Somatic Disorders

The presence of an anxiety or depressive disorder in asthmatic children aged 11–17 years is associated with an increase in asthma symptoms, reported Dr. Laura P. Richardson of the University of Washington, Seattle, and her colleagues.

“We found that youth with an anxiety or depressive disorder reported significantly more asthma symptom days than youth without anxiety or depressive disorders after controlling for asthma severity,” reported Dr. Richardson and her associates.

The researchers conducted a telephone survey of 767 children and adolescents aged 11–17 with a history of asthma who belonged to a health maintenance organization in Washington State. The study participants were considered to have asthma if they met certain criteria for the number of office or emergency department visits, hospitalizations, and medication prescriptions for asthma in the 12− to 18-month period preceding the study (Pediatrics 2006;118:1042–51).

Nine percent of the study participants had an anxiety disorder, 2.5% had a depressive disorder, and 4.8% had both.

The results showed that the youth with an anxiety or depressive disorder reported more asthma symptom days in a 2-week period, compared with youth without one of these disorders: 5.4 symptom days, compared with 3.5 symptom days. In addition, compared with youth without an anxiety or depressive disorder, youth with one of these disorders were more likely to be girls, to have a parent without a college education, to have a recent asthma diagnosis, and to be taking one medication to control asthma symptoms.

The presence of an anxiety or depressive disorder in asthmatic children aged 11–17 years is associated with an increase in asthma symptoms, reported Dr. Laura P. Richardson of the University of Washington, Seattle, and her colleagues.

“We found that youth with an anxiety or depressive disorder reported significantly more asthma symptom days than youth without anxiety or depressive disorders after controlling for asthma severity,” reported Dr. Richardson and her associates.

The researchers conducted a telephone survey of 767 children and adolescents aged 11–17 with a history of asthma who belonged to a health maintenance organization in Washington State. The study participants were considered to have asthma if they met certain criteria for the number of office or emergency department visits, hospitalizations, and medication prescriptions for asthma in the 12− to 18-month period preceding the study (Pediatrics 2006;118:1042–51).

Nine percent of the study participants had an anxiety disorder, 2.5% had a depressive disorder, and 4.8% had both.

The results showed that the youth with an anxiety or depressive disorder reported more asthma symptom days in a 2-week period, compared with youth without one of these disorders: 5.4 symptom days, compared with 3.5 symptom days. In addition, compared with youth without an anxiety or depressive disorder, youth with one of these disorders were more likely to be girls, to have a parent without a college education, to have a recent asthma diagnosis, and to be taking one medication to control asthma symptoms.

The presence of an anxiety or depressive disorder in asthmatic children aged 11–17 years is associated with an increase in asthma symptoms, reported Dr. Laura P. Richardson of the University of Washington, Seattle, and her colleagues.

“We found that youth with an anxiety or depressive disorder reported significantly more asthma symptom days than youth without anxiety or depressive disorders after controlling for asthma severity,” reported Dr. Richardson and her associates.

The researchers conducted a telephone survey of 767 children and adolescents aged 11–17 with a history of asthma who belonged to a health maintenance organization in Washington State. The study participants were considered to have asthma if they met certain criteria for the number of office or emergency department visits, hospitalizations, and medication prescriptions for asthma in the 12− to 18-month period preceding the study (Pediatrics 2006;118:1042–51).

Nine percent of the study participants had an anxiety disorder, 2.5% had a depressive disorder, and 4.8% had both.

The results showed that the youth with an anxiety or depressive disorder reported more asthma symptom days in a 2-week period, compared with youth without one of these disorders: 5.4 symptom days, compared with 3.5 symptom days. In addition, compared with youth without an anxiety or depressive disorder, youth with one of these disorders were more likely to be girls, to have a parent without a college education, to have a recent asthma diagnosis, and to be taking one medication to control asthma symptoms.

Anxiety disorders are associated with a broad range of physical conditions, including respiratory diseases, gastrointestinal diseases, arthritic conditions, allergic conditions, thyroid diseases, and migraines, reported Dr. Jitender Sareen of the University of Manitoba, Winnipeg, and his associates.

The researchers conducted what they described as the first study aimed at systematically evaluating the association between anxiety disorders and physical conditions in a large epidemiologic sample that included standardized physician-based diagnoses. They used data from the German Health Survey, a nationally representative sample of more than 4,000 members of the German population aged 18–79 years in 1997–1999.

Subjects were assessed for 44 physical conditions and for panic disorder, agoraphobia, social phobia, simple phobia, generalized anxiety disorder, and obsessive-compulsive disorder, Dr. Sareen and his associates reported.

The presence of an anxiety disorder was associated with respiratory diseases such as asthma and chronic bronchitis; gastrointestinal diseases such as gastritis and ulcer; arthritic conditions such as inflammatory joint disease; allergic conditions such as hay fever, eczema, hives, food allergy, and conjunctivitis; thyroid diseases; and migraine headaches.

Anxiety disorders were not found to be associated with cardiac disease, hypertension, or diabetes in this study.

In most cases of comorbidity, onset of the anxiety disorder preceded onset of the physical conditions, the investigators said (Arch. Intern. Med. 2006;166:2109–16).

Compared with subjects who had these physical conditions alone, those who had comorbid anxiety disorders were more likely to report a poor quality of life and significant disability because of the physical illness.

“These findings underscore the importance of recognition of comorbidity of anxiety disorders among people who present with these physical health problems,” Dr. Sareen and his associates said.

The nature of this link between anxiety disorders and physical illnesses remains unclear. There may be a direct causal relationship mediated by biological mechanisms. Or there may be common genetic, environmental, or personality factors that underlie both types of disorders, the investigators noted.

Anxiety disorders are associated with a broad range of physical conditions, including respiratory diseases, gastrointestinal diseases, arthritic conditions, allergic conditions, thyroid diseases, and migraines, reported Dr. Jitender Sareen of the University of Manitoba, Winnipeg, and his associates.

The researchers conducted what they described as the first study aimed at systematically evaluating the association between anxiety disorders and physical conditions in a large epidemiologic sample that included standardized physician-based diagnoses. They used data from the German Health Survey, a nationally representative sample of more than 4,000 members of the German population aged 18–79 years in 1997–1999.

Subjects were assessed for 44 physical conditions and for panic disorder, agoraphobia, social phobia, simple phobia, generalized anxiety disorder, and obsessive-compulsive disorder, Dr. Sareen and his associates reported.

The presence of an anxiety disorder was associated with respiratory diseases such as asthma and chronic bronchitis; gastrointestinal diseases such as gastritis and ulcer; arthritic conditions such as inflammatory joint disease; allergic conditions such as hay fever, eczema, hives, food allergy, and conjunctivitis; thyroid diseases; and migraine headaches.

Anxiety disorders were not found to be associated with cardiac disease, hypertension, or diabetes in this study.

In most cases of comorbidity, onset of the anxiety disorder preceded onset of the physical conditions, the investigators said (Arch. Intern. Med. 2006;166:2109–16).

Compared with subjects who had these physical conditions alone, those who had comorbid anxiety disorders were more likely to report a poor quality of life and significant disability because of the physical illness.

“These findings underscore the importance of recognition of comorbidity of anxiety disorders among people who present with these physical health problems,” Dr. Sareen and his associates said.

The nature of this link between anxiety disorders and physical illnesses remains unclear. There may be a direct causal relationship mediated by biological mechanisms. Or there may be common genetic, environmental, or personality factors that underlie both types of disorders, the investigators noted.

Anxiety disorders are associated with a broad range of physical conditions, including respiratory diseases, gastrointestinal diseases, arthritic conditions, allergic conditions, thyroid diseases, and migraines, reported Dr. Jitender Sareen of the University of Manitoba, Winnipeg, and his associates.

The researchers conducted what they described as the first study aimed at systematically evaluating the association between anxiety disorders and physical conditions in a large epidemiologic sample that included standardized physician-based diagnoses. They used data from the German Health Survey, a nationally representative sample of more than 4,000 members of the German population aged 18–79 years in 1997–1999.

Subjects were assessed for 44 physical conditions and for panic disorder, agoraphobia, social phobia, simple phobia, generalized anxiety disorder, and obsessive-compulsive disorder, Dr. Sareen and his associates reported.

The presence of an anxiety disorder was associated with respiratory diseases such as asthma and chronic bronchitis; gastrointestinal diseases such as gastritis and ulcer; arthritic conditions such as inflammatory joint disease; allergic conditions such as hay fever, eczema, hives, food allergy, and conjunctivitis; thyroid diseases; and migraine headaches.

