not known, prevention and early intervention efforts in this high-risk medical group should begin in the pre-teen years, and should probably target multiple factors in order to prevent the persistence and worsening of disturbed eating behaviour and its medical sequelae.

Eating disturbances in girls with diabetes: the contribution of adolescent self-concept, maternal weight and shape concerns and mother-daughter relationships.

BACKGROUND: This study examined the relative contribution of adolescent self-concept, maternal weight and shape concerns (WSC), and mother-daughter relationships to eating disturbances among girls with type 1 diabetes mellitus (DM). METHOD: Eighty-eight adolescent girls (mean = 15.0 years, S.D. = 2.2) and their mothers completed self-report measures of disordered eating and weight control behaviours, with teens also reporting on disturbed eating and body attitudes. Based on reported symptoms, adolescents were classified as highly (N = 18), mildly (N = 30) and non-eating disturbed (N = 40). Self-concept was assessed by adolescent self-report. Mother-daughter relationships were assessed by adolescent self-report and by observed mother-daughter interactions that were rated using a macroanalytic coding system that assesses intimacy and autonomy in these relationships. RESULTS: Hierarchical regressions illustrated that adolescent self-concept deficits, maternal WSC, and impaired mother-daughter relationships significantly predicted eating disturbances in girls with DM, accounting for 57% of the variance. Mothers who engaged in dieting and binge-eating were more impaired in their ability to support their daughters' emerging autonomy. The quality of mother-daughter relationships partly mediated the influence of maternal WSC on adolescent eating disturbances. Moreover, the impact of maternal WSC and mother-daughter relationships on eating disturbances was mediated by adolescent self-concept. CONCLUSIONS: Findings illustrate two pathways through which mother-daughter relationships may impact upon risk of eating disturbances in girls with DM and highlight the need to evaluate family-based interventions specifically tailored for this high-risk population.

Disordered eating attitudes and behaviours in teenaged girls: a school-based study.

BACKGROUND: Disordered eating attitudes and behaviours are common in older teens and young women in Western countries. Recent evidence suggests that the prevalence of these disorders is rising and that the age of onset has fallen. In the present study, disturbed eating attitudes and behaviours were evaluated in a large school-based population in Ontario in order to determine their prevalence and demographic distribution. METHODS: Females, aged 12-18 years, from schools in Toronto, Hamilton and Ottawa were invited to complete questionnaires, including 3 subscales of the Eating Disorder Inventory (Drive for Thinness, Body Dissatisfaction, Bulimia), the Eating Attitudes Test-26 (EAT-26) and the Diagnostic Survey for Eating Disorders (DSED). RESULTS: Questionnaires were completed by 1739 (70%) of the 2483 adolescent females who were approached. The mean age of subjects in the sample was 14.6 (standard deviation 1.9) years. Thirteen percent of those aged 12-14 years and 16% of those aged 15-18 years had scores above the recommended cut-off (> or = 20) for disordered eating on the EAT-26. Current dieting to lose weight was reported by 23% of participants. Binge eating with associated loss of control was reported by 15% of participants, self-induced vomiting by 8.2% and the use of diet pills by 2.4%. Laxative and diuretic misuse were uncommon. Dieting was associated with an increased risk of binge-eating and purging behaviours. Older age and body mass index in the highest quartile were independently related to symptoms of eating disorders. INTERPRETATION: Disordered eating attitudes and behaviours were present in over 27% of girls aged 12-18 years and were seen to increase gradually throughout adolescence. Prevention programs to diminish the progression and impact of these disorders should be implemented and assessed.

Physical sequelae and self-perceived attachment in adult survivors of childhood cancer.

The association between the physical sequelae of childhood cancer and self-reported attachment behavior was investigated in 97 adult survivors. Attachment was assessed using standardized self-report questionnaires. Functional disability and cosmetic sequelae of the cancer and its treatment were evaluated by the attending oncologist using a standardized rating scale. Results suggest that attachment is not significantly associated with physician-rated physical sequelae, but may be related to the time of onset of the functional deficits, independent of the current age or age at diagnosis. Further, survivors with functional sequelae in adulthood describe themselves as more insecure in their relationships in general and more ambivalent in their relationship with their parents. These findings, if replicated, suggest that the duration of the functional deficits as well as the developmental stage of the individual when they began may be important variables which affect the survivor's capacity to develop and maintain intimate relationships that are secure and satisfying.

Can assessment of psychosocial orientation assist continuing education program development in psychosocial oncology?

BACKGROUND: A pilot study was designed to aid in the development of a formal, interdisciplinary curriculum in psychosocial oncology for front-line health care professionals. METHOD: A 190-item questionnaire was distributed to psychosocial (PP) and non-psychosocial (NPP) oncology professionals attending a psychosocial skills workshop. A 38-item attitudinal survey of psychosocial orientation was used in an attempt to identify unperceived needs of the learners. RESULTS: Of the 150 questionnaires distributed, 104 (69%) were completed and returned. Overall scores for satisfaction with the workshop were high, and significantly higher in the PP group. No interdisciplinary difference existed in the preferred learning formats for future events, and both groups preferred interactive, experiential forums for developing skills relevant to patient management. The two groups' perceived learning needs differed. NPPs wanted to focus on skills such as communication, counseling, crisis intervention, palliative care, and coping with life-threatening illness. The attitudinal survey results demonstrated a significant difference between the psychosocial orientations of PPs and NPPs and suggested that NPPs would benefit from: 1) information to correct misconceptions about patients' psychosocial needs and experiences, 2) demonstrations of how to overcome contextual barriers to the delivery of psychosocial care. CONCLUSIONS: Front-line oncology professionals in many disciplines are interested in continuing education in psychosocial oncology. The attitudinal survey provided insight into unperceived learning needs that can help in designing future curricula. Its value as a tool to measure impact of these programs is worthy of future study.

