Sandra Schlegl

The potential of telemental health applications for obsessive-compulsive disorder

BACKGROUNDnOnly a small percentage of patients with obsessive-compulsive disorder (OCD) receive adequate treatment. Reasons include a high level of shame and stigmatisation and the paucity of specialised treatment services. Telemental health (TMH) treatment could improve the therapeutic situation as has been shown for various mental disorders. This review critically evaluates the current body of evidence on TMH applications for OCD patients. The review focuses on studies that include exposure therapy with response prevention as the best validated treatment component.nnnMETHODSnRelevant publications were identified through computerised searches of the databases PsycINFO and PubMed and manual searches. No date or study type restrictions were applied.nnnRESULTSnTwenty-four studies on different types of TMH applications were identified: bibliotherapy (7), telephone-delivered (11), computer-aided (3), online self-help group (1) and video-conference (2). Nearly all interventions lead to a significant improvement of OC symptoms. Effect sizes ranged from 0.46 to 2.5.nnnCONCLUSIONSnPreliminary evidence suggests that TMH applications represent a low-threshold, efficacious, time-effective and economic treatment for patients with OCD. Future studies are needed to further investigate the potential of TMH treatment to improve health care for patients with OCD.

Specialized inpatient treatment of adult anorexia nervosa: effectiveness and clinical significance of changes

BackgroundPrevious studies have predominantly evaluated the effectiveness of inpatient treatment for anorexia nervosa at the group level. The aim of this study was to evaluate treatment outcomes at an individual level based on the clinical significance of improvement. Patients’ treatment outcomes were classified into four groups: deteriorated, unchanged, reliably improved and clinically significantly improved. Furthermore, the study set out to explore predictors of clinically significant changes in eating disorder psychopathology.MethodsA total of 435 inpatients were assessed at admission and at discharge on the following measures: body-mass-index, eating disorder symptoms, general psychopathology, depression and motivation for change.Results20.0-32.0% of patients showed reliable changes and 34.1-55.3% showed clinically significant changes in the various outcome measures. Between 23.0% and 34.5% remained unchanged and between 1.7% and 3.0% deteriorated. Motivation for change and depressive symptoms were identified as positive predictors of clinically significant changes in eating disorder psychopathology, whereas body dissatisfaction, impulse regulation, social insecurity and education were negative predictors.ConclusionsDespite high rates of reliable and clinically significant changes following intensive inpatient treatment, about one third of anorexia nervosa patients showed no significant response to treatment. Future studies should focus on the identification of non-responders as well as on the development of treatment strategies for these patients.

A comparison of schemas, schema modes and childhood traumas in obsessive-compulsive disorder, chronic pain disorder and eating disorders

Background: In this study, we investigated early maladaptive schemas (EMS), schema modes and childhood traumas in patients suffering from obsessive-compulsive disorder (OCD) in contrast to patients with other Axis I disorders. Based on cognitive theories on OCD, our main research question was whether schemas belonging to the domain of ‘impaired autonomy and performance are more prevalent in OCD than in both eating disorders (ED) and chronic pain disorder (CPD). Sampling and Methods: EMS, schema modes and traumatic childhood experiences were measured in 60 patients with OCD, 41 with ED, 40 with CPD and 142 healthy controls. To analyze differences between the groups, MANCOVAs were conducted followed by deviation contrasts. Depression level, age and gender were considered as possible covariates. Results: OCD patients scored higher on 4 EMS, 2 of which belong to the domain ‘impaired autonomy and performance. ED patients had higher scores in the EMS ‘emotional inhibition and CPD patients on the Childhood Trauma Questionnaire subscale ‘physical neglect. Conclusions: These results suggest that there might be typical schema patterns associated with OCD and ED. We can also conclude that a higher prevalence of traumatic experiences does not necessarily coincide with more EMS and schema modes.