Anxiety disorders were not found to be associated with cardiac disease, hypertension, or diabetes in this study.

In most cases of comorbidity, onset of the anxiety disorder preceded onset of the physical conditions, the investigators said (Arch. Intern. Med. 2006;166:2109–16).

Compared with subjects who had these physical conditions alone, those who had comorbid anxiety disorders were more likely to report a poor quality of life and significant disability because of the physical illness.

“These findings underscore the importance of recognition of comorbidity of anxiety disorders among people who present with these physical health problems,” Dr. Sareen and his associates said.

The nature of this link between anxiety disorders and physical illnesses remains unclear. There may be a direct causal relationship mediated by biological mechanisms. Or there may be common genetic, environmental, or personality factors that underlie both types of disorders, the investigators noted.

SALT LAKE CITY – Anxiety in patients with chronic obstructive pulmonary disease is common, disruptive, and responds favorably to cognitive behavioral group therapy, Dr. Sandra G. Adams reported at the annual meeting of the American College of Chest Physicians.

Other investigators have shown that clinically significant anxiety occurs in up to half of COPD patients, and that it's associated with greater disability and impairment of quality of life. Moreover, in a prospective five-country Scandinavian study involving 416 COPD patients, anxiety conferred a 76% increase in risk for rehospitalization within 12 months (Eur. Respir. J. 2005;26:414–9).

This raises the possibility–as yet not examined in a clinical trial–that treating anxiety in patients with COPD might reduce rehospitalization, noted Dr. Adams of the University of Texas, San Antonio.

Experts agree COPD is underdiagnosed. And among patients with known COPD, anxiety is also greatly underdiagnosed, she said. For example, only 1 of the 22 patients with severe COPD and moderate to severe anxiety in her randomized trial of cognitive behavioral therapy (CBT) had been diagnosed with anxiety.

Study participants had a mean baseline forced expiratory volume in 1 second of 33% of predicted, indicative of very severe COPD. They also acknowledged having a “somewhat difficult” problem with at least one anxiety symptom on the Prime-MD screening instrument.

Patients were randomized to one group session of CBT per week for 6 weeks or to a general health education class with the same schedule. There were five to seven patients per group. CBT sessions covered relaxation techniques, stress and coping skills, practical goal setting, and general COPD information. The control group received information on COPD, exercise and nutrition, Social Security benefits, and advance directives.

Six weeks after completing the program, patients in the CBT arm showed significant improvement in quality of life, as reflected in a mean 11-point improvement on the St. George's Respiratory Questionnaire. In contrast, scores in the control group worsened by nearly 6 points. Neither group, however, showed a significant change on the Beck Anxiety or Beck Depression inventories.

SALT LAKE CITY – Anxiety in patients with chronic obstructive pulmonary disease is common, disruptive, and responds favorably to cognitive behavioral group therapy, Dr. Sandra G. Adams reported at the annual meeting of the American College of Chest Physicians.

Other investigators have shown that clinically significant anxiety occurs in up to half of COPD patients, and that it's associated with greater disability and impairment of quality of life. Moreover, in a prospective five-country Scandinavian study involving 416 COPD patients, anxiety conferred a 76% increase in risk for rehospitalization within 12 months (Eur. Respir. J. 2005;26:414–9).

This raises the possibility–as yet not examined in a clinical trial–that treating anxiety in patients with COPD might reduce rehospitalization, noted Dr. Adams of the University of Texas, San Antonio.

Experts agree COPD is underdiagnosed. And among patients with known COPD, anxiety is also greatly underdiagnosed, she said. For example, only 1 of the 22 patients with severe COPD and moderate to severe anxiety in her randomized trial of cognitive behavioral therapy (CBT) had been diagnosed with anxiety.

Study participants had a mean baseline forced expiratory volume in 1 second of 33% of predicted, indicative of very severe COPD. They also acknowledged having a “somewhat difficult” problem with at least one anxiety symptom on the Prime-MD screening instrument.

Patients were randomized to one group session of CBT per week for 6 weeks or to a general health education class with the same schedule. There were five to seven patients per group. CBT sessions covered relaxation techniques, stress and coping skills, practical goal setting, and general COPD information. The control group received information on COPD, exercise and nutrition, Social Security benefits, and advance directives.

Six weeks after completing the program, patients in the CBT arm showed significant improvement in quality of life, as reflected in a mean 11-point improvement on the St. George's Respiratory Questionnaire. In contrast, scores in the control group worsened by nearly 6 points. Neither group, however, showed a significant change on the Beck Anxiety or Beck Depression inventories.

SALT LAKE CITY – Anxiety in patients with chronic obstructive pulmonary disease is common, disruptive, and responds favorably to cognitive behavioral group therapy, Dr. Sandra G. Adams reported at the annual meeting of the American College of Chest Physicians.

Other investigators have shown that clinically significant anxiety occurs in up to half of COPD patients, and that it's associated with greater disability and impairment of quality of life. Moreover, in a prospective five-country Scandinavian study involving 416 COPD patients, anxiety conferred a 76% increase in risk for rehospitalization within 12 months (Eur. Respir. J. 2005;26:414–9).

This raises the possibility–as yet not examined in a clinical trial–that treating anxiety in patients with COPD might reduce rehospitalization, noted Dr. Adams of the University of Texas, San Antonio.

Experts agree COPD is underdiagnosed. And among patients with known COPD, anxiety is also greatly underdiagnosed, she said. For example, only 1 of the 22 patients with severe COPD and moderate to severe anxiety in her randomized trial of cognitive behavioral therapy (CBT) had been diagnosed with anxiety.

Study participants had a mean baseline forced expiratory volume in 1 second of 33% of predicted, indicative of very severe COPD. They also acknowledged having a “somewhat difficult” problem with at least one anxiety symptom on the Prime-MD screening instrument.

Patients were randomized to one group session of CBT per week for 6 weeks or to a general health education class with the same schedule. There were five to seven patients per group. CBT sessions covered relaxation techniques, stress and coping skills, practical goal setting, and general COPD information. The control group received information on COPD, exercise and nutrition, Social Security benefits, and advance directives.

Six weeks after completing the program, patients in the CBT arm showed significant improvement in quality of life, as reflected in a mean 11-point improvement on the St. George's Respiratory Questionnaire. In contrast, scores in the control group worsened by nearly 6 points. Neither group, however, showed a significant change on the Beck Anxiety or Beck Depression inventories.

ATLANTA – Anxiety, depression, and pain are often overlooked in older cancer survivors, according to results of a study presented at the annual meeting of the American Society of Clinical Oncology.

In this study of 150 men who had been diagnosed with cancer an average of 3 years prior, pain, anxiety, and depression were common, occurring in 64%, 26%, and 21% of men, respectively, according to prospective analysis of responses to a questionnaire.

Despite the high frequency of these issues, in many cases, oncologists did not discuss pain and well-being with their patients. According to blinded chart reviews, oncologists did not inquire about pain in 22% of the men. Inquiries about mental health were more infrequent: 95% of men were not asked about anxiety, and 88% of men were not asked about depression.

Because of this failure to inquire about pain and mental health, a significant proportion of men with each condition was overlooked, including 18% of men with pain, 85% with anxiety, and 75% with depression.

In an interview during his poster presentation, Dr. Harvey Jay Cohen said this information is very relevant for primary care physicians. “People need to be aware that cancer survivors, older ones at least, not infrequently are anxious and showing signs of depression,” said Dr. Cohen, professor and interim chair in the department of medicine and director of the Center for the Study of Aging and Human Development at Duke University Medical Center in Durham, N.C. “That's something people at least need to inquire about.”

In the study, Dr. Cohen and his colleagues evaluated 153 male patients who visited a single oncology clinic at a Veterans Affairs Medical Center. The men filled out questionnaires reporting pain using the pain thermometer and mental health using the Hospital Anxiety and Depression Scale.

The patients averaged 68 years old, and 40% were African American. Most of the men (64%) were married, though 22% lived alone. They had, on average, about five comorbidities. The most common cancers involved were prostate (47%), head and neck (19%), and lung (12%).

A total of 147 men were evaluable for the pain component of the study, 128 for anxiety, and 136 for depression, based on the presence of responses to each segment of the evaluation and available chart information.

