Eric Sigel

A Double-Blind, Placebo-Controlled Study of Risperidone for the Treatment of Adolescents and Young Adults with Anorexia Nervosa: A Pilot Study.

OBJECTIVE The purpose of this double-blind, placebo-controlled exploratory pilot study was to evaluate the safety and efficacy of risperidone for the treatment of anorexia nervosa. METHOD Forty female subjects 12 to 21 years of age (mean, 16 years) with primary anorexia nervosa in an eating disorders program were randomized to receive risperidone (n = 18) or placebo (n = 22). Subjects completed the Eating Disorder Inventory 2, Color-A-Person Test, Body Image Software, and Multidimensional Anxiety Scale for Children at baseline and regular intervals. Weight, laboratory values, and electrocardiograms were monitored. Study medication was started at 0.5 mg daily and titrated upward weekly in 0.5-mg increments to a maximum dose of 4 mg until the subject reached a study endpoint. RESULTS The mean dose for the risperidone group was 2.5 mg and for the placebo group was 3 mg for a mean duration of 9 weeks. Subjects taking risperidone had a significant decrease on the Eating Disorder Inventory 2 Drive for Thinness subscale over the first 7 weeks (effect size, 0.88; p = .002), but this difference was not sustained to the end of the study (p = .13). The Eating Disorder Inventory 2 Interpersonal Distrust subscale decreased significantly more in subjects taking risperidone (effect size, 0.60; p = .03). Subjects taking risperidone had increased prolactin levels (week 7; p = .001). There were no significant differences between groups at baseline or the end of the study for the other rating scales, change in weight, or laboratory measurements. CONCLUSIONS This study does not demonstrate a benefit for the addition of risperidone in adolescents with anorexia nervosa during the weight-restoration phase of care. Clinical trial registration information-A Double-Blind, Placebo-Controlled Study of Risperidone for the Treatment of Anorexia Nervosa, http://www.clinicaltrials.gov, NCT00140426.

Predictors of Outcome at 1 Year in Adolescents With DSM-5 Restrictive Eating Disorders: Report of the National Eating Disorders Quality Improvement Collaborative

PURPOSE The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year. METHODS Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed. RESULTS At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration. CONCLUSIONS The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.

An eleven site national quality improvement evaluation of adolescent medicine-based eating disorder programs: predictors of weight outcomes at one year and risk adjustment analyses.

PURPOSE This quality improvement project collected and analyzed short-term weight gain data for patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED programs nationally. METHODS Data on presentation and treatment of low-weight ED patients aged 9-21 years presenting in 2006 were retrospectively collected from 11 independent ED programs at intake and at 1-year follow-up. Low-weight was defined as < 90% median body weight (MBW) which is specific to age. Treatment components at each program were analyzed. Risk adjustment was performed for weight gain at 1 year for each site, accounting for clinical variables identified as significant in bivariate analyses. RESULTS The sites contained 6-51 patients per site (total N = 267); the mean age was 14.1-17.1 years; duration of illness before intake was 5.7-18.6 months; % MBW at intake was 77.5-83.0; and % MBW at follow-up was 88.8-93.8. In general, 40%-63% of low weight ED subjects reached ≥90% MBW at 1-year follow-up. At intake, patients with higher % MBW (p = .0002) and shorter duration of illness (p = .01) were more likely to be ≥90% MBW at follow-up. Risk-adjusted odds ratios controlled for % MBW and duration of illness were .8 (.5, 1.4)-1.3 (.3, 3.8), with no significant differences among sites. CONCLUSION A total of 11 ED programs successfully compared quality improvement data. Shorter duration of illness before intake and higher % MBW predicted improved weight outcomes at 1 year. After adjusting for risk factors, program outcomes did not differ significantly. All adolescent medicine-based ED programs were effective in assisting patients to gain weight.

Development and psychometric properties of a violence screening tool for primary care.

PURPOSE The aim of this study was to develop and validate a screening tool to detect youth at risk for future violence perpetration for primary care. METHODS Youth (n = 165) aged 11-17 years enrolled during a primary care appointment. Two clinics served as study sites. Youth filled out questionnaires confidentially at baseline and at 1-year follow-up. Primary outcome was violent behavior during the preceding year. At baseline, youth answered 18 risk and protective factor questions that predicted future violence involvement. Additional violence scales were asked for a total of 47 questions. Item analysis determined which combination best predicted future violence involvement. Psychometric properties, including internal consistency, test-retest reliability, convergent validity, and predictive validity, were analyzed. RESULTS A total of 101 youth (61%) completed 1-year follow-up: 16% reported violent behavior with no difference between gender or race/ethnicity. Twenty-five baseline questions correlated with violence involvement 1 year later. After item analysis, 14 questions demonstrated the strongest psychometric functioning with Cronbachs α = .77. External validity was strong, with the 14 item violence injury protection and risk screen correlating with the aggression (.74) and victimization (.54) scales, the Strength and Difficulties Questionnaire (.39), and current violence involvement (.78). For youth aged 14-17 years, predictive validity was strongly correlated (.78) with future violence perpetration. A score of 5.0 for males and 6.0 for females revealed a sensitivity of 77%, a specificity of 98%, and a positive predictive value of 91%. Seventeen percent of youth aged 14-17 screened positive using these cutpoints. CONCLUSION A brief, 14-item questionnaire demonstrated strong psychometric functioning and performed well as a screening tool to predict future violence perpetration for youth aged 14-17.

Primary Care Practitioners’ Detection of Youth Violence Involvement

Background. Youth violence is a widespread public health problem. Despite recommendations to address youth violence by the American Academy of Pediatrics, it is unclear how often primary care practitioners (PCPs) do so. Purpose. To determine PCPs’ documentation of violence involvement. Methods. Children 11 to 17 years old were enrolled while attending a clinic. They completed questionnaires assessing violence involvement confidentially without the knowledge of the PCP. The primary outcome, documented reference to violence involvement, was determined by chart review. Results. A total of 165 youth participated: mean age = 14.5 years (standard deviation = 1.7), 43% male, 46% white. In all, 14.5% of charts documented any violence involvement. Of the 20% of youth who reported serious violence involvement, PCPs documented violence issues 19.4% of the time. Factors associated with documentation included nonwhite race (P < .05), having public (or no) insurance (P < .001), visit type (routine checkup (P < .05), and clinic site (P < .001). Conclusion. PCPs infrequently document discussion of violence-related issues, specifically in youth who are demonstrating risk.

Increasing Documentation and Referral for Youth at Risk for Violence Through the Primary Health Care Setting

Objective. Evaluate the use of a previsit violence risk screen to determine whether screening during routine care increases health care practitioner’s (HCP’s) documentation of violence risk. Methods. Once consented, adolescents filled out the Violence Injury, Protection and Risk Screen Tool (VIPRS). For usual care screen results were not viewed by the HCP. For the intervention screen results were imbedded in the electronic medical record and viewed by the HCP. The primary outcome—documented reference to violence risk—was determined by chart review. Results. Three hundred and fifty-six youth participated. Age was 14.5 years (SD 0.3); 65% female, 45% Hispanic, 38% black. Odds of violence related documentation was 47.4 (P < .001) in the intervention compared with usual care. Those who were positive on the VIPRS had a 10 times greater odds of receiving a violence intervention compared with controls. Conclusions. Previsit screening for violence risk significantly increases HCP’s documentation of violent behavior and referral for intervention.