Josie Geller

The effect of adherence on the association between depressive symptoms and mortality among HIV-infected individuals first initiating HAART.

Objective:To determine the impact of depressive symptoms on mortality among HIV/AIDS patients first initiating HAART and the potential role of patient adherence as a confounder and effect modifier in this association. Methods:The study comprised HIV-positive individuals who were first prescribed HAART between August 1996 and June 2002. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale. Cox proportional hazards models were used to determine the association between depressive symptoms, adherence and all-cause mortality while controlling for several baseline confounding factors. Results:A total of 563 participants met the study inclusion criteria. Of these subjects, 51% had depressive symptoms at baseline and 23% of participants were less than 95% adherent in the first year of follow-up. The overall all-cause mortality rate was 10%. Multivariate analysis showed that individuals with depressive symptoms and adherence < 95% were 5.90 times (95% confidence interval, 2.55–13.68) more likely to die than adherent patients with no depressive symptoms. The estimated median model-based survival probabilities stratified by adherence and depressive symptoms levels ranged from 81% (interquartile range, 72–89%) for depressive symptoms and adherence < 95% to 97% (interquartile range, 94–98%) for no depressive symptoms and adherence ≥ 95%. Conclusion:The results indicate that both depressive symptoms and adherence were associated with shorter survival among individuals with HIV accessing HAART. Given the high prevalence of depressive symptoms in HIV-positive patients and a strong association with adherence, the findings support improvement in the diagnosis and treatment of depression as well as adherence in order to maximize the effectiveness of HAART.

Inhibited expression of negative emotions and interpersonal orientation in anorexia nervosa.

OBJECTIVE This study examined inhibited expression of negative feelings and interpersonal orientation in women with anorexia nervosa. METHOD Twenty-one women meeting DSM-IV criteria for anorexia nervosa were compared with 21 psychiatric and 21 normal control women matched on education. Two measures were used to assess inhibited expression of negative feelings and interpersonal orientation: the State-Trait Anger Expression Inventory assesses the suppression and expression of anger and the Silencing the Self Scale assesses four cognitive schemas involving the repression of needs and feelings to protect interpersonal relationships. RESULTS Women with anorexia nervosa reported significantly higher scores on the four Silencing the Self schemas and on suppressed anger after controlling for age. These group differences were maintained for two of the cognitive schemas (Care and Silence) after controlling for depression, self-esteem, and global assessment of functioning. Inhibited expression of negative emotion and interpersonal orientation scores were also significantly related to cognitive and affective components of body image dissatisfaction and to trait and self-presentational dimensions of perfectionism. DISCUSSION These findings are reviewed in the context of health psychology, as well as feminist and temperament theories. Implications for treatment are addressed.

Assessing readiness for change in the eating disorders: the psychometric properties of the readiness and motivation interview.

This study examined the psychometric properties of the Readiness and Motivation Interview (RMI), a symptom-specific measure of readiness and motivation for change in the eating disorders. For 4 symptom domains, the RMI assesses the extent to which individuals are in precontemplation, contemplation, and action/maintenance, and the extent to which change is made for internal versus external reasons. Ninety-nine individuals with eating disorders completed the RMI and measures to assess convergent, divergent, and criterion validity. RMI profiles revealed differences in readiness and motivation across symptom domains. The RMI demonstrated good reliability and construct validity, and RMI scores predicted anticipated difficulty of recovery activities, completion of recovery activities, decision to enroll in an intensive symptom-reduction program, and treatment dropout. The RMI may have important clinical applications by providing much-needed information on client readiness for action-oriented treatment.

Readiness to Change Dietary Restriction Predicts Outcomes in the Eating Disorders

This study examined the relationship between readiness and motivation to change eating disorder symptoms and clinical outcomes during and following intensive residential eating disorder treatment. Sixty-four women completed the Readiness and Motivation Interview (RMI) at baseline, and a subset of participants were reassessed at post-treatment (n=45) and at 6month follow-up (n=38). The RMI provides readiness scores for each of four symptom domains: restriction, cognitive, bingeing, and compensatory strategies. RMI scores were used to predict decision to enroll in treatment, dropout, symptom change following treatment, and maintenance of symptom change at six-month follow-up. The extent to which participants did not want to make changes to their dietary restriction at baseline (restriction precontemplation) was the most consistent predictor of short-term clinical outcome. The extent to which participants reported changing their restriction for themselves versus others (restriction internality) predicted outcome at 6-month follow-up. These preliminary findings suggest that assessing client readiness and motivation to change dietary restriction is most useful in predicting short and long-term clinical outcomes.

Shape- and weight-based self-esteem and the eating disorders

OBJECTIVES To determine the psychometric properties of the Shape- and Weight-Based Self-Esteem (SAWBS) Inventory in women with eating disorders, and to compare SAWBS scores in women who have eating disorders with women from psychiatric and normal control groups. METHOD Women with eating disorders (n = 48), women with other psychiatric disorders (n = 44), and undergraduate control women (n = 82) completed the SAWBS Inventory and measures of depression, self-esteem, and eating disorder symptomatology. Twenty women from the eating disorder group completed the SAWBS Inventory a second time 1 week later. RESULTS Similar to previous work in undergraduate samples, SAWBS scores were stable over 1 week, and demonstrated concurrent and discriminant validity in women with eating disorders. In between-group comparisons, SAWBS scores were higher among women with eating disorders than in either control group, even after controlling for age, socioeconomic status, body mass index, and self-esteem. A differing relationship between depression and SAWBS emerged as a function of group; SAWBS scores differed significantly among depressed, but not nondepressed women from the three groups. CONCLUSION The psychometric properties of the SAWBS Inventory were established in women with eating disorders. As expected, SAWBS scores were higher in women with eating disorders than in the control groups. Clinical implications of these findings are discussed.