The investigators looked for any notes about mood, anxiety, depression, other psychological or psychiatric conditions, notes about treatment, and suggestions for psychiatric referrals in the chart. They analyzed a 3-month period of charts to rule out that they had not overlooked the appointment where the issues were discussed.

“We looked for anything that in the chart would've indicated that [the oncologist] had noticed anything–they said something, treated the patients–we took absolutely anything,” Dr. Cohen said.

ATLANTA – Anxiety, depression, and pain are often overlooked in older cancer survivors, according to results of a study presented at the annual meeting of the American Society of Clinical Oncology.

In this study of 150 men who had been diagnosed with cancer an average of 3 years prior, pain, anxiety, and depression were common, occurring in 64%, 26%, and 21% of men, respectively, according to prospective analysis of responses to a questionnaire.

Despite the high frequency of these issues, in many cases, oncologists did not discuss pain and well-being with their patients. According to blinded chart reviews, oncologists did not inquire about pain in 22% of the men. Inquiries about mental health were more infrequent: 95% of men were not asked about anxiety, and 88% of men were not asked about depression.

Because of this failure to inquire about pain and mental health, a significant proportion of men with each condition was overlooked, including 18% of men with pain, 85% with anxiety, and 75% with depression.

In an interview during his poster presentation, Dr. Harvey Jay Cohen said this information is very relevant for primary care physicians. “People need to be aware that cancer survivors, older ones at least, not infrequently are anxious and showing signs of depression,” said Dr. Cohen, professor and interim chair in the department of medicine and director of the Center for the Study of Aging and Human Development at Duke University Medical Center in Durham, N.C. “That's something people at least need to inquire about.”

In the study, Dr. Cohen and his colleagues evaluated 153 male patients who visited a single oncology clinic at a Veterans Affairs Medical Center. The men filled out questionnaires reporting pain using the pain thermometer and mental health using the Hospital Anxiety and Depression Scale.

The patients averaged 68 years old, and 40% were African American. Most of the men (64%) were married, though 22% lived alone. They had, on average, about five comorbidities. The most common cancers involved were prostate (47%), head and neck (19%), and lung (12%).

A total of 147 men were evaluable for the pain component of the study, 128 for anxiety, and 136 for depression, based on the presence of responses to each segment of the evaluation and available chart information.

The investigators looked for any notes about mood, anxiety, depression, other psychological or psychiatric conditions, notes about treatment, and suggestions for psychiatric referrals in the chart. They analyzed a 3-month period of charts to rule out that they had not overlooked the appointment where the issues were discussed.

“We looked for anything that in the chart would've indicated that [the oncologist] had noticed anything–they said something, treated the patients–we took absolutely anything,” Dr. Cohen said.

ATLANTA – Anxiety, depression, and pain are often overlooked in older cancer survivors, according to results of a study presented at the annual meeting of the American Society of Clinical Oncology.

In this study of 150 men who had been diagnosed with cancer an average of 3 years prior, pain, anxiety, and depression were common, occurring in 64%, 26%, and 21% of men, respectively, according to prospective analysis of responses to a questionnaire.

Despite the high frequency of these issues, in many cases, oncologists did not discuss pain and well-being with their patients. According to blinded chart reviews, oncologists did not inquire about pain in 22% of the men. Inquiries about mental health were more infrequent: 95% of men were not asked about anxiety, and 88% of men were not asked about depression.

Because of this failure to inquire about pain and mental health, a significant proportion of men with each condition was overlooked, including 18% of men with pain, 85% with anxiety, and 75% with depression.

In an interview during his poster presentation, Dr. Harvey Jay Cohen said this information is very relevant for primary care physicians. “People need to be aware that cancer survivors, older ones at least, not infrequently are anxious and showing signs of depression,” said Dr. Cohen, professor and interim chair in the department of medicine and director of the Center for the Study of Aging and Human Development at Duke University Medical Center in Durham, N.C. “That's something people at least need to inquire about.”

In the study, Dr. Cohen and his colleagues evaluated 153 male patients who visited a single oncology clinic at a Veterans Affairs Medical Center. The men filled out questionnaires reporting pain using the pain thermometer and mental health using the Hospital Anxiety and Depression Scale.

The patients averaged 68 years old, and 40% were African American. Most of the men (64%) were married, though 22% lived alone. They had, on average, about five comorbidities. The most common cancers involved were prostate (47%), head and neck (19%), and lung (12%).

A total of 147 men were evaluable for the pain component of the study, 128 for anxiety, and 136 for depression, based on the presence of responses to each segment of the evaluation and available chart information.

The investigators looked for any notes about mood, anxiety, depression, other psychological or psychiatric conditions, notes about treatment, and suggestions for psychiatric referrals in the chart. They analyzed a 3-month period of charts to rule out that they had not overlooked the appointment where the issues were discussed.

“We looked for anything that in the chart would've indicated that [the oncologist] had noticed anything–they said something, treated the patients–we took absolutely anything,” Dr. Cohen said.

KEYSTONE, COLO. – Depression is twice as common in adults with diabetes as in the general population, William H. Polonsky, Ph.D., said at a conference on the management of diabetes in youth.

Moreover, coexistent depression and diabetes is associated with significantly greater all-cause mortality risk than either condition alone, hence the need to regularly screen adult diabetic patients for depression and to promote vigilance among patients and their families regarding its signs and symptoms, added Dr. Polonsky of the department of psychiatry at the University of California, San Diego, and president of the Behavioral Diabetes Institute, also in San Diego.

Multiple large epidemiologic studies indicate that at any given time, 17%–20% of adult diabetic patients meet criteria for moderate to major depression, a rate up to twofold greater than that in adults overall.

South Carolina investigators recently studied the impact of depression and diabetes on all-cause and coronary heart disease mortality in 10,025 participants in the population-based National Health and Nutrition Examination Survey-I Epidemiologic Follow-Up Study.

During 8 years of follow-up there were 1,925 deaths, including 522 caused by coronary heart disease. Compared with subjects who were nondiabetic and nondepressed, adjusted all-cause mortality was increased by 20% among those who had depression but not diabetes, by 88% in subjects who had diabetes but not depression, and by 150% in participants with both diabetes and depression.

Coronary heart disease mortality was increased by 29% in individuals with baseline depression, by 126% in those with diabetes but not depression, and by 142% in subjects with both conditions (Diabetes Care 2005;28:1339–45).

Several studies also have shown threefold greater rates of new-onset coronary artery disease and retinopathy over a 10-year follow-up period in depressed diabetic patients compared with nondepressed diabetic patients, Dr. Polonsky said at the conference, sponsored by the University of Colorado and the Children's Diabetes Foundation at Denver.

Other studies have demonstrated that depression makes it tougher to initiate and maintain constructive behavioral change. In persons with diabetes, depression is associated with worse glycemic control as reflected in hemoglobin A_1c levels 2.0%–3.3% higher than in nondepressed patients, along with an increased hospitalization rate, more lost work days, and greater functional disability.

Screening diabetic patients regularly for depression is a simple matter even in a busy office practice. Many screening questionnaires are available that patients can fill out in the waiting room. Or the physician can simply ask two straightforward questions:

▸ During the past month, have you felt down, depressed, or hopeless?

▸ Have you had no interest or pleasure in doing things?

A yes response to either screening question warrants further inquiry. By far the most widely used tool for this purpose in adults is the Patient Health Questionnaire-9. A Google search for “PHQ-9” will provide the scale itself for free, as well as the history of the test instrument, how to score the PHQ-9 properly, and other useful information.

Antidepressant therapy in diabetics is as effective as in nondiabetics. But if baseline glycemic control is good, antidepressant therapy will have little impact on diabetes-specific outcomes, Dr. Polonsky said.

That was shown in a preplanned subgroup analysis involving 417 depressed elderly patients with type 2 diabetes in the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial. This analysis compared usual antidepressant therapy in the primary care setting with enhanced care given in collaboration with a depression care manager who provided patient education, problem-solving treatment, and intensification of antidepressant medication as needed.

After 1 year, patients in the collaborative care arm were significantly less depressed and had better overall function than did those assigned to usual care; however, HbA_1c values in the groups didn't differ (Ann. Intern. Med. 2004;140:1015–24).

Dr. Polonsky, who works chiefly with adults, said the data regarding depression in diabetic adolescents are more limited and equivocal. “It's not clear that their depression rates are as high as in adults,” he noted.

At any given time, 17%–20% of adult diabetes patients meet criteria for moderate to major depression. DR. POLONSKY

KEYSTONE, COLO. – Depression is twice as common in adults with diabetes as in the general population, William H. Polonsky, Ph.D., said at a conference on the management of diabetes in youth.

