Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual were compared in treating outpatients with anorexia nervosa. 242 patients were randomly assigned to receive one of the three treatments for 10 months. At the end of treatment and at 12-month follow-up, all groups showed increased BMI, but with no significant differences between groups. At 12-month follow-up, focal psychodynamic therapy proved more advantageous in terms of recovery rates, and cognitive behaviour therapy was more effective for speed of weight gain and improving eating disorder psychopathology. Long-term outcomes will help further improve these manual-based treatment approaches.
This clinical practice guideline provides evidence-based recommendations for diagnosing and treating unipolar depression in Germany. It was developed through consensus conferences integrating existing national and international guidelines as well as new literature searches. The guideline recommends diagnosing depression according to ICD-10 criteria and using screening questionnaires to aid diagnosis. It provides treatment recommendations based on depression severity, including watchful waiting for mild episodes, psychotherapy or medication for moderate, and combination treatment for severe episodes. The guideline also addresses treatment of chronic forms of depression and management of non-response and therapy-resistant cases.
This randomized controlled trial investigated whether acupuncture or sham acupuncture was more effective than no acupuncture in reducing migraine headaches in 302 patients. The trial found that both acupuncture and sham acupuncture led to greater reductions in moderate or severe headache days compared to the waiting list control group. However, acupuncture was not found to be more effective than sham acupuncture for reducing headache days. The proportion of "responders", defined as at least a 50% reduction in headache days, was similar between the acupuncture (51%) and sham acupuncture (53%) groups, and higher than the waiting list group (15%). The trial concluded that acupuncture was no more effective than sham acupuncture for reducing migraine headaches, although both were more
This document summarizes research on applying positive psychology to the treatment of substance use disorders. Several studies have found positive psychology interventions like gratitude exercises, mindfulness, and strengths-based assessment to be effective in increasing positive affect and reducing relapse. For example, one study found gratitude exercises interrupted negative thought patterns and increased optimism in those recovering from alcoholism. Another study found mindfulness training reduced opioid misuse and craving for those with chronic pain. Overall, the research suggests positive psychology shows promise in enhancing addiction treatment outcomes, though more research with larger sample sizes is still needed.
This study evaluated the drug utilization and rationality of antiepileptic drugs used to treat epilepsy patients at a tertiary care hospital in Dehradun, India. The study found that most epilepsy patients had generalized tonic-clonic seizures. Polytherapy was used more than monotherapy, with 2-drug combinations being most common. First generation antiepileptic drugs like phenytoin were prescribed more than second generation drugs. Phenytoin was the most commonly prescribed antiepileptic drug. The majority of patients receiving polytherapy had a rational drug regimen.
Fricchione psychosomatic medicine in mental healthjasonharlow
This document discusses the global burden of mental illness and the role that psychosomatic medicine can play in addressing it, particularly in Africa. It notes that mental disorders account for 13% of the global burden of disease and reviews strategies like integrating mental health treatment into primary care. Psychosomatic medicine is well-suited to contribute through its expertise in managing co-morbid medical and psychiatric conditions and working at the interface of different medical fields. The document argues that training consultation-liaison psychiatrists could help address Africa's lack of psychiatric resources and lack of treatment for co-occurring conditions.
MAP0004, an orally inhaled formulation of dihydroergotamine (DHE), was evaluated in a randomized, double-blind, placebo-controlled study for the acute treatment of migraine. 903 patients experiencing a migraine attack were randomized to receive either MAP0004 (0.63 mg emitted dose) or placebo via inhalation. The primary endpoints were pain relief and absence of photophobia, phonophobia, and nausea at 2 hours. MAP0004 was superior to placebo for all primary endpoints. A greater percentage of patients treated with MAP0004 experienced pain relief, absence of photophobia, absence of phonophobia, and absence of nausea compared to those receiving placebo. MAP0004 was well tolerated with no serious
This document discusses targeted intermittent treatment in end stage schizophrenia. It suggests that continuous antipsychotic treatment may not be necessary and beneficial in late stage schizophrenia due to tolerance development and brain changes with long-term use. Intermittent or "as-needed" treatment, similar to approaches used in dementia, may better address the neuronal loss characteristics of late stage schizophrenia while mitigating side effects of chronic antipsychotic exposure. Further research is needed to evaluate intermittent treatment strategies for individuals in the chronic "burn out" phase of schizophrenia.
This document summarizes a study investigating the efficacy of stimulating acupuncture points known as Jing-Well points. The study reviewed 35 studies published between 2001-2012 focusing on the clinical applications and mechanisms of Jing-Well point stimulation. The evidence found that stimulating various Jing-Well points can effectively treat conditions such as stroke, persistent vegetative state, respiratory infections, gynecological issues, and more. However, the authors call for more high-quality randomized controlled trials to improve the level of evidence regarding their effectiveness and safety.
This clinical practice guideline provides evidence-based recommendations for diagnosing and treating unipolar depression in Germany. It was developed through consensus conferences integrating existing national and international guidelines as well as new literature searches. The guideline recommends diagnosing depression according to ICD-10 criteria and using screening questionnaires to aid diagnosis. It provides treatment recommendations based on depression severity, including watchful waiting for mild episodes, psychotherapy or medication for moderate, and combination treatment for severe episodes. The guideline also addresses treatment of chronic forms of depression and management of non-response and therapy-resistant cases.
This randomized controlled trial investigated whether acupuncture or sham acupuncture was more effective than no acupuncture in reducing migraine headaches in 302 patients. The trial found that both acupuncture and sham acupuncture led to greater reductions in moderate or severe headache days compared to the waiting list control group. However, acupuncture was not found to be more effective than sham acupuncture for reducing headache days. The proportion of "responders", defined as at least a 50% reduction in headache days, was similar between the acupuncture (51%) and sham acupuncture (53%) groups, and higher than the waiting list group (15%). The trial concluded that acupuncture was no more effective than sham acupuncture for reducing migraine headaches, although both were more
This document summarizes research on applying positive psychology to the treatment of substance use disorders. Several studies have found positive psychology interventions like gratitude exercises, mindfulness, and strengths-based assessment to be effective in increasing positive affect and reducing relapse. For example, one study found gratitude exercises interrupted negative thought patterns and increased optimism in those recovering from alcoholism. Another study found mindfulness training reduced opioid misuse and craving for those with chronic pain. Overall, the research suggests positive psychology shows promise in enhancing addiction treatment outcomes, though more research with larger sample sizes is still needed.
This study evaluated the drug utilization and rationality of antiepileptic drugs used to treat epilepsy patients at a tertiary care hospital in Dehradun, India. The study found that most epilepsy patients had generalized tonic-clonic seizures. Polytherapy was used more than monotherapy, with 2-drug combinations being most common. First generation antiepileptic drugs like phenytoin were prescribed more than second generation drugs. Phenytoin was the most commonly prescribed antiepileptic drug. The majority of patients receiving polytherapy had a rational drug regimen.
Fricchione psychosomatic medicine in mental healthjasonharlow
This document discusses the global burden of mental illness and the role that psychosomatic medicine can play in addressing it, particularly in Africa. It notes that mental disorders account for 13% of the global burden of disease and reviews strategies like integrating mental health treatment into primary care. Psychosomatic medicine is well-suited to contribute through its expertise in managing co-morbid medical and psychiatric conditions and working at the interface of different medical fields. The document argues that training consultation-liaison psychiatrists could help address Africa's lack of psychiatric resources and lack of treatment for co-occurring conditions.
MAP0004, an orally inhaled formulation of dihydroergotamine (DHE), was evaluated in a randomized, double-blind, placebo-controlled study for the acute treatment of migraine. 903 patients experiencing a migraine attack were randomized to receive either MAP0004 (0.63 mg emitted dose) or placebo via inhalation. The primary endpoints were pain relief and absence of photophobia, phonophobia, and nausea at 2 hours. MAP0004 was superior to placebo for all primary endpoints. A greater percentage of patients treated with MAP0004 experienced pain relief, absence of photophobia, absence of phonophobia, and absence of nausea compared to those receiving placebo. MAP0004 was well tolerated with no serious
This document discusses targeted intermittent treatment in end stage schizophrenia. It suggests that continuous antipsychotic treatment may not be necessary and beneficial in late stage schizophrenia due to tolerance development and brain changes with long-term use. Intermittent or "as-needed" treatment, similar to approaches used in dementia, may better address the neuronal loss characteristics of late stage schizophrenia while mitigating side effects of chronic antipsychotic exposure. Further research is needed to evaluate intermittent treatment strategies for individuals in the chronic "burn out" phase of schizophrenia.
This document summarizes a study investigating the efficacy of stimulating acupuncture points known as Jing-Well points. The study reviewed 35 studies published between 2001-2012 focusing on the clinical applications and mechanisms of Jing-Well point stimulation. The evidence found that stimulating various Jing-Well points can effectively treat conditions such as stroke, persistent vegetative state, respiratory infections, gynecological issues, and more. However, the authors call for more high-quality randomized controlled trials to improve the level of evidence regarding their effectiveness and safety.
The Psychological Changes of Horticultura Therapy Intervention for Elderly Women of Earthquake-Related Areas
`
For more information, Please see websites below:
`
Organic Edible Schoolyards & Gardening with Children
http://scribd.com/doc/239851214
`
Double Food Production from your School Garden with Organic Tech
http://scribd.com/doc/239851079
`
Free School Gardening Art Posters
http://scribd.com/doc/239851159`
`
Increase Food Production with Companion Planting in your School Garden
http://scribd.com/doc/239851159
`
Healthy Foods Dramatically Improves Student Academic Success
http://scribd.com/doc/239851348
`
City Chickens for your Organic School Garden
http://scribd.com/doc/239850440
`
Simple Square Foot Gardening for Schools - Teacher Guide
http://scribd.com/doc/239851110
This randomized controlled trial examined whether cognitive behavioral therapy for insomnia (CBT-I) delivered by a therapist is more effective than self-help CBT-I materials at reducing insomnia and depression in individuals with comorbid insomnia and depression being treated with antidepressants. 41 participants were randomized to receive either 4 sessions of CBT-I or self-help materials over 8 weeks. Compared to the self-help group, the CBT-I group showed significantly greater reductions in both insomnia and depression scores post-treatment and at 3-month follow-up. The results suggest that targeting insomnia through CBT-I can effectively treat comorbid insomnia and depression and should be considered an important adjunct treatment for patients whose depression has not fully
This document discusses the relationship between pain and depression. It notes that around 30% of community members suffer from a mental health issue, but only a small portion receive treatment. Major depressive disorder is associated with functional and structural brain changes. Depression and pain commonly occur together and negatively impact health and quality of life. The neurobiology of depression and pain involve neurotransmitters like serotonin, norepinephrine, and dopamine. Depression and chronic pain have overlapping symptoms and biological underpinnings related to these neurotransmitter systems and brain regions like the hippocampus. The document examines theories on how depression and pain may influence each other.
This document summarizes the prophylactic treatment of migraines. It discusses that migraines are a common neurological disease characterized by episodic headache attacks. Prophylactic treatment aims to reduce attack frequency, duration, and severity. A wide variety of medications can be used for prophylactic treatment, including beta-blockers, antidepressants, anticonvulsants, calcium channel blockers, and others. The best agent depends on efficacy, side effects, and any comorbid conditions. Prophylactic treatment may prevent progression to chronic migraines and reduce healthcare costs.
This document reviews various treatment options for major depressive disorder (MDD), one of the most common clinical depressions. The three main treatment approaches discussed are: pharmacotherapy (typically antidepressants), psychotherapies (cognitive-behavioral therapy and interpersonal therapy are most effective), and electroconvulsive therapy (recommended only for severe cases where other treatments haven't worked). Combined treatment of antidepressants and psychotherapy is found to have higher success rates than single treatments alone. While medications and therapies are usually first-line, electroconvulsive therapy may be considered for treatment-resistant MDD.
This document summarizes current research on EEG neurofeedback applied to seven areas of brain health: attention-deficit hyperactivity disorder (ADHD), addictive disorders, anxiety, cognitive decline, depression, peak performance, and post-traumatic stress disorder (PTSD). For ADHD, two neurofeedback protocols have been shown effective based on meta-analyses and large randomized controlled trials. For addictive disorders, neurofeedback has been shown to reduce addiction severity and craving as an adjunctive treatment. Neurofeedback has also been shown as an efficacious treatment for anxiety disorders. Initial evidence suggests neurofeedback may be promising for improving cognitive function in conditions like mild cognitive impairment. Protocols targeting left-frontal brain asymmetry have shown effectiveness
This document summarizes research on neurofeedback efficacy for various brain disorders and conditions. It finds neurofeedback effective for ADHD, with over 60 studies showing large reductions in inattention and impulsivity. Over 30 studies show neurofeedback helps treat addictive disorders using alpha-theta protocols. Neurofeedback also helps anxiety disorders by rewarding relaxing frequencies. It is a promising new treatment for autism spectrum disorder and helps chronic fatigue syndrome, though more research is needed. Neurofeedback improves cognition in the elderly and enhances memory in healthy adults. Over 30 studies show it alleviates depression symptoms using frontal alpha asymmetry protocols.
Practice of hypnosis in anesthesiologyssuserb3286b
This document provides an overview of the history and development of hypnosis. It discusses how hypnosis was used and viewed in ancient times, including practices from over 30,000 years ago. It describes how hypnosis was later seen as magic, entertainment, or a toy rather than a serious medical tool due to lack of understanding. The document also outlines how hypnosis has regained acceptance as its mechanisms and safe applications have become clearer to medical researchers and practitioners in recent decades.
Transition from methylphenidate or amphetamine to atomoxetine in children and...hospital higueras
This study investigated transitioning children and adolescents with ADHD from methylphenidate or amphetamine to atomoxetine. 62 patients participated, with most having ADHD-combined type and previously receiving methylphenidate. Patients transitioned from their stimulant to atomoxetine over 2 weeks. ADHD symptoms improved significantly from baseline to study end based on parent ratings. Most parents and over half of patients preferred atomoxetine treatment to their previous stimulant. The transition was generally well-tolerated, though some increases in blood pressure and heart rate were observed. This pilot study suggests children and adolescents can be successfully switched from stimulants to atomoxetine with resulting ADHD symptom improvement.
