Physical fitness, bone mineral density and associations with physical activity in females with longstanding eating disorders and non-clinical controls.

AIM: To examine (i) aerobic fitness, muscular strength, and bone mineral density (BMD) in female inpatients with longstanding eating disorders and non-clinical controls, and (ii) associated and explanatory factors for BMD among the inpatients. METHODS: Adult females with DSM-IV anorexia nervosa (AN), bulimia nervosa (BN) or eating disorders not otherwise specified (EDNOS) (n=59, mean(SD) age 30.1(8.5) yrs and ED duration 14.3 yrs) and non-clinical age-matched controls (n=53, mean(SD) age 31.3(8.3) yrs) accepted participation in this cross-sectional study. Measurements included accelerometer assessed and self reported amount of different types of physical activities, VO2max on treadmill, 1RM in leg and chest press, and BMD in lumbar spine (L2-L4), femur neck and total body analyzed by DXA. RESULTS: Muscular strength and BMD were lower in patients with AN, not in patients with BN or EDNOS, compared to controls. Aerobic fitness did not differ between patients and controls. BMD in the patients was positively associated with body weight, muscular strength and self reported high impact PA (min.w-1), not self reported general weight-bearing PA (min.w-1) or accelerometer assessed PA (counts.min). History of AN (28%) and muscular strength (9%) contributed significantly to explain the variance in total body BMD. CONCLUSION: Muscular strength and only high impact PA are associated with BMD in patients with longstanding ED. An implication of this is the need for more specific guidelines regarding types of PA recommended for this patient population. Special considerations should be made for severely malnourished patients, and for patients with osteoporosis.

Physical activity in treatment units for eating disorders: clinical practice and attitudes.

OBJECTIVE: Physical activity (PA) in eating disorders (ED) may be harmful, but in a therapeutic setting also beneficial. The purpose of this survey was to examine these contradictory aspects of PA in ED specialist treatment settings. We examined whether 1) PA is assessed by the unit, 2) the units have guidelines for managing excessive PA, 3) the units have staff with higher education and special competence in PA and exercise science, 4) how units regard PA in ED, 5) whether regular PA is integrated in the treatment programs, and 6) how the units rate the role of PA in the treatment of ED compared with other mental disorders. METHODS: Of the 49 units located in Scandinavia and the United Kingdom, 41 (84%) responded to a questionnaire. RESULTS: In 28 units (68%) PA was assessed regularly. Excessive PA was considered a harmful symptom in ED, and most units reported guidelines to manage excessive PA. Thirty-two units included PA in their treatment programmes. Clinicians found PA most relevant in the treatment of obesity and, except for binge eating, less for ED. CONCLUSION: PA was more commonly integrated in treatment compared to previous studies. Future research should address how to manage excessive PA, and the potential beneficial role of PA in the treatment of ED.

The aerobic fitness of substance abusers voluntary participating in a rehabilitation project.

AIM: The aim of the study was to assess the physical fitness in a group of substance abusers using direct, maximal testing and testing of blood lactate threshold. METHODS: Forty-seven patients, 34 males and 13 females, with substance dependence, taking part in a rehabilitation project, served as subjects. Mean age and SD were 30.5+/-9.2 years for the males and 29.7+/-10.2 for the females. They performed a lactate threshold test and a maximal oxygen uptake test (V.O(2max)). The threshold test was performed on either a cycle ergometer or a treadmill, the V.O(2max) test was the Bruce protocol. RESULTS: The range in aerobic fitness was large, and the mean result of aerobic power (V.O(2max)) was somewhat higher than previously estimated in groups of similar age: 39+/-10 and 31+/-8 mL.kg(-1).min(-1) for males and females, respectively. The mean heart rate at blood lactate threshold did not differ between the sexes and was 74+/-7% of maximal heart rate (HRmax). There was no statistical difference between the users of different intoxicants on either V.O(2max) or lactate threshold. CONCLUSIONS: This group of substance abusers did show a large range in physical fitness. The maximal oxygen uptake was better than previously assessed in groups of substance dependent people using indirect methods. The primary intoxicant had no significant influence on the fitness.

Cardiorespiratory fitness in relation to self-reported physical function in cancer patients after chemotherapy.