Moreover, coexistent depression and diabetes is associated with significantly greater all-cause mortality risk than either condition alone, hence the need to regularly screen adult diabetic patients for depression and to promote vigilance among patients and their families regarding its signs and symptoms, added Dr. Polonsky of the department of psychiatry at the University of California, San Diego, and president of the Behavioral Diabetes Institute, also in San Diego.

Multiple large epidemiologic studies indicate that at any given time, 17%–20% of adult diabetic patients meet criteria for moderate to major depression, a rate up to twofold greater than that in adults overall.

South Carolina investigators recently studied the impact of depression and diabetes on all-cause and coronary heart disease mortality in 10,025 participants in the population-based National Health and Nutrition Examination Survey-I Epidemiologic Follow-Up Study.

During 8 years of follow-up there were 1,925 deaths, including 522 caused by coronary heart disease. Compared with subjects who were nondiabetic and nondepressed, adjusted all-cause mortality was increased by 20% among those who had depression but not diabetes, by 88% in subjects who had diabetes but not depression, and by 150% in participants with both diabetes and depression.

Coronary heart disease mortality was increased by 29% in individuals with baseline depression, by 126% in those with diabetes but not depression, and by 142% in subjects with both conditions (Diabetes Care 2005;28:1339–45).

Several studies also have shown threefold greater rates of new-onset coronary artery disease and retinopathy over a 10-year follow-up period in depressed diabetic patients compared with nondepressed diabetic patients, Dr. Polonsky said at the conference, sponsored by the University of Colorado and the Children's Diabetes Foundation at Denver.

Other studies have demonstrated that depression makes it tougher to initiate and maintain constructive behavioral change. In persons with diabetes, depression is associated with worse glycemic control as reflected in hemoglobin A_1c levels 2.0%–3.3% higher than in nondepressed patients, along with an increased hospitalization rate, more lost work days, and greater functional disability.

Screening diabetic patients regularly for depression is a simple matter even in a busy office practice. Many screening questionnaires are available that patients can fill out in the waiting room. Or the physician can simply ask two straightforward questions:

▸ During the past month, have you felt down, depressed, or hopeless?

▸ Have you had no interest or pleasure in doing things?

A yes response to either screening question warrants further inquiry. By far the most widely used tool for this purpose in adults is the Patient Health Questionnaire-9. A Google search for “PHQ-9” will provide the scale itself for free, as well as the history of the test instrument, how to score the PHQ-9 properly, and other useful information.

Antidepressant therapy in diabetics is as effective as in nondiabetics. But if baseline glycemic control is good, antidepressant therapy will have little impact on diabetes-specific outcomes, Dr. Polonsky said.

That was shown in a preplanned subgroup analysis involving 417 depressed elderly patients with type 2 diabetes in the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial. This analysis compared usual antidepressant therapy in the primary care setting with enhanced care given in collaboration with a depression care manager who provided patient education, problem-solving treatment, and intensification of antidepressant medication as needed.

After 1 year, patients in the collaborative care arm were significantly less depressed and had better overall function than did those assigned to usual care; however, HbA_1c values in the groups didn't differ (Ann. Intern. Med. 2004;140:1015–24).

Dr. Polonsky, who works chiefly with adults, said the data regarding depression in diabetic adolescents are more limited and equivocal. “It's not clear that their depression rates are as high as in adults,” he noted.

At any given time, 17%–20% of adult diabetes patients meet criteria for moderate to major depression. DR. POLONSKY

KEYSTONE, COLO. – Depression is twice as common in adults with diabetes as in the general population, William H. Polonsky, Ph.D., said at a conference on the management of diabetes in youth.

Moreover, coexistent depression and diabetes is associated with significantly greater all-cause mortality risk than either condition alone, hence the need to regularly screen adult diabetic patients for depression and to promote vigilance among patients and their families regarding its signs and symptoms, added Dr. Polonsky of the department of psychiatry at the University of California, San Diego, and president of the Behavioral Diabetes Institute, also in San Diego.

Multiple large epidemiologic studies indicate that at any given time, 17%–20% of adult diabetic patients meet criteria for moderate to major depression, a rate up to twofold greater than that in adults overall.

South Carolina investigators recently studied the impact of depression and diabetes on all-cause and coronary heart disease mortality in 10,025 participants in the population-based National Health and Nutrition Examination Survey-I Epidemiologic Follow-Up Study.

During 8 years of follow-up there were 1,925 deaths, including 522 caused by coronary heart disease. Compared with subjects who were nondiabetic and nondepressed, adjusted all-cause mortality was increased by 20% among those who had depression but not diabetes, by 88% in subjects who had diabetes but not depression, and by 150% in participants with both diabetes and depression.

Coronary heart disease mortality was increased by 29% in individuals with baseline depression, by 126% in those with diabetes but not depression, and by 142% in subjects with both conditions (Diabetes Care 2005;28:1339–45).

Several studies also have shown threefold greater rates of new-onset coronary artery disease and retinopathy over a 10-year follow-up period in depressed diabetic patients compared with nondepressed diabetic patients, Dr. Polonsky said at the conference, sponsored by the University of Colorado and the Children's Diabetes Foundation at Denver.

Other studies have demonstrated that depression makes it tougher to initiate and maintain constructive behavioral change. In persons with diabetes, depression is associated with worse glycemic control as reflected in hemoglobin A_1c levels 2.0%–3.3% higher than in nondepressed patients, along with an increased hospitalization rate, more lost work days, and greater functional disability.

Screening diabetic patients regularly for depression is a simple matter even in a busy office practice. Many screening questionnaires are available that patients can fill out in the waiting room. Or the physician can simply ask two straightforward questions:

▸ During the past month, have you felt down, depressed, or hopeless?

▸ Have you had no interest or pleasure in doing things?

A yes response to either screening question warrants further inquiry. By far the most widely used tool for this purpose in adults is the Patient Health Questionnaire-9. A Google search for “PHQ-9” will provide the scale itself for free, as well as the history of the test instrument, how to score the PHQ-9 properly, and other useful information.

Antidepressant therapy in diabetics is as effective as in nondiabetics. But if baseline glycemic control is good, antidepressant therapy will have little impact on diabetes-specific outcomes, Dr. Polonsky said.

That was shown in a preplanned subgroup analysis involving 417 depressed elderly patients with type 2 diabetes in the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial. This analysis compared usual antidepressant therapy in the primary care setting with enhanced care given in collaboration with a depression care manager who provided patient education, problem-solving treatment, and intensification of antidepressant medication as needed.

After 1 year, patients in the collaborative care arm were significantly less depressed and had better overall function than did those assigned to usual care; however, HbA_1c values in the groups didn't differ (Ann. Intern. Med. 2004;140:1015–24).

Dr. Polonsky, who works chiefly with adults, said the data regarding depression in diabetic adolescents are more limited and equivocal. “It's not clear that their depression rates are as high as in adults,” he noted.

At any given time, 17%–20% of adult diabetes patients meet criteria for moderate to major depression. DR. POLONSKY

MONTREAL – Sleep apnea patients receiving continuous positive airway pressure therapy have changes in brain function that can be seen with functional magnetic resonance imaging when the therapy is withdrawn for just 2 consecutive nights.

“The brains of these patients must work harder, and possibly in less efficient ways, to perform at the same level [as when they are on the therapy],” said Mark S. Aloia, Ph.D., who reported the findings at the 8th World Congress on Sleep Apnea.

His study included eight subjects with moderate to severe sleep apnea who were compliant with continuous positive airway pressure (CPAP) therapy. The subjects were asked to complete a cognitive function test called the N-back test while undergoing functional magnetic resonance imaging (fMRI) of their brains. The testing was performed both when patients were compliant with CPAP (at least 2 consecutive nights) and when the therapy had been withdrawn for 2 consecutive nights.

While subjects performed similarly both on and off CPAP therapy (because of extensive task training), the fMRI showed significant differences in which regions of their brains were activated in the presence or absence of CPAP, said Dr. Aloia, who serves as director of sleep research at National Jewish Medical and Research Center in Denver.

Specifically, there was significantly greater activation of the left middle frontal gyrus and a trend toward greater activation of the right inferior parietal regions when CPAP was withdrawn. In contrast, when patients had been treated with CPAP, there was significantly more activation of the right middle frontal gyrus.