Epidemiologie und Versorgungssituation von Zwangsstörungen

Obsessive-compulsive disorders are with a 12-month prevalence of up to 1% and a lifetime prevalence of 1-2% among the more common mental disorders. This is, however, neither reflected in the health care utilization of patients nor in the daily practice of psychotherapists, where obsessive-compulsive disorders still do not seem to play a major role. Due to feelings of shame, patients often tend to conceal their obsessive-compulsive symptoms. Furthermore, besides deficits in the health care situation for this disorder, treatment practice is not satisfying as well. Current guidelines recommend exposure and response prevention as the psychotherapeutic intervention of choice. Although this treatment has proved to be effective, it is still underutilized in psychotherapeutic routine care.Lack of experience or training on the part of therapists as well as insufficient information about the disorder and treatment possibilities on the part of patients contribute to the existing insufficient and inappropriate health care situation. Further education for therapists as well as more information for patients may help to sensitize them to this disorder and therefore increase the prognosis considerably.ZusammenfassungZwangsstörungen gehören mit einer 12-Monats-Prävalenz von bis zu 1% und einer Lebenszeitprävalenz von 1–2% zu den häufigeren psychischen Störungen. Dies spiegelt sich allerdings weder im Inanspruchnahmeverhalten der Betroffenen noch im therapeutischen Versorgungsalltag wider, in dem die Zwangsstörung nach wie vor nur eine geringe Rolle zu spielen scheint. Aufgrund von Schamgefühlen besteht seitens der Patienten eine hohe Verheimlichungstendenz. Des Weiteren ist neben Defiziten in der psychotherapeutischen Versorgungssituation dieses Störungsbildes auch die Behandlungspraxis gegenwärtig nicht zufriedenstellend. So empfehlen aktuelle Leitlinien als psychotherapeutisches Verfahren der 1.xa0Wahl die Exposition mit Reaktionsverhinderung. Nach wie vor kommt dieses Verfahren in der psychotherapeutischen Routineversorgung nicht adäquat genug zum Einsatz.Mangelnde Erfahrung oder fehlende Ausbildung auf Therapeutenseite sowie unzureichende Informationen über das Störungsbild und Behandlungsmöglichkeiten auf Patientenseite tragen zur bestehenden Unter- und Fehlversorgung bei. Fortbildungs- und Aufklärungsmaßnahmen könnten helfen, für diese Erkrankung zu sensibilisieren und somit die Chancen auf eine langfristige Besserung zu erhöhen.SummaryObsessive-compulsive disorders are with a 12-month prevalence of up to 1% and a lifetime prevalence of 1–2% among the more common mental disorders. This is, however, neither reflected in the health care utilization of patients nor in the daily practice of psychotherapists, where obsessive-compulsive disorders still do not seem to play a major role. Due to feelings of shame, patients often tend to conceal their obsessive-compulsive symptoms. Furthermore, besides deficits in the health care situation for this disorder, treatment practice is not satisfying as well. Current guidelines recommend exposure and response prevention as the psychotherapeutic intervention of choice. Although this treatment has proved to be effective, it is still underutilized in psychotherapeutic routine care.Lack of experience or training on the part of therapists as well as insufficient information about the disorder and treatment possibilities on the part of patients contribute to the existing insufficient and inappropriate health care situation. Further education for therapists as well as more information for patients may help to sensitize them to this disorder and therefore increase the prognosis considerably.

Inpatient Treatment for Adolescents with Anorexia Nervosa: Clinical Significance and Predictors of Treatment Outcome.

This study evaluated the clinical significance as well as predictors of outcome for adolescents with severe anorexia nervosa (AN) treated in an inpatient setting. Body mass index (BMI), eating disorder (ED) symptoms [Eating Disorder Inventory-2 (EDI-2)], general psychopathology and depression were assessed in 238 patients at admission and discharge. BMI increased from 14.8 + 1.2 to 17.3 + 1.4 kg/m(2). Almost a fourth (23.6%) of the patients showed reliable changes, and 44.7% showed clinically significant changes (EDI-2). BMI change did not significantly differ between those with reliable or clinically significant change or no reliable change in EDI-2. Length of stay, depression and body dissatisfaction were negative predictors of a clinically significant change. Inpatient treatment is effective in about two thirds of adolescents with AN and should be considered when outpatient treatment fails. About one third of patients showed significant weight gain, but did not improve regarding overall ED symptomatology. Future studies should focus on treatment strategies for non-responders.