AIM: The aim of this study was to estimate the association between objective cardiorespiratory fitness (CRF) and subjective self-reported physical function, taking into account the influence of mental distress. We hypothesized an association between these parameters, since they might be thought to measure parts of the same phenomenon. METHODS: Approximately 1 month after discontinuation of all primary treatment, 90 cancer patients aged 18-50 years treated with chemotherapy were surveyed. CRF was determined by the Astrand-Ryhming indirect cycle ergometer test, which indicate peak VO2 in mL x kg(-1) x min(-1) (predicted VO2max). Self-reported physical function was assessed by The European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30). The relation between VO2max and self-reported physical function was estimated by multiple linear regression. Mental distress (assessed by The Hospital Anxiety and Depression scale), age, gender, body mass index (BMI), time from treatment to physical test and diagnoses were included as potential confounders. RESULTS: There was no association between predicted VO2max and self-reported physical function. Mental distress was negatively associated with self-reported physical function (P<0.001), but is not associated with predicted VO2max. CONCLUSIONS: The results suggest that predicted VO2max does not reflect self-reported physical function and vice versa in cancer patients after chemotherapy. If information about cardiac and/or pulmonary status is required, direct or indirect measures of VO2max should be used.

Short-term follow-up of adults with long standing anorexia nervosa or non-specified eating disorder after inpatient treatment.

OBJECTIVE: There are few follow-up studies on outcome for patients with long standing anorexia nervosa (AN) or non-specified eating disorder with several comorbid psychiatric disorders. Inpatient treatment is one option for these patients. The aim of this prospective study was to report one-year follow-up for a consecutive sample of these patients after an inpatient treatment program. METHOD: All 24 patients with a mean age of 28 years and mean duration of an eating disorder of 11 years were treated in a 23-week inpatient group treatment program for AN. Patients were assessed using Eating Disorder Examination interview (EDE), Eating Disorder Inventory (EDI) and Symptom Check List (SCL-90-R) at pre-treatment, post-treatment and at one year after start of treatment. At the follow-up 24 patients were personally interviewed. On admission 12 (50%) had AN, 8 (33%) non-specified eating disorder (EDNOS) and 4 (17%) bulimia nervosa (BN). All had previously suffered from AN and were clinically evaluated to have mostly anorectic psychopathology. RESULTS: Ten (42%) patients had improved at follow-up and 14 (58%) had a poor outcome. There was a moderate but significant improvement on the EDE, EDI and GSI from pre-treatment to follow-up. The improvement occurred during inpatient treatment, and no significant differences from post-treatment to follow-up were found. Patients with low weight on admission showed a significant mean weight increase of about 4 kg at the follow-up. CONCLUSIONS: At one-year follow-up there was a moderate reduction of eating disorder symptoms and general psychiatric symptoms for patients with long standing anorexic symptoms. The improvement occurred during inpatient treatment. Inpatient treatment may be a treatment option in long-time rehabilitation for some of these patients.

[Rehabilitation of women with breast cancer]. / Rehabilitering av kvinner med brystkreft.

BACKGROUND: Previous studies on effects of rehabilitation programmes for women with breast cancer are rare, but promising. This study aimed to examine the physical and psychological conditions for these patients before and after a rehabilitation programme at Red Cross Haugland Rehabilitation Centre in Norway. MATERIAL AND METHODS: Included in the study were a total of 50 women, aged 31-66 (mean 49) years, who had undergone surgical treatment, chemotherapy and radiation therapy for cancer mammae stage 1 and 2 (limited to the breast only or spread to the axillary lymph nodes, respectively). They received a three-week rehabilitation programme, followed by a three-month period at home and a one-week follow-up at the rehabilitation centre. Examinations of physical and psychological status were performed before and after the three-week stay and at follow-up. RESULTS: Maximum oxygen uptake increased from 67% to 77% of predicted value, the mental status and subjective rating of life quality improved, the physical activity level increased, and 36 out of 46 subjects returned to their jobs during the three-month follow-up. The women themselves reported subjective positive effects of participating in the programme. INTERPRETATION: Although the present study was non-controlled, the positive results were so promising that further controlled studies should be encouraged, as well as rehabilitation programmes for women with breast cancer.

[Physical activity for mental health]. / Fysisk aktivitet for sinnets helse.

BACKGROUND: About 50% of the population will be affected by a mental disorder during their lifetime; the most common forms are mood and anxiety disorders and abuse of or dependence on drugs or alcohol. The standard forms of therapy are medication and various forms of psychotherapy. The cost of treating disease is escalating, and the health care system will never be able to meet the need for treatment in this large group of patients. Hence, development of effective self help strategies is important. MATERIAL AND METHODS: In this paper, the scientific basis for promoting exercise as treatment for mental disorders is evaluated on the basis of a review of the literature. RESULTS: Beneficial psychological effects of exercise are best documented for mild to moderate forms of unipolar depression and chronic fatigue syndrome; in these disorders, exercise is an alternative to traditional forms of treatment. A therapeutic effect may also be achieved in panic and generalised anxiety disorder, schizophrenia, conversion and somatoform pain disorder, and alcohol abuse and dependence. INTERPRETATION: Beneficial effects of exercise are well documented. A simple and inexpensive approach like exercise is helpful and might be important for public health.

