Longer-term effectiveness of systemic family therapy compared with treatment as usual for young people after self-harm: An extended follow up of pragmatic randomised controlled trial.

BACKGROUND: Self-harm in adolescents is common and repetition frequent. Evidence for effective interventions to reduce self-harm is limited. Long term follow-up of existing studies is rare. METHODS: Extended follow up, from 18 to at least 36-months, of the SHIFT trial: a pragmatic, multi-centre, individually-randomised, controlled trial involving young people (11-17) who had self-harmed at least twice and presented to Child & Adolescent Mental Health Services (CAMHS). SHIFT evaluated manualised family therapy (FT) versus treatment as usual (TAU) in reducing repetition of self-harm leading to hospital attendance 18 months post-randomisation.We obtained ONS mortality data, adult mental health data, and further details of hospital attendance from routine Hospital Episode Statistics (HES) data plus researcher follow-up. We assessed longer-term differences in outcome using multivariable Cox Proportional Hazards regression analysis, and assessed all-cause mortality and morbidity relating to hospital attendances for reasons other than self-harm. STUDY REGISTRATION: ISRCTN 59793150. OUTCOMES: The original sample of 832 were randomised between April 2010 and December 2013. Extended follow-up continued until February 2017 for a median 55·4 months (range 0-82·5 months), providing post 18-month data for 804 (96·6%) participants, of whom 785 (94·4%) had a minimum of 36-months follow-up.There was no evidence of a between-group difference in the primary outcome during the extended follow-up period (Hazard Ratio (HR) 1·03; 95% CI: 0·83, 1·28; p-value=0·78), consistent with our findings in the original trial with 18 months follow-up (HR 1·14, 95% CI 0·87, 1·49; p-value 0·33). There was a reduced rate of self-harm in older participants aged 15-17 (HR 0·7, 95% CI 0·56, 0·88), as compared with those aged 11-14; and significantly increased rates of self-harm in participants whose index episode combined self-injury and poisoning (HR 1·8, 95% CI 1·2, 2·7). Two deaths were reported during the extended follow up period. INTERPRETATION: For adolescents referred to CAMHS after self-harm, having self-harmed at least once before, trial FT confers no benefits over TAU in reducing subsequent hospitalisation for self-harm over 18 months or 36 months. FUNDING: NIHR HTA Reference: 07/33/01.

A randomized controlled trial of an Internet-based cognitive-behavioural skills package for carers of people with anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) poses a major burden on families. Carers (e.g. parents or partners) of people with AN are often highly distressed and may inadvertently respond in ways that can contribute to the maintenance of the disorder, e.g. through high levels of over-involvement and criticism [also known as expressed emotion (EE)]. This study aimed to evaluate the efficacy of a novel web-based systemic cognitive-behavioural (CBT) intervention for carers of people with AN, designed to reduce carer distress and teach skills in how to offer effective support. METHOD: Carers of people with AN (n=64) were randomly allocated to either the web-intervention, overcoming anorexia online, with limited clinician supportive guidance (by email or phone), or to ad-hoc usual support from the UK patient and carer organization Beat. Carer outcomes were assessed at post-treatment (4 months) and follow-up (6 months). RESULTS: Compared with the control intervention, web-based treatment significantly reduced carers' anxiety and depression (primary outcome) at post-treatment, with a similar trend in carers' EE. Other secondary outcomes did not favour the online intervention. Gains were maintained at follow-up. CONCLUSIONS: This is the first ever study to use an online CBT program to successfully reduce carer distress and improve carers' ability to support the person with AN.

Therapeutic processes in multi-family groups for major depression: results of an interpretative phenomenological study.

BACKGROUND: Recent research indicates that different couple and family interventions are effective in the treatment of depressed patients. However, how these psychosocial interventions work, has been less well investigated. In order to better understand the underlying treatment processes, helpful treatment experiences of depressive patients and their partners were examined in a multi-family therapy group. METHOD: 24 patients hospitalized for depression and 20 partners participated in this study. Therapeutic factors were assessed using an open-ended questionnaire. Responses were analyzed using interpretative phenomenological approach (IPA). RESULTS: Eight recurring therapeutic factors were reported by both the patients and their partners: (1) Presence of others, (2) cohesion and understanding, (3) self-disclosure, (4) openness, (5) discussion, (6) insights, (7) observational experiences and (8) guidance from the therapist. LIMITATIONS: Results were not fed back to the participants following analysis and only therapeutic factors that operate on a conscious level could be identified. CONCLUSIONS: Several important therapeutic factors were identified in multi-family therapy groups for depression. These factors help to gain understanding into the processes, which should be emphasized in treatment and ought to be explored in future outcome and process research.