Response und Non-Response in der stationären Psychotherapie depressiver Patienten

ZusammenfassungHintergrund und FragestellungMisserfolge im Sinne von Non-Response psychotherapeutischer Behandlungen wurden bisher kaum systematisch erforscht. Es wird vermutet, dass es bei 25–30% der Patienten zu Misserfolgen und bei 5–10% sogar zu Verschlechterungen kommt.Studiendesign und UntersuchungsmethodenAnhand von Selbsteinschätzungsverfahren und Routinedaten bei Aufnahme und Entlassung [Beck-Depressions-Inventar-II (BDI-II), Brief Symptom Inventory (BSI)] wurde der Therapieerfolg von insgesamt 2323 konsekutiv in stationäre Behandlung aufgenommene Patienten mit depressiven Störungen (F32.0-2, F33.0-2) untersucht. In „Intention-to-treat“(ITT)- und „Completer“-Analysen wurden verschiedene Operationalisierungen von Therapieerfolg (statistische Signifikanz, Effektstärken, klinische Signifikanz) verglichen.ErgebnisseEffektstärken der ITT-Analyse lagen bei 1,59 (BDI-II) bzw. bei 0,86 (BSI) sowie bei 1,64 und 0,89 (Completer-Analyse). Nach den Kriterien der klinischen Signifikanz wurden Response-Raten von 75,5% (BDI-II) bzw. 68,7% (BSI) und Remissionsraten von 62,2% (BDI-II) bzw. 40,8% (BSI) erreicht. Non-Response-Raten, die auch geringe Verbesserungen einschließen, lagen zwischen 23,4% (BDI-II) und 27,4% (BSI); Verschlechterungen traten lediglich bei 1% (BDI-II) bis 3,9% (BSI) der Patienten auf. Die genannten Ergebnisse von Completer-Analysen weisen nur marginale Unterschiede zu Ergebnissen der ITT-Analysen auf.DiskussionEtwa zwei Drittel der depressiven Patienten berichten im Verlauf einer multimodalen stationären, vorrangig psychotherapeutischen Behandlung klinisch signifikante Verbesserungen bezüglich ihrer Primärsymptomatik. Verschlechterungsraten hingegen fielen geringer aus als erwartet. Zur Optimierung der Behandlung erscheint erforderlich, insbesondere Misserfolge bzw. „minor responder“ möglichst frühzeitig im Behandlungsverlauf zu identifizieren.AbstractBackgroundPoor outcome of psychotherapeutic treatment has not yet been sufficiently investigated. It is assumed that approximately 25–30% of patients are treatment non-responders and about 5–10% suffer deterioration.Study design and methodsThe therapeutic success of a total of 2,323 consecutively admitted inpatients with a depressive episode (F32.0-2, F33.0-2) was evaluated by using different strategies based on self ratings at admission and at discharge, i.e. the Beck depression inventory II (BDI-II) and the brief symptom inventory (BSI). In intention to treat (ITT) and completer analyses various measures of therapy success were compared (e.g. statistical significance, effect sizes and clinical significance).ResultsEffect sizes were 1.59 (BDI-II) and 0.86 (BSI) for the ITT sample and 1.64 and 0.89 for the completer sample. Analyses using criteria of clinical significance resulted in response rates of 75.5% (BDI-II) and of 68.7% (BSI) for completer analyses and remission rates of 62.2% (BDI-II) and of 40.8% (BSI). Non-Response rates, also including minor responders, varied between 23.4% (BDI-II) and 27.4% (BSI). Deterioration was observed in only 1% (BDI-II) and 3.9% (BSI) of the patients.DiscussionThe results demonstrate that about two thirds of depressive patients show clinically significant improvements within a multimodal, primarily psychotherapeutic inpatient setting, whereas the rates of deterioration are lower than expected. The aim for the future should be to identify poor or minor response as early as possible in order to optimize treatment.

