Mixed messages? Exposure to reports about alcohol's suggested cardiovascular effects and hazardous alcohol use: a cross-sectional study of patients in cardiology care.

BACKGROUND: Hazardous alcohol use is a leading risk factor for disability and death, yet observational studies have also reported reduced cardiovascular disease mortality among regular, low-level drinkers. Such findings are refuted by more recent research, yet have received significant media coverage. We aimed to explore: (1) how patients with cardiovascular diseases access health information about moderate drinking and cardiovascular health; (2) the perceived messages these sources convey, and (3) associations with own level of alcohol use. METHODS: We conducted a cross-sectional survey of patients in cardiology services at three hospitals in Sweden. The study outcome was hazardous alcohol use, assessed using the AUDIT-C questionnaire and defined as ≥ 3 in women and ≥ 4 in men. The exposure was accessing information sources suggesting that moderate alcohol consumption can be good for the heart, as opposed to accessing information that alcohol is bad for the heart. Health information sources were described using descriptive statistics. Gender, age and education were adjusted for in multiple logistic regression analyses. RESULTS: A total of 330 (66.3%) of 498 patients (mean age 70.5 years, 65% males) who had heard that drinking moderately can affect the heart described being exposed to reports that moderate alcohol use can be good for the heart, and 108 (21.7%) met criteria for hazardous alcohol use. Health information sources included newspapers (32.9%), television (29.2%), healthcare staff (13.4%), friends/family (11.8%), social media (8.9%) and websites (3.7%). Participants indicated that most reports (77.9%) conveyed mixed messages about the cardiovascular effects of moderate drinking. Exposure to reports of healthy heart effects, or mixed messages about the cardiovascular effects of alcohol, was associated with increased odds of hazardous alcohol use (OR = 1.67, 95%CI = 1.02-2.74). CONCLUSIONS: This study suggests that many patients in cardiology care access health information about alcohol from media sources, which convey mixed messages about the cardiovascular effects of alcohol. Exposure to reports that moderate drinking has protective cardiovascular effects, or mixed messages about the cardiovascular effects of alcohol, was associated with increased odds of hazardous alcohol use. Findings highlight a need for clear and consistent messages about the health effects of alcohol.

Feasibility of alcohol interventions in cardiology: A qualitative study of clinician perspectives in Sweden.

AIM: To identify barriers and facilitators to implementing alcohol screening and brief interventions (SBI) in cardiology services. METHODS AND RESULTS: Qualitative study. Individual, semi-structured interviews were conducted with 24 clinical cardiology staff (doctors, nurses, assistant nurses) of varying experience levels, and from various clinical settings (high dependency unit, ward, outpatient clinic), in three regions of Sweden. Reflexive thematic analysis was used, with deductive coding applying the Capability, Opportunity, Motivation (COM-B) theoretical framework. A total of 41 barriers and facilitators were identified, including twelve related to capability, nine to opportunity, and 20 to motivation. Four themes were developed: 1. Uncharted territory, where clinicians expressed a need to address alcohol use but lacked knowledge and a roadmap for implementing SBI; 2. Cardiology as a cardiovascular specialty, where tasks were prioritized according to established roles; 3. Alcohol stigma, where alcohol was reported to be a sensitive topic that staff avoid discussing with patients; 4. Window of opportunity, where staff expressed potential for implementing SBI in routine cardiology care. CONCLUSION: Findings suggest that opportunities exist for early identification and follow-up of hazardous alcohol use within routine cardiology care. Several barriers, including low knowledge, stigma, a lack of ownership, and a greater focus on other risk factors must be addressed prior to the implementation of SBI in cardiology. To meet current clinical guidelines, there is a need to increase awareness and to improve pathways to addiction care. In addition, there may be a need for clinicians dedicated to alcohol interventions within cardiology services. REGISTRATION: OSF (osf.io/hx3ts).