Eating problems and the observed quality of mother-daughter interactions among girls with type 1 diabetes.

This study examined how eating problems are linked to autonomy and intimacy in the observed interactions of 88 diabetic girls (M = 14.9 years) and their mothers. On the basis of self-reported symptoms, teens were classified as having no eating problems (n = 40), mild eating problems (n = 30), and frequent eating problems (n = 18). Mothers and daughters participated in 2 videotaped problem-solving tasks (1 diabetes related and I a general parent-teen issue) that were rated with a macroanalytic coding system (Autonomy and Intimacy Rating System). Compared with interactions among mothers and daughters with no eating problems, interactions among mothers and daughters with eating problems simultaneously constrained the expression of autonomy and intimacy. Findings support clinical theory that links eating problems to emotional misattunement in the mother-daughter relationship, which is postulated to interfere with the teen's capacity for individuation.

A province-wide needs assessment of oncology health care professionals in psychosocial oncology.

BACKGROUND: Oncology professionals still lack the knowledge and skills to provide effective psychosocial care. Continuing education (CE) aimed at addressing this lack may improve the provision of psychosocial care to patients and their families. METHODS: The authors conducted a province-wide cross-sectional mail survey of oncology health care professionals [oncologists (MDs), nurses (RNs) and radiation therapists (RTs)] and assessed psychosocial orientation, self-assessed knowledge, and motivation to learn about psychosocial oncology. In addition, they sought factors that might influence professionals' willingness to attend CE programs. RESULTS: In total, 241 surveys were completed and returned. Psychosocial orientation was highest in the RN subgroup. MDs rated their knowledge to deal with specific psychosocial issues higher than did RNs and RTs, while their motivation to learn more about providing psychosocial care was significantly lower. Seventy-three percent of respondents indicated that they would like CE in psychosocial oncology. Self-reported motivation to learn was the most significant factor associated with this interest. CONCLUSION: These findings raise questions about perceived learning needs and aided in the development of an interprofessional curriculum in psychosocial oncology.

Stress, coping, and depression in non-ulcer dyspepsia patients.

Thirty adults with upper gastrointestinal symptoms in the absence of structural organic disease diagnosed with non-ulcer dyspepsia (NUD) were compared to 30 healthy adults who had visited the hepatobiliary clinic for medical evaluation of non-organic complaints without NUD. Medical investigation in both groups were negative. Before independent gastrointestinal physicians conducted diagnostic evaluations, all subjects were evaluated for anxiety and depressive symptoms, stressful life events, coping style, and social support. The measures included Symptom Checklist 90-Revised (SCL-90-R), Beck Depression Inventory (BDI), Spielberger State-Trait Anxiety Inventory (STAI), Ways of Coping Checklist, and Interpersonal Support Evaluation List, and a self-report questionnaire, which measured the quantity of perceived stressful life events. The NUD patients reported significantly more symptoms of depression, more perceived stressful life events, less problem-focused coping, and less social support than the control subjects. Depressive symptoms were negatively correlated with interpersonal support, whereas, problem-focused coping was positively correlated with interpersonal support in the NUD patients. The two groups did not differ significantly in terms of anxiety and emotion-focused coping. The implications of these findings for the diagnosis and treatment of NUD are discussed.

Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study.

OBJECTIVE: To determine the prevalence of eating disorders in adolescent females with type 1 diabetes mellitus compared with that in their non-diabetic peers. DESIGN: Cross sectional case-control led study. SETTING: Diabetes clinics and schools in three Canadian cities. SUBJECTS: 356 females aged 12-19 with type 1 diabetes and 1098 age matched non-diabetic controls. MAIN OUTCOME MEASURE: Eating disorders meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. RESULTS: Eating disorders that met DSM-IV criteria were more prevalent in diabetic subjects (36, 10%) than in non-diabetic controls (49, 4%) (odds ratio 2.4, 95% confidence interval 1.5 to 3.7; P<0.001). Subthreshold eating disorders were also more common in those with diabetes (49, 14%) than in controls (84, 8%) (odds ratio 1.9, 95% confidence interval 1.3 to 2.8; P<0.001). Mean haemoglobin A(1c) concentration was higher in diabetic subjects with an eating disorder (9.4% (1.8)) than in those without (8.6% (1.6)), P=0.04). CONCLUSIONS: DSM-IV and subthreshold eating disorders are almost twice as common in adolescent females with type 1 diabetes as in their non-diabetic peers. In diabetic subjects, eating disorders are associated with insulin omission for weight loss and impaired metabolic control.