The role of shape and weight in self-concept : The shape and Weight Based Self-Esteem Inventory

The purpose of this study was to establish the psychometric properties of the Shape and Weight Based Self-Esteem (SAWBS) Inventory, a newly-developed measure of the influence of shape and weight on feelings of self-worth. The results from a nonclinical sample of young women indicated that SAWBS scores were stable over time (N = 24), and correlated moderately with one of two measures of shape and weight schemata (N = 50). In a sample of 84 women, SAWBS scores also correlated moderately with two measures of eating disorder symptomatology, and in regression analyses contributed statistically significant unique variances to both measures of symptomatology, even after the effects of body mass index, depression, and global self-esteem were controlled. Finally, SAWBS scores discriminated between women reporting few or no disturbed eating symptoms and possible/probable eating disorder cases. In sum, the SAWBS Inventory is a reliable and valid measure, and may be a useful tool in the assessment of eating disorders.

Development and multi-site validation of a new condition-specific quality of life measure for eating disorders.

BackgroundIn eating disorders (EDs) treatment, outcome measurement has traditionally focused on symptom reduction rather than functioning or quality of life (QoL). Generic QoL measures lack sensitivity for some diagnoses and many not be responsive in eating disorder patients. This article describes the development and validation of a condition-specific QoL measure for adolescents and adults with eating disorders – the Eating Disorders Quality of Life Scale (EDQLS).MethodsMulti-source and multi-stage methods were used to develop the EDQLS, with participation of patients with EDs, their family members and ED treatment providers. Sources for domain and item development included 39 articles, 12 patient and 10 treatment provider interviews, and 31 first person narratives from the internet. Four stages of validation and pre-testing involving 17 patients, 10 family members and 18 providers reduced 233 items to 40 items in 12 domains. These items were pilot tested in 41 ED patients.ResultsThe final instrument was then validated in a 12 site sample of 171 individuals aged 14–60 with EDs. All items showed good dispersion. The total raw mean score was 110 out of 200 (SD 27.6) with higher scores indicating better QoL. Internal consistency was excellent (Cronbachs alpha = .96) and subscale internal consistency ranged from alpha .36 to .79 providing evidence for a strong overall construct and some multi-dimensionality. Validity was supported by significant differences in mean EDQLS according to severity levels on the EDI-2 (F = 95.3, p <.001) and the BSI (F = 86.9, p <.001). EDQLS scores were positively associated with time in treatment (F = 4.65, p = .01) suggesting responsiveness. A strong positive association was also found between EDQLS scores and stage of change (F = 15.1 p <.001). Pearsons correlations between the EDQLS and criterion instrument scores were .71 for the SF-12 mental subscale, .61 for the QoLI and .78 for the 16D, supporting construct validity. Exploratory principal components and item response theory analyses identified only a few poor fitting items.ConclusionThe EDQLS has promising psychometric characteristics and may be useful for evaluating ED treatment effectiveness.

Maintaining change following eating disorder treatment

Residential eating disorder treatment involves emotional, financial, and time commitments from clients, staff, and the health care system. At discharge, most clients have made substantial nutritional, social, and psychological changes. However, maintaining these changes when intensive support is no longer available represents a significant challenge, and it is common for individuals to slip back into previous eating disorder patterns. Interviews with 32 individuals were conducted 6 months after discharge. Qualitative analyses revealed a pattern of factors that facilitated and hindered recovery. These factors were integrated with past research findings to develop a conceptual model about how changes are maintained. Recommendations regarding ways that health care professionals can assist with the transition from intensive treatment to community living are discussed.

Tracking Readiness and Motivation for Change in Individuals with Eating Disorders Over the Course of Treatment

Ambivalence about recovery is a key aspect of the symptom presentation of individuals with eating disorders and increased attention has focused on understanding readiness for change in this group. This research examined shifts in global and symptom-specific readiness and motivation for change during residential eating disorders treatment. Forty-two participants completed the Readiness and Motivation Interview (RMI) prior to treatment, at week 7, and following the 12–15 week program. Demographic and symptom severity measures were completed at pre and at post. Overall, increases in readiness to change behavioral symptoms occurred prior to increases in readiness to change cognitive symptoms. Shifts in locus of control for change were less pronounced during treatment, and occurred only for the cognitive symptom domain. Subgroup analyses revealed that relative to the other eating disorder diagnostic groups (bulimia nervosa and eating disorder not otherwise specified), readiness for change in individuals with anorexia nervosa shifted less over the course of treatment.

Assessment of shape- and weight-based self-esteem in adolescents

OBJECTIVES The Adolescent version of the Shape and Weight-Based Self-Esteem (SAWBS-A) Inventory provides a contextual measure of the importance of shape and weight to overall feelings of self-worth. The psychometric properties of the adult SAWBS Inventory have been previously established. The present research examined the psychometric properties of this measure in adolescent females, and compared structural aspects of self-concept in symptomatic and nonsymptomatic individuals. METHOD A school sample of 197 adolescents completed the SAWBS-A Inventory and measures to assess concurrent and discriminant validity. A subsample completed the SAWBS-A Inventory a second time, 1 week later. RESULTS SAWBS-A scores were stable over 1 week and correlated with measures of eating disorder symptomatology. The scores also discriminated between adolescents reporting few or no disturbed eating symptoms and possible/probable cases. Comparison of self-esteem profiles in these two groups revealed that in addition to body, the groups differed in the extent to which facial appearance contributed to feelings of self-worth. CONCLUSIONS The SAWBS-A Inventory may be useful in examining structural dimensions of self-esteem in adolescents.