Study protocol for the 'preventing functional decline in acutely hospitalised older patients (PREV_FUNC)' study: effects of two multicomponent exercise programmes on physical function - a three-armed randomised controlled trial.

INTRODUCTION: Acutely hospitalised older patients often live with frailty and have an increased risk of impaired physical function. Previous studies suggest that exercise might mitigate the risk of physical impairment; however, further research is needed to compare the effect of different types of exercise interventions. In this paper, we report a protocol for a trial that aims to examine (1) if multicomponent exercise interventions (interventions that include both mobility and strengthening exercises) have effects on physical function compared with usual care in older adults and (2) if a comprehensive multicomponent exercise programme is more effective than a simple multicomponent exercise programme that only include walking and sit-to-stand exercises. METHODS AND ANALYSIS: This is a three-armed randomised controlled trial, with two intervention groups (comprehensive and simple exercise programme) and a control group receiving usual care. We will include 320 participants aged ≥75 years from geriatric medical departments of four hospitals in Stockholm, Sweden. Assessments will be conducted at hospital admission, discharge and 3 months thereafter concerning physical function (primary outcome), activities of daily living, health-related quality of life, sarcopenia and falls. The number of readmissions will be registered up to 1 year after discharge. Data will be analysed with linear mixed effects models, according to the intention-to-treat approach. ETHICS AND DISSEMINATION: Ethical approval for this trial has been granted by the Swedish Ethical Review Authority (approval number 2022-03032-01). Data collection will consider the information requirement, the requirement of consent, confidentiality obligations and the utilisation requirement. Trial findings will be disseminated through multiple channels, including scientific publications and conferences, and workshops with healthcare professionals and the public. TRIAL REGISTRATION NUMBER: NCT05366075.

Internet-based cognitive behavioral therapy for bulimic eating disorders in a clinical setting: Results from a randomized trial with one-year follow-up.

Background: Those who suffer from eating disorders often experience serious impairment in quality of life and the majority never receive treatment. Treatment availability may be increased by implementing methods that demand less resources and are more easy accessible such as internet-based treatments, but knowledge about their effects is still insufficient. The study evaluated effects of two types of internet-based cognitive behavioral therapy and a structured day patient program, the latter being a standard treatment at an eating disorder clinic at the time for the study. Methods: 150 participants with bulimic eating disorders randomized to two types of internet based treatments (one pure online treatment and one based on a self-help guide in book-format) or an intensive 16-week day patient program. The number of participants that started treatment was 120 of which 98 in internet treatment and 22 in the day program. Outcome assessments were carried out at baseline, post treatment, and at one-year follow-up. Results: All treatments were associated with significantly improved eating disorder pathology, self-image, and clinical impairment. Although the day program generally showed larger effects, only one significant difference found was in diagnostic remission post treatment; 51 % of the participant was in remission in internet treatment and 88 % in the day program. At one-year follow-up, participants in the internet treatments had continued to improve, whereas in the day patient program the effect sustained. Internet treatment had a 36 % drop out rate, there were no dropouts found in the day program. Conclusions: All treatments were comparable in effect at follow-up, suggesting that internet treatment is a conceivable alternative to standard treatment. Internet treatment in a book-based format was also equally effective as a pure online format. Internet delivered cognitive behavioral treatment forms can make important contributions to achieve increased access to treatment for patients with bulimic eating disorders. Future research and clinical implications for internet delivered treatments in eating disorder services are discussed. Clinical trial registration: ISRCTN registry https://www.isrctn.com/ISRCTN44999017. The study was registered retrospectively.

Initial self-blame predicts eating disorder remission after 9 years.

