Frances A. Carter

Lifetime comorbidity of alcohol dependence in women with bulimia nervosa

To determine how women with comorbid bulimia nervosa and alcohol dependence differed from those with bulimia nervosa alone, 114 women with DSM-III-R bulimia nervosa were assessed at intake for a randomized clinical trial with structure diagnostic interviews and psychometric instruments. The sample was divided on the basis of the presence (47%) or absence (53%) of lifetime alcohol dependence. Axis I and Axis II disorders, clinical features of bulimia, and personality and temperament characteristics were then compared. Women with comorbid alcohol dependence and bulimia nervosa reported a higher prevalence of suicide attempts, anxiety disorders, other substance dependence, conduct disorder and personality disorders (especially borderline and histrionic), and higher scores on novelty seeking, impulsivity, and immature defenses. There were few differences in the severity of bulimic symptoms. Findings revealed that women with comorbid bulimia nervosa and alcohol dependence bear a greater burden of Axis I and Axis II psychopathology and display greater symptoms of impulsivity and novelty seeking.

The Long-Term Efficacy of Three Psychotherapies for Anorexia Nervosa: A Randomized, Controlled Trial

OBJECTIVE To evaluate the long-term efficacy of three psychotherapies for anorexia nervosa. METHOD Participants were women with broadly defined anorexia nervosa who had participated in a RCT comparing specialized psychotherapies (cognitive behavior therapy, CBT, and interpersonal psychotherapy, IPT) with a control condition (specialist supportive clinical management, SSCM), and attended long-term follow-up assessment (mean 6.7 years ± 1.2). RESULTS Forty three of the original sample of 56 women participated in long-term follow-up assessment (77%). No significant differences were found on any pre-selected primary, secondary or tertiary outcome measures among the three psychotherapies at long-term follow-up assessment. Significantly different patterns of recovery were identified for the psychotherapies across time on the primary global outcome measure. Although SSCM was associated with a more rapid response than IPT, by follow-up all three treatments were indistinguishable. DISCUSSION Potential implications for the timing of interventions to improve treatment response in anorexia nervosa are critically examined.

Cesarean section and postpartum depression: a review of the evidence examining the link.

Objective: The objective of this study was to examine the evidence for an association between cesarean section and postpartum depression. Methods: Medline and PsychInfo databases were searched. All studies on cesarean section that evaluated maternal mood between 10 days and 1 year after delivery were reviewed. Nine methodologically superior studies, including the only randomized, controlled trial (RCT), were analyzed separately. The nine studies that provided adequate summary statistics were combined in a meta-analysis. Results: Of the 24 studies that have examined the association between cesarean section and postpartum depression, five found a significant adverse association, 15 found no significant association, and four found mixed results. With only one exception, methodologically superior studies found either no significant association or mixed evidence for an association between cesarean section and postpartum depression. Meta-analyses of suitable studies failed to find evidence for a significant association between cesarean section and postpartum depression. Possible reasons why different studies have obtained different results are critically evaluated. Conclusion: A link between cesarean section and postpartum depression has not been established. CS = cesarean section; EPDS = Edinburgh Postnatal Depression Scale; PPD = postpartum depression; RCT = randomized, controlled trial.

Screening and treatment for depression during pregnancy: a cautionary note

OBJECTIVE The aim of this study was to evaluate the recruitment and retention of depressed pregnant women, identified initially through screening, to a randomized controlled psychotherapy trial. METHOD Consecutive pregnant women presenting for routine ultrasound scan were asked to complete the Edinburgh Postnatal Depression Scale (EPDS). Women who scored greater than 12 on the EPDS and who agreed to contact were invited to attend an initial assessment to determine eligibility for the trial. Consenting, eligible women were randomized to either cognitive behaviour therapy (CBT) or routine clinical care (RCC). Follow-up assessments were conducted at mid (6 weeks following initial assessment), end (approximately 36 weeks gestation), and postpartum (approximately 4 months postdelivery) for all participants. RESULTS 400 women were offered the EPDS, and 93% completed the questionnaire (370/400). Thirteen percent (49/370) of these women scored greater than 12, although only a minority of these women agreed to be contacted (15/49). Of those who agreed to be contacted, less than half attended initial interview (7/15 attended; 3/15 ineligible; 5/15 declined). Upon interview, all women except for one, were eligible and consenting (6/7). Three women were randomized to CBT and three to RCC. Only one woman randomized to CBT chose to commence treatment, and only one woman randomized to RCC was offered treatment for her low mood by her lead maternity provider. CONCLUSIONS While the vast majority of pregnant women were willing to complete a depression screening questionnaire, most did not agree to additional contact or assessment, and either were not offered treatment or did not accept treatment. This was not an effective recruitment strategy for a randomized controlled psychotherapy trial.