Cognitive-behavioural therapy for adolescents with bulimic symptomatology: the acceptability and effectiveness of internet-based delivery.

BACKGROUND: The evidence base for the treatment of adolescents with bulimia nervosa (BN) is limited. AIMS: To assess the feasibility, acceptability, and clinical outcomes of a web-based cognitive-behavioural (CBT) intervention for adolescents with bulimic symptomatology. METHOD: 101 participants were recruited from eating disorders clinics or from beat, a UK-wide eating disorders charity. The programme consisted of online CBT sessions ('Overcoming Bulimia Online'), peer support via message boards, and email support from a clinician. Participants' bulimic symptomatology and service utilisation were assessed by interview at baseline and at three and six months. Participants' views of the treatment package were also determined. RESULTS: There were significant improvements in eating disorder symptoms and service contacts from baseline to three months, which were maintained at six months. Participants' views of the intervention were positive. CONCLUSIONS: The intervention has the potential for use as a first step in the treatment of adolescents with bulimic symptomatology.

Randomised controlled trial of CD-ROM-based cognitive-behavioural self-care for bulimia nervosa.

BACKGROUND: Cognitive-behavioural self-care is advocated as a first step in the treatment of bulimia nervosa. AIMS: To examine the effectiveness of a CD-ROM-based cognitive-behavioural intervention in bulimia nervosa and eating disorder not otherwise specified (NOS) (bulimic type) in a routine setting. METHOD: Ninety-seven people with bulimia nervosa or eating disorder NOS were randomised to either CD-ROM without support for 3 months followed by a flexible number of therapist sessions or to a 3-month waiting list followed by 15 sessions of therapist cognitive-behavioural therapy (CBT) (ISRCTN51564819). Clinical symptoms were assessed at pre-treatment, 3 months and 7 months. RESULTS: Only two-thirds of participants started treatment. Although there were significant group x time interactions for bingeing and vomiting, favouring the CD-ROM group at 3 months and the waiting-list group at 7 months, post hoc group comparisons at 3 and 7 months found no significant differences for bingeing or vomiting. CD-ROM-based delivery of this intervention, without support from a clinician, may not be the best way of exploiting its benefits.

Motivation to change in recent onset and long-standing bulimia nervosa: are there differences?

UNLABELLED: REASON FOR THE STUDY: Little is known about how motivation to change evolves over the course of an eating disorder. The present study compared 'stage of change' and motivation, confidence and readiness to change in two groups of patients with bulimia nervosa (BN), adolescents with a short duration of illness and adults with a long duration of illness. METHOD: Patients completed the Severity of eating disorder symptomatology scale, Hospital Anxiety and Depression Scale and measures of stage of change and motivation, readiness and confidence to change their bulimic symptomatology at pre-treatment. MAIN FINDINGS: Short- and long duration groups did not differ in illness severity, comorbidity, stage of change, motivation, readiness, and confidence to change. There were, however, some differences between groups in terms of the relationship between motivational measures, illness severity, duration and comorbidity. CONCLUSIONS: There seem to be more similarities than differences between adolescents with short duration of illness and those with well-established BN in terms of their motivation to change.

Psychological therapies for adults with anorexia nervosa: randomised controlled trial of out-patient treatments.

BACKGROUND: Currently, without systematic evidence, psychotherapy for anorexia nervosa in adults draws on psychodynamic, cognitive and systemic theories. AIMS: To assess effectiveness of specific psychotherapies in out-patient management of adult patients with anorexia nervosa. METHOD: Eighty-four patients were randomised to four treatments: three specific psychotherapies - (a) a year of focal psychoanalytic psychotherapy; (b) 7 months of cognitive-analytic therapy (CAT); (c) family therapy for 1 year - and (d) low contact, 'routine' treatment for 1 year (control). RESULTS: At 1 year, there was symptomatic improvement in the whole group of patients. This improvement was modest, several patients being significantly undernourished at follow-up. Psychoanalytic psychotherapy and family therapy were significantly superior to the control treatment; CAT tended to show benefits. CONCLUSIONS: Psychoanalytic and family therapy are of specific value in the out-patient treatment of adult patients with anorexia.

Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family interventions.

This paper reports the results of a randomised treatment trial of two forms of outpatient family intervention for anorexia nervosa. Forty adolescent patients with anorexia nervosa were randomly assigned to "conjoint family therapy" (CFT) or to "separated family therapy" (SFT) using a stratified design controlling for levels of critical comments using the Expressed Emotion index. The design required therapists to undertake both forms of treatment and the distinctiveness of the two therapies was ensured by separate supervisors conducting live supervision of the treatments. Measures were undertaken on admission to the study, at 3 months, at 6 months and at the end of treatment. Considerable improvement in nutritional and psychological state occurred across both treatment groups. On global measure of outcome, the two forms of therapy were associated with equivalent end of treatment results. However, for those patients with high levels of maternal criticism towards the patient, the SFT was shown to be superior to the CFT. When individual status measures were explored, there were further differences between the treatments. Symptomatic change was more marked in the SFT whereas there was considerably more psychological change in the CFT group. There were significant changes in family measures of Expressed Emotion. Critical comments between parents and patient were significantly reduced and that between parents was also diminished. Warmth between parents increased.

Disruption and reconstruction: narrative insights into the experience of family members caring for a relative diagnosed with serious mental illness.

The findings of a study investigating carers' accounts about serious mental illness occurring in their family are presented. The narrative form is a primary means of ordering, structuring, and communicating illness experiences, reflecting some of the processes that carers intend to master and understand. Psychotic episodes entail a frightening disruption that forces carers to face fundamental existential, moral, and psychological issues because they call into question the continuity of lives and life-projects. This study has explored how carers articulate the consequences of a devastating experience and turn it into a meaningful event that can in some way be incorporated into the course of their life. Two types of narrative structure were identified. In stories of restitution or reparation, the experience of the event is transformed into phenomena having meaning, occupying a place in carers' lives. In chaotic and frozen narratives, the illness remains a series of random events. The effects on coping of these two narrative types were explored, as well as gender-related themes and beliefs about mastery and control. Therapeutic implications are discussed and also possible connections to other research constructs (for example, Expressed Emotion). It is argued that the concept of illness must be approached from a systemic, multidetermined perspective that includes our narrative constructions.

The assessment of expressed emotion in a standardised family interview.

This study compared the expressed emotion (EE) scores obtained using individual interviews with parents with the scores obtained in whole family interviews. Interviews were carried out with 31 parents of 16 adolescents referred because of an eating disorder. There was moderate correlation of scores between the two interviews regarding critical comments, emotional overinvolvement, and warmth, but it was low for positive remarks. The study suggests that the whole family interview, which is time saving, is useful in assessing expressed emotion. The levels of expressed emotion, particularly the relatively low levels of critical comments and emotional overinvolvement, are similar to those of previous studies.

Mothers with anorexia nervosa who underfeed their children: their recognition and management.

BACKGROUND: Women with anorexia nervosa have a reduced fertility but they may have borne children before the onset of their illness or after partial recovery. Little is known on how to identify the anorexic mothers who underfeed their children and how to manage them. This article aims to remedy these gaps. METHODS: The clinical scientific method is the only means of identifying the children of anorexic mothers who are at risk. Eight such mothers were identified as a result of obtaining serial measurements of the children's weights and heights over time. Tanner-Whitehouse charts were used to plot weight for age and height for age. A simple rating scale was devised to measure the acceptance of treatment involving both mother and child. RESULTS: Nine children (eight boys and one girl) were found to have suffered food deprivation: with severe reduction in weight-for-age in six and in height-for-age in eight. Five siblings were not affected. Catch-up growth was correlated with the degree of engagement in treatment of both mother and child. Long-term treatment of one mother, combining family therapy with admissions to hospital, resulted in catch-up growth in her two sons. CONCLUSIONS: The mechanisms underlying the privation of the children stem from the anorexic mother's abnormal concerns with body size extending to her children. The children may become unduly accepting of the underfeeding. It is essential to obtain the confidence of anorexic mothers suspected of underfeeding their children and to adopt a whole family approach to treatment.

Incomplete adherence after pediatric heart and heart-lung transplantation.