Integrated Psychological Therapy (IPT) and Wellness Self-Management (WSM) are two multimodal workbook-based treatments for individuals with schizophrenia. IPT was developed in 1994 and focuses on remediating cognitive deficits through group exercises before building social skills. Research shows IPT improves neurocognition, symptoms, and functioning. WSM was developed in 2001 from Illness Management and Recovery and uses a personal workbook to build competencies like medication management. Over 80% of facilities using WSM continued ten months later. Both treatments aim to improve functioning through cognitive and social rehabilitation, though IPT has more extensive research support currently.
This document summarizes various interventional treatments for headaches including occipital nerve blocks, pulsed radiofrequency of the occipital nerve, and occipital nerve stimulation. It provides epidemiological data on migraine and cluster headaches. It also discusses indications for occipital nerve blocks including various headache types. Peripheral nerve blocks are described as commonly used but with variable methodology. Effectiveness of occipital nerve stimulation is supported for various intractable headache conditions but lead migration is a technical challenge.
Role of atypical antipsychotics in the treatement of generalized anxiety diso...Paul Coelho, MD
This review article examines the evidence for using atypical antipsychotics as adjunctive therapy or monotherapy to treat generalized anxiety disorder (GAD). The most evidence has been collected for quetiapine, which approximately 50% of participants tolerated, most commonly experiencing sedation and fatigue. Among those who continued treatment, significant reductions in anxiety were demonstrated when used as adjunctive therapy or monotherapy. While atypical antipsychotics show promise based on evidence from other disorders, their use for GAD remains off-label and careful consideration of risks and benefits is needed, especially regarding long-term use.
Original ArticleDesign and implementation of a randomized.docxgerardkortney
Original Article
Design and implementation of a randomized
trial evaluating systematic care for bipolar
disorder
Abundant evidence demonstrates that treatments
for bipolar disorder can reduce the severity of
mood symptoms and improve daily functioning.
Specific pharmacotherapies have been proven effi-
cacious in the acute management of mania and
depression (1, 2) as well as in the prevention of
recurrence (1). For lithium, more intensive treat-
ment has been shown to improve both long-term
clinical outcomes and psychosocial functioning.
Promising evidence also supports the efficacy of
several disease-specific psychosocial interventions
for bipolar disorder (3, 4).
Unfortunately, treatments provided in everyday
practice fall far short of those proven in clinical
Simon GE, Ludman E, Unützer J, Bauer MS. Design and implementation
of a randomized trial evaluating systematic care for bipolar disorder.
Bipolar Disord 2002: 4: 226–236. ª Blackwell Munksgaard, 2002
Objectives: Everyday care of bipolar disorder typically falls short of
evidence-based practice. This report describes the design and
implementation of a randomized trial evaluating a systematic program to
improve quality and continuity of care for bipolar disorder.
Methods: Computerized records of a large health plan were used to
identify all patients treated for bipolar disorder. Following a baseline
diagnostic assessment, eligible and consenting patients were randomly
assigned to either continued usual care or a multifaceted intervention
program including: development of a collaborative treatment plan,
monthly telephone monitoring by a dedicated nurse care manager,
feedback of monitoring results and algorithm-based medication
recommendations to treating mental health providers, as-needed outreach
and care coordination, and a structured psychoeducational group
program (the Life Goals Program by Bauer and McBride) delivered by the
nurse care manager. Blinded assessments of clinical outcomes, functional
outcomes, and treatment process were conducted every 3 months for
24 months.
Results: A total of 441 patients (64% of those eligible) consented to
participate and 43% of enrolled patients met criteria for current major
depressive episode, manic episode, or hypomanic episode. An additional
39% reported significant subthreshold symptoms, and 18% reported
minimal or no current mood symptoms. Of patients assigned to the
intervention program, 94% participated in telephone monitoring and 70%
attended at least one group session.
Conclusions: In a population-based sample of patients treated for bipolar
disorder, approximately two-thirds agreed to participate in a randomized
trial comparing alternative treatment strategies. Nearly all patients
accepted regular telephone monitoring and over two-thirds joined a
structured group program. Future reports will describe clinical
effectiveness and cost-effectiveness of the intervention program compared
with usual care.
Gregory E Simona, Evette
Lud.
Moti messiah - ULD buprenorphine for suicidal ideationמוטי משיח
This randomized controlled trial tested the efficacy and safety of ultra-low-dose buprenorphine as a time-limited treatment for severe suicidal ideation. Patients receiving buprenorphine had greater reductions in suicidal ideation scores after 2 and 4 weeks compared to placebo, as measured by the Beck Suicide Ideation Scale. No withdrawal symptoms were reported after discontinuing buprenorphine treatment after 4 weeks. While further research is still needed, this study provides preliminary evidence that short-term use of very low doses of buprenorphine may help reduce suicidal ideation in patients without substance abuse issues.
Case # 29- The depressed man who thought he was out of options. .docxannandleola
Case # 29- The depressed man who thought he was out of options.
Depression has become a common mental disorder in our elderly population. This has caused a global concern for occur, geriatric patients, as depression often results in a significant burden for families as well as communities. Elderly people who suffer from depression may have an inferior baseline and record for medical assessments than those individuals without depression. Despite consistent evidence of the effectiveness of antidepressants for many with depression,
3
particularly those with more severe depression, remission rates are disappointingly low. An AHRQ-sponsored report found that only 46% of patients experienced remission from depression during 6 to 12 weeks of treatment with second-generation antidepressants. One major reason for this issue is non-adherence to medications and treatment plans. Studies have shown that patients' age, race and ethnicity are consistently associated with predictions of outcomes. (Rossom et al., 2016).
This case study involves a 69-year old man whose chief complaint is unremitting, chronic depression. After several years of medications and treatments, he feels hopeless for a recovery from his chronic depression. This assignments seeks to explore his family and social support systems, diagnostic testing, differential diagnosis and pharmacologic treatment options for this patient.
Questions for the client
How have you been sleeping lately?
How many times in the last week have you had feelings of hopelessness?
Are you having thoughts of harming yourself? Do you have a plan?
These questions are an important yet simple place to start when treating patients. Sleep disturbances plague much of the world's population and have shown to be a major indicator for mental health issues. Changes in sleep neurophysiology are often observed in depressive patients, and impaired sleep is, in many cases, the chief complaint of depression (Armitage, 2007). Depressed patients with sleep disturbance are likely to present more severe symptoms and difficulties in treatment. In addition, persistent insomnia is the most common residual symptom in depressed patients and is considered a vital predictor of depression relapse and may contribute to unpleasant clinical outcomes (Hinkelmann et al., 20120. Questions involving feelings of hopelessness and suicidal ideations with or without a plan relate to issues of patient safety. Across psychiatric disorders, hopelessness is associated with suicidal ideation and behavior. A meta-analysis of 166 longitudinal studies (sample size not reported) found that hopelessness was associated with an increased risk of ideation (Ribeiro, Huang, Fox, & Franklin, 2018).
Family and social support system
Family and social support systems are imperative for any patient in recovery. If the patient is agreeable to discussions with family members, then a discussion with his wife would be helpful. Researc.
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise was the only intervention with a "strong for" recommendation based on meta-analyses showing benefits for pain, fatigue, sleep and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies. Pharmacological therapies (amitriptyline, pregabalin, cyclobenzaprine, duloxetine, milnacipran) received "weak for" recommendations for severe pain or sleep issues.
- Growth hormone, sodium oxybate, NSAIDs, S
The Psychological Changes of Horticultura Therapy Intervention for Elderly Women of Earthquake-Related Areas
`
For more information, Please see websites below:
`
Organic Edible Schoolyards & Gardening with Children
http://scribd.com/doc/239851214
`
Double Food Production from your School Garden with Organic Tech
http://scribd.com/doc/239851079
`
Free School Gardening Art Posters
http://scribd.com/doc/239851159`
`
Increase Food Production with Companion Planting in your School Garden
http://scribd.com/doc/239851159
`
Healthy Foods Dramatically Improves Student Academic Success
http://scribd.com/doc/239851348
`
City Chickens for your Organic School Garden
http://scribd.com/doc/239850440
`
Simple Square Foot Gardening for Schools - Teacher Guide
http://scribd.com/doc/239851110
This randomized controlled trial examined whether cognitive behavioral therapy for insomnia (CBT-I) delivered by a therapist is more effective than self-help CBT-I materials at reducing insomnia and depression in individuals with comorbid insomnia and depression being treated with antidepressants. 41 participants were randomized to receive either 4 sessions of CBT-I or self-help materials over 8 weeks. Compared to the self-help group, the CBT-I group showed significantly greater reductions in both insomnia and depression scores post-treatment and at 3-month follow-up. The results suggest that targeting insomnia through CBT-I can effectively treat comorbid insomnia and depression and should be considered an important adjunct treatment for patients whose depression has not fully
This document discusses the relationship between pain and depression. It notes that around 30% of community members suffer from a mental health issue, but only a small portion receive treatment. Major depressive disorder is associated with functional and structural brain changes. Depression and pain commonly occur together and negatively impact health and quality of life. The neurobiology of depression and pain involve neurotransmitters like serotonin, norepinephrine, and dopamine. Depression and chronic pain have overlapping symptoms and biological underpinnings related to these neurotransmitter systems and brain regions like the hippocampus. The document examines theories on how depression and pain may influence each other.
This document summarizes the prophylactic treatment of migraines. It discusses that migraines are a common neurological disease characterized by episodic headache attacks. Prophylactic treatment aims to reduce attack frequency, duration, and severity. A wide variety of medications can be used for prophylactic treatment, including beta-blockers, antidepressants, anticonvulsants, calcium channel blockers, and others. The best agent depends on efficacy, side effects, and any comorbid conditions. Prophylactic treatment may prevent progression to chronic migraines and reduce healthcare costs.
This document reviews various treatment options for major depressive disorder (MDD), one of the most common clinical depressions. The three main treatment approaches discussed are: pharmacotherapy (typically antidepressants), psychotherapies (cognitive-behavioral therapy and interpersonal therapy are most effective), and electroconvulsive therapy (recommended only for severe cases where other treatments haven't worked). Combined treatment of antidepressants and psychotherapy is found to have higher success rates than single treatments alone. While medications and therapies are usually first-line, electroconvulsive therapy may be considered for treatment-resistant MDD.
This document summarizes current research on EEG neurofeedback applied to seven areas of brain health: attention-deficit hyperactivity disorder (ADHD), addictive disorders, anxiety, cognitive decline, depression, peak performance, and post-traumatic stress disorder (PTSD). For ADHD, two neurofeedback protocols have been shown effective based on meta-analyses and large randomized controlled trials. For addictive disorders, neurofeedback has been shown to reduce addiction severity and craving as an adjunctive treatment. Neurofeedback has also been shown as an efficacious treatment for anxiety disorders. Initial evidence suggests neurofeedback may be promising for improving cognitive function in conditions like mild cognitive impairment. Protocols targeting left-frontal brain asymmetry have shown effectiveness
This document summarizes research on neurofeedback efficacy for various brain disorders and conditions. It finds neurofeedback effective for ADHD, with over 60 studies showing large reductions in inattention and impulsivity. Over 30 studies show neurofeedback helps treat addictive disorders using alpha-theta protocols. Neurofeedback also helps anxiety disorders by rewarding relaxing frequencies. It is a promising new treatment for autism spectrum disorder and helps chronic fatigue syndrome, though more research is needed. Neurofeedback improves cognition in the elderly and enhances memory in healthy adults. Over 30 studies show it alleviates depression symptoms using frontal alpha asymmetry protocols.
Practice of hypnosis in anesthesiologyssuserb3286b
This document provides an overview of the history and development of hypnosis. It discusses how hypnosis was used and viewed in ancient times, including practices from over 30,000 years ago. It describes how hypnosis was later seen as magic, entertainment, or a toy rather than a serious medical tool due to lack of understanding. The document also outlines how hypnosis has regained acceptance as its mechanisms and safe applications have become clearer to medical researchers and practitioners in recent decades.
Transition from methylphenidate or amphetamine to atomoxetine in children and...hospital higueras
This study investigated transitioning children and adolescents with ADHD from methylphenidate or amphetamine to atomoxetine. 62 patients participated, with most having ADHD-combined type and previously receiving methylphenidate. Patients transitioned from their stimulant to atomoxetine over 2 weeks. ADHD symptoms improved significantly from baseline to study end based on parent ratings. Most parents and over half of patients preferred atomoxetine treatment to their previous stimulant. The transition was generally well-tolerated, though some increases in blood pressure and heart rate were observed. This pilot study suggests children and adolescents can be successfully switched from stimulants to atomoxetine with resulting ADHD symptom improvement.
Integrated Psychological Therapy (IPT) and Wellness Self-Management (WSM) are two multimodal workbook-based treatments for individuals with schizophrenia. IPT was developed in 1994 and focuses on remediating cognitive deficits through group exercises before building social skills. Research shows IPT improves neurocognition, symptoms, and functioning. WSM was developed in 2001 from Illness Management and Recovery and uses a personal workbook to build competencies like medication management. Over 80% of facilities using WSM continued ten months later. Both treatments aim to improve functioning through cognitive and social rehabilitation, though IPT has more extensive research support currently.
This document summarizes various interventional treatments for headaches including occipital nerve blocks, pulsed radiofrequency of the occipital nerve, and occipital nerve stimulation. It provides epidemiological data on migraine and cluster headaches. It also discusses indications for occipital nerve blocks including various headache types. Peripheral nerve blocks are described as commonly used but with variable methodology. Effectiveness of occipital nerve stimulation is supported for various intractable headache conditions but lead migration is a technical challenge.
Role of atypical antipsychotics in the treatement of generalized anxiety diso...Paul Coelho, MD
This review article examines the evidence for using atypical antipsychotics as adjunctive therapy or monotherapy to treat generalized anxiety disorder (GAD). The most evidence has been collected for quetiapine, which approximately 50% of participants tolerated, most commonly experiencing sedation and fatigue. Among those who continued treatment, significant reductions in anxiety were demonstrated when used as adjunctive therapy or monotherapy. While atypical antipsychotics show promise based on evidence from other disorders, their use for GAD remains off-label and careful consideration of risks and benefits is needed, especially regarding long-term use.
Original ArticleDesign and implementation of a randomized.docxgerardkortney
Original Article
Design and implementation of a randomized
trial evaluating systematic care for bipolar
disorder
Abundant evidence demonstrates that treatments
for bipolar disorder can reduce the severity of
mood symptoms and improve daily functioning.
Specific pharmacotherapies have been proven effi-
cacious in the acute management of mania and
depression (1, 2) as well as in the prevention of
recurrence (1). For lithium, more intensive treat-
ment has been shown to improve both long-term
clinical outcomes and psychosocial functioning.