BACKGROUND: Research into predictors of outcome in eating disorders (ED) has shown conflicting results, with few studies of long-term predictors and the possible importance of psychological variables that may act as risk- and maintenance factors. AIM: To identify baseline predictors of ED remission nine years after initial clinical assessment using self-report measures of ED psychopathology, psychiatric symptoms, and self-image in a sample of adult ED patients (N = 104) treated at specialist units in Stockholm, Sweden. Sixty patients participated in the follow-up, of whom 41 patients (68%) had achieved remission. RESULTS: Results suggested that the only significant predictor of diagnostic remission after nine years was initial levels of self-blame. CONCLUSION: In order to ensure long-term recovery in ED it may be important for clinicians to widen their therapeutic repertoire and utilise techniques that reduce self-blame and increase self-compassion. It is difficult to predict how an eating disorder will develop, and research has found varying factors that affect the outcome of the condition. Recovery rates vary from nearly nil to over 90%. This variation could be explained by different research factors, but are more likely due to varying definitions of 'recovery', with less stringent definitions yielding high recovery rates and more stringent definitions yielding lower rates. The present study investigated whether the severity of eating disorder symptoms and other psychiatric symptoms could predict recovery nine years from first admission to specialised eating disorder care. Sixty patients at three eating disorder treatment units participated, and their scores on self-report measures of symptoms were used as predictor variables. Forty-one participants had no eating disorder diagnosis at nine-year follow-up. Most participants with binge-eating disorder had recovered, while the poorest outcome was found for anorexia nervosa with slightly over half of patients recovered after nine years. The only predictor for the nine-year outcome was a higher initial rating of self-blame, measured with the Structural Analysis of the Social Behavior. It was concluded that it may be important for clinicians to detect and address self-blame early in the treatment of eating disorders in order to enhance the possibility of recovery. Treatment should focus on reducing self-blame and increasing self-acceptance.

Diagnostic validity of the MINI-KID disorder classifications in specialized child and adolescent psychiatric outpatient clinics in Sweden.

BACKGROUND: Missing diagnostic information often results poor accuracy of the clinical diagnostic decision process. The Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) is a short standardized diagnostic interview and covers a rather broad range of diagnoses applicable to children and adolescents. MINI-KID disorder classifications have shown test-retest reliability and validity comparable to other standardized diagnostic interviews and is claimed to be a useful tool for diagnostic screening in Child and Adolescent Psychiatric care. The concordance between the Swedish language version of the MINI-KID Interview and LEAD (Longitudinal, Expert, All Data) research diagnoses was studied in secondary child and adolescent psychiatric outpatient care. METHODS: MINI-KID interviews were performed for 101 patients, boys n = 50, girls n = 51, aged 4 to 18 years. The duration of the interview was on average 46 min, the child/adolescent participating together with the parent(s) in most cases. The seven most prevalent diagnoses were included in the analyses. RESULTS: The average overall percent agreement (OPA) between MINI-KID and LEAD was 79.5%, the average percent positive agreement (PPA) 35.4 and the average percent negative agreement (NPA) 92.7. OPA was highest for Obsessive-Compulsive Disorder (OCD) (0.89), Tic disorders (0.88) and Pervasive developmental disorders (0.81). There were similar results in diagnostic agreement comparing the two versions: the standard MINI-KID and MINI-KID for parents. The specific screening questions in MINI-KID resulted in additional preliminary diagnoses compared with the regular initial clinical assessment. CONCLUSIONS: Overall, there was an acceptable agreement between MINI-KID disorder classifications and research diagnoses according to LEAD. The standardized interview MINI-KID could be considered as a tool with the possibility to give valuable information in the diagnostic process in child and adolescent care which is similar to the setting in the present study.

Personality predicts drop-out from therapist-guided internet-based cognitive behavioural therapy for eating disorders. Results from a randomized controlled trial.