[Quality of life, loneliness and social contacts among persons with long-term mental illness]. / Livskvalitet, ensomhet og sosial kontakt hos mennesker med langvarige psykiske lidelser.

Chronic long-term patients who were residents in psychiatric nursing homes at a given point in time were traced six years later. Over this period, there had been deep cuts in the number of psychiatric beds in the county in question; we wanted to assess how the patients now perceived their quality of life. All 107 patients were traced; of the 75 who were still alive, 74 took part in the study and were visited at their place of residence. 42 patients, mean age 56.9 years, were able to respond to personal questions regarding social contact, loneliness and quality of life. Health care providers were the most important persons in the patients' networks. Most patients reported a satisfactory quality of life; those who lived outside institutions (N = 21) tended to be more satisfied than those in residential care, they were more socially active and had better contact with their families. The variables loneliness, satisfaction with neighbourhood and leisure activities explained 63% of the variance in quality of life.

Quality of life, loneliness, and social contact among long-term psychiatric patients.

OBJECTIVE: Long-term patients who resided in county-operated psychiatric nursing homes in a county in Norway as of November 15, 1989, were visited by researchers in 1996 to assess how they perceived their living situations and how they had adjusted to a large reduction in county psychiatric beds during the six-year period. METHODS: Of 107 patients identified in 1989, a total of 75 were still alive in 1995. Seventy-four took part in the study and were visited at their place of residence. Thirty patients were living in general nursing homes, 23 patients remained in the psychiatric nursing homes, and 21 patients lived outside of institutions, in a personal residence. The quality of the patients' contact with others was rated by health care providers who were familiar with the patients. Forty-two patients, with a mean age of 56.9 years, responded to personal questions about their life situation, loneliness, and quality of life. RESULTS: Health care providers constituted the patients' most important network. Patients outside of institutions were the most socially active and had the most satisfying contact with their families. Patients reported a satisfactory quality of life, and those who lived outside institutions tended to be most satisfied. The variables of loneliness, satisfaction with neighborhood, and leisure time activities explained 63 percent of the variance in patients' subjective well-being. CONCLUSIONS: Most long-term patients who had moved out of psychiatric institutions were satisfied with their living situation and reported a relatively high quality of life.

The fate of chronic in-patients after closure of psychiatric nursing homes in Norway: a personal follow-up 6 years later.

We evaluated all 107 chronic in-patients in a catchment area before and 6 years after a planned reduction in the number of psychiatric institution beds was implemented. At follow-up, 32 of the patients had died. One had probably committed suicide, while the others were elderly people who had died of natural causes. In the remaining patients the level of functioning was low, and below that which could be deduced from their level of symptoms, which was also low. The majority of the patients still lived in institutions, mostly in general nursing homes. Among those who had moved out, there were non-significant trends towards a reduction in symptoms and an increase in functioning. In general, the patients were satisfied with their new accommodation. Most of them needed extensive help and support to establish an acceptable standard of living in the community.

Tolerance to intensive exercise and high levels of lactate in panic disorder.

We wanted to test the tolerance of intensive exercise and corresponding high levels of lactate in patients with panic disorder. Thirty-five consecutive patients with DSM-III-R panic disorder completed submaximal tests, and 24 completed additional supramaximal exercise tests. All experienced high values of lactate during the supramaximal test (M = 10.7 mmol/L, SD = 2.9), but only 1 patient experienced a panic attack. The blood lactate values in the present study were higher than the usually achieved values of 5 to 6 mmol/L during infusion. In general, 67% of patients panic during infusion, compared to 4% in the present study. This discrepancy in frequency of panic following exposure to endogenous and exogenous lactate is discussed on the basis of various hypotheses of panic disorder, with an emphasis on cognitive theory of panic. The study indicates that patients with panic disorder can safely undergo vigorous exercise of such intensity to result in significant lactate production, with the chances of panic being small.

Cognitive-behavioral group therapy for panic disorder in the general clinical setting: a naturalistic study with 1-year follow-up.