Promising evidence also supports the efficacy of
several disease-specific psychosocial interventions
for bipolar disorder (3, 4).
Unfortunately, treatments provided in everyday
practice fall far short of those proven in clinical
Simon GE, Ludman E, Unützer J, Bauer MS. Design and implementation
of a randomized trial evaluating systematic care for bipolar disorder.
Bipolar Disord 2002: 4: 226–236. ª Blackwell Munksgaard, 2002
Objectives: Everyday care of bipolar disorder typically falls short of
evidence-based practice. This report describes the design and
implementation of a randomized trial evaluating a systematic program to
improve quality and continuity of care for bipolar disorder.
Methods: Computerized records of a large health plan were used to
identify all patients treated for bipolar disorder. Following a baseline
diagnostic assessment, eligible and consenting patients were randomly
assigned to either continued usual care or a multifaceted intervention
program including: development of a collaborative treatment plan,
monthly telephone monitoring by a dedicated nurse care manager,
feedback of monitoring results and algorithm-based medication
recommendations to treating mental health providers, as-needed outreach
and care coordination, and a structured psychoeducational group
program (the Life Goals Program by Bauer and McBride) delivered by the
nurse care manager. Blinded assessments of clinical outcomes, functional
outcomes, and treatment process were conducted every 3 months for
24 months.
Results: A total of 441 patients (64% of those eligible) consented to
participate and 43% of enrolled patients met criteria for current major
depressive episode, manic episode, or hypomanic episode. An additional
39% reported significant subthreshold symptoms, and 18% reported
minimal or no current mood symptoms. Of patients assigned to the
intervention program, 94% participated in telephone monitoring and 70%
attended at least one group session.
Conclusions: In a population-based sample of patients treated for bipolar
disorder, approximately two-thirds agreed to participate in a randomized
trial comparing alternative treatment strategies. Nearly all patients
accepted regular telephone monitoring and over two-thirds joined a
structured group program. Future reports will describe clinical
effectiveness and cost-effectiveness of the intervention program compared
with usual care.
Gregory E Simona, Evette
Lud.
Moti messiah - ULD buprenorphine for suicidal ideationמוטי משיח
This randomized controlled trial tested the efficacy and safety of ultra-low-dose buprenorphine as a time-limited treatment for severe suicidal ideation. Patients receiving buprenorphine had greater reductions in suicidal ideation scores after 2 and 4 weeks compared to placebo, as measured by the Beck Suicide Ideation Scale. No withdrawal symptoms were reported after discontinuing buprenorphine treatment after 4 weeks. While further research is still needed, this study provides preliminary evidence that short-term use of very low doses of buprenorphine may help reduce suicidal ideation in patients without substance abuse issues.
Case # 29- The depressed man who thought he was out of options. .docxannandleola
Case # 29- The depressed man who thought he was out of options.
Depression has become a common mental disorder in our elderly population. This has caused a global concern for occur, geriatric patients, as depression often results in a significant burden for families as well as communities. Elderly people who suffer from depression may have an inferior baseline and record for medical assessments than those individuals without depression. Despite consistent evidence of the effectiveness of antidepressants for many with depression,
3
particularly those with more severe depression, remission rates are disappointingly low. An AHRQ-sponsored report found that only 46% of patients experienced remission from depression during 6 to 12 weeks of treatment with second-generation antidepressants. One major reason for this issue is non-adherence to medications and treatment plans. Studies have shown that patients' age, race and ethnicity are consistently associated with predictions of outcomes. (Rossom et al., 2016).
This case study involves a 69-year old man whose chief complaint is unremitting, chronic depression. After several years of medications and treatments, he feels hopeless for a recovery from his chronic depression. This assignments seeks to explore his family and social support systems, diagnostic testing, differential diagnosis and pharmacologic treatment options for this patient.
Questions for the client
How have you been sleeping lately?
How many times in the last week have you had feelings of hopelessness?
Are you having thoughts of harming yourself? Do you have a plan?
These questions are an important yet simple place to start when treating patients. Sleep disturbances plague much of the world's population and have shown to be a major indicator for mental health issues. Changes in sleep neurophysiology are often observed in depressive patients, and impaired sleep is, in many cases, the chief complaint of depression (Armitage, 2007). Depressed patients with sleep disturbance are likely to present more severe symptoms and difficulties in treatment. In addition, persistent insomnia is the most common residual symptom in depressed patients and is considered a vital predictor of depression relapse and may contribute to unpleasant clinical outcomes (Hinkelmann et al., 20120. Questions involving feelings of hopelessness and suicidal ideations with or without a plan relate to issues of patient safety. Across psychiatric disorders, hopelessness is associated with suicidal ideation and behavior. A meta-analysis of 166 longitudinal studies (sample size not reported) found that hopelessness was associated with an increased risk of ideation (Ribeiro, Huang, Fox, & Franklin, 2018).
Family and social support system
Family and social support systems are imperative for any patient in recovery. If the patient is agreeable to discussions with family members, then a discussion with his wife would be helpful. Researc.
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise was the only intervention with a "strong for" recommendation based on meta-analyses showing benefits for pain, fatigue, sleep and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies. Pharmacological therapies (amitriptyline, pregabalin, cyclobenzaprine, duloxetine, milnacipran) received "weak for" recommendations for severe pain or sleep issues.
- Growth hormone, sodium oxybate, NSAIDs, S
The document provides revised recommendations for the management of fibromyalgia based on a review of evidence from systematic reviews and meta-analyses published since the original 2005 guidelines. Key findings include:
- Exercise is the only therapy strongly recommended based on meta-analyses showing benefit for pain, sleep, and functioning.
- A graduated four-stage approach is proposed, beginning with patient education and non-pharmacological therapies.
- If non-response, further therapies such as psychological therapies, pharmacotherapy, or rehabilitation may be tailored to the individual. However, meta-analyses only found weak evidence for all potential pharmacological therapies.
- Most treatments show relatively modest effects. Future research priorities are identifying who benefits from specific interventions,
This document summarizes a systematic review that analyzed randomized controlled drug trials for fibromyalgia syndrome (FMS) and painful diabetic peripheral neuropathy (DPN) to determine the impact of nocebo effects on adverse events reported. The review found that nocebo effects substantially accounted for adverse events in the drug groups for both conditions. Specifically, nocebo effects accounted for 72.0% of dropouts due to adverse events in the FMS drug groups and 44.9% in the DPN drug groups. The review calls for standards to better assess and report adverse events in clinical trials to more accurately determine the risks and benefits of drug therapies.
MINDFULGym: 7 Mindful Habits for Behavioral Therapists Self-CarePhang Kar
This document discusses mindfulness and mindfulness-based therapies. It begins by defining mindfulness as paying attention to the present moment with kindness, an open mind, and wisdom. It then discusses how mindfulness was introduced into medicine by Jon Kabat-Zinn in the 1970s through mindfulness-based stress reduction programs. Several mindfulness-based therapies are described, including MBCT and DBT. Research findings on the effectiveness of mindfulness-based therapy in reducing anxiety, depression, and stress are summarized. The document also provides examples of mindfulness training programs for healthcare professionals and describes habits to incorporate mindfulness into one's daily life and work.
Effect of homeopathy on chronic tension-type headache: a pragmatic, randomise...home
Homeopathy is increasingly used by headache patients in
general practice but scientific evidence is lacking. We
therefore designed a clinical trial in a way that would not
change the practice pattern of homeopathic physicians.
Neurofeedback shows promise as a treatment for anxiety, depression, and other conditions. Research indicates it can significantly reduce test anxiety and symptoms of generalized anxiety. Studies found neurofeedback reduced anxiety scores more than relaxation training or no treatment. Clinical reports also suggest neurofeedback may effectively treat mild to severe depression. It has produced significant, enduring changes in mood and depression symptoms in approximately 80% of patients. Neurofeedback also seems to have minimal risks and be less invasive than other treatments like antidepressants. More research is still needed, but it qualifies as an evidence-based treatment for certain anxiety disorders and could be an effective alternative treatment for modifying dysfunctional brain patterns associated with psychiatric conditions.
This document provides an overview of advanced counseling methods and psychotherapy. It discusses different theoretical perspectives like Adlerian, cognitive, and family systems theories. It also addresses the difference between psychosocial models of counseling that rely on talk therapy compared to biological/neurogenomic models in psychiatry that emphasize medication. The document notes how clinical orientation impacts assessment, treatment planning, and intervention methods. It also discusses debates around whether mental disorders are caused primarily by psychosocial or biological factors.
Cognitive behavioral therapy can help treat depression in patients with congestive heart failure. Up to 60% of heart failure patients experience some level of depression. An interdisciplinary team approach is needed to properly treat both the physical and mental health aspects of patients. This includes cardiologists, psychiatrists, psychologists, nurses, and others. Cognitive behavioral therapy focuses on changing negative thoughts and behaviors to improve coping skills and reduce depression symptoms. Studies show this therapy can be effective for heart failure patients with depression, improving quality of life and reducing hospitalizations.
This document summarizes key findings from recent research studies. It discusses research showing that benzodiazepines are often inappropriately prescribed to patients with certain conditions like depression, COPD, or substance abuse issues. Another study found that antidepressants were not effective for treating complicated grief on their own but did help reduce depressive symptoms when added to psychotherapy for grief. A third study examined global sleep patterns and found that while social factors influence bedtimes, biological clocks primarily determine wake times, meaning later bedtimes can lead to less sleep.
The document summarizes guidelines from Canada, Germany, Israel, and Europe for the diagnosis and management of fibromyalgia (FM). Key points include:
- FM is a prevalent condition affecting approximately 2% of the population. It is characterized by chronic widespread pain, fatigue, sleep disturbances, and other symptoms.
- Diagnosis is based on a history and exam showing widespread tenderness. Basic tests can rule out other conditions.
- Optimal management begins with education and a graduated approach focusing first on lifestyle changes like exercise. Cognitive behavioral therapy and medications may also be considered.
- Guidelines agree the diagnosis is clinical. Exams and tests aim to rule out other conditions causing pain. History should include symptoms of pain, fatigue,
This document summarizes a systematic review and meta-analysis of idiopathic sudden sensorineural hearing loss (ISSNHL) in children. The review found that the overall recovery rate for pediatric ISSNHL was 67.91%, similar to adults. A meta-analysis found no significant difference between combined systemic-intratympanic steroid therapy versus solely systemic treatment. The review was limited by the rarity of pediatric ISSNHL and heterogeneity between retrospective case studies. Larger prospective studies are still needed to determine the most effective treatment options for this condition in children.
Homeopathy in the treatment of fibromyalgia A comprehensive literature-review...home
Given the low number and included trials and the lowmethodological quality, any conclusion based on the resultsof this review have to be regarded as preliminary. However,as single case studies and clinical trials indicate a positiveeffect, homeopathy could be considered a complementarytreatment for patients with fibromyalgia
This study examined antidepressant use among 3,226 elderly patients receiving home healthcare. Over one-third of patients were taking antidepressants, including 29.15% without a documented depression diagnosis. Blacks used antidepressants less than whites even after controlling for other factors. Increased antidepressant use was associated with younger age, more disabilities, use of other psychotropics like benzodiazepines, and higher overall medication counts. The high rates of antidepressant use without depression raise questions about appropriate prescribing in this vulnerable population.
This study examined psychiatric comorbidities and treatment outcomes in 100 mentally ill prisoners referred to a tertiary psychiatric hospital in India. The most common primary diagnoses were substance use disorder (45%) and adjustment disorder (36%). 46% of prisoners had more than one psychiatric diagnosis, most commonly intellectual disabilities, personality disorders, and substance use disorders. 59% were treated with medication alone, 27% required inpatient admission, and outcomes were generally positive with patients responding well to treatment. The high rates of comorbidities suggest the need for integrated treatment approaches within prison psychiatric services.
The conundrum of opioid tapering in long term opioid therapy for chronic pain...Paul Coelho, MD
The document discusses the challenges clinicians face when tapering patients off long-term opioid therapy for chronic pain. It explains that opioid dependence can cause worsening pain, psychiatric symptoms, and functioning during tapering due to neuroplastic changes. While tapering seems logical to address risks of high-dose opioids, it may paradoxically make a patient's issues worse due to protracted abstinence syndrome. The document provides guidance for managing these complex patients focused on both pain and opioid dependence.
Este documento analiza las ceremonias de emoción desde una perspectiva antropológica y psicológica. Explora cómo estas ceremonias satisfacen una necesidad humana de trascender el individuo y conectar con algo más grande a través de la emoción compartida. También examina cómo la música y los rituales pueden crear estados alterados de conciencia que dotan de sentido a la vida de los creyentes. Finalmente, sugiere que más que distinguir entre religión y cultura, debemos ver estas prácticas como auténticas expresiones del sentido
Este documento presenta una colección de 57 poemas cortos sobre temas científicos como el universo, la física cuántica, la cosmología y otros temas relacionados con la ciencia. Los poemas exploran conceptos como el espacio, el tiempo, la materia, la luz, la gravedad y las partículas subatómicas de una manera poética y reflexiva.
Este documento contiene una colección de 57 poemas cortos sobre temas científicos como el universo, la física cuántica, la cosmología y otros temas relacionados con la ciencia. Los poemas exploran conceptos como el espacio, el tiempo, la materia, la luz, los quarks, los neutrinos y otros fenómenos científicos de manera lírica y metafórica. La colección parece intentar transmitir ideas científicas complejas de una manera poética y accesible al lector común.
Este poema contiene 57 poemas cortos sobre temas relacionados con la ciencia como el universo, la física, la química y la naturaleza. Los poemas exploran conceptos como el espacio, la materia, el tiempo, la luz y las galaxias de una manera lírica y filosófica.
La película ¡Qué bello es vivir! de Frank Capra es un alegato contra el suicidio que muestra cómo la vida de George Bailey ha tenido un impacto positivo en muchos otros y cómo Bedford Falls sería un lugar peor sin él. La película también sugiere que encontrar un sentido a la propia vida a través de vivir para los demás es el mejor antídoto contra el suicidio.
La película Days of Wine and Roses de Blake Edwards cuenta la historia de amor destructiva entre dos personas vulnerables, Joe y Kirsten, que caen en la adicción al alcohol para evitar enfrentar su fragilidad emocional. A medida que su relación progresa, cada uno induce al otro a beber más para evitar que el otro permanezca sobrio y los haga sentir expuestos. Al final, aunque Joe elige la recuperación, Kirsten elige seguir el camino del alcoholismo.