The findings lend support to the hypothesis that untreated sleep apnea creates an inefficiency in brain function, Dr. Aloia said. “There seems to be a compensatory response of the brain off CPAP such that subjects are using more brain resources to perform at the same level,” he said in an interview.

In addition to altering brain function, there is also evidence that sleep apnea impairs certain cognitive functions–and CPAP can reverse some of this impairment, Dr. Aloia added. In another study currently in press, he found that sleep apnea patients with impaired memory were eight times more likely to normalize their memory if they received adequate CPAP therapy–defined as 3 months of 6 or more hours per night–compared with patients who were less compliant with CPAP, averaging 1 hour or less a night.

Dr. Aloia and his colleagues also have done imaging studies that show differences in white matter in the brains of patients with severe sleep apnea, compared with those with mild disease–suggesting that some of the changes in brain functioning among sleep apnea patients could be caused by microvascular damage.

“From a neuropsychological perspective, we see fine motor discoordination, memory, and executive problems in microvascular disease,” he said. “So, we posited the idea that the relationship we know between apnea and cardiovascular disease probably extends to vessels in the brain.”

It is possible that CPAP therapy might reverse some of this ischemia, Dr. Aloia said.

Functional magnetic resonance imaging shows that activity in the brain increases (red areas) when continuous positive airway pressure is withdrawn. Courtesy Dr. Mark S. Aloia

MONTREAL – Sleep apnea patients receiving continuous positive airway pressure therapy have changes in brain function that can be seen with functional magnetic resonance imaging when the therapy is withdrawn for just 2 consecutive nights.

“The brains of these patients must work harder, and possibly in less efficient ways, to perform at the same level [as when they are on the therapy],” said Mark S. Aloia, Ph.D., who reported the findings at the 8th World Congress on Sleep Apnea.

His study included eight subjects with moderate to severe sleep apnea who were compliant with continuous positive airway pressure (CPAP) therapy. The subjects were asked to complete a cognitive function test called the N-back test while undergoing functional magnetic resonance imaging (fMRI) of their brains. The testing was performed both when patients were compliant with CPAP (at least 2 consecutive nights) and when the therapy had been withdrawn for 2 consecutive nights.

While subjects performed similarly both on and off CPAP therapy (because of extensive task training), the fMRI showed significant differences in which regions of their brains were activated in the presence or absence of CPAP, said Dr. Aloia, who serves as director of sleep research at National Jewish Medical and Research Center in Denver.

Specifically, there was significantly greater activation of the left middle frontal gyrus and a trend toward greater activation of the right inferior parietal regions when CPAP was withdrawn. In contrast, when patients had been treated with CPAP, there was significantly more activation of the right middle frontal gyrus.

The findings lend support to the hypothesis that untreated sleep apnea creates an inefficiency in brain function, Dr. Aloia said. “There seems to be a compensatory response of the brain off CPAP such that subjects are using more brain resources to perform at the same level,” he said in an interview.

In addition to altering brain function, there is also evidence that sleep apnea impairs certain cognitive functions–and CPAP can reverse some of this impairment, Dr. Aloia added. In another study currently in press, he found that sleep apnea patients with impaired memory were eight times more likely to normalize their memory if they received adequate CPAP therapy–defined as 3 months of 6 or more hours per night–compared with patients who were less compliant with CPAP, averaging 1 hour or less a night.

Dr. Aloia and his colleagues also have done imaging studies that show differences in white matter in the brains of patients with severe sleep apnea, compared with those with mild disease–suggesting that some of the changes in brain functioning among sleep apnea patients could be caused by microvascular damage.

“From a neuropsychological perspective, we see fine motor discoordination, memory, and executive problems in microvascular disease,” he said. “So, we posited the idea that the relationship we know between apnea and cardiovascular disease probably extends to vessels in the brain.”

It is possible that CPAP therapy might reverse some of this ischemia, Dr. Aloia said.

Functional magnetic resonance imaging shows that activity in the brain increases (red areas) when continuous positive airway pressure is withdrawn. Courtesy Dr. Mark S. Aloia

MONTREAL – Sleep apnea patients receiving continuous positive airway pressure therapy have changes in brain function that can be seen with functional magnetic resonance imaging when the therapy is withdrawn for just 2 consecutive nights.

“The brains of these patients must work harder, and possibly in less efficient ways, to perform at the same level [as when they are on the therapy],” said Mark S. Aloia, Ph.D., who reported the findings at the 8th World Congress on Sleep Apnea.

His study included eight subjects with moderate to severe sleep apnea who were compliant with continuous positive airway pressure (CPAP) therapy. The subjects were asked to complete a cognitive function test called the N-back test while undergoing functional magnetic resonance imaging (fMRI) of their brains. The testing was performed both when patients were compliant with CPAP (at least 2 consecutive nights) and when the therapy had been withdrawn for 2 consecutive nights.

While subjects performed similarly both on and off CPAP therapy (because of extensive task training), the fMRI showed significant differences in which regions of their brains were activated in the presence or absence of CPAP, said Dr. Aloia, who serves as director of sleep research at National Jewish Medical and Research Center in Denver.

Specifically, there was significantly greater activation of the left middle frontal gyrus and a trend toward greater activation of the right inferior parietal regions when CPAP was withdrawn. In contrast, when patients had been treated with CPAP, there was significantly more activation of the right middle frontal gyrus.

The findings lend support to the hypothesis that untreated sleep apnea creates an inefficiency in brain function, Dr. Aloia said. “There seems to be a compensatory response of the brain off CPAP such that subjects are using more brain resources to perform at the same level,” he said in an interview.

In addition to altering brain function, there is also evidence that sleep apnea impairs certain cognitive functions–and CPAP can reverse some of this impairment, Dr. Aloia added. In another study currently in press, he found that sleep apnea patients with impaired memory were eight times more likely to normalize their memory if they received adequate CPAP therapy–defined as 3 months of 6 or more hours per night–compared with patients who were less compliant with CPAP, averaging 1 hour or less a night.

Dr. Aloia and his colleagues also have done imaging studies that show differences in white matter in the brains of patients with severe sleep apnea, compared with those with mild disease–suggesting that some of the changes in brain functioning among sleep apnea patients could be caused by microvascular damage.

“From a neuropsychological perspective, we see fine motor discoordination, memory, and executive problems in microvascular disease,” he said. “So, we posited the idea that the relationship we know between apnea and cardiovascular disease probably extends to vessels in the brain.”

It is possible that CPAP therapy might reverse some of this ischemia, Dr. Aloia said.

Functional magnetic resonance imaging shows that activity in the brain increases (red areas) when continuous positive airway pressure is withdrawn. Courtesy Dr. Mark S. Aloia

BETHESDA, MD. – A complex set of predisposing, precipitating, and perpetuating factors appears to play a major role in driving the behavioral and neurochemical changes of patients with anorexia or bulimia, Craig Johnson, Ph.D., said at the annual conference of the National Eating Disorders Association.

“A belief system develops, and from that belief system, behaviors emerge. When those behaviors emerge, that also starts to alter the psychology and physiology of the patient and can set up these perpetuating factors so that they feed back on the predisposing and precipitating factors,” said Dr. Johnson, founder and director of the eating disorders program at the Laureate Psychiatric Clinic and Hospital in Tulsa, Okla.

The factors that serve to perpetuate an eating disorder may have little to do with why the illness is continuing. The structural and functional changes to neurochemical pathways in the brain that occurred as a result of the eating disorder behavior will continue to reinforce whatever stimulation was gained from the behavior, he said.

“Without exception, patients we're taking care of entered into these behaviors to try to fix something in themselves. It was a self-improvement strategy. They thought they were doing a good thing. They were doing the same things they saw encouraged throughout our culture,” Dr. Johnson said.

As they lost weight or altered their neurochemistry, though, “they stepped on a land mine, which is going to have a strong genetic predisposition to turn something on in their brain, which then sends them cascading down that road of being obsessed with weight loss and being compelled to accomplish it,” he explained.

“Eating disorders are as heritable, have the same level of relative risk, and look to be as genetically mediated as the other major psychiatric illnesses,” Dr. Johnson said.

If a relative has anorexia nervosa, other members of the family are 12 times more likely to develop the disorder than members of the general population. Similarly, if one family member has bulimia nervosa, other members are four times more likely to have it.

About two-thirds of eating disorder patients have a comorbid diagnosis of anxiety or depression, which predates the onset of the eating disorder in about half of such patients, he said.