BACKGROUND: Cognitive-behavioral therapy (CBT) is well documented in the treatment of panic disorder. As most investigators have studied selected patients without comorbid disorders, it is less clear how well the treatment will perform in the usual clinical setting for patients with comorbid disorders and with physicians who do not have training in CBT. During the last 6 years, we have offered CBT in outpatient groups for patients with panic disorder and agoraphobia. The purpose of this prospective study was to assess the outcome of group treatment and compare the results with those of studies that used individual treatment. We wanted to identify variables that might predict outcome at follow-up and to assess the number and characteristics of dropouts. METHOD: Eighty-three consecutive patients with DSM-III-R panic disorder (56 women and 27 men; mean age = 34.5 years) were studied. Mean duration of panic disorder was 7.5 years. There was a high degree of comorbid major depression, social phobia, and psychoactive substance abuse/dependence. Treatment consisted of 4-hour group sessions conducted once a week for 11 weeks. More than half of the patients used antidepressant drugs. Degree of phobic avoidance, bodily sensations, anxiety cognitions, and depression were assessed at pretreatment, baseline, and end of treatment and at follow-up after 3 and 12 months. RESULTS: There was a large decrease in scores from start to end on all assessments. Sixty-three (89%) of 73 completers responded (> or = 50% reduction in Phobic Avoidance Rating Scale scores). Gains were maintained and even improved upon at follow-up. The results are comparable with studies that used individual therapy. A high depression score at the end of treatment predicted poor outcome at 1-year follow-up. Twelve (14%) of 83 did not complete the program. The presence of severe personality disorders and ongoing alcohol or substance abuse or dependence was associated with poor outcome and high dropout rate. CONCLUSION: CBT appears to be effective in the usual clinical setting, even in the hands of therapists without formal competence. Group therapy is a feasible arrangement, and the results from group treatment are comparable to those of individual approaches. Precise diagnosis and treatment of comorbid depression are of utmost importance. Patients with additional substance abuse or dependence, as well as severe personality disorders, may find this treatment modality less helpful.

Chronic patients in psychiatric institutions: psychopathology, level of functioning and need for care.

A total of 107 chronic in-patients in a catchment area of 106,000 inhabitants were rated for psychopathology on the Brief Psychiatric Rating Scale expanded version (BPRS-E), for level of functioning on the Rehabilitation Evaluation Hall And Baker (REHAB), and for geriatric problems on the Geriatric Rating Scale (GRS). The results showed low levels of severe psychopathology and low to moderate levels of functioning, indicating that the main obstacle to community placement was the lack of functioning. Global assessment by ward nurses with regard to the future level of care needed divided the patients into three categories: 40 patients in need of a psychiatric nursing home, 30 patients in need of a general nursing home, and 37 patients who could potentially be discharged to apartments with community support. This study indicates that the REHAB may help to identify patients who are potential candidates for community placement, while the BPRS-E may help to identify patients who are still in need of care in a psychiatric institution.

Assessment of depression: comparison between Beck Depression Inventory and subscales of Comprehensive Psychopathological Rating Scale.

The purpose of this study was to investigate the relationship between self-rating and therapist rating in nonpsychotic patients with unipolar depressive disorders. We also wanted to find out whether the presence of personality disorders would influence the results. At admission and discharge 117 patients filled in the Beck Depression Inventory (BDI) and were rated by a therapist on the Comprehensive Psychopathological Rating Scale (CPRS). Based on the CPRS-scores, two indices of depression were calculated: CPRS-dep and Montgomery Asberg Depression Rating Scale (MADRS). Sixty-three patients had DSM-III-R major depression, 30 had dysthymic disorder, while 24 had no depressive disorder. Eighty suffered from one or more personality disorders, mostly within cluster C. The self rating (BDI) and therapist ratings (CPRS-dep and MADRS) were strongly intercorrelated, with a nonsignificant tendency for weaker correlations in patients with personality disorders. All scales were useful to separate depressed from non-depressed, and to discriminate between major depression and dysthymic disorder, with a tendency in favour of BDI. As cut-off scores for major depression we recommend the sum score of 23 on the BDI, and mean scores of 1 on CPRS-dep and 1.1 on MADRS on a 0-3 scale. When these values are used, 70-79% of patients are correctly classified.

Physical activity and depression: clinical experience.

Two quasi-experimental and 10 experimental exercise intervention studies have been performed in depressed subjects. Some of the studies have methodological shortcomings, but in all studies the results point in the same direction: aerobic exercise is more effective than no treatment, but not significantly different from other forms of therapy, including various forms of psychotherapy. Aerobic and anaerobic forms of exercise are equally effective. The results are restricted to patients with mild to moderate forms of unipolar depression. Patients appreciate exercise and consider it a useful form of therapy. Physical exercise may be an alternative or adjunct to traditional forms of treatment in mild to moderate forms of unipolar depression.

Coping strategies in major depressed, agoraphobic and comorbid in-patients: a longitudinal study.