La película de Blake Edwards relata la historia de amor destructiva entre dos alcohólicos, Joe y Kirsten. Ambos se sienten vulnerables y avergonzados por su adicción, por lo que se inducen mutuamente a beber para evitar que el otro permanezca sobrio y los haga sentir expuestos. A medida que su dependencia al alcohol empeora, su relación también se deteriora a pesar de sus sentimientos de amor.
La película Days of Wine and Roses de Blake Edwards cuenta la historia de amor destructiva entre dos personas vulnerables, Joe y Kirsten, que caen en la adicción al alcohol para evitar enfrentar su fragilidad emocional. A medida que su relación progresa, cada uno induce al otro a beber más para evitar que el otro vea su verdadera debilidad, atrapándolos en un ciclo de dependencia mutua y autodestrucción. Al final, Joe elige la sobriedad pero ve cómo Kirsten elige hundirse aún más en su adic
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central19various
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa CentralClinic ^%[+27633867063*Abortion Pills For Sale In Tembisa CentralClinic ^%[+27633867063*Abortion Pills For Sale In Tembisa CentralClinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
1. Articles
www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61746-8 1
Focal psychodynamictherapy, cognitive behaviourtherapy,
and optimisedtreatment as usual in outpatients with
anorexia nervosa (ANTOP study): randomised controlledtrial
Stephan Zipfel, BeateWild, Gaby Groß, Hans-Christoph Friederich, MartinTeufel, Dieter Schellberg, Katrin E Giel, Martina de Zwaan,
Andreas Dinkel, Stephan Herpertz, Markus Burgmer, Bernd Löwe, SefikTagay, Jörn vonWietersheim, Almut Zeeck, Carmen Schade-Brittinger,
Henning Schauenburg,Wolfgang Herzog on behalf of the ANTOP study group*
Summary
Background Psychotherapy is the treatment of choice for patients with anorexia nervosa, although evidence of efficacy
is weak. The Anorexia Nervosa Treatment of OutPatients (ANTOP) study aimed to assess the efficacy and safety of
two manual-based outpatient treatments for anorexia nervosa—focal psychodynamic therapy and enhanced cognitive
behaviour therapy—versus optimised treatment as usual.
Methods The ANTOP study is a multicentre, randomised controlled efficacy trial in adults with anorexia nervosa.
We recruited patients from ten university hospitals in Germany. Participants were randomly allocated to 10 months of
treatment with either focal psychodynamic therapy, enhanced cognitive behaviour therapy, or optimised treatment as
usual (including outpatient psychotherapy and structured care from a family doctor). The primary outcome was
weight gain, measured as increased body-mass index (BMI) at the end of treatment. A key secondary outcome
was rate of recovery (based on a combination of weight gain and eating disorder-specific psychopathology).
Analysis was by intention to treat. This trial is registered at http://isrctn.org, number ISRCTN72809357.
Findings Of 727 adults screened for inclusion, 242 underwent randomisation: 80 to focal psychodynamic therapy,
80 to enhanced cognitive behaviour therapy, and 82 to optimised treatment as usual. At the end of treatment, 54 patients
(22%) were lost to follow-up, and at 12-month follow-up a total of 73 (30%) had dropped out. At the end of treatment,
BMI had increased in all study groups (focal psychodynamic therapy 0·73 kg/m², enhanced cognitive behaviour
therapy 0·93 kg/m², optimised treatment as usual 0·69 kg/m²); no differences were noted between groups
(mean difference between focal psychodynamic therapy and enhanced cognitive behaviour therapy –0·45,
95% CI –0·96 to 0·07; focal psychodynamic therapy vs optimised treatment as usual –0·14, –0·68 to 0·39; enhanced
cognitive behaviour therapy vs optimised treatment as usual –0·30, –0·22 to 0·83). At 12-month follow-up, the mean
gain in BMI had risen further (1·64 kg/m², 1·30 kg/m², and 1·22 kg/m², respectively), but no differences between
groups were recorded (0·10, –0·56 to 0·76; 0·25, –0·45 to 0·95; 0·15, –0·54 to 0·83, respectively). No serious adverse
events attributable to weight loss or trial participation were recorded.
Interpretation Optimised treatment as usual, combining psychotherapy and structured care from a family doctor,
should be regarded as solid baseline treatment for adult outpatients with anorexia nervosa. Focal psychodynamic
therapy proved advantageous in terms of recovery at 12-month follow-up, and enhanced cognitive behaviour therapy
was more effective with respect to speed of weight gain and improvements in eating disorder psychopathology.
Long-term outcome data will be helpful to further adapt and improve these novel manual-based treatment approaches.
Funding German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung,
BMBF), German Eating Disorders Diagnostic and Treatment Network (EDNET).
Introduction
Anorexia nervosa is associated with serious medical
morbidity1,2
and pronounced psychosocial comorbidity.3
It has the highest mortality rate of all mental disorders4,5
and relapse happens frequently.6
The course of illness is
very often chronic, particularly if left untreated.7
Partial
syndromes are also associated with adverse health
outcomes. Quality of life for patients is poor, and the cost
and burden placed on individuals, families,1
and society
is high.8
The overall incidence of anorexia nervosa is at
least eight people per 100000 per year, with an average
prevalence of 0·3% in girls and young women.9
The
severity, poor prognosis, and low prevalence of the
disorder are reasons why large randomised controlled
trials are needed and why difficulties arise in imple-
mentation of treatment studies.10
According to international treatment guidelines, psycho-
therapy is the treatment of choice for patients with anor-
exia, although no evidence clearly supports the efficacy of
any specific form of psychotherapy.11
Guidelines from the
UK’s National Institute for Health and Care Excellence
(NICE) outline 75 recommendations for the treatment of
anorexia nervosa.12
74 of these treatments have received a
grade of C, meaning that good quality, directly applicable
Published Online
October 14, 2013
http://dx.doi.org/10.1016/
S0140-6736(13)61746-8
See Online/Comment
http://dx.doi.org/10.1016/
S0140-6736(13)61940-6
*See end of report for ANTOP
study group members
Department of Psychosomatic
Medicine and Psychotherapy,
University HospitalTübingen,
Tübingen, Germany
(Prof S Zipfel MD, G Groß PhD,
MTeufel MD, K E Giel PhD);
Center for Psychosocial
Medicine, Department of
General Internal Medicine and
Psychosomatics, Heidelberg
University Hospital,
Heidelberg, Germany
(BWild PhD, H-C Friederich MD,
D Schellberg PhD,
Prof H Schauenburg MD,
ProfW Herzog MD);
Department of Psychosomatic
Medicine and Psychotherapy,
University Hospital Erlangen,
Erlangen, Germany
(Prof M de Zwaan MD); Clinic for
Psychosomatic Medicine and
Psychotherapy, University of
Technology Munich, Munich,
Germany (A Dinkel PhD); Clinic
for Psychosomatic Medicine
and Psychotherapy, LWL
University Hospital of the Ruhr,
University of Bochum,
Bochum, Germany
(Prof S Herpertz MD); Clinic for
Psychosomatic Medicine and
Psychotherapy, University
Hospital Münster, Münster,
Germany (Prof M Burgmer MD);
Institute and Outpatient Clinic
for Psychosomatic Medicine
and Psychotherapy, University
Hospital Hamburg-Eppendorf,
Hamburg, Germany
(Prof B Löwe MD); Clinic for
Psychosomatic Medicine and
Psychotherapy, LVR Hospital
Essen, University of
Duisburg-Essen, Essen,
Germany (STagay PhD);
Department of Psychosomatic
2. Articles
2 www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61746-8
Medicine and Psychotherapy,
University Hospital of Ulm,
Ulm, Germany
(Prof J vonWietersheim PhD);
Department of Psychosomatic
Medicine and Psychotherapy,
University Hospital Freiburg,
Freiburg, Germany
(Prof A Zeeck MD); and
Coordination Center for Clinical
Trials (KKS), Marburg, Germany
(C Schade-Brittinger MA)
Correspondence to:
Prof Stephan Zipfel, Department
of Psychosomatic Medicine and
Psychotherapy, University
HospitalTübingen,Tübingen,
Germany
stephan.zipfel@
med.uni-tuebingen.de
clinical studies are absent and that recommendations are
based solely on the opinions, clinical experience, or both
of respected authorities in the field. According to NICE
guidelines, psychological treatment of anorexia nervosa
aims to lessen risk, encourage weight gain and healthy
eating, reduce other symptoms related to the eating
disorder, and facilitate psychological and physical recovery.
In a Cochrane review of outpatient treatment for anorexia
nervosa,13
only seven small trials were identified, two of
which included children or adolescents. Findings of two
of the trials implied that treatment as usual might be less
effective than a specific psychotherapy. No particular
treatment, however, was consistently superior to any
other approach.
In adults with anorexia nervosa, some evidence shows
the effectiveness of outpatient focal psychodynamic
therapy and cognitive behaviour therapy.14–16
In one trial,17
at the end of the treatment period, a supportive therapy
delivered by specialists was superior to two specific
psychotherapies, with respect to a combined global
outcome measure. However, long-term follow-up of this
trial showed that interpersonal therapy was the most
successful treatment.18
Findings of intervention studies
applying deep-brain stimulation19
or adapting psycho-
therapeutic approaches for patients with chronic anorexia
nervosa20
have also showed some promising results for
this cohort.
Evidence accumulated thus far does not support any one
particular psychotherapeutic method for the treatment of
adults with anorexia nervosa.1,13
However, therapeutic sup-
port from a non-specialist clinician might be less success-
ful than a specific form of psychotherapy provided by a
specialist. Additionally, no evidence strongly advocates
drug treatment either in the acute or maintenance phase
of the illness.21
Large, well designed psychotherapeutic
trials are needed urgently. We designed the Anorexia
Nervosa Treatment of OutPatients (ANTOP) study to
investigate the efficacy of two manual-based, psycho-
therapeutic, eating disorder-specific outpatient therapies
for adults with anorexia nervosa—focal psychodynamic
therapy and enhanced cognitive behaviour therapy—
compared with optimised treatment as usual.
Methods
Study design and participants
ANTOP was a multicentre, randomised controlled efficacy
trial in adult patients with anorexia nervosa. The trial
protocol, outlining details on study design, has been
published elsewhere.22
Over a 2-year period, we screened
patients from outpatient departments of ten German
university departments of psychosomatic medicine and
psychotherapy (Bochum, Erlangen, Essen, Freiburg,
Hamburg, Heidelberg, Munich, Münster, Tübingen, and
Ulm) for inclusion in the study. Inclusion criteria were:
adult patient (aged ≥18 years); female sex; a diagnosis of
anorexia nervosa or subsyndromal anorexia nervosa (one
diagnostic criterion absent), according to the diagnostic
and statistical manual of mental disorders, 4th edition
(DSM-IV); and a body-mass index (BMI) of 15–18·5 kg/m².
Exclusion criteria were: current substance abuse; use of
neuroleptic drugs; psychotic or bipolar disorder; serious
unstable medical problems; and ongoing psychotherapy.
We medically assessed patients at baseline and did a
comprehensive diagnostic assessment, which included
measuring weight and height and undertaking structured
diagnostic interviews specific to psychiatry and eating
disorders. We obtained written informed consent from
every participant at the baseline visit. Independent
research ethics committees at every participating centre
approved the study.
Randomisation and masking
The independent coordination centre for clinical trials
(Marburg, Germany) did centralised randomisation.
Patients were randomly assigned to 10 months of treat-
ment with either focal psychodynamic therapy, enhanced
cognitive behaviour therapy, or optimised treatment as
usual in a 1:1:1 ratio. We used the Rosenberg and Lachin
covariate-adaptive randomisation procedure23
based on
Nordle and Brantmark’s design.24
This procedure com-
bines elements of the minimisation approach (to
optimally allocate a treatment to a particular patient
based on his or her prognostic factor combination) with
the biased-coin technique to avoid a deterministic treat-
ment allocation. We stratified randomisation by centre
and duration of anorexia nervosa (≤6 years vs >6 years).
After patients were randomised into groups, the indepen-
dent centre faxed trial sites the treatment allocation.
Complete masking of participants was not feasible
because a third of patients were allocated optimised treat-
ment as usual and, therefore, were not treated at the
respective centres. More information about the masking
procedure is provided in the appendix (p 2).
Procedures
Patients allocated to either focal psychodynamic therapy
or enhanced cognitive behaviour therapy received an
individual outpatient intervention based on standardised
treatment manuals.25,26
To avoid contamination between
treatment arms, the two approaches were provided by
different therapists, who were all skilled at the underlying
therapeutic approach (panel 1). Therapists received initial
2-day training from experts (focal psychodynamic therapy:
WH, HS, H-CF; enhanced cognitive behaviour therapy:
C Fairburn), followed by annual training updates (focal
psychodynamic therapy: WH, HS, H-CF; enhanced cog-
nitive behaviour therapy: GG, MdZ). At every fourth
session, experienced local supervisors oversaw the thera-
pists’ work. Panel 1 outlines the essentials of the three
treatment manuals. Information about adherence control
and treatment fidelity is provided in the appendix (p 4).
We did the study according to International Conference
on Harmonisation Good Clinical Practice guidelines. We
incorporated quality-control methods including case-report
See Online for appendix
3. Articles
www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61746-8 3
forms, independent data management, on-site monitoring,
and documentation of adverse and severe adverse events.
Data management included regular checks for consistency
and plausibility, and queries if inconsistencies or missing
data were noted. In addition to an initiation site visit in
2007 and a close-out visit in 2011, the independent
coordination centre made three annual on-site data
monitoring visits to every study centre, according to
existing standard operating procedures. The main aim of
the monitoring procedure was to verify patients’ safety and
the completeness, accuracy, and validity of the trial data,
and to comply with the study protocol. Additionally, the
principal investigators (SZ, WH, BW, and GG) had to
report to the independent data safety and monitoring
committee during annual meetings. After the study
protocol was published and finally approved by the
independent coordination centre, two statisticians not
involved in treatment and diagnostics of the ANTOP study
did biometric analyses.