Predictors of rapid and sustained response to cognitive-behavioral therapy for bulimia nervosa

OBJECTIVE To examine characteristics of individuals who show a rapid and sustained response to cognitive-behavioral therapy (CBT) for bulimia nervosa (BN). METHOD As part of a randomized clinical trial designed to dismantle CBT for BN, we compared 19 individuals who exhibited complete abstinence from binging and purging after only eight sessions of CBT and maintained abstinence throughout the duration of treatment and the 1-year follow-up interval, to 79 individuals who had a more variable response to treatment. Demographics, baseline clinical characteristics, lifetime comorbidity, and personality disorder symptoms and profiles from the Temperament and Character Inventory were examined. RESULTS In univariate analyses, frequency of binging and purging at baseline, low scores on the Eating Disorders Inventory (EDI) Bulimia subscale, lower harm avoidance, and higher self-directedness were associated with rapid response. In multiple regression analyses, frequency of binging at baseline (OR = 0.87; 95% CI 0.77-0.98) and self-directedness (OR = 1.12; 95% CI 1.04-1.21) independently predicted rapid and sustained treatment response. CONCLUSION Frequency of binging and the character quality of self-directedness may be useful predictors of those individuals who are likely to respond positively to a brief course of CBT for BN.

The nutrient intake of women with bulimia nervosa

OBJECTIVE The objective of this study was to evaluate the meal patterns and nutrient intake of women with bulimia nervosa (BN), and to compare them to clinical variables and recommended dietary allowances (RDA). METHOD The nutrient intake of 50 women with BN was analyzed from 14 day dietary records. The data were compared to the median intakes of a random sample of women and to the RDA. Clinical variables for the women with BN were also available. RESULTS Compared to nonbinge episodes per day, binge eating was significantly higher in energy from sucrose, fat, saturated fatty acids (SFA), monounsaturated fatty acids (MUFA) and lower in protein. Compared to the population median, binge eating was significantly lower in percent energy from protein, and higher in percent carbohydrate (CHO), sucrose, SFA, and MUFA, while nonbinge eating was significantly lower in percent energy from fat, SFA, and MUFA. Total intakes were significantly higher in energy and percent energy sucrose compared to the population. Despite significantly lower nonbinge energy intake, calcium, vitamins A and C, iron, and folate were not significantly different to the population median. However, one half or more of the subjects had less than two-thirds the RDA for nonbinge calcium, iron, zinc and for total intake one fourth remained less than two-thirds the RDA for iron and zinc. CONCLUSION Nonbinge eating was characterized by low energy intake and by low intake of iron, calcium, and zinc. Binge eating, characterized by high sucrose and SFA content, overcompensated for these low energy intakes. Where treatment reduces or eliminates binge eating, it should also encourage consumption of regular meals and in particular, consumption of foods rich in zinc and iron.

