Health status, activity limitations, work-related restrictions and level of disability among Canadians with mood and/or anxiety disorders. / État de santé, limitations d'activité, restrictions professionnelles et degré d'invalidité chez les Canadiens atteints d'un trouble de l'humeur ou d'anxiété.

INTRODUCTION: This study provides the first overview of the perceived general and mental health, activity limitations, work-related restrictions and level of disability, as well as factors associated with disability severity, among Canadian adults with mood and/or anxiety disorders, using a population-based household sample. METHODS: We used data from the 2014 Survey on Living with Chronic Diseases in Canada- Mood and Anxiety Disorders Component. The sample consists of Canadians aged 18 years and older with self-reported mood and/or anxiety disorders from the 10 provinces (n = 3361; response rate 68.9%). We conducted descriptive and multinomial multivariate logistic regression analyses. RESULTS: Among Canadian adults with mood and/or anxiety disorders, over one-quarter reported "fair/poor" general (25.3%) and mental (26.1%) health; more than one-third (36.4%) reported one or more activity limitations; half (50.3%) stated a job modification was required to continue working; and more than one-third (36.5%) had severe disability. Those with concurrent mood and anxiety disorders reported poorer outcomes: 56.4% had one or more activity limitations; 65.8% required a job modification and 49.6% were severely disabled. Upon adjusting for individual characteristics, those with mood and/or anxiety disorders who were older, who had a household income in the lowest or lower-middle adequacy quintile or who had concurrent disorders were more likely to have severe disability. CONCLUSION: Findings from this study affirm that mood and/or anxiety disorders, especially concurrent disorders, are associated with negative physical and mental health outcomes. Results support the role of public health policy and programs aimed at improving the lives of people living with these disorders, in particular those with concurrent disorders.

INTRODUCTION: Cette étude fournit, au moyen d'un échantillon de ménages fondé sur la population, le premier aperçu, chez des Canadiens adultes atteints de troubles de l'humeur ou d'anxiété, de leur état de santé globale et de santé mentale perçu, de leurs limitations fonctionnelles, de leurs restrictions professionnelles et de leur degré d'invalidité, ainsi que des facteurs associés à une invalidité grave. MÉTHODOLOGIE: Nous avons obtenu les données de l'Enquête sur les personnes ayant une maladie chronique au Canada ­ Composante des troubles de l'humeur et d'anxiété. L'échantillon est composé de Canadiens âgés de 18 ans et plus, atteints d'un trouble de l'humeur ou d'anxiété autodéclaré et habitant l'une des 10 provinces (n = 3 361; taux de réponse 68,9 %). Nous avons mené des analyses de régression logistiques multidimensionnelles multinomiales et descriptives. RÉSULTATS: Parmi les Canadiens adultes atteints d'un trouble de l'humeur ou d'anxiété, plus d'un quart ont rapporté un état de santé globale (25,3 %) et de santé mentale (26,1 %) « passable ou médiocre ¼, plus du tiers (36,4 %) ont mentionné avoir une ou plusieurs limitations fonctionnelles, la moitié (50,3 %) ont déclaré qu'une modification de leur emploi a été nécessaire pour continuer à travailler et plus du tiers (36,5 %) souffrait d'une invalidité grave. Les personnes avec troubles de l'humeur et d'anxiété concomitants ont mentionné de moins bons résultats : 56,4 % avaient une ou plusieurs limitations fonctionnelles, 65,8 % ont mentionné qu'une modification de leur emploi a été nécessaire et 49,6 % souffraient d'une invalidité grave. Après ajustement pour les caractéristiques individuelles, les personnes atteintes d'un trouble de l'humeur ou d'anxiété qui étaient plus âgées, dont le revenu familial était situé dans le quintile du plus faible revenu ou du revenu faible à moyen ou qui avaient des troubles concomitants étaient plus susceptibles d'avoir une invalidité grave. CONCLUSION: Les résultats de cette étude confirment que les troubles de l'humeur ou d'anxiété, surtout dans le cas de troubles concomitants, sont associés à des résultats en santé physique et mentale négatifs. Ces constats soutiennent les actions en politique et programmes de santé publique qui visent à améliorer la vie des personnes atteintes de ces troubles, surtout celles qui sont atteintes de troubles concomitants.