Some patients also have an impaired ability to work with different sets of challenges on neuropsychological tests, although this measure is not correlated with intelligence. These test results “make sense, in terms of what we see happening to them when they move into increasing levels of complexity developmentally, starting with puberty,” he said.

Even though he and his colleagues are seeing gender, ethnic, and socioeconomic drift in the epidemiology of anorexia nervosa and bulimia, Dr. Johnson noted that they are still illnesses that primarily affect white females. Girls who drop below about 17% body fat lose the secondary sexual characteristics associated with puberty and flatten out their hormone profiles so that they don't “feel” the effects of puberty, Dr. Johnson said.

“In our treatment center, one of the things we want to know as soon as we can is where the menstrual threshold is. At what point with our weight restoration are we going to be sending them clearly on the other side of puberty?” he said.

If patients do not stay in treatment long enough to restore their weight past the menstrual threshold, they will not have dealt adequately with their phobic fear of menstruation, he said.

Patients with bulimia nervosa often report that bingeing on carbohydrate-rich food calms them down, which may be the result of increased blood levels of tryptophan, an amino acid that can pass the blood-brain barrier and is synthesized into serotonin; treatment with selective serotonin reuptake inhibitors may make this effect even more pronounced by increasing the amount of serotonin available at synapses, Dr. Johnson suggested.

Vomiting also causes a sedating effect in bulimic patients because of the release of vasopressin. An autoaddiction to the vasopressin release may explain why binges become smaller and vomiting becomes disproportionate to the volume of food, he said.

Excessive exercise also appears to be a reinforcing and possibly anorexia-inducing behavior. “Running seems to have some unique interaction with restricting behavior that essentially stimulates something very, very toxic for the patients that have the more severe forms of the illness. We've found that very few patients are able to successfully return to running in our treatment program,” he said.

Functional MRI studies of the brains of anorexic patients and healthy controls have revealed some striking differences in dopamine pathways that suggest that patients with the disorder do not discriminate between positive and negative feedback and have a blunted response to pleasurable stimuli, according to Dr. Walter Kaye, who gave a separate presentation during the same session at the conference.

During a gambling task in which participants could win or lose money, trials in which patients with anorexia nervosa won money produced brain activity similar to that of control patients during winning trials, but anorexic patients who lost money also had brain activity similar to that of controls who won money, said Dr. Kaye, research director of the eating disorder program at the University of Pittsburgh.

In a separate fMRI study, the taste of sugar produced blunted responses in the insula (the primary taste cortex) of recovered anorexic patients, compared with healthy controls. Unlike in the healthy patients, however, there was no correlation between the taster's rating of pleasantness and the insula's response to sugar in recovered anorexic individuals, he noted.

Even before these data can be used to develop new treatments, it will be useful to let patients understand that this particular temperament is wired into their brains and that they might be able to learn to modulate their feelings and thoughts and develop adaptive coping strategies, said Dr. Kaye, also of the University of California, San Diego.

BETHESDA, MD. – A complex set of predisposing, precipitating, and perpetuating factors appears to play a major role in driving the behavioral and neurochemical changes of patients with anorexia or bulimia, Craig Johnson, Ph.D., said at the annual conference of the National Eating Disorders Association.

“A belief system develops, and from that belief system, behaviors emerge. When those behaviors emerge, that also starts to alter the psychology and physiology of the patient and can set up these perpetuating factors so that they feed back on the predisposing and precipitating factors,” said Dr. Johnson, founder and director of the eating disorders program at the Laureate Psychiatric Clinic and Hospital in Tulsa, Okla.

The factors that serve to perpetuate an eating disorder may have little to do with why the illness is continuing. The structural and functional changes to neurochemical pathways in the brain that occurred as a result of the eating disorder behavior will continue to reinforce whatever stimulation was gained from the behavior, he said.

“Without exception, patients we're taking care of entered into these behaviors to try to fix something in themselves. It was a self-improvement strategy. They thought they were doing a good thing. They were doing the same things they saw encouraged throughout our culture,” Dr. Johnson said.

As they lost weight or altered their neurochemistry, though, “they stepped on a land mine, which is going to have a strong genetic predisposition to turn something on in their brain, which then sends them cascading down that road of being obsessed with weight loss and being compelled to accomplish it,” he explained.

“Eating disorders are as heritable, have the same level of relative risk, and look to be as genetically mediated as the other major psychiatric illnesses,” Dr. Johnson said.

If a relative has anorexia nervosa, other members of the family are 12 times more likely to develop the disorder than members of the general population. Similarly, if one family member has bulimia nervosa, other members are four times more likely to have it.

About two-thirds of eating disorder patients have a comorbid diagnosis of anxiety or depression, which predates the onset of the eating disorder in about half of such patients, he said.

Some patients also have an impaired ability to work with different sets of challenges on neuropsychological tests, although this measure is not correlated with intelligence. These test results “make sense, in terms of what we see happening to them when they move into increasing levels of complexity developmentally, starting with puberty,” he said.

Even though he and his colleagues are seeing gender, ethnic, and socioeconomic drift in the epidemiology of anorexia nervosa and bulimia, Dr. Johnson noted that they are still illnesses that primarily affect white females. Girls who drop below about 17% body fat lose the secondary sexual characteristics associated with puberty and flatten out their hormone profiles so that they don't “feel” the effects of puberty, Dr. Johnson said.

“In our treatment center, one of the things we want to know as soon as we can is where the menstrual threshold is. At what point with our weight restoration are we going to be sending them clearly on the other side of puberty?” he said.

If patients do not stay in treatment long enough to restore their weight past the menstrual threshold, they will not have dealt adequately with their phobic fear of menstruation, he said.

Patients with bulimia nervosa often report that bingeing on carbohydrate-rich food calms them down, which may be the result of increased blood levels of tryptophan, an amino acid that can pass the blood-brain barrier and is synthesized into serotonin; treatment with selective serotonin reuptake inhibitors may make this effect even more pronounced by increasing the amount of serotonin available at synapses, Dr. Johnson suggested.

Vomiting also causes a sedating effect in bulimic patients because of the release of vasopressin. An autoaddiction to the vasopressin release may explain why binges become smaller and vomiting becomes disproportionate to the volume of food, he said.

Excessive exercise also appears to be a reinforcing and possibly anorexia-inducing behavior. “Running seems to have some unique interaction with restricting behavior that essentially stimulates something very, very toxic for the patients that have the more severe forms of the illness. We've found that very few patients are able to successfully return to running in our treatment program,” he said.

Functional MRI studies of the brains of anorexic patients and healthy controls have revealed some striking differences in dopamine pathways that suggest that patients with the disorder do not discriminate between positive and negative feedback and have a blunted response to pleasurable stimuli, according to Dr. Walter Kaye, who gave a separate presentation during the same session at the conference.

During a gambling task in which participants could win or lose money, trials in which patients with anorexia nervosa won money produced brain activity similar to that of control patients during winning trials, but anorexic patients who lost money also had brain activity similar to that of controls who won money, said Dr. Kaye, research director of the eating disorder program at the University of Pittsburgh.

In a separate fMRI study, the taste of sugar produced blunted responses in the insula (the primary taste cortex) of recovered anorexic patients, compared with healthy controls. Unlike in the healthy patients, however, there was no correlation between the taster's rating of pleasantness and the insula's response to sugar in recovered anorexic individuals, he noted.

Even before these data can be used to develop new treatments, it will be useful to let patients understand that this particular temperament is wired into their brains and that they might be able to learn to modulate their feelings and thoughts and develop adaptive coping strategies, said Dr. Kaye, also of the University of California, San Diego.

BETHESDA, MD. – A complex set of predisposing, precipitating, and perpetuating factors appears to play a major role in driving the behavioral and neurochemical changes of patients with anorexia or bulimia, Craig Johnson, Ph.D., said at the annual conference of the National Eating Disorders Association.

“A belief system develops, and from that belief system, behaviors emerge. When those behaviors emerge, that also starts to alter the psychology and physiology of the patient and can set up these perpetuating factors so that they feed back on the predisposing and precipitating factors,” said Dr. Johnson, founder and director of the eating disorders program at the Laureate Psychiatric Clinic and Hospital in Tulsa, Okla.

The factors that serve to perpetuate an eating disorder may have little to do with why the illness is continuing. The structural and functional changes to neurochemical pathways in the brain that occurred as a result of the eating disorder behavior will continue to reinforce whatever stimulation was gained from the behavior, he said.