BACKGROUND: Poor adherence to treatment after organ transplantation is life threatening. Clinical experience indicates that failure to adhere to the medical regimen after pediatric heart or heart-lung transplantation is more common than might be anticipated. This is the first empirical study of adherence in this population. METHODS: The subjects were 53 children and adolescents (mean age 10.3 years) who underwent transplantation and were followed up for 12 months after transplantation. At each attendance blood levels of cyclosporine were measured and medical diaries checked. For children who had undergone heart-lung transplantation, serial measures of respiratory function were obtained, both at home and in the laboratory. Levels of adherence to the immunosuppressive therapy and completion of the medical diary were determined on the basis of prior operational definitions. RESULTS: Satisfactory adherence to medication and satisfactory completion of the diaries were found in 37 children (70%). Satisfactory adherence to medication but unsatisfactory completion of the diaries were found in 11 children (21%). There was poor adherence to medication in 5 other children (9%) regardless of whether the diary was satisfactorily completed. Independent variables associated with poor adherence to medication were heart-lung as opposed to heart transplantation, one-parent or blended families, and family adjustment. CONCLUSION: Nearly one third of the sample showed unsatisfactory adherence to the treatment regimen. This relatively high prevalence indicates the importance of close monitoring of adherence. The identification of family characteristics as risk factors indicates a need for more intensive psychoeducational family counseling in the 12 months after transplantation.

Family and individual therapy in anorexia nervosa. A 5-year follow-up.

BACKGROUND: There is evidence that specific psychological treatments are effective in patients with eating disorders. Our goal was to determine by means of a controlled trial whether psychological treatments, previously found to be effective in anorexia nervosa, gave rise to enduring benefits. METHODS: A 5-year follow-up was conducted on patients who had participated in a previous trial of family therapy for anorexia and bulimia nervosa. Family therapy or individual supportive therapy had been administered to 80 outpatients for 1 year beginning on discharge from hospital after weight restoration. The 80 patients had been subdivided into 4 prognostically homogeneous groups of which 2 turned out to be the most important: patients with early onset and short history of anorexia nervosa, and patients with late-onset anorexia nervosa. At the 5-year follow-up, the efficacy of the outpatient therapies was again assessed by the maintenance of weight, and the categories of general outcome and dimensions of clinical functioning defined by the Morgan-Russell scales. RESULTS: Significant improvements were found in the group of 80 patients as a whole, mainly attributable to the natural outcome of anorexia nervosa, and most evident in the early onset and short history group, as expected. Within 2 of the prognostic groups, significant benefits attributable to previous psychological treatments were still evident, favoring family therapy for patients with early onset and short history of anorexia nervosa and favoring individual supportive therapy for patients with late-onset anorexia nervosa. CONCLUSIONS: Much of the improvements found at a 5-year follow-up can be attributed to the natural outcome of the illness. Nevertheless, it was still possible to detect long-term benefits of psychological therapies completed 5 years previously.

Redefining the psychosomatic family: family process of 26 eating disorder families.

This paper reports part of the data from a comparative trial of two forms of family intervention for the management of eating disorders in adolescents. Measures of family process at the beginning of treatment included Expressed Emotion (EE) and the Family Adaptability and Cohesion Evaluation Scales (FACES). EE in the families of both anorexic and bulimic patients were, on the whole, at low levels. The low levels of parental Critical Comments might be taken to represent the conflict avoiding character of the families of psychosomatic patients. However, the families showed low levels of Emotional Overinvolvement, which contradicts the clinical descriptions. The FACES scores revealed patterns that were superficially contradictory to the accepted clinical descriptions in that the patients appeared to have perceived their families as not close and as highly structured. The parents experienced their family structure as more similar to the clinical descriptions, scoring their families as more flexible and cohesive than do the patients. The FACES ideals for family organization scored by patients and parents more nearly equate with the clinical descriptions of enmeshment and lack of boundary structure. The relationship between the research findings and the clinical evaluation will be discussed.

Personality disorder and treatment response in bulimia nervosa.