Weight Suppression But Not Symptom Improvement Predicts Weight Gain During Inpatient Treatment for Bulimia Nervosa: Treatment and weight gain in bulimia nervosa

OBJECTIVEnFear of gaining weight is a common obstacle to seeking treatment for bulimia nervosa (BN). We investigated changes in body mass index (BMI) during inpatient treatment for BN in relation to treatment outcome and weight suppression (WS).nnnMETHODSnFemale inpatients of a specialized eating disorders clinic were grouped as deteriorated/unchanged, reliably improved, and clinically significantly improved based on Eating Disorder Inventory-2 scores. Repeated measures ANOVA was employed to examine changes in BMI between admission and discharge depending on treatment outcome and WS.nnnRESULTSnOne-hundred seventy-nine patients were included. Overall, the average BMI significantly increased by 0.54xa0kg/m2 (SDu2009=u20091.24). Repeated measures ANOVA revealed no association of change in BMI with treatment outcome [F(df)u2009=u20091.13 (2166), pu2009=u20090.327] but with WS [F(df)u2009=u20092.76 (3166), pu2009<u20090.044].nnnDISCUSSIONnBulimia nervosa can be successfully treated without causing excessive weight gain. Patients with higher WS might expect somewhat more weight gain. Copyright

Effectiveness of a multimodal inpatient treatment for adolescents with anorexia nervosa in comparison with adults: an analysis of a specialized inpatient setting

ObjectiveThere is evidence for an increased prevalence and an earlier onset of anorexia nervosa (AN) in adolescents. Early specialized treatment may improve prognosis and decrease the risk of a chronic course. The current study evaluates the effectiveness of a multimodal inpatient treatment for adolescent AN patients treated in a highly specialized eating disorder unit for adults.Method177 adolescents and 1,064 adult patients were included. The evaluation focused on eating behavior, depressive symptoms and general psychopathology.ResultsAll measured variables decreased significantly in both groups during inpatient treatment. No differences were found concerning weight gain, improvement of global eating disorder symptomatology as well as depressive symptoms. However, adults showed a higher psychological distress and in this regard also a greater improvement.ConclusionResults indicate that treating adolescent AN patients in a highly specialized eating disorder unit for adults can be an effective treatment setting for these patients.

[Eating disorders: state of the art research and future challenges].

Eating disorders are a common mental disorder during adolescence and young adulthood. While prevalence rates of eating disorders dramatically increased during the second half of the last century, these rates have remained relatively stable over the last 20 years. According to ICD-10 eating disorders are diagnostically categorized as anorexia nervosa, bulimia nervosa and atypical eating disorders or eating disorders not otherwise specified. Concerning the etiology, genetic factors are involved, especially in anorexia nervosa, as well as psychological and sociocultural factors. Evidence-based recommendations are available for the treatment of bulimia nervosa and binge eating disorder and in this context cognitive behavioral therapy is seen as the first choice. In contrast, the state of knowledge concerning the treatment of anorexia nervosa is still limited, especially concerning effective treatments for adults. Recent data only provide evidence for the effectiveness of family therapy for adolescents. Due to the lack of high quality studies, research on therapy for anorexia nervosa is a future challenge.

Association between depressive symptoms, weight and treatment outcome in a very large anorexia nervosa sample

Eating disorders (ED) are often associated with other mental disorders, most frequently depression [5]. In their review, O’Brian and Vincent [5] cite studies that found rates of about 50 % for a comorbid depression in ED patients. Depression and anxiety in anorexia nervosa (AN) patients are often attributed to the effects of reduced caloric intake. However, studies that address the link between depression and body weight in anorectic patients are contradictory. Kawai et al. [4] did not find an association between BMI and depression in a sample of 24 patients, whereas, e.g., Pollice et al. [6] had investigated 48 AN patients and had found that depressive symptoms were more intense in patients with lower body weight. Calugi et al. [3] found that the presence of a comorbid major depression did not predict treatment outcome in AN. Their sample consisted of 63 patients. Methodological issues, such as different sample compositions and a wide range of different assessment methods complicate the interpretation of findings. In this study, we examined the relation between weight status and depression levels in a very large sample of AN inpatients. Given the existing contradictory evidence, our first research question was whether the degree to which patients were underweight and level of depression were associated. Secondly, we examined whether the level of depression before treatment as well as changes in depressive symptoms, among other possible variables, predicted treatment outcome in AN.