Outcome measures
We took measurements at five timepoints: at a baseline
assessment (before randomisation); 4 months after treat-
ment was started; 10 months after the start of treatment
(which accorded with the end of treatment); after
3 months of follow-up (short-term); and at a 12-month
Panel 1:Treatment provided
Overview
We developed a framework of medical care for all patients in
the ANTOP study.This framework included at least five regular
sessions of specialist assessment at the patient’s specific study
centre.To avoid and reduce medical complications during the
study period, we asked all patients to see their family doctor at
least once a month. Every individual study centre gave patients’
family doctors written instructions on how to provide care in
relation to this study.Treatment was provided face-to-face by
doctors and psychologists specialising in anorexia nervosa and
the respective assigned treatment method. Additionally, we
implemented a rigorous system of supervision, adherence
control, and treatment fidelity (appendix p 3).
Focal psychodynamic therapy
At the beginning of focal psychodynamic therapy (FPT), we
identified psychodynamic foci with a standardised,
operationalised, psychodynamic diagnostic interview.The
psychodynamic treatment manual can be divided roughly into
three treatment phases.The first phase focuses mainly on
therapeutic alliance, pro-anorectic behaviour and ego-syntonic
beliefs (attitudes and behaviour viewed as acceptable), and
self-esteem. In the second phase of treatment, main focus is
placed on relevant relationships and the association between
interpersonal relationships and eating (anorectic) behaviour.
The pertinent aspects of the final phase are the transfer to
everyday life, anticipation of treatment termination, and
parting. Before every treatment session, an independent
assessor measured every patient’s weight and reported it to his
or her therapist.26
Enhanced cognitive behaviour therapy
TheunpublishedGerman versionofthe manual for enhanced
cognitive behaviourtherapy (CBT-E)used inthistrialwas
developed in 2007during initialtraining. It is basedon a report
written by Fairburn before publicationof his manual.25
Therapists
in enhanced cognitive behaviourtherapy haveused Fairburn’s
manual since its publication.The cognitive behaviourtreatment
plan consistsof several modules,ofwhich motivation (starting
well), nutrition, creating a formulation, and relapse prevention
(endingwell) are essential.Other modulestarget cognitive
restructuring, mood regulation, social skills, shape concern, and
self-esteem.Thetreatment plan represents an extensionofthe
focused versionof enhanced cognitive behaviourtherapy,
combinedwith elementsofthe broad version. It focuseson
educationof patients about beingunderweight and starvation
and helps patients initiate and maintain regular eating and
healthyweight gain. Enhancementof self-efficacy and
self-monitoring are crucial elementsofthe entiretreatment
process.Therefore,therapists selected additional practice and
homeworkworksheets,written inGerman,whichthey gave
patients atthe endof every session.The patients receivedthese
homework assignments (next steps)to ensurethe generalisation
andtransferoftherapeutic changestodaily life. Furtherdetailsof
thetwo interventions aredescribed inthetreatment manuals
and additional published materials.
Optimised treatment as usual
Patients assigned to optimised treatment as usual received
support in accessing therapy and were given a list of established
outpatient psychotherapists with experience in treating eating
disorders and who work in accordance with German general
psychotherapy guidelines. Patients’ family doctors had an
active role in treatment and monitoring. In the German
health-care system, psychotherapy for patients with eating
disorders—in particular, those with anorexia nervosa—is usually
covered by health insurance.To further optimise the treatment
as usual approach, patients’ family doctors had three roles.
First, they were asked to take regular weight measurements, do
monthly blood tests, and make structured reports to the study
centre. Second, they were advised to admit patients to hospital
should they fall under a particular weight (body-mass index
<14 kg/m²). Finally, they were informed about physical and
psychiatric risks in patients with anorexia nervosa and were
instructed to contact the respective study centre should a
patient become at risk. In the study protocol, treatment
(dosage and type of therapy) in the optimised treatment as
usual study group was not regulated. Patients assigned to this
group had at least five contact sessions with the study centre,
at which their weight, laboratory findings, eating pathology,
and psychiatric comorbidity were investigated and monitored.
4. Articles
4 www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61746-8
follow-up visit (appendix p 7). BMI measurements taken
at the end of treatment and at the 12-month follow-up
visit served as the ANTOP trial’s primary outcome.
Masked and trained assessors measured patients’ height
and weight at the baseline assessment. Assessors
checked patients’ weight at every timepoint. Patients
were weighed wearing light clothing (without shoes),
using a balance-beam scale that was recalibrated
regularly. We calculated BMI using bodyweight in kg
divided by height in m squared (kg/m²).
Masked assessors measured secondary outcomes of
general psychopathology and eating disorder-specific
psychopathology (appendix p 5). They used a self-
assessment test—the eating disorder inventory-2
(EDI-2)—to investigate eating disorder pathology. We
used the structured clinical interview for DSM-IV axis I
mental disorders (SCID-I) to measure psychiatric
comorbidity. Furthermore, we used the full structured
interview for anorexic and bulimic syndromes (SIAB-EX)
to measure in detail the symptomatology of anorexia
nervosa and bulimia nervosa. In addition to receiving
certified SCID-I training, the authors of the SIAB-EX
interview held a 2-day workshop to train assessors how to
do expert ratings, before patient recruitment began.
Annual 1-day workshops were held throughout the study
period to ensure the high quality of data assessment.
Masked assessors also applied the psychiatric status
rating (PSR) scale based on the patient’s SIAB-EX
interview (appendix p 5). The PSR scale is used to
measure the general severity of the anorexic disorder.
PSR scores range from 1 (patient has no symptoms of
anorexia nervosa) to 6 (patient has severe symptoms of
anorexia nervosa that require admission). A score
of 5 indicates that all DSM-IV criteria for anorexia
nervosa have been fulfilled. At baseline, all patients had a
PSR score of 4 (subsyndromal anorexia nervosa) or 5 (full
syndromal anorexia nervosa). To ascertain a strictly
defined rating of outcome at the end of treatment and at
the 12-month follow-up visit, we established a global
outcome score based on the following combinations of
PSR scores and BMI: recovery (scored as 3) was defined
as a PSR score of 1 or 2 and BMI greater than 18·5 kg/m²;
full syndrome anorexia nervosa (scored as 1) was a PSR
score of 5 or 6 and BMI of 17·5 kg/m² or lower; and
partial syndrome anorexia nervosa (scored as 2) included
all other cases.
We recorded service dosage in terms of the number of
outpatient psychotherapy sessions accessed (includ-
ing the studied interventions of focal psychodynamic
therapy and enhanced cognitive behaviour therapy) and
use of any inpatient or day-patient treatment. Addition-
ally, we asked patients assigned to both focal psycho-
dynamic therapy and enhanced cognitive behaviour
therapy groups to give brief feedback about the helpful-
ness of the sessions (gauged on a visual analogue scale
from 0 to 10) and the length of treatment (too short,
adequate, or too long).
Statistical analysis
Our primary hypothesis had two parts. The first part
stated that the outpatient intervention of focal psycho-
dynamic therapy would have a better outcome with
respect to BMI at the end of treatment compared with
optimised treatment as usual. The second part stated that,
compared with optimised treatment as usual, the
outpatient intervention of enhanced cognitive behaviour
therapy would have a better outcome with respect to BMI
at the end of treatment.22
Before we began to obtain data,
we also proposed the same hypotheses for the 12-month
follow-up visit. Additionally, we expected that both at the
end of treatment and at the 12-month follow-up visit,
recovery rates defined in terms of a combined outcome
(in accordance with DSM-IV) would be higher for
treatments specific for anorexia nervosa (ie, focal psycho-
dynamic therapy and enhanced cognitive behaviour
therapy) than for optimised treatment as usual.
On the basis of the results of two smaller randomised
controlledtrials,inwhichtheeffectsoffocalpsychodynamic
therapy and enhanced cognitive behaviour therapy were
assessed in outpatients with anorexia nervosa,13,14
we
assumed that the different interventions would result in
an improvement in BMI of 1·0 kg/m² compared with
optimised treatment as usual (assumed SD 1·7; effect
size 0·59). Because the hypothesis for the primary efficacy
endpoint entails two statistical tests—namely, focal
psychodynamic therapy versus optimised treatment as
usual, and enhanced cognitive behaviour therapy versus
optimised treatment as usual—the nominal α for the
primary hypothesis was set to 2·5% (two-sided) to restrict
the type 1 error to 5%. For a two-sided t test with 2·5%
significance and 80% power, we needed a sample size of
55 patients per group, resulting in a study sample size
of 165. We increased the sample size to 242 patients to
allow for a dropout rate of at least 30%. The independent
coordination centre approved the statistical analysis plan
before outcome data were examined.
We analysed the primary outcome by intention to treat,
which included all patients who underwent random-
isation, at the end of treatment and at the 12-month
follow-up visit. We imputed missing data with a longitu-
dinal approach (mixed model for repeated measures
[MMRM]). The ANTOP schedule of measurements
provided a precondition for using MMRM—ie, one
additional measurement timepoint between baseline and
end of treatment—so time trends could be modelled. We
decided to use MMRM as the first imputation method
because findings of a series of studies showed that
MMRM is more robust to biases from missing data than
is the last-observation-carried-forward method.27
This
decision was noted in the statistical analysis plan before
data were examined. We also applied the mean-other
imputation method. With this approach, missing values
are replaced with the mean of the other group to provide
a conservative approach (in our trial, this process was
done to avoid erroneous decisions in favour of focal
5. Articles
www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61746-8 5
psychodynamic therapy or enhanced cognitive behaviour
therapy; appendix p 8). As an additional sensitivity
measure, we did a complete case analysis (appendix p 9)
that included all patients who had BMI values at all
measurement timepoints. We also did a per-protocol
analysis that included all patients who received at least
27 therapy sessions, had a BMI measurement taken
either at the end of treatment or at the 12-month
follow-up visit, were not pregnant during the trial or at
12-month follow-up, and were not admitted to hospital
for more than 4 weeks during the trial.
For the primary outcome analysis, we compared both
treatment groups (focal psychodynamic therapy and
enhanced cognitive behaviour therapy) with the optimised
treatment as usual group. The primary outcome—BMI
at the end of treatment—was analysed with a mixed
modelling approach. We entered the grand mean,
treatment effects, and the binary stratification variable
(duration of anorexia nervosa, ≤6 years vs >6 years) as
fixed effects. Because trial sides were not chosen at
random, we decided before data analysis started to model
the centre effect as a fixed effect. Baseline BMI was
entered as a covariate. The mathematical equation for our
modelling approach is described elsewhere.22
We tested
the main hypothesis (primary outcome) by doing a series
of pairwise comparisons. To investigate secondary
hypotheses, we did exploratory analyses with a similar
approach. In all analyses, we entered the variable of
centre as a control variable. We analysed the global
outcome with the MMRM approach, and this variable
was treated as continuous. For the moderator analysis of
anorexia nervosa subtypes, we divided the study sample
into two groups and did the MMRM analysis for each
group separately. We set the significance level to 5% for
exploratory analyses. We used SAS versions 9.1 and 9.2
for statistical analyses.
In patients with anorexia nervosa, food restriction and
purging behaviour can lead to life-threatening starvation
that requires inpatient medical monitoring. Because
severe weight loss is central to the psychopathology of
anorexia nervosa, intermittent inpatient treatment of up
to 4 weeks as a crisis intervention was not judged a serious
adverse event. All other life-threatening or fatal events
were defined as serious adverse events, and these had to
be reported immediately to the principal investigator.
Additionally, we set up an independent safety and data
monitoring board. This board consisted of internationally
renowned experts in the area of eating disorder research
and treatment, and in data and safety monitoring. Further
details about medical complications in the ANTOP trial
have been published elsewhere.22
This trial is registered at
http://isrctn.org, number ISRCTN72809357.
Role of the funding source
The sponsors of the study had no role in study design,
data collection, data analysis, data interpretation, or
writing of the report. All authors had access to the data,
and SZ, WH, BW, GG, H-CF, and KEG were responsible
for submitting the manuscript. SZ made the final
decision to submit the paper for publication.
Results
Between May, 2007, and June, 2009, we screened
727 patients for eligibility; 242 underwent randomisation
after baseline assessment (figure 1). The number of
patients enrolled per study centre was between 12 and 35.
Table 1 shows baseline characteristics. We did not record
any differences between groups with respect to demo-
graphic characteristics, BMI, illness duration, subtype of
anorexia nervosa, and affective disorders. However, a
comorbid anxiety disorder was more frequent in patients
allocated either enhanced cognitive behaviour therapy or
optimised treatment as usual, compared with focal
psychodynamic therapy (table 1). Overall, mean BMI at
baseline was 16·7 kg/m² (SD 1·0) and mean weight was
727 screened for eligibility*
485 excluded
197 did not meet eligibility criteria
39 no current DSM-IV diagnosis of
anorexia nervosa or subsyndromal
anorexia nervosa
158 did not meet required weight range
157 did not meet exclusion criteria
45 psychiatric exclusion
16 medical exclusion
37 lived too far away
52 ongoing psychotherapy
2 pregnancy
5 other reasons
127 patients declined participation
4 unrecorded
242 randomly allocated to treatment groups
80 assigned to receive focal
psychodynamic therapy
53 completed treatment
80 assigned to receive enhanced
cognitive behaviour therapy
65 completed treatment
3 months after treatment start
71 assessed
9 lost to follow-up
End of treatment
63 assessed
17 lost to follow-up
3-month follow-up
57 assessed
23 lost to follow-up
12-month follow-up
58 assessed
22 lost to follow-up
80 analysed for primary outcome
3 months after treatment start
74 assessed
6 lost to follow-up
End of treatment
72 assessed
8 lost to follow-up
3-month follow-up
66 assessed
14 lost to follow-up
12-month follow-up
65 assessed
15 lost to follow-up
80 analysed for primary outcome
3 months after treatment start
66 assessed
16 lost to follow-up
End of treatment
53 assessed
29 lost to follow-up
3-month follow-up
48 assessed
34 lost to follow-up
12-month follow-up
46 assessed
36 lost to follow-up
82 analysed for primary outcome
82 assigned to receive optimised
treatment as usual
Figure 1:Trial profile
*Six male patients were excluded before screening because of predefined inclusion criteria.
6. Articles
6 www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61746-8
46·5 kg (SD 4·2). 94 (39%) patients had anorexia nervosa
for longer than 6 years. A restrictive subtype of anorexia
nervosa was present in 131 (53%) patients, and 96 (40%)
had at least one additional SCID-I diagnosis of a co-
morbid mental disorder.