“Without exception, patients we're taking care of entered into these behaviors to try to fix something in themselves. It was a self-improvement strategy. They thought they were doing a good thing. They were doing the same things they saw encouraged throughout our culture,” Dr. Johnson said.

As they lost weight or altered their neurochemistry, though, “they stepped on a land mine, which is going to have a strong genetic predisposition to turn something on in their brain, which then sends them cascading down that road of being obsessed with weight loss and being compelled to accomplish it,” he explained.

“Eating disorders are as heritable, have the same level of relative risk, and look to be as genetically mediated as the other major psychiatric illnesses,” Dr. Johnson said.

If a relative has anorexia nervosa, other members of the family are 12 times more likely to develop the disorder than members of the general population. Similarly, if one family member has bulimia nervosa, other members are four times more likely to have it.

About two-thirds of eating disorder patients have a comorbid diagnosis of anxiety or depression, which predates the onset of the eating disorder in about half of such patients, he said.

Some patients also have an impaired ability to work with different sets of challenges on neuropsychological tests, although this measure is not correlated with intelligence. These test results “make sense, in terms of what we see happening to them when they move into increasing levels of complexity developmentally, starting with puberty,” he said.

Even though he and his colleagues are seeing gender, ethnic, and socioeconomic drift in the epidemiology of anorexia nervosa and bulimia, Dr. Johnson noted that they are still illnesses that primarily affect white females. Girls who drop below about 17% body fat lose the secondary sexual characteristics associated with puberty and flatten out their hormone profiles so that they don't “feel” the effects of puberty, Dr. Johnson said.

“In our treatment center, one of the things we want to know as soon as we can is where the menstrual threshold is. At what point with our weight restoration are we going to be sending them clearly on the other side of puberty?” he said.

If patients do not stay in treatment long enough to restore their weight past the menstrual threshold, they will not have dealt adequately with their phobic fear of menstruation, he said.

Patients with bulimia nervosa often report that bingeing on carbohydrate-rich food calms them down, which may be the result of increased blood levels of tryptophan, an amino acid that can pass the blood-brain barrier and is synthesized into serotonin; treatment with selective serotonin reuptake inhibitors may make this effect even more pronounced by increasing the amount of serotonin available at synapses, Dr. Johnson suggested.

Vomiting also causes a sedating effect in bulimic patients because of the release of vasopressin. An autoaddiction to the vasopressin release may explain why binges become smaller and vomiting becomes disproportionate to the volume of food, he said.

Excessive exercise also appears to be a reinforcing and possibly anorexia-inducing behavior. “Running seems to have some unique interaction with restricting behavior that essentially stimulates something very, very toxic for the patients that have the more severe forms of the illness. We've found that very few patients are able to successfully return to running in our treatment program,” he said.

Functional MRI studies of the brains of anorexic patients and healthy controls have revealed some striking differences in dopamine pathways that suggest that patients with the disorder do not discriminate between positive and negative feedback and have a blunted response to pleasurable stimuli, according to Dr. Walter Kaye, who gave a separate presentation during the same session at the conference.

During a gambling task in which participants could win or lose money, trials in which patients with anorexia nervosa won money produced brain activity similar to that of control patients during winning trials, but anorexic patients who lost money also had brain activity similar to that of controls who won money, said Dr. Kaye, research director of the eating disorder program at the University of Pittsburgh.

In a separate fMRI study, the taste of sugar produced blunted responses in the insula (the primary taste cortex) of recovered anorexic patients, compared with healthy controls. Unlike in the healthy patients, however, there was no correlation between the taster's rating of pleasantness and the insula's response to sugar in recovered anorexic individuals, he noted.

Even before these data can be used to develop new treatments, it will be useful to let patients understand that this particular temperament is wired into their brains and that they might be able to learn to modulate their feelings and thoughts and develop adaptive coping strategies, said Dr. Kaye, also of the University of California, San Diego.

SAN FRANCISCO – Breast cancer patients who cope using spirituality are most likely to report personal growth resulting from their illness, Valerie Bussell, Ph.D., reported in a poster at the annual meeting of the Society of Behavioral Medicine.

“Positive things do come out of trauma,” she said in an interview. “Two years after their chemotherapy, these women are able to look back on it as something good that happened to change them.”

Her 2-year prospective study of coping in these women highlights the importance of a holistic approach to cancer treatment, she noted. “We are social and spiritual beings as well as physical,” said Dr. Bussell, a social psychologist at Houston Baptist University, Texas.

She surveyed 53 women (mean age of 51 years) who were undergoing adjuvant chemotherapy for breast cancer. The survey assessed the women's type of coping (emotional, problem-based, or spiritual/religious) and levels of distress, including depression, anxiety, perceived stress, and fatigue.

Dr. Bussell surveyed survivors of the same group 2 years later, looking for the same symptoms of distress and ways of coping, but also looking at how they reported any posttraumatic personal growth. She found that only spiritual coping was positively associated with reports of personal growth.

SAN FRANCISCO – Breast cancer patients who cope using spirituality are most likely to report personal growth resulting from their illness, Valerie Bussell, Ph.D., reported in a poster at the annual meeting of the Society of Behavioral Medicine.

“Positive things do come out of trauma,” she said in an interview. “Two years after their chemotherapy, these women are able to look back on it as something good that happened to change them.”

Her 2-year prospective study of coping in these women highlights the importance of a holistic approach to cancer treatment, she noted. “We are social and spiritual beings as well as physical,” said Dr. Bussell, a social psychologist at Houston Baptist University, Texas.

She surveyed 53 women (mean age of 51 years) who were undergoing adjuvant chemotherapy for breast cancer. The survey assessed the women's type of coping (emotional, problem-based, or spiritual/religious) and levels of distress, including depression, anxiety, perceived stress, and fatigue.

Dr. Bussell surveyed survivors of the same group 2 years later, looking for the same symptoms of distress and ways of coping, but also looking at how they reported any posttraumatic personal growth. She found that only spiritual coping was positively associated with reports of personal growth.

SAN FRANCISCO – Breast cancer patients who cope using spirituality are most likely to report personal growth resulting from their illness, Valerie Bussell, Ph.D., reported in a poster at the annual meeting of the Society of Behavioral Medicine.

“Positive things do come out of trauma,” she said in an interview. “Two years after their chemotherapy, these women are able to look back on it as something good that happened to change them.”

Her 2-year prospective study of coping in these women highlights the importance of a holistic approach to cancer treatment, she noted. “We are social and spiritual beings as well as physical,” said Dr. Bussell, a social psychologist at Houston Baptist University, Texas.

She surveyed 53 women (mean age of 51 years) who were undergoing adjuvant chemotherapy for breast cancer. The survey assessed the women's type of coping (emotional, problem-based, or spiritual/religious) and levels of distress, including depression, anxiety, perceived stress, and fatigue.

Dr. Bussell surveyed survivors of the same group 2 years later, looking for the same symptoms of distress and ways of coping, but also looking at how they reported any posttraumatic personal growth. She found that only spiritual coping was positively associated with reports of personal growth.

NEW YORK – Major life events and other stressors cannot be definitively associated with the initiation or progression of cancer, according to Bert Garssen, Ph.D., of the Centre for Psycho-Oncology at the Helen Dowling Institute in Utrecht, the Netherlands.

In a series of long-term follow-up studies reviewed at a dermatology symposium sponsored by Cornell University, Dr. Garssen reviewed the medical literature on the role of stress in the initiation and progression of cancer. Included in the review were a total of 77 “truly prospective studies, restricted to studies with adequate design,” he said. About 34 studies included breast cancer patients only, while 29 examined cancer initiation and 48 cancer progression.

Stress was defined as having experienced serious life events, bereavement, and negative emotional states, including anxiety, distress, and depression, having (or having had) a psychiatric diagnosis–in particular a depressive disorder–or exhibiting a tendency toward helplessness.

Breast cancer was the only cancer in which stress was associated with poorer outcomes, seen in 5 of 6 studies (83%) of patients with metastatic disease and in 9 of 14 studies (64%) of patients with localized breast cancers. One hypothesis is that stress may influence hormone levels and could play a role in hormone-sensitive tumors, Dr. Garssen noted.

He also had performed an earlier review of 70 longitudinal studies published between 1978 and 2002 on the role of psychological factors on cancer initiation and progression, and established that the majority of studies found a relationship between psychological factors and disease, but rarely for the same factor (Clin. Psychol. Rev. 2004;24:315–38).