A controlled study of light therapy for bulimia nervosa.

OBJECTIVE: Winter worsening of mood and eating symptoms, similar to that of seasonal affective disorder, has recently been reported in patients with bulimia nervosa. To assess the effectiveness of light therapy for treatment of bulimia nervosa, the authors conducted a study of light therapy during winter comparing an active (bright white light) condition to a control (dim red light) condition in bulimic patients who were not selected for a seasonal pattern of bulimia. METHOD: After a 2-week baseline assessment, 17 female patients with a DSM-III-R diagnosis of bulimia nervosa underwent early morning light treatment with 2 weeks of bright white light exposure (10,000 lux for 30 min/day) and 2 weeks of dim red light exposure (500 lux for 30 min/day) in a counterbalanced, crossover design. Outcome measures included daily binge/purge diaries, objective and subjective measures of mood, and the Eating Attitudes Test. Expectation of response for each condition was also assessed before treatment. RESULTS: Although pretreatment expectation ratings were similar for each condition, the bright white light condition was superior to the dim red light condition for all mood and eating outcome measures. Patients with "seasonal" bulimia (N = 7) had significantly greater improvement after the bright white light treatment than patients with nonseasonal bulimia (N = 10). No significant order effects were noted, nor differential effects for patients taking concurrent antidepressant medications (N = 4). CONCLUSIONS: These data suggest that bright white light therapy is an effective short-term treatment for both mood and eating disturbances associated with bulimia nervosa, although the therapeutic effect may be greater in those patients with a seasonal pattern.

Sertraline treatment of generalized social phobia: a 20-week, double-blind, placebo-controlled study.

OBJECTIVE: The authors evaluated the efficacy, safety, and tolerability of sertraline, a selective serotonin reuptake inhibitor, in the treatment of generalized social phobia. METHOD: Adult outpatients with generalized social phobia (N=204) from 10 Canadian centers were randomly assigned to receive sertraline or placebo in a 2:1 ratio for a 20-week double-blind study following a 1-week, single-blind, placebo run-in. The initial dose of sertraline was 50 mg/day with increases of 50 mg/day every 3 weeks permitted after the fourth week of treatment (dosing was flexible up to a maximum of 200 mg/day). Primary efficacy assessments were the percentage of patients rated much or very much improved on the Clinical Global Impression (CGI) improvement item and the mean changes from baseline to study endpoint in total score on the social phobia subscale of the Marks Fear Questionnaire and total score on the Brief Social Phobia Scale. RESULTS: In intent-to-treat endpoint analyses of 203 of the patients, significantly more of the 134 patients given sertraline (N=71 [53%]) than of the 69 patients receiving placebo (N=20 [29%]) were considered responders according to their CGI improvement scores at the end of treatment. The mean reductions in the social phobia subscale of the Marks Fear Questionnaire and in the total score on the Brief Social Phobia Scale were 32.6% and 34.3% in the sertraline group and 10.8% and 18.6% in the placebo group, respectively. Analysis of covariance showed superiority of sertraline over placebo on all primary and secondary efficacy measures. Sertraline was well tolerated: 103 (76%) of the 135 sertraline-treated patients and 54 (78%) of the 69 placebo-treated patients completed the study. CONCLUSIONS: Sertraline is an effective treatment for patients with generalized social phobia.

Evening urine cortisol excretion and DST results in depression and anorexia nervosa.

Cortisol determination in a single one-hour urine sample collected between 2200 h and 2300 h has been shown to identify accurately patients with Cushing's disease. To examine the usefulness of this procedure for identifying psychiatric patients with a pituitary-adrenal disturbance, we studied 17 drug-free depressed patients, 6 euthymic anorectic patients and 10 healthy volunteers. We found that there was good agreement between DST results and evening urine cortisol excretion in this sample (when cortisol levels were expressed as ng of cortisol per mg of creatinine), and that adopting as a criterion a urine cortisol value two standard deviations above the mean cortisol value of the controls predicts 74% of the dexamethasone suppression test (DST) results. We would like to suggest that this measure deserves further study as a potentially useful and simple alternative to the DST for identifying psychiatric patients with a pituitary-adrenal disturbance.