The significance of a prior history of anorexia in bulimia nervosa

OBJECTIVE Some authors stratify women with current, normal-weight bulimia nervosa into groups defined by the presence or absence of a past history of anorexia nervosa. Unlike the distinction between current anorexia nervosa with or without bulimic symptoms, fewer studies have investigated the significance of stratifying bulimic women by a past history of anorexia. METHOD One hundred and fourteen women with bulimia nervosa in a clinical trial were studied via structured clinical interviews covering Axis I and II disorders and measures of personality and symptomatology. Prospective, 14-day dietary analysis was available for a subset of subjects. RESULTS Bulimic women with a past history of anorexia nervosa were significantly more likely to have a lifetime anxiety disorder, lower current body mass index, increased cooperativeness on the Temperament and Character Inventory, and increased mature and neurotic scores on the Defense Style Questionnaire. These women also reported lower scores on the bulimia subscale of the Eating Disorders Inventory, but these self-report data were not consistent with the numbers of objective binges or reported energy intake. The prevalence of other Axis I disorders, Axis II personality disorders, and bulimic symptomatology was quite similar across groups. CONCLUSIONS Although bulimic women with a prior history of anorexia nervosa differed in limited respects from those without such a history, the differences were outweighed by the similarities. A past history of anorexia nervosa did not appear to define particularly meaningful subgroups of women with current, normal-weight bulimia nervosa.

Bipolar II disorder: personality and outcome in two clinical samples

OBJECTIVE To compare the personality traits and disorders of patients with bipolar II disorder and major depression and to examine the impact on treatment outcome of a bipolar II diagnosis. METHOD Patients from two clinical trials, a depressive sample (n = 195, 10% bipolar II) and a bulimic sample (n = 135, 16% bipolar II), were assessed for personality traits using DSM-IV criteria. Patients were randomised to treatments (fluoxetine or nortriptyline for depressive sample; cognitive behaviour therapy for bulimic sample) and followed for 3 years (depressive sample) or 5 years (bulimic sample) to assess the impact on outcome of a bipolar II diagnosis. RESULTS Bipolar II patients were assessed as having more borderline, histrionic and schizotypal personality traits than patients with major depression. A baseline bipolar II diagnosis did not impact negatively on treatment outcome, and less than 5% of bipolar II patients developed bipolar I disorder during follow up. CONCLUSIONS The low rate of conversion of bipolar II to bipolar I disorder and the lack of adverse impact of the diagnosis on outcome, questions the need for antimanic or mood stabiliser medication in most bipolar II patients.

Weight suppression predicts weight gain over treatment but not treatment completion or outcome in bulimia nervosa.

The authors attempted to replicate previous findings that weight suppression is a significant predictor of treatment completion and treatment outcome (M. L. Butryn, M. R. Lowe, D. L. Safer, & W. S. Agras, 2006) and weight gain over treatment (M. R. Lowe, W. Davis, D. Lucks, R. A. Annunziato, & M. L. Butryn, 2006) among women with bulimic disorders. The authors also examined 2 alternative measures of weight variability. Participants were 132 women with bulimia nervosa treated with cognitive-behavioral therapy. Participants who dropped out of treatment did not have significantly higher levels of weight suppression than did treatment completers. Among those who completed treatment, weight suppression did not significantly predict binge eating and purging at post-treatment. Weight suppression did significantly predict weight change and, in particular, weight gain (>/=5 kg) over treatment. Alternative measures of weight variability did not significantly predict treatment completion or treatment outcome, but 1 measure significantly predicted weight gain over treatment. In conclusion, the authors failed to replicate the previous finding that weight suppression predicts treatment compliance and treatment outcome, but they did replicate the finding that weight suppression predicts weight gain over treatment.

Menstrual cycle irregularity in bulimia nervosa Associated factors and changes with treatment

OBJECTIVES This study determined the clinical and nutritional variables associated with menstrual disturbance in women with bulimia nervosa (BN). METHODS Eighty-two women with DSM-IV BN underwent psychiatric, nutritional and menstrual related assessments prior to an outpatient treatment programme and at 12 months follow-up. RESULTS Forty-five percent reported a current irregular menstrual cycle. A high frequency of vomiting, low thyroxine concentrations and low dietary fat intake were independently associated with irregular menses at pretreatment. At 12 months follow-up, 30.5% reported irregular menstrual cycles. A greater difference between past maximum and minimum body weight, smoking and depression were associated with menstrual irregularity at 12 months follow-up. Of those with irregular menstrual cycles at pretreatment, 56.8% became regular at 12 months follow-up. CONCLUSION Menstrual irregularity in BN is associated with indices of nutritional restriction that are not reflected by low body weight or energy intake. Depression, cigarette smoking and fluctuations in body weight may act as metabolic stresses that contribute to the perpetuation of menstrual disturbances.