Thirty-nine female out-patients with bulimia nervosa were assessed for personality disorders using the PAS. All subjects then entered a therapeutic trial, comprising eight weeks of cognitive-behavioural therapy with follow-up after eight weeks and at one year. Thirty-nine per cent of the patients were diagnosed as having personality disorders. Patients with personality disorders were more depressed and had a lower BMI than those without. They also had a significantly poorer response to treatment, but the difference between groups did not reach significance when mood and BMI were controlled for. Personality disorder alone does not predict a poor response to treatment, but comorbidity with depression and low weight increases the likelihood of a poor response; these patients are unlikely to respond to brief psychotherapeutic interventions.

A placebo-controlled trial of d-fenfluramine in bulimia nervosa.

d-Fenfluramine is a 5-HT agonist which decreases food intake and excessive carbohydrate intake in humans. A placebo-controlled trial of d-fenfluramine (45 mg/day) was conducted in 43 patients with bulimia nervosa. The patients entered an eight-week trial of medication during which they also received cognitive-behavioural therapy. Treatment response was assessed using food diaries to record eating behaviour, and self-rating questionnaires to measure psychopathology. The drug trial, and a follow-up assessment after a further eight weeks, were completed by 39 patients. Abnormal eating behaviour and psychopathology improved significantly in both the d-fenfluramine and placebo groups during the treatment trial. The study failed to show that the addition of d-fenfluramine affords an advantage over brief psychotherapy alone. Although d-fenfluramine is effective in suppressing the overeating, excessive snacking, and excessive carbohydrate consumption which are frequently found in overweight or obese patients, this study suggests that the drug is not an effective treatment for bulimia nervosa.

Impulsivity and eating disorders.

Sixty-seven patients with bulimia nervosa and 29 patients with anorexia nervosa completed the Impulsiveness Questionnaire and questionnaires detailing severity of eating disorder. Bulimic patients had higher impulsivity scores than anorexic patients. Bulimics with high impulsivity scores did not have more severe eating disorders than low scorers. When 39 bulimics and 25 anorexics were interviewed about other impulsive behaviour, 51% of bulimics and 28% of anorexics reported at least one other impulsive behaviour. Patients with so-called 'multi-impulsive' bulimia reported more severe eating disturbance, but this was not reflected on more reliable measures of symptoms. Thirty-nine bulimics entered an eight-week treatment trial and their progress was assessed at eight weeks, 16 weeks and one year. 'Non-impulsive' bulimics had a more rapid response than 'impulsives' during treatment, but there was no difference at follow-up. There was no evidence of an association between high impulsivity trait scores and poor treatment response. It is concluded that impulsivity may shape the expression of eating disorders, but that 'multi-impulsives' do not constitute a categorically distinct subgroup of bulimics.

Anorexia nervosa: outcome and prognostic factors after 20 years.

Forty-one patients with anorexia nervosa, admitted to the Maudsley Hospital between 1959 and 1966, were followed up after a mean of 20 years. An assessment of general outcome (based on the Morgan-Russell scales) yielded three outcome categories: 'good' (n = 12), 'intermediate' (n = 13) and 'poor' (n = 15). Six patients (15%) had died from causes related to anorexia nervosa; at least 15% had developed bulimia nervosa. There was a general consistency between the follow-up at 20 years and that previously conducted five years after admission, although with a few individual patients there were serious prognostic errors at the earlier follow-up. A poorer outcome was associated with a later age of onset, a history of neurotic and personality disturbances, disturbed relationships in the family and a longer duration of illness.

A controlled trial of d-fenfluramine in bulimia nervosa.

A double-blind, placebo-controlled trial of d-fenfluramine in bulimia nervosa was undertaken in order to assess its efficacy in controlling bulimic behavior and relieving more general symptoms. A high proportion of the patients evaluated were reluctant to enter the drug trial in spite of the offer of additional supportive psychotherapy and counselling on dietary control. Moreover, 17 out of the 42 enrolled patients withdrew halfway through the 12 week trial. Were it not for this high rate of defaulting, there might be clearer support for the efficacy of d-fenfluramine in reducing the frequency of overeating and self-induced vomiting in these bulimic patients. An unexpected finding was that among the noncompleters, those on d-fenfluramine had experienced relief of their bulimic symptoms. The persistence of depressive symptoms and features of the eating disorder probably contributed to the noncompleters leaving the trial. Reassuring findings were the absence of weight loss and serious unwanted effects from d-fenfluramine. By itself, d-fenfluramine did not benefit some of the patients with severe bulimia nervosa, but it may yet prove a useful adjunct to psychological treatments.