Eating attitudes in seasonal affective disorder and bulimia nervosa.

Markedly increased appetite and eating are commonly found in seasonal affective disorder (SAD) and bulimia nervosa (BN). To investigate dysfunctional eating attitudes, we administered the Eating Disorders Inventory (EDI), a self-rating questionnaire that assesses abnormal eating attitudes and behaviours, to 30 female SAD patients, 30 matched BN patients, and 30 non-clinical subjects. The SAD patients had higher scores on most EDI subscales compared to the non-clinical subjects; the BN patients had higher scores than the SAD patients on only two of three EDI subscales that are specific to eating disorders. These data add to the evidence supporting a clinical overlap between SAD and BN.

Dimensional assessment of personality pathology in patients with eating disorders.

This study examined patients with eating disorders on personality pathology using a dimensional method. Female subjects who met DSM-IV diagnostic criteria for eating disorder (n = 136) were evaluated and compared to an age-controlled general population sample (n = 68). We assessed 18 features of personality disorder with the Dimensional Assessment of Personality Pathology - Basic Questionnaire (DAPP-BQ). Factor analysis and cluster analysis were used to derive three clusters of patients. A five-factor solution was obtained with limited intercorrelation between factors. Cluster analysis produced three clusters with the following characteristics: Cluster 1 members (constituting 49.3% of the sample and labelled 'rigid') had higher mean scores on factors denoting compulsivity and interpersonal difficulties; Cluster 2 (18.4% of the sample) showed highest scores in factors denoting psychopathy, neuroticism and impulsive features, and appeared to constitute a borderline psychopathology group; Cluster 3 (32.4% of the sample) was characterized by few differences in personality pathology in comparison to the normal population sample. Cluster membership was associated with DSM-IV diagnosis -- a large proportion of patients with anorexia nervosa were members of Cluster 1. An empirical classification of eating-disordered patients derived from dimensional assessment of personality pathology identified three groups with clinical relevance.

The relationship between stealing and eating disorders: a review.

The literature exploring stealing behavior in individuals with an eating disorder is reviewed. Although epidemiological data are lacking, clinical observations and preliminary studies suggest an association between stealing behavior and eating disorders. Stealing appears to be strongly associated with bulimic symptoms in patients with eating disorders, and the presence of stealing behavior may serve as a marker of eating-disorder severity. The apparent connection between the two problems is discussed, and nine putative explanatory factors are examined: starvation-induced mental dysfunction, effects of medications, affective spectrum disorder, personality disorder, psychodynamic features, dissociative phenomena, tension reduction, pseudopubertal impulsivity, and sociocultural influences. Various combinations of these factors may operate in any particular patient. One of the challenges to our current understanding is the scarcity of information regarding the prevalence and distribution of stealing behavior in the general population. Areas for future research are suggested and include epidemiological surveys to investigate the proposed connection between stealing and eating disorders, examination of the effects of legal intervention, systematic study of the treatment of stealing in patients with eating disorders, and longitudinal studies exploring prognostic implications of stealing behavior.

Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature.

The aim of this paper was to review the existing literature pertaining to stigma, negative attitudes and discrimination towards mental illness, specifically as viewed through the lens of the nursing profession. The results of the literature review were synthesized and analysed, and the major themes drawn from this were found to correspond with Schulze's model identifying three positions that healthcare workers may assume in relation to stigma of mental illness: 'stigmatizers', 'stigmatized' and 'de-stigmatizers'. In this paper, the nursing profession is examined from the perspectives of the first two major themes: the 'stigmatizers' and 'stigmatized'. Their primary sub-themes are identified and discussed: (1) Nurses as 'the stigmatizers': (a) nurses' attitudes in general medical settings towards patients with psychiatric illness and (b) psychiatric nurses; (2) Nurses as 'the stigmatized': (a) nurses who have mental illness and (b) stigma within the profession against psychiatric nurses and/or psychiatry in general. The secondary and tertiary sub-themes are also identified and reviewed.