Internet-based guided self-help cognitive behavioural therapy (ICBT) seems a promising way of delivering eating disorder treatment. However, treatment drop-out is a common problem and little is known about the correlates, especially in clinical settings. The study aimed to explore prediction of drop-out in the context of a randomized controlled trial within specialized eating disorder care in terms of eating disorder symptomatology, personality traits, comorbidity, and demographic characteristics. 109 outpatients diagnosed with bulimia nervosa or similar eating disorder were randomized to two types of ICBT. Participants were assessed with several clinical- and self-ratings. The average drop-out rate was 36%. Drop-out was predicted by lower scores in the personality traits Dutifulness and Assertiveness as measured by the NEO Personality Inventory Revised, and by higher scores in Self-affirm as measured by the Structural Analysis of Social Behaviour. Drop-out was also predicted by therapist factors: one therapist had significantly more drop-outs (82%) than the other three (M = 30%). Theoretical and clinical implications of the impact of the predictors are discussed.

How effective is bibliotherapy-based self-help cognitive behavioral therapy with Internet support in clinical settings? Results from a pilot study.

Cognitive behavioral therapy-based guided self-help (CBT-GSH) via the Internet has been shown to be effective in the treatment of bulimia nervosa (BN) and similar eating disorders (EDs), but it is rarely offered, and little is known about the effects, in clinical settings. The present study investigated the effects of a bibliotherapy-based CBT-GSH with Internet support in a clinical setting. Participants were 48 adult outpatients who were recruited without randomization from a specialized ED clinic, diagnosed with BN or similar eating disorder. Forty-eight patients in an intensive day patient program (DPP) were used as comparison group. The Eating Disorder Examination Questionnaire (EDE-Q) and the Eating Disorder Inventory 2 measured pre- and post treatment symptoms. Results showed that both groups attained significant improvements in core- as well as related ED symptoms in both instruments. As expected, treatment effects were larger in the more intensive DPP. Nonetheless, bibliotherapy CBT-GSH appears to be a cost-effective treatment that represents a new way to provide more CBT in clinical settings.

Quality assurance of specialised treatment of eating disorders using large-scale Internet-based collection systems: methods, results and lessons learned from designing the Stepwise database.

Computer-based quality assurance of specialist eating disorder (ED) care is a possible way of meeting demands for evaluating the real-life effectiveness of treatment, in a large-scale, cost-effective and highly structured way. The Internet-based Stepwise system combines clinical utility for patients and practitioners, and provides research-quality naturalistic data. Stepwise was designed to capture relevant variables concerning EDs and general psychiatric status, and the database can be used for both clinical and research purposes. The system comprises semi-structured diagnostic interviews, clinical ratings and self-ratings, automated follow-up schedules, as well as administrative functions to facilitate registration compliance. As of June 2009, the system is in use at 20 treatment units and comprises 2776 patients. Diagnostic distribution (including subcategories of eating disorder not otherwise specified) and clinical characteristics are presented, as well as data on registration compliance. Obstacles and keys to successful implementation of the Stepwise system are discussed, including possible gains and on-going challenges inherent in large-scale, Internet-based quality assurance.

What happened to the ones who dropped out? Outcome in eating disorder patients who complete or prematurely terminate treatment.

INTRODUCTION: There is a lack of knowledge about the outcome of eating disorder patients who terminate treatment prematurely. The present study followed-up eating disorder patients who had previously dropped out of treatment and examined clinical status 36 months after intake. METHOD: Dropouts (n = 30) were compared with treatment completers (n = 52) on diagnostic status, clinical symptoms, psychosocial adjustment and treatment satisfaction at follow-up. Patterns of change from intake to follow-up within groups, as well as between groups, were explored. RESULTS: No significant differences were found between groups at follow-up, except for more treatment dissatisfaction reported among dropouts. When patterns of change were examined between groups, patients who completed treatment were found to have made significantly greater changes (less eating disorder symptoms, less psychological problems and more positive self-image) compared to dropouts. DISCUSSION: Although no significant differences in outcome were found between dropouts and completers, greater clinical improvement was found among those who completed treatment. The dropouts examined in this study did well despite premature termination of treatment. Clinical and research implications are discussed.

Anorexic self-control and bulimic self-hate: differential outcome prediction from initial self-image.