After 10 months of treatment (at the end of treatment),
54 (22%) of 242 patients were lost to follow-up, and
73 (30%) had dropped out by 12-month follow-up. At both
these timepoints, rates of loss-to-follow-up differed
significantly between study groups, with the highest rate
noted in the optimised treatment as usual group. We did
a sensitivity analysis to detect any possible selection bias
attributable to different dropout rates at the end of
treatment and at 12-month follow-up; BMI at baseline,
difference in BMI between baseline and the end of treat-
ment, anorexia nervosa subtype, and comorbid diagnosis
of a mental disorder were not related to the dropout rate.
Table 2 shows outcome data after 4 months of treat-
ment, at the end of treatment, at 3-month follow-up, and
at 12-month follow-up. Figure 2 depicts the course of
weight gain during treatment and at follow-up. At the
end of treatment, patients in all study groups showed
substantial weight gains from baseline (focal psycho-
dynamic therapy, 0·73 kg/m²; enhanced cognitive behav-
iour therapy, 0·93 kg/m²; optimised treatment as usual,
0·69 kg/m²). We recorded no differences in BMI between
study groups at the end of treatment in the adjusted
models (table 2), using the MMRM algorithm to replace
missing values. At 12-month follow-up, mean BMI values
for patients from all study groups had risen further (focal
psychodynamic therapy, 1·64 kg/m²; enhanced cognitive
behaviour therapy, 1·30 kg/m²; optimised treatment as
usual, 1·22 kg/m²). Again, we did not note a significant
difference in BMI between study groups (table 2). A
sensitivity analysis using the mean-other imputation
method showed the same result pattern as with the
MMRM approach (appendix, p 8). Complete case analysis
(appendix, p 9) and per-protocol analysis (data not shown)
did not show any different results.
Exploratory data analyses were done to investigate the
proportion of patients with full and partial anorexia
nervosa syndrome at baseline and those showing full
recovery at the end of treatment and at 12-month follow-up
(figure 3). Study groups did not differ in terms of global
outcome between baseline and the end of treatment. At
12-month follow-up, however, patients assigned focal
psychodynamic therapy had a significantly higher recovery
rate compared with optimised treatment as usual (full
recovery, 35% vs 13%; p=0·036). Table 3 shows BMI-related
within-group effect sizes and table 4 provides additional
information for the 12-month follow-up outcome.
Because fewer patients allocated focal psychodynamic
therapy had comorbid anxiety disorders at baseline,
compared with the other treatment groups, we did a
sensitivity analysis to investigate whether an anxiety
disorder at baseline could have affected the BMI outcome
at the end of treatment or at 12-month follow-up. Results
of the MMRM analysis showed no such association.
Further subgroup analyses were done of patients with
baseline BMI less than 17·5 kg/m², which accords with the
weight criterion for full syndrome anorexia nervosa. In
this subgroup, at the end of treatment, mean BMI in
patients assigned focal psychodynamic therapy was
lower than in those allocated enhanced cognitive behav-
iour therapy (16·9 kg/m² vs 17·5 kg/m²; p=0·038). Analysis
of anorexia nervosa subtypes (restrictive vs binge-purge)
showed no differences in treatment response between
these two intervention groups.
Eating disorder psychopathology with respect to self-
rating (EDI-2) did not differ over the course of treatment
and follow-up (table 2). However, with the expert inter-
view (SIAB-EX), patients with anorexia nervosa who were
assigned enhanced cognitive behaviour therapy had the
lowest SIAB-EX scores at the end of treatment (table 2).
At 12-month follow-up, however, this difference was no
longer detectable.
No serious adverse events attributable to weight loss
or trial participation were reported during the study.
Focalpsycho-
dynamictherapy
(n=80)
Enhancedcognitive
behaviour therapy
(n=80)
Optimised
treatment
as usual
(n=82)
Demographic characteristics
Mean (SD) age at entry (years) 28·0 (8·6) 27·4 (7·9) 27·7 (8·1)
Marital status
Single, never married 65 (81%) 66 (83%) 66 (81%)
Married, or living as such 12 (15%) 7 (9%) 13 (16%)
Separated or divorced 3 (4%) 5 (6%) 3 (4%)
Unknown 0 2 (3%) 0
Clinical characteristics
Mean (SD) weight (kg) 46·37 (4·3) 46·33 (3·9) 46·71 (4·4)
Mean (SD) body-mass index (kg/m²) 16·57 (1·0) 16·82 (1·0) 16·75 (1·0)
Body-mass index
<17·5 kg/m² 62 (78%) 53 (66%) 56 (68%)
17·5 to ≤18·5 kg/m² 18 (23%) 27 (34%) 26 (32%)
Duration of illness
≤6 years 49 (61%) 49 (61%) 50 (61%)
>6 years 31 (39%) 31 (39%) 32 (39%)
Anorexia nervosa subtypes
Binge-purge 34 (43%) 38 (48%) 39 (48%)
Restrictive 46 (58%) 42 (53%) 43 (52%)
Comorbidities
Affective disorder 14 (18%) 25 (31%) 19 (23%)
Anxiety disorder 11 (14%) 20 (25%) 28 (34%)
Somatoform disorder 1 (1%) 3 (4%) 1 (1%)
Substance abuse 0 0 0
Mean (SD)total scoreonthe eatingdisorder inventory 256 (54·6) 271 (53·4) 275 (51·7)
Mean (SD)total scoreonthe structured inventory for
anorexic and bulimic syndromes
1·0 (0·3) 1·1 (0·3) 1·1 (0·3)
Data are mean (SD) or number of patients (%).
Table 1: Baseline characteristics
7. Articles
www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61746-8 7
Between baseline and 12-month follow-up, 13 (23%) of
57 patients assigned focal psychodynamic therapy (with
available data), 20 (34%) of 58 allocated enhanced cog-
nitive behaviour therapy, and 21 (41%) of 51 assigned
optimised treatment as usual received additional in-
patient treatment. The proportion receiving treatment
differed significantly between the focal psychodynamic
therapy group and the optimised treatment as usual
group (p=0·044), whereas other group comparisons did
not differ by much. Between baseline and the end of
treatment, two patients assigned focal psychodynamic
therapy, three allocated enhanced cognitive behaviour
therapy, and five assigned optimised treatment as usual
had inpatient treatment due to weight loss for 28 days or
less; inpatient treatment for longer than 28 days was
given to five patients assigned focal psychodynamic
therapy, eight allocated enhanced cognitive behaviour
therapy, and nine assigned optimised treatment as usual.
The mean duration of admissions that arose between
baseline and the end of treatment was 6·8 days (SD 22·9)
for focal psychodynamic therapy, 12·6 days (36·9) for
enhanced cognitive behaviour therapy, and 12·5 days
(30·6) for optimised treatment as usual (p=0·49). For
admissions between baseline and 12-month follow-up,
mean duration was 19·0 days (SD 52·7) for focal
psychodynamic therapy, 29·4 days (55·3) for enhanced
cognitive behaviour therapy, and 29·3 days (54·2) for
optimised treatment as usual (p=0·52). However, the
distributions of days in hospital were skewed such that a
few patients had a comparably long duration and more
patients had short durations.
The overall dosage of outpatient psychotherapy ses-
sions did not differ from baseline to 12-month follow-up
between treatment groups (focal psychodynamic therapy,
mean 39·9 sessions, 95% CI 33·8–46·5; enhanced cog-
nitive behaviour therapy, 44·8, 38·4–50·8; optimised
treatment as usual, 41·6, 35·1–48·1; p=0·503). At the end
of treatment, 110 (81%) of 135 participants who were
assessed from the focal psychodynamic therapy and
enhanced cognitive behaviour therapy groups gave full or
partial feedback about their treatment. On a scale of 0
(therapy was not at all helpful) to 10 (therapy was very
helpful), mean values were reported of 7·3 (SD 2·6) for
focal psychodynamic therapy and 7·6 (2·3) for enhanced
Focal psycho-
dynamic therapy
Enhancedcognitive
behaviourtherapy
Optimised
treatment asusual
Focal psychodynamictherapy
vs enhanced cognitive
behaviourtherapy
Focal psychodynamictherapy vs
optimisedtreatment as usual
Enhancedcognitivebehaviour
therapyvsoptimisedtreatment
asusual
Ls-mean
(SE)
95% CI Ls-mean
(SE)
95% CI Ls-mean
(SE)
95% CI Ls-mdiff
(95%CI)
p Effect
size
Ls-m diff
(95% CI)
p Effect
size
Ls-m
diff (95% CI)
p Effect
size
Body-mass index
After 4 months
of treatment
16·94
(0·14)
16·67–
17·21
17·08
(0·13)
16·81–
17·34
16·96
(0·14)
16·68–
17·23
−0·14 (−0·51
to 0·23)
0·46 −0·12 −0·01
(−0·39to 0·36)
0·94 −0·01 0·12
(−0·25to 0·50)
0·52 0·11
After 10 months
oftreatment (end
oftreatment)
17·30
(0·19)
16·92–
17·67
17·75
(0·18)
17·39–
18·11
17·44
(0·20)
17·05–
17·83
–0·45
(−0·96to 0·07)
0·09 −0·29 −0·14
(−0·68to 0·39)
0·60 −0·09 0·3
(−0·22to 0·83)
0·26 0·20
At 3-month
follow-up
17·63
(0·22)
17·20–
18·05
17·74
(0·21)
17·33–
18·15
17·74
(0·23)
17·29–
18·19
−0·11
(−0·70to 0·47)
0·70 −0·07 −0·11
(−0·73to 0·51)
0·72 −0·07 0
(−0·60to 0·60)
1·00 0·00
At 12-month
follow-up
18·20
(0·24)
17·72–
18·69
18·10
(0·23)
17·64–
18·56
17·95
(0·26)
17·44–
18·47
0·10
(−0·56to 0·76)
0·76 0·05 0·25
(−0·45to 0·95)
0·48 0·13 0·15
(−0·54to 0·83)
0·67 0·08
EDI, total score
After 4 months
of treatment
295
(4·46)
286–
304
295
(4·32)
287–
304
293
(4·57)
284–
302
−0·27
(−12·30to 11·77)
0·97 −0·01 1·81
(−10·68to 14·30)
0·78 0·05 2·08
(−10·08to14·24)
0·74 0·06
After 10 months
oftreatment (end
oftreatment)
272
(6·18)
260–
284
270
(5·83)
259–
282
277
(6·46)
264–
289
1·67
(−14·92to 18·26)
0·84 0·03 −4·98
(−22·53to 12·58)
0·58 −0·10 −6·64
(−23·63to10·34)
0·44 −0·14
At 3-month
follow-up
269
(6·41)
257–
282
270
(6·03)
258–
282
274
(6·76)
260–
287
−0·89
(−18·10to 16·32)
0·92 −0·02 −4·41
(−22·71to 13·90)
0·64 −0·09 −3·52
(−21·23to 14·19)
0·70 −0·07
At 12-month
follow-up
257
(6·76)
244–
271
263
(6·47)
251–
276
260
(7·22)
246–
275
−6·17
(−24·49to 12·15)
0·51 −0·12 −2·98
(−22·42to16·47)
0·76 −0·06 3·19
(−15·79to 22·17)
0·74 0·06
SIAB-EX, total score
After 10 months
oftreatment (end
oftreatment)
0·86
(0·05)
0·77–
0·95
0·77
(0·04)
0·68–
0·85
0·89
(0·05)
0·80–
0·98
0·09
(−0·03to 0·21)
0·14 0·26 −0·03
(−0·16to 0·09)
0·61 −0·09 −0·12
(−0·25to −0·00)
0·05 −0·35
At 12-month
follow-up
0·72
(0·05)
0·61–
0·82
0·73
(0·05)
0·63–
0·83
0·71
(0·06)
0·59–
0·82
−0·01
(−0·15to 0·13)
0·88 −0·03 0·01
(−0·15to 0·16)
0·92 0·02 0·02
(−0·13to 0·17)
0·81 0·05
Differences between groups were tested using the final adjusted models; missing values were replaced by the mixed model for repeated measures algorithm. 95% CIs are given for estimated least square means
(Ls-mean) for every treatment group and for least square mean differences (Ls-m diff) between treatment groups. EDI=eating disorder inventory. SIAB-EX=structured inventory of anorexic and bulimic
syndromes, expert version.
Table 2: Adjusted mean scores for body-mass index and eating disorder pathology, by treatment group
8. Articles
8 www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61746-8
cognitive behaviour therapy. 44% of patients assigned
focal psychodynamic therapy found the length of treat-
ment adequate, 52% said it was too short, and 4% judged
it too long; by comparison, 40% of patients allocated
enhanced cognitive behaviour therapy said the treatment
length was adequate, 49% thought it was too short, and
11% judged it too long.
Discussion
Findings of the ANTOP study show that outpatient
treatment of adults with anorexia nervosa by either
optimised treatment as usual, focal psychodynamic
therapy, or enhanced cognitive-behaviour therapy leads
to relevant weight gains and a decrease in general and
eating disorder-specific psychopathology during the
course of treatment. These positive effects continue
beyond treatment until 12-month follow-up. However,
the primary hypothesis of the ANTOP study was not
confirmed: no difference in weight gain was recorded by
the end of treatment between the study groups. Weight
gains noted in the ANTOP study accord with those
reported in small single-centre studies.16,17,20
However,
with respect to the global outcome measure, patients
allocated focal psychodynamic therapy had higher
recovery rates compared with those assigned optimised
treatment as usual at 12-month follow-up.
Under close guidance from their family doctor—eg,
regular weight monitoring and essential blood testing—
and with close supervision of their respective study
centre, patients allocated optimised treatment as usual
were able to choose their favourite treatment approach
and setting (intensity, inpatient, day patient, or out-
patient treatment) and their therapist, in accordance
with German national treatment guidelines for anorexia
nervosa.11
Moreover, comparisons of applied dosage and
intensity of treatment showed that all patients—
irrespective of treatment allocation—averaged a similar
number of outpatient sessions over the course of the
treatment and follow-up periods (about 40 sessions).
These data partly reflect an important achievement of
the German health-care system: that access to psycho-
therapy treatment is covered by insurance. However,
patients allocated optimised treatment as usual needed
additional inpatient treatment more frequently (41%)
than either those assigned focal psychodynamic therapy
(23%) or enhanced cognitive behaviour therapy (35%).
In a study in adolescent patients, similar results were
noted over a 2-year period, with fewer admissions
reported with family-based treatment (15%) compared
with a more general approach of adolescent-focused
therapy (37%).28
Although, to date, clear consensus has
not been reached with respect to the definition of
outcome in anorexia nervosa,29
analysis of recovery rates
is common in psychotherapy trials.30
Our results showed
that at follow up, patients assigned focal psychodynamic
therapy had significantly higher recovery rates compared
with those receiving optimised treatment as usual.