Evidence-based psychiatry.

OBJECTIVE: To apply the evidence-based medicine paradigm to the domain of psychiatric practice and to bring out the consequences for psychiatry of this approach in order to foster the emergence of an evidence-based psychiatry. METHODS: The basic assumptions of traditional and evidence-based paradigms, as delineated by the Evidence-Based Working Group, are used to structure an exploration of the evidence-based approach to psychiatry. Theoretical and practical issues are considered and an example of evidence-based decision making is given. RESULTS: An evidence-based approach to psychiatry is described as one that emphasizes the importance of systematic observation and the use of rules of evidence in hypothesis testing. It is suggested that psychiatrists using this approach will be in a position to provide superior patient care. DISCUSSION: The application of scientific method to psychiatric problems is discussed as the essence of an evidence-based approach. The common error of "scientism" is described. The authors identify advantages and limitations of an evidence-based approach to psychiatric practice and advocate a decision-making process that balances individualized clinical acumen (phronesis) and information derived from empirical study of groups of patients (techne).

Polyglandular autoimmune syndrome and anorexia nervosa.

The first case of polyglandular autoimmune syndrome (PAS) in a patient with anorexia nervosa is reported. The association of pernicious anemia with vitiligo and endocrine hypofunction (PAS) is reviewed. Eating disorder patients with B12 deficiency who have vitiligo or a history of endocrine hypofunction should have a Schilling test to exclude pernicious anemia.

Randomized trial of measures of body fat versus body weight in the treatment of anorexia nervosa.

OBJECTIVE: To determine whether treatment goals based on body weight or body fat assessed by anthropometrics caused a larger reduction in the Eating Disorder Examination (EDE) over 3 months during the treatment of anorexia nervosa (AN). METHODS: Randomized trial comparing the use of body weight versus measures of body fat by anthropometrics, with the EDE as the outcome measure. Of 23 patients enrolled, 11 subjects who met diagnostic criteria for AN (DSM-IV) and received outpatient treatment from the Eating Disorders clinic of a university teaching hospital completed the study. RESULTS: Comparison of the 2 methods by independent t-tests, verified by Mann-Whitney and Sign tests, suggests no difference (p = 0.33). Due to the small sample size, statistical significance could not be assured. A cross-sectional survey of 48 clinic users found the majority of patients preferred to be followed by skinfold measurements and felt they were more helpful than weight. DISCUSSION: Regardless of which measurement is used, if the clinic staff firmly believe that a method is more helpful and more useful, it is likely that the patients will find it acceptable.

Chest pain in anorexia nervosa.

OBJECTIVE: To determine the incidence and characteristics of chest pain in patients with anorexia nervosa. METHOD: A cross-sectional survey of 54 patients. A pain history according to a diagnostic algorithm that was constructed from a Medline search (1966-1996) was used. RESULTS: Eighty-seven percent of patients had experienced chest pain. The most common diagnosis was idiopathic, occurring in 38% of participants. The incidence of typical and atypical angina was 11% and 9%, respectively. Increasing age, smoking history, and a family history of chest pain were more common in those with the atypical or typical angina. CONCLUSIONS: Chest pain is a common symptom in patients with eating disorders, and the incidence of typical and atypical angina is surprisingly high. All patients with eating disorders should be screened for chest pain and other risk factors for coronary heart disease.

Controlled trial of zinc supplementation in anorexia nervosa.

Zinc supplementation of anorexia nervosa (AN) patients has been reported to increase the weight gain of AN patients in open trials. In this randomized, double-blind, placebo-controlled trial 100 mg of zinc gluconate, or placebo, was given daily to 35 female AN inpatients until they achieved a 10% increase in body mass index (BMI). The rate of increase in BMI of the zinc supplemented group (n = 16) was twice that of the placebo group (n = 19), and this difference was statistically significant (p = .03). The use of zinc supplementation should be considered in the treatment of AN patients.

Anorexia nervosa: refeeding and hypophosphatemia.