OBJECTIVE: The study investigated initial self-image (structural analysis of social behavior) and its relation to 36-month outcome, among patients with anorexia nervosa and bulimia nervosa. Hypotheses were that degree of different aspects of self-image would predict outcome in the groups. METHOD: Participants were 52 patients with anorexia and 91 with bulimia from a longitudinal naturalistic database, and outcome measures included eating disorder and psychiatric symptoms and a general outcome index. Stepwise regression was used to investigate which self-image variables were related to outcome, and multiple regression contrasted the groups directly on each obtained predictor. RESULTS: Consistent with hypotheses, in bulimia degree of self-hate/self-love moderately predicted outcome, whereas self-control-related variables powerfully predicted outcome in anorexia. DISCUSSION: It is important to focus on self-image in the treatment of both diagnostic groups, but especially in anorexia nervosa, where control-submission interactions between patient and therapist should be handled with care.

Self-image and treatment drop-out in eating disorders.

INTRODUCTION: Drop-out from treatment is a serious problem in eating disorders which remains poorly understood. The present study investigated whether self-image and interpersonal theory could help to explain why eating disorder patients drop out of treatment. METHOD: Intake data on eating disorder patients who terminated treatment prematurely (N=54) were compared with patients who had completed treatment (N=54) and those who were still in treatment after 12 months (N=54). Self-image was assessed using the structural analysis of social behaviour (SASB), and comparisons were made on demographic and clinical variables. RESULTS: Patients who dropped out had initially presented with less negative self-image and fewer psychological problems compared with remainers. Low levels of SASB self-blame discriminated drop-outs from completers and remainers and significantly predicted treatment drop-out. DISCUSSION: Drop-out in eating disorders appears to be a complex phenomenon, not necessarily as pathological as often assumed. There may be important differences in the treatment goals of drop-outs and therapists; patients who drop out may be choosing to disengage at a time when symptom improvement creates space for closer examination of interpersonal issues.

Negative self-image and outcome in eating disorders: results at 3-year follow-up.

INTRODUCTION: Negative self-image has been hypothesised to be of aetiological significance in eating disorders; however, its relationship to outcome remains unclear. The present study examined the relationship between self-image and follow-up status in a heterogeneous sample of eating disorder patients (N=246). METHODS: Patients were assessed at intake and after 36 months. Self-image was measured using SASB, and a general outcome measure was calculated comprising eating disorder symptoms, occupational status, interpersonal relationships and general psychopathology. RESULTS: SASB self-hate was the most important variable for predicting poor outcome, followed by occupational status, interpersonal relationships, eating disorder symptoms, SASB self-emancipation and general psychiatric symptoms. Together these variables predicted 23% of the variance in outcome. DISCUSSION: High levels of self-hate may increase the risk of poor outcome in eating disorders by adversely affecting interpersonal relationships and making it difficult for patients to engage in treatment.

Interpersonal profiles in eating disorders: ratings of SASB self-image.

INTRODUCTION: Although evidence suggests that interpersonal psychotherapy may be an efficacious treatment for eating disorders, there is surprisingly little systematic knowledge about the interpersonal world of these patients. METHOD: SASB self-image ratings were used to explore interpersonal profiles in a large heterogeneous sample of eating disorders (N = 830), matched normal controls (N = 105) and a small group of controls with subclinical depression (N = 26). RESULTS: Eating disorder patients clearly presented with significantly more negative interpersonal profiles compared to controls. Within the eating disorder group, anorexics were characterized by high self-control, self-blame and self-attack. Patients with binge eating disorder expressed the least negative self-image, and were significantly more self-affirming than bulimics and less self-controlling than patients with atypical eating disorders. CONCLUSIONS: Eating disorder patients may have distinct interpersonal profiles that increase the risk of negative therapeutic reaction. Better knowledge of interpersonal processes in eating disorders may help to improve both diagnostic assessment and treatment.