The first aim of this study was to explore the diagnostic specificity of coping styles by comparing ways of coping in non-anxious major depressed, non-depressed agoraphobic, and both major depressed and agoraphobic (comorbid) in-patients. The second aim was to investigate whether a vulnerability model, a state model, or a combined vulnerability-state model of coping accounted best for the data. On admission and when discharged, 95 patients completed the Way of Coping Checklist and were evaluated on several symptom scales. Self-report symptom scales were completed at one-year follow-up as well. The 'purely' agoraphobic and the comorbid patients showed less seeking of social support and more wishful thinking than the major depressed patients. For the wishful thinking scale, these differences were related to differences in level of global psychopathology. Overall, the results for the seeking social support scale were consistent with a combined vulnerability-state model. The problem-focused coping and wishful thinking scores behaved mostly as state phenomena. The avoidance scores provided ambiguous evidence. In a subsample of 30 agoraphobic patients who received a combination of exposure and psychodynamic treatment, higher pre-treatment levels of seeking social support and lower pre-treatment levels of avoidance as coping both predicted a more favourable course of symptoms pertaining to fear of fear in the one-year follow-up period.

[Psychiatric consultations at a somatic central hospital. Review of 383 referrals over 3 years]. / Psykiatrisk tilsyn ved et somatisk sentralsykehus. En gjennomgang av 383 henvisninger over tre år.

We present an analysis of all psychiatric consultations with inpatients in the somatic wards at the Central Hospital in Alesund over a period of three years. About 1% of the patients were referred for psychiatric consultation. Most of these patients had no previous experience of psychiatry. Mean age was 45 years (range 16-90), and 56% were females. The reasons for referral were assessment of suicidal behaviour (47%), depression (16%) and psychosis (11%). The most common psychiatric diagnoses were personality disorders (16%), affective disorders (14%) and alcohol and drug abuse and dependence (14%). About 10% were admitted to psychiatric wards, and 21% were referred to psychiatric outpatient clinics. The referring physicians were satisfied with the psychiatric consultation service.

[Inadequate treatment of affective disorders]. / Inadekvat behandling av affektive lidelser.

Inadequate treatment of mood (affective) disorders is related to the mind/body dualism, desinformation about methods of treatment, the stigma of psychiatry, low funding of psychiatric research, low educational priority, and slow acquisition of new knowledge of psychiatry. The "respectable minority rule" has often been accepted without regard to the international expertise, and the consequences of undertreatment have not been weighed against the benefits of optimal treatment. The risk of chronicity increases with delayed treatment, and inadequately treated affective disorders are a leading cause of suicide. During the past 20 years the increase in suicide mortality in Norway has been the second largest in the world. Severe mood disorders are often misclassified as schizophrenia or other non-affective psychoses. Atypical mood disorders, notably rapid cycling and bipolar mixed states, are often diagnosed as personality, adjustment, conduct, attention deficit, or anxiety disorders, and even mental retardation. Neuroleptic drugs may suppress the most disturbing features of mood disorders, a fact often misinterpreted as supporting the diagnosis of a schizophrenia-like disorder. Treatment with neuroleptics is not sufficient, however, and serious side effects may often occur. The consequences are too often social break-down and post-depression syndrome.

[Affective disorders. Drug treatment and electroconvulsive therapy]. / Affektive lidelser. Medikamentell behandling og elektrokonvulsiv terapi.

Optimal treatment of mood disorders and prevention of suicide requires biological and psychosocial methods, therapeutic alliance and psycho-education. In moderate unipolar depression an antidepressant may be sufficient, if necessary potentiated by another antidepressant or triiodothyronine. In moderate bipolar depression lithium or carbamazepine are preferred. In severe unipolar and bipolar depression the combination of an antidepressant and lithium (or carbamazepine) or electroconvulsive therapy (ECT) is indicated, in psychotic depression neuroleptics, too. Non-selective monoamine oxidase inhibitors (MAOIs) are the most potent antidepressants. Moderate acute mania and mixed state may respond to lithium, carbamazepine or valproate only. In severe cases a neuroleptic and lithium are combined, or these drugs may be combined with carbamazepine or valproate. Electroconvulsive therapy is preferable in acute mixed states with marked confusion or depression. In chronic mixed state and rapid cycling, withdrawal of antidepressants and neuroleptics should be tried. Most patients will need a combination of lithium and carbamazepine or valproate. Added to these drugs, antidepressants are less risky. Adding thyroxin may stabilize rapid cycling. The combination of lithium and an antidepressant is the most potent prophylaxis in unipolar disorder and bipolar disorder dominated by depression.