A case of anorexia nervosa (AN) is reported where heart failure occurred secondary to severe hypophosphatemia despite oral phosphate supplementation. We recommend starting patients with AN on oral phosphate when refeeding is begun, monitoring serum phosphate every 1 to 2 days for at least the first week of refeeding, and discontinuation of refeeding during phosphate supplementation should severe hypophosphatemia develop.

Seasonality of symptoms in anorexia and bulimia nervosa.

OBJECTIVE: Recent research has suggested that a large proportion of patients with bulimia nervosa have seasonal (winter) worsening of mood symptoms similar to seasonal affective disorder (SAD). The objectives of this study were to determine the specificity of this finding in anorexia and bulimia nervosa, and to further delineate the seasonal mood and eating patterns in bulimia nervosa. METHOD: A modified Seasonal Pattern Assessment Questionnaire (SPAQ) was administered to consecutive female patients assessed at an Eating Disorders Clinic with DSM-III-R diagnoses of bulimia nervosa (BN, N = 60) and anorexia nervosa (AN, N = 31), and to female nonclinical comparison subjects (NC, N = 50). RESULTS: The BN group had higher global seasonality scores and more presumptive diagnoses of SAD than the other two groups; the AN patients, whether they had the restricting or binge eating/purging subtype, did not differ from the NC subjects. Thirty-two percent of the identified seasonal BN patients did not have parallel worsening of mood and eating symptoms in the same season. DISCUSSION: These results suggest that seasonality of symptoms is specific to BN and that there may be separate mechanisms for the seasonality of mood and eating symptoms in some BN patients.

Dietary zinc intake of vegetarian and nonvegetarian patients with anorexia nervosa.

Anorexia nervosa (AN) and zinc deficiency, found most frequently in young females, have a number of symptoms in common. These include weight loss, alterations in taste and appetite, depression, and amenorrhea. Approximately half of anorexia nervosa patients (ANs) are vegetarian (VANs), a practice that may increase their risk for zinc deficiency. This study compared the dietary intake of zinc and related nutrients in 9 outpatient VANs with that of 11 outpatient nonvegetarian patients with anorexia nervosa (NVANs). VANs reported significantly lower (p < .05) dietary intakes of zinc, fat, and protein, and a significantly higher (p < .05) intake of calories from carbohydrates than NVANs. There were no significant differences between the groups in dietary intake of calories, calcium, copper, iron, or magnesium. These findings indicate that zinc intake should be routinely assessed in VANs and that zinc supplementation of their diets may be indicated.

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.

Olfactory identification ability in anorexia nervosa.

OBJECTIVE: The hypothesis tested was that patients with severe eating disorders would demonstrate olfactory identification deficits as a result of zinc deficiency or malnutrition. METHOD: The University of Pennsylvania Smell Identification Test (UPSIT) was administered to 27 hospitalized female patients with anorexia nervosa and 50 normal control female subjects. For a subgroup of patients, serum zinc levels and body mass indices were obtained at pre- and post-nutritional repletion phases. RESULTS: UPSIT scores for patients with eating disorders were equivalent to normal control subjects in spite of the fact that the patients were nutritionally compromised as determined by body mass index. Serum zinc levels were not significantly different at pre- and post-nutritional repletion. CONCLUSIONS: In contrast to patients with schizophrenia, patients with severe eating disorders have intact olfactory function. This finding suggests that transient metabolic or nutritional disturbances alone cannot account for previously reported olfactory deficits.

Comparison of shoplifting behaviours in patients with eating disorders, psychiatric control subjects, and undergraduate control subjects.

Shoplifting behaviours were examined in an eating disorder group (EDG, n = 48), a psychiatric control group (PCG, n = 46), and an undergraduate control group (UCG, n = 82). They were examined in relation to self-esteem, depression, and eating disorder symptomatology. The 3 groups did not differ in overall history of shoplifting, but EDG women were more likely to have shoplifted in the past 6 months (current shoplifting) and to have shoplifted often than were women from the PCG or UCG. Across all 3 groups, current shoplifting was associated with low self-esteem, elevated depression, and purging behaviours at the time of the assessment. The implications of these findings with regard to the relationship between shoplifting and eating disorder symptomatology will be addressed.