Focal psychodynamic
therapy
Enhanced cognitive
behaviour therapy
Optimised treatment
as usual
Effect size
(95% CI)
p Effect size
(95% CI)
p Effect size
(95% CI)
p
After 4 months of treatment 0·23
(0·06–0·50)
0·12 0·37
(0·12–0·61)
0·003 0·23
(0·04–0·52)
0·10
After 10 months of
treatment (end of treatment)
0·62
(0·29–0·90)
0·0003 1·00
(0·60–1·41)
<0·0001 0·71
(0·35–1·10)
0·0003
At 3-month follow-up 0·95
(0·56–1·28)
<0·0001 1·00
(0·54–1·48)
<0·0001 1·00
(0·60–1·46)
<0·0001
At 12-month follow-up 1·60
(1·10–2·00)
<0·0001 1·40
(0·87–1·87)
<0·0001 1·20
(0·74–1·77)
<0·0001
Data are effect size (95% CI), standardised by the mixed model for repeated measures.
Table 3:Within-group changes in body-mass index from baseline, by treatment group
Figure 3: Recovery rates during treatment and follow-up, by treatment group
Baseline End of
treatment
12-month
follow-up
Baseline End of
treatment
12-month
follow-up
Baseline End of
treatment
12-month
follow-up
0
10
20
30
40
50
60
70
80
90
100
Proportionofpatients(%)
Focal psychodynamic therapy Enhanced cognitive
behaviour therapy
Optimised treatment as usual
Recovered anorexia nervosa Partial syndrome anorexia nervosa Full syndrome anorexia nervosa
Baseline 4 months
of treatment
10 months
of treatment
3-month
follow-up
12-month
follow-up
16·5
16·7
16·9
17·1
17·3
17·5
17·7
17·9
18·1
18·3
18·5
Body-massindex(kg/m2
)
Measurement timepoints
Focal psychodynamic therapy
Enhanced cognitive behaviour therapy
Optimised treatment as usual
End of treatment
End of follow-up
Figure 2: Course of weight gain during treatment and follow-up, by treatment group
Data are least square means (Ls-mean). Error bars show SE.
9. Articles
www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61746-8 9
Psychodynamic treatments make interpersonal
relationships the major theme. Compared with cognitive
behaviour therapy they are less directive, induce
augmented emotional arousal, and target insight more
(vs behaviour and cognition).31
In view of difficulties in the
field of autonomy that individuals with anorexia nervosa
have, we postulate that these specific aspects of psycho-
dynamic therapy contribute to the positive effects of treat-
ment in this patient group. Substantial and lasting
changes after interpersonal treatment for eating disorders
have been shown for bulimia nervosa.32
Findings of a New
Zealand study17,18
indicate that psychotherapy focusing on
interpersonal aspects (eg, interpersonal therapy and focal
psychodynamic therapy) across different eating dis-
orders might need a prolonged timeframe to show effects,
thereby producing better long-term results.18,32
In a single-
centre study comparing two manual-based treatments in
anorexia nervosa outpatients,30
significant weight gains
were noted for patients in both study groups, with no
differences recorded between the two approaches with
respect to the amount of weight gained. However, these
researchers showed that the estimated proportion of
recovered anorexia nervosa patients depended strongly on
the underlying definition of recovery. When applying a
strict definition of recovery, as we did in our study
(a combination of objective measure [weight] and eating
disorder pathology based on expert assessment), recovery
rates were 7–13% at 6 months and 14–19% at 12 months.
Again, no differences with respect to recovery rates were
noted between treatments.
Treatment acceptance is a major challenge in the
management of patients with anorexia nervosa.33
The
main reason for this difficulty is typically the patient’s
high ambivalence and lack of acceptance of the serious-
ness of their illness. Thus, therapists not only have to
cope with a frequently difficult therapy process but also
must take responsibility for management of physical and
psychiatric complications of this potentially lethal
disorder. In the ANTOP study, we had a clear framework
of rules for medical and psychiatric monitoring and a
minimum weight limit for admission to short-term in-
patient treatment (BMI <14 kg/m²). In both manual-
based treatments, we included a brief nutrition guideline,
and a structured session for close family and other
relatives was also offered. These design aspects of the
ANTOP study contributed to relatively high treatment
completion rates (76% average; 70% with focal psycho-
dynamic therapy; 81% with enhanced cognitive behaviour
therapy) compared with other small-scale adult anorexia
nervosa studies.10,15
Moreover, patients allocated either
focal psychodynamic therapy or enhanced cognitive
behaviour therapy gave positive ratings to their treatment
experience, which might have contributed further to the
comparably low dropout rates.
Previous findings show that a comorbid anxiety
disorder could be associated with a poorer treatment
outcome in individuals with anorexia nervosa.34,35
In the
Focal psychodynamic
therapy (n=58)
Cognitive behaviour
therapy (n=65)
Treatment as
usual (n=46)
F or χ² p
Mean (SD) weight (kg) 51·3 (7·2) 51·0 (8·8) 48·6 (9·7) 1·60 0·20
Body-mass index
≤17·5 kg/m² 18 (31%) 22 (34%) 19 (41%) 1·24 0·54
>17 5 kg/m² 40 (69%) 43 (66%) 27 (59%)
Full criteria for anorexia
nervosa*
12 (21%) 14 (22%) 13 (28%) 0·97 0·62
Comorbidities
Affective disorder 7 (12%) 10 (15%) 4 (9%) 1·12 0·57
Anxiety disorder 5 (9%) 8 (12%) 9 (20%) 2·76 0·25
Somatoform disorder 1 (2%) 2 (3%) 0 1·46 0·48
Substance abuse 0 1 (2%) 0 1·61 0·45
Bulimia nervosa 4 (7%) 4 (6%) 3 (7%) 0·03 0·99
Data are number of patients (%), unless otherwise stated. F values (and corresponding p values) are derived from
ANOVA tests to compare the three groups. χ2 values (and corresponding p values) compare percentages between the
three groups. *Patients with a body-mass index of ≤17·5 kg/m² and psychiatric status rating score of 5 or 6 met full
criteria for anorexia nervosa.
Table 4: Clinical characteristics at 12-month follow-up
Panel 2: Research in context
Systematic review
We searched PubMed andtheCochrane Library for full papers
published before May 3, 2013, reporting randomised controlled
trials, systematic reviews, and meta-analyses,withthe MeSH
terms: “anorexia nervosa”, “treatment”, “psychotherapy”,
“cognitive behaviortherapy”, and “psychodynamictherapy”.
Wedid not apply any language restrictions.We excludedtrials
focused exclusivelyon adolescents, group interventions, and
familytherapy andthose reportingon pure education.Our
search identified five systematic reviews,1,3,29
one meta-analysis,13
andthree additionaltrialsthatwere not included inthe
respective reviews.16,20,30
Todate, no evidence provides solid
support for a particulartherapeutic approach, setting,or
procedure fortreatmentof adultswith anorexia nervosa.Thus,
large, multicentre, randomised controlledtrialsof commonly
used psychotherapies forolder adolescents and adultswith
anorexia nervosa are neededurgently.
Interpretation
The findings of the ANTOP trial showed that multicentre
outpatient studies in patients with anorexia nervosa are
possible. We also showed that patients can be treated
safely, many individuals with anorexia nervosa gain weight,
and that a substantial proportion have striking
improvements in eating disorder pathology and comorbid
psychopathology. The findings of the ANTOP study provide
evidence to support use of manual-based interventions;
focal psychodynamic therapy proved most advantageous in
terms of recovery at 12-month follow-up, and enhanced
cognitive behaviour therapy was most effective in terms of
the speed of weight gain and improvements in eating
disorder psychopathology.
10. Articles
10 www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61746-8
ANTOP study sample, despite the randomisation algo-
rithm, fewer patients allocated focal psychodynamic
therapy had comorbid anxiety disorders at baseline com-
pared with those assigned enhanced cognitive behaviour
therapy and optimised treatment as usual. However,
results of a sensitivity analysis showed no association
between anxiety disorders at baseline and BMI at the end
of treatment or at 12-month follow-up.
The ANTOP study was designed as a large, multicentre,
randomised controlled trial in adults with anorexia
nervosa. These design features overcome the shortcom-
ings of previous studies (panel 2) by providing a random-
ised controlled design, a large sample size, appropriate
inclusion criteria, a detailed treatment protocol, and a
clear separation of intervention conditions.22
We judged
our study a success because most patients completed
treatment and reported high satisfaction scores with the
treatments; the dropout rate was much lower than in
previous anorexia nervosa treatment studies.10,17
Our trial, however, had several limitations. First, we
chose gain in BMI as a simple, objective, and conservative
primary outcome measure. This approach might have
been too one-dimensional. To get a more comprehensive
picture, we also looked at a combined secondary outcome
that included core aspects of eating disorder psycho-
pathology. Second, although the dropout rate within our
overall sample was acceptable, we noted a higher
dropout rate for patients assigned optimised treatment
as usual compared with the other groups. Therefore,
information on the course of the illness in individuals in
this group is limited. We only had scant contact with
patients assigned optimised treatment as usual at our
centres and, thus, formed a weaker alliance with
these patients. This diminished personal contact might
have contributed to the dropout rate. Finally, we were
restricted by funding to intermediate follow-up of
12 months. Additional long-term follow-up measurement
points for outcome data (for at least 5 years after initial
treatment ends) are necessary.
Although the findings of the ANTOP study suggest
that adults with anorexia nervosa have a realistic chance
of recovery or, at least, can achieve substantial improve-
ment, a relevant proportion of patients still had anorexic
symptoms at the end of our study. Anorexia nervosa
“remains an enigma and its clinical challenge is [still]
intimidating”.36
Besides strategies of prevention and early
intervention, we have to refine our treatments further to
fight the vicious cycles of dieting behaviour.37
Contributors
The principal investigators (SZ, WH, BW, and GG) designed the study
and obtained funding. The ANTOP trial management group, trial
steering committee, and the data monitoring and ethics committee
further developed study design. The statistical analysis plan was written
by the analysis strategy group and approved by the trial steering
committee and the data monitoring and ethics committee before the
analysis began. DS and BW did the main statistical analysis. Patient
recruitment was done by SH (Bochum), MdZ (Hannover), Prof W Senf
(Essen), AZ (Freiburg), BL (Hamburg), WH (Heidelberg),
Prof P Henningsen (Munich), SZ (Tübingen), and JvW (Ulm).
Treatment leaders for focal psychodynamic therapy were HS, H-CF, and
WH, for enhanced cognitive behaviour therapy were GG, MdZ, and MT
(with initial support from C Fairburn), and for optimised treatment as
usual were SZ, GG, MT, KEG, H-CF, and WH. Treatment leaders
designed the treatment manuals in collaboration with the principal
investigators, and trained and supervised the trial therapists. The writing
and publication oversight committee wrote the report. All authors
commented on drafts and approved the final version.
ANTOP study group
Trial management group—SZ (chair), BW, GG, H-CF, MT, DS, KEG,
MdZ, AD, SH, MB, BL, ST, JvW, AZ, CS-B, HS, and WH (co-chair); trial
steering committee—SZ (chair) and WH (co-chair); data monitoring and
ethics committee—U Schmidt (London, UK), H-C Deter (Berlin,
Germany), S Schneider (Bochum, Germany), and A Faldum (Münster,
Germany); analysis strategy group—BW (chair), DS, WH, KEG, GG, SZ,
and CS-B; writing and publication oversight committee—SZ (co-chair), BW
(co-chair), GG, H-CF, MT, DS, MdZ, and KEG; trial manager—GG.
Conflicts of interest
We declare that we have no conflicts of interest.
Acknowledgments
The German Federal Ministry of Education and Research
(Bundesministerium für Bildung und Forschung [BMBF], project
number 01GV0624) funded the ANTOP study, which is part of the
BMBF research programme Research Networks on Psychotherapy. The
ANTOP study was designed at the Department of Psychosomatic
Medicine and Psychotherapy, University Hospital Tübingen, and the
Department of General Internal Medicine and Psychosomatics,
Heidelberg University Hospital. The University of Tübingen undertook
the responsibilities of sponsor in terms of the guidelines of good
clinical practice in clinical trials (ICH-GCP, E6); the sponsor declaration
was signed by the Dean of the Medical Faculty. Data management was
provided by the Coordination Center for Clinical Trials, Marburg (CS-B).
F Schmid (University Hospital Erlangen) was responsible for
independent data monitoring. C Fairburn (Oxford, UK) provided the
initial 2 days of training for enhanced cognitive behaviour therapy and
the provisional manual, before its publication in English and German,
but was not involved in any further conduct of the ANTOP study. We
thank Doro Niehoff for help with data management and
Nichole Martinson for editorial assistance; the participants who took
part in the ANTOP study; and the therapists and staff from all study
centres, who helped with patient recruitment, diagnostic procedures,
and monitoring.
References
1 Treasure J, Claudino AM, Zucker N. Eating disorders. Lancet 2010;
375: 583–93.
2 Herzog W, Deter HC, Fiehn W, Petzold E. Medical findings and
predictors of long-term physical outcome in anorexia nervosa:
a prospective, 12-year follow-up study. Psychol Med 1997; 27: 269–79.
3 Fairburn CG, Harrison PJ. Eating disorders. Lancet 2003; 361: 407–16.
4 Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients
with anorexia nervosa and other eating disorders: a meta-analysis of
36 studies. Arch Gen Psychiatry 2011; 68: 724–31.
5 Zipfel S, Löwe B, Reas DL, Deter H-C, Herzog W. Long-term
prognosis in anorexia nervosa: lessons from a 21-year follow-up
study. Lancet 2000; 355: 721–22.
6 Klump KL, Bulik CM, Kaye WH, Treasure J, Tyson E. Academy for
eating disorders position paper: eating disorders are serious mental
illnesses. Int J Eat Disord 2009; 42: 97–103.
7 Herzog W, Schellberg D, Deter HC. First recovery in anorexia
nervosa patients in the long-term course: a discrete-time survival
analysis. J Consult Clin Psychol 1997; 65: 169–77.
8 Stuhldreher N, Konnopka A, Wild B, et al. Cost-of-illness studies
and cost-effectiveness analyses in eating disorders: a systematic
review. Int J Eat Disord 2012; 45: 476–91.
9 Smink FR, van Hoeken D, Hoek HW. Epidemiology of eating
disorders: incidence, prevalence and mortality rates.
Curr Psychiatry Rep 2012; 14: 406–14.
10 Halmi KA, Agras WS, Crow S, et al. Predictors of treatment
acceptance and completion in anorexia nervosa: implications for
future study designs. Arch Gen Psychiatry 2005; 62: 776–81.
11. Articles
www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61746-8 11
11 Herpertz S, Hagenah U, Vocks S, von Wietersheim J, Cuntz U,
Zeeck A, and the German Society of Psychosomatic Medicine and
Psychotherapy, and the German College for Psychosomatic
Medicine. The diagnosis and treatment of eating disorders.
Dtsch Arztebl Int 2011; 108: 678–85.
12 NICE. Eating disorders: core interventions in the treatment and
management of anorexia nervosa, bulimia nervosa and related
eating disorders. Jan 28, 2004. http://www.nice.org.uk/nicemedia/
live/10932/29220/29220.pdf (accessed Sept 5, 2013).
13 Hay PP, Bacaltchuk J, Byrnes RT, Claudino AM, Ekmejian AA,
Yong PY. Individual psychotherapy in the outpatient treatment of
adults with anorexia nervosa. Cochrane Database Syst Rev 2009;
published online Jan 21. DOI:10.1002/14651858.CD003909.
14 Dare C, Eisler I, Russell G, Treasure J, Dodge L. Psychological
therapies for adults with anorexia nervosa: randomised controlled
trial of out-patient treatments. Br J Psychiatry 2001; 178: 216–21.
15 Pike KM, Walsh BT, Vitousek K, Wilson GT, Bauer J. Cognitive
behavior therapy in the posthospitalization treatment of anorexia
nervosa. Am J Psychiatry 2003; 160: 2046–49.
16 Fairburn CG, Cooper Z, Doll HA, O’Connor ME, Palmer RL,
Dalle Grave R. Enhanced cognitive behaviour therapy for adults
with anorexia nervosa: a UK-Italy study. Behav Res Ther 2013;
51: R2–8.
17 McIntosh VV, Jordan J, Carter FA, et al. Three psychotherapies for
anorexia nervosa: a randomized, controlled trial. Am J Psychiatry
2005; 162: 741–47.
18 Carter FA, Jordan J, McIntosh VV, et al. The long-term efficacy of
three psychotherapies for anorexia nervosa: a randomized,
controlled trial. Int J Eat Disord 2011; 44: 647–54.
19 Lipsman N, Woodside DB, Giacobbe P, et al. Subcallosal cingulate
deep brain stimulation for treatment-refractory anorexia nervosa:
a phase 1 pilot trial. Lancet 2013; 381: 1361–70.
20 Touyz S, Le Grange D, Lacey H, et al. Treating severe and
enduring anorexia nervosa: a randomized controlled trial.
Psychol Med 2013; published online May 3. DOI:10.1017/
S0033291713000949.
21 Flament MF, Bissada H, Spettigue W. Evidence-based
pharmacotherapy of eating disorders. Int J Neuropsychopharmacol
2012; 15: 189–207.
22 Wild B, Friederich HC, Gross G, et al. The ANTOP study:
focal psychodynamic psychotherapy, cognitive-behavioural therapy,
and treatment-as-usual in outpatients with anorexia
nervosa—a randomized controlled trial. Trials 2009; published
online April 23. DOI:10.1186/1745-6215-10-23.
23 Rosenberg WF, Lachin JM. Randomization in clinical trials: theory
and practice. New York: John Wiley and Sons, 2002.
24 Nordle O, Brantmark B. A self-adjusting randomization plan for
allocation of patients into two treatment groups.
Clin Pharmacol Ther 1977; 22: 825–30.
25 Fairburn CG. Cognitive behavior therapy and eating disorders.
New York: The Guilford Press, 2008.
26 Schauenburg H, Friederich H-C, Wild B, Zipfel S, Herzog W. Focal
psychodynamic psychotherapy of anorexia nervosa: a treatment
manual. Psychotherapeut 2009; 54: 270–80 (in German).
27 Mallinckrodt CH, Watkin JG, Molenberghs G, Carroll RJ. Choice of
the primary analysis in longitudinal clinical trials. Pharm Stat 2004;
3: 161–69.
28 Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B.
Randomized clinical trial comparing family-based treatment with
adolescent-focused individual therapy for adolescents with anorexia
nervosa. Arch Gen Psychiatry 2010; 67: 1025–32.
29 Watson HJ, Bulik CM. Update on the treatment of anorexia
nervosa: review of clinical trials, practice guidelines and emerging
interventions. Psychol Med 2012; 10: 1–24.
30 Schmidt U, Oldershaw A, Jichi F, et al. Out-patient psychological
therapies for adults with anorexia nervosa: randomised controlled
trial. Br J Psychiatry 2012; 201: 392–99.
31 Malik ML, Beutler LE, Alimohamed S, Gallagher-Thompson D,
Thompson L. Are all cognitive therapies alike? A comparison of
cognitive and noncognitive therapy process and implications for the
application of empirically supported treatments.
J Consult Clin Psychol 2003; 71: 150–58.
32 Fairburn CG, Norman PA, Welch SL, O’Connor ME, Doll HA,
Peveler RC. A prospective study of outcome in bulimia nervosa and
the long-term effects of three psychological treatments.
Arch Gen Psychiatry 1995; 52: 304–12.
33 Dejong H, Broadbent H, Schmidt U. A systematic review of
dropout from treatment in outpatients with anorexia nervosa.
Int J Eat Disord 2012; 45: 635–47.
34 Zerwas S, Lund BC, Von Holle A, et al. Factors associated with
recovery from anorexia nervosa. J Psychiatr Res 2013; 47: 972–79.
35 Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K.
Comorbidity of anxiety disorders with anorexia and bulimia
nervosa. Am J Psychiatry 2004; 161: 2215–21.
36 Strober M, Johnson C. The need for complex ideas in anorexia
nervosa: why biology, environment, and psyche all matter, why
therapists make mistakes, and why clinical benchmarks are needed
for managing weight correction. Int J Eat Disord 2012; 45: 155–78.
37 Walsh BT. The enigmatic persistence of anorexia nervosa.
Am J Psychiatry 2013; 170: 477–84.
12. Comment
www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61940-6 1
The challenges of treating anorexia nervosa
The evidence base for anorexia nervosa treatment is
meagre1–3
considering the extent to which this disorder
erodes quality of life and takes far too many lives
prematurely.4
But clinical trials for anorexia nervosa are
difficult to conduct, attributable partly to some patients’
deep ambivalence about recovery, the challenging task
of offering a treatment designed to remove symp-
toms that patients desperately cling to, the fairly low
prevalence of the disorder, and high dropout rates.
The combination of high dropout and low treatment
acceptability has led some researchers to suggest that
we pause large-scale clinical trials for anorexia nervosa
until we resolve these fundamental obstacles.5,6
In The Lancet, Stephan Zipfel and colleagues7
present
results of the Anorexia NervosaTreatment of OutPatients
(ANTOP) study, in which two manual-based outpatient
treatments (focal psychodynamic therapy and enhanced
cognitive behaviour therapy) were compared with
optimised treatment as usual, which included careful
and regular monitoring by family doctors linked to care
at specialist treatment centres. The findings provide
some rather sobering observations about treatment
of anorexia nervosa, and highlight the difficulties of
implementing clinicaltrials forthis disorder.
First, ten sites across Germany were needed for recruit-
ment of 242 patients. Second, the trial was facilitated by
the German health-care system, which provides insurance
coverage for psychotherapy for eating disorders. This
system enabled patients assigned to the control arm of
optimised treatment as usual to select their preferred
type of community intervention. Third, treatment for
anorexia nervosa takes a long time, at an average of
10 months’ duration. No brief interventions for the
disorder have been judged effective. Fourth, almost
a third of patients were lost to follow-up a year after
the end of treatment (although, compared with other
anorexia trials, this dropout rate is quite good). Fifth, for
many patients, psychotherapy alone did not suffice, and
inpatient treatment was needed for some patients during
the trial. Allowances should be made for intermittent
hospitalisations during anorexia outpatient trials because
recovery from this disorder is rarely linear. Moreover,
precipitous weight loss and other medical complications
needing hospital treatment do not necessarily mean that
outpatient carewillultimately fail.
For all the psychotherapeutic attention the patients
received, how much progress was made? Body-mass
index (BMI) increased by about 0·70 kg/m² in all three
study groups after 10 months of treatment and an
additional 0·40 kg/m² by 12 months of follow-up.
This rise is good because average BMI did not drop
during the follow-up period and improvements were
made on psychological aspects of the disorder. Yet,
at the end of treatment and at 12-month follow-up,
mean BMI across the three treatment groups was
still in the underweight range. It is noteworthy how
the bodies (and minds) of individuals with anorexia
nervosa vigorously defend low bodyweight. In terms of
absolute outcomes, after 10 months of treatment just
over a quarter of patients had full syndrome anorexia
nervosa (29% receiving focal psychodynamic therapy,
26% assigned enhanced cognitive behaviour therapy,
and 27% allocated optimised treatment as usual), and
at 12-month follow-up about a fifth of patients had full
anorexia (21%, 22%, and 28%, respectively). In view of
the generally poor outcomes of anorexia nervosa trials,
we might feel encouraged by these findings. From the
outside looking in, we have to do better.
We can glean some positive points from the ANTOP
study. First,the results—andthose of a small New Zealand
study8
—suggest that treatments that concentrate on
interpersonal factors might be beneficial in the long term.
Bothfocalpsychodynamictherapy(aspresentedhere)and
interpersonal psychotherapy (done in the New Zealand
study) focus on the role of interpersonal relationships in
the maintenance of anorexia nervosa symptoms. Second,
the findings of both studies suggest that variations of
optimised treatment as usual for anorexia nervosa might
be an acceptable therapeutic option. Zipfel and colleagues
expected their manual-based specialised treatments to
have the best results, but that expectation wasn’t borne
out, at least intermsof BMI.
What are the real-world implications of the ANTOP
study findings for clinicians, patients, and their families?
The results in no way suggest that the only way to
treat anorexia nervosa is via specialised manual-based
approaches. This finding is important for two reasons:
first, we cannot train every clinician to deliver these
specialised treatments; and second, patients might live
too far from specialist centres to receive manual-based
Published Online
October 14, 2013
http://dx.doi.org/10.1016/
S0140-6736(13)61940-6
See Online/Articles
http://dx.doi.org/10.1016/
S0140-6736(13)61746-8
AJPhoto/SciencePhotoLibrary
13. Comment
2 www.thelancet.com Published online October 14, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61940-6
treatment delivered by an expert. Results of the ANTOP
study coupled with the New Zealand findings raise an
important point. In the New Zealand study, specialist
supportive clinical management—designed to be a
control arm—outperformed both cognitive behaviour
therapy and interpersonal therapy in the short term,
and in the ANTOP study, outcomes with optimised
treatment as usual did not differ significantly from the
two specialised treatments. Linking family doctors to
clinicians skilled in the treatment of eating disorders and
guiding them through the delivery of anorexia nervosa
treatment while implementing solid principles of clinical
management could be an approach worth considering.
The addition of telemedicine or other technology-aided
supervision or consultation might help to extend the
reach of specialist services.
Despite the positive aspects gleaned from the ANTOP
study, we still need to serve patients with anorexia
nervosa and their families better. We need to discover
how to provide better, faster, and lasting results in
the management of this disorder. Psychotherapeutic
interventions are only partly effective; up to now,
no pharmacological agents are effective in the treat-
ment of anorexia nervosa. Ongoing work in genetics,
neurobiology, and studies of the microbiome provide
some hope for the future. We know little about the
biological factors that allow individuals with anorexia
nervosato defend such low bodyweights andto maintain
high activity levels in the absence of nutritional fuel. For
too long, people have presumed that anorexia nervosa
is simply a behavioural choice and that all individuals
with the disorder wilfully maintain a low bodyweight
to chase a societal appearance ideal. Anyone who has
worked with anorexia patients will attest that even if
the disorder started with a desire to attain a physical
ideal (and it often does not), the low weight soon eludes
wilful control. Identification of aberrant pathways that
contribute to these regulatory anomalies and uncovering
gut–brain connections that interrupt the usual processes
of hunger and satiety will hopefully lead to novel ways to
interruptthis perplexing biological obstinacy.
Cynthia M Bulik
University of North Carolina at Chapel Hill, Chapel Hill,
NC 27599, USA
cbulik@med.unc.edu
CMB is a consultant for Shire Pharmaceuticals.
1 Bulik CM, Berkman ND, Brownley KA, Sedway JA, Lohr KN. Anorexia
nervosa treatment: a systematic review of randomized controlled trials.
Int J Eat Disord 2007; 40: 310–20.
2 Watson HJ, Bulik CM. Update on the treatment of anorexia nervosa: review
of clinical trials, practice guidelines and emerging interventions.
Psychol Med 2012; published online Dec 10. DOI:10.1017/
S0033291712002620.
3 Hay PPJ, Bacaltchuk J, Byrnes RT, Claudino AM, Ekmejian AA,Yong PY.
Individual psychotherapy in the outpatient treatment of adults with
anorexia nervosa. Cochrane Database Syst Rev 2009; published online
Jan 21. DOI:10.1002/14651858.CD003909.
4 Arcelus J, Mitchell AJ,Wales J, Nielsen S. Mortality rates in patients with
anorexia nervosa and other eating disorders: a meta-analysis of 36 studies.
Arch Gen Psychiatry 2011; 68: 724–31.
5 Fairburn CG. Evidence-based treatment of anorexia nervosa.
Int J Eat Disord 2005; 37 (suppl): S26–30.
6 Halmi K, AgrasW, Crow S, et al. Predictors of treatment acceptance and
completion in anorexia nervosa: implications for future study designs.
Arch Gen Psychiatry 2005; 62: 776–81.
7 Zipfel S,Wild B, Groß G, et al, on behalf of the ANTOP study group. Focal
psychodynamic therapy, cognitive behaviour therapy, and optimised
treatment as usual in outpatients with anorexia nervosa (ANTOP study):
randomised controlled trial. Lancet 2013; published online Oct 14. http://
dx.doi.org/10.1016/S0140-6736(13)61746-8
8 McIntoshV, Jordan J, Carter F, et al.Three psychotherapies for anorexia
nervosa: a randomized controlled trial. Am J Psychiatry 2005; 162: 741–47.