In most prospective studies of psychological factors in disease, the design does not resolve whether psychological factors influence disease or whether the disease influences psychological well-being. “The illness process may have had a direct influence on the psychological function,” he said, and “the assumption patients have about the diagnosis” before the actual diagnosis is made, may play a role.

A review of five studies found no evidence that major life events, such as partner loss or child loss, play a role in cancer progression. It did show, however, that the loss of a mother in childhood increased the chance of breast cancer.

This was not found to be true with the loss of a father during the same time period.

Helplessness also was not associated with disease outcomes in 8 of 12 studies, Dr. Garssen said.

NEW YORK – Major life events and other stressors cannot be definitively associated with the initiation or progression of cancer, according to Bert Garssen, Ph.D., of the Centre for Psycho-Oncology at the Helen Dowling Institute in Utrecht, the Netherlands.

In a series of long-term follow-up studies reviewed at a dermatology symposium sponsored by Cornell University, Dr. Garssen reviewed the medical literature on the role of stress in the initiation and progression of cancer. Included in the review were a total of 77 “truly prospective studies, restricted to studies with adequate design,” he said. About 34 studies included breast cancer patients only, while 29 examined cancer initiation and 48 cancer progression.

Stress was defined as having experienced serious life events, bereavement, and negative emotional states, including anxiety, distress, and depression, having (or having had) a psychiatric diagnosis–in particular a depressive disorder–or exhibiting a tendency toward helplessness.

Breast cancer was the only cancer in which stress was associated with poorer outcomes, seen in 5 of 6 studies (83%) of patients with metastatic disease and in 9 of 14 studies (64%) of patients with localized breast cancers. One hypothesis is that stress may influence hormone levels and could play a role in hormone-sensitive tumors, Dr. Garssen noted.

He also had performed an earlier review of 70 longitudinal studies published between 1978 and 2002 on the role of psychological factors on cancer initiation and progression, and established that the majority of studies found a relationship between psychological factors and disease, but rarely for the same factor (Clin. Psychol. Rev. 2004;24:315–38).

In most prospective studies of psychological factors in disease, the design does not resolve whether psychological factors influence disease or whether the disease influences psychological well-being. “The illness process may have had a direct influence on the psychological function,” he said, and “the assumption patients have about the diagnosis” before the actual diagnosis is made, may play a role.

A review of five studies found no evidence that major life events, such as partner loss or child loss, play a role in cancer progression. It did show, however, that the loss of a mother in childhood increased the chance of breast cancer.

This was not found to be true with the loss of a father during the same time period.

Helplessness also was not associated with disease outcomes in 8 of 12 studies, Dr. Garssen said.

NEW YORK – Major life events and other stressors cannot be definitively associated with the initiation or progression of cancer, according to Bert Garssen, Ph.D., of the Centre for Psycho-Oncology at the Helen Dowling Institute in Utrecht, the Netherlands.

In a series of long-term follow-up studies reviewed at a dermatology symposium sponsored by Cornell University, Dr. Garssen reviewed the medical literature on the role of stress in the initiation and progression of cancer. Included in the review were a total of 77 “truly prospective studies, restricted to studies with adequate design,” he said. About 34 studies included breast cancer patients only, while 29 examined cancer initiation and 48 cancer progression.

Stress was defined as having experienced serious life events, bereavement, and negative emotional states, including anxiety, distress, and depression, having (or having had) a psychiatric diagnosis–in particular a depressive disorder–or exhibiting a tendency toward helplessness.

Breast cancer was the only cancer in which stress was associated with poorer outcomes, seen in 5 of 6 studies (83%) of patients with metastatic disease and in 9 of 14 studies (64%) of patients with localized breast cancers. One hypothesis is that stress may influence hormone levels and could play a role in hormone-sensitive tumors, Dr. Garssen noted.

He also had performed an earlier review of 70 longitudinal studies published between 1978 and 2002 on the role of psychological factors on cancer initiation and progression, and established that the majority of studies found a relationship between psychological factors and disease, but rarely for the same factor (Clin. Psychol. Rev. 2004;24:315–38).

In most prospective studies of psychological factors in disease, the design does not resolve whether psychological factors influence disease or whether the disease influences psychological well-being. “The illness process may have had a direct influence on the psychological function,” he said, and “the assumption patients have about the diagnosis” before the actual diagnosis is made, may play a role.

A review of five studies found no evidence that major life events, such as partner loss or child loss, play a role in cancer progression. It did show, however, that the loss of a mother in childhood increased the chance of breast cancer.

This was not found to be true with the loss of a father during the same time period.

Helplessness also was not associated with disease outcomes in 8 of 12 studies, Dr. Garssen said.

BETHESDA, MD. – The release this year of American Psychiatric Association guidelines on treating eating disorders and two analyses of the available evidence to support such treatments have highlighted the dearth of effective, evidence-based interventions for the disorders.

The lack of such data and the funding to support eating disorders research show that much remains to be accomplished before the disorders get the recognition they deserve from the medical community and insurers, said speakers and attendees at the annual conference of the National Eating Disorders Association. At least 5 million Americans have the disorders, and anorexia nervosa has the highest premature mortality of any mental illness.

The National Institute of Mental Health is funding 10 extramural studies on eating disorders at outside locations (seven of which are in New York), but none of the institutes within the National Institutes of Health are conducting any intramural studies on the disorders. In comparison, the NIMH and other NIH institutes are funding 12 intramural studies on schizophrenia and 14 on bipolar disorder, in addition to many more extramural studies, said Dr. Pauline S. Powers of the department of psychiatry at the University of South Florida, Tampa. The total NIMH/NIH funding for schizophrenia, which affects 3 million Americans, is estimated to be $291 million, while about $30 million is spent on eating disorders research, Dr. Powers said.

Efforts aimed at spreading the word about the high prevalence, morbidity, and mortality of eating disorders to legislators may be the best bet for greater funding of eating disorders, which in turn may attract greater interest from researchers to submit research grant proposals, said Dr. Thomas R. Insel, director of the NIMH.

While the lack of research funding has made it difficult to discern which treatments are best for particular eating disorders, the APA's new guidelines will still be helpful for clinicians who “are not real familiar with the kinds of things that you see as complications in patients with eating disorders,” said Dr. Powers, who was a member of the APA work group on eating disorders that wrote the guidelines.

For providers to make the best judgment of the level of care and specific type of treatment that a patient needs, the APA guidelines stress the assessment of physical complications and laboratory tests that may be relevant in patients with anorexia nervosa or bulimia nervosa (Am. J. Psychiatry 2006;163[suppl.]:1–54). For different organ systems, the guidelines list symptoms and signs to look for and particular laboratory tests that may help to diagnose the problem.

“Almost everyone seeing patients with eating disorders should at least know the symptoms and then be able to choose how they're going to work with those particular problems–either by themselves, or [by] consult with a primary care doctor or a specialist,” Dr. Powers advised.

Bulimia nervosa patients may have many of the same symptoms as anorexia nervosa patients because they have a past history of anorexia.

According to the guidelines, basic laboratory tests for bulimia and anorexia patients should include urinalysis for ketones and blood tests for electrolytes, urea nitrogen, creatinine, thyroid-stimulating hormone, a complete blood count, liver enzymes, and erythrocyte sedimentation rate.

Other tests may be necessary in certain circumstances, such as dual-energy x-ray absorptiometry in anorexic patients who haven't had a menstrual period for more than 6 months, Dr. Powers said. At her center, clinicians also routinely order an electrocardiogram, a 24-hour urine creatinine clearance test, and a test for level of complement 3, which is an immune system protein that often drops to low levels early in anorexic patients.

It also may be easier to make a case for insurance coverage with reviewers if you have baseline values for laboratory tests, she noted.

The guidelines recommend placing patients at different levels of care (outpatient, intensive outpatient, partial hospitalization, residential treatment center, inpatient hospitalization) according to categories that are used to assess the severity of their illness, even though there is little evidence to substantiate such placements.

The independent, nonprofit health services research agency ECRI (formerly the Emergency Care Research Institute) conducted a meta-analysis of 48 unique randomized clinical trials on bulimia nervosa.

The report found weak to moderate evidence supporting the effectiveness of medications in reducing bingeing and purging behaviors, as well as anxiety and depression. Except for moderate evidence suggesting some benefit of cognitive-behavioral therapy (CBT) on purging, little data were available to support its effectiveness on bingeing and anxiety or depression.

Weak evidence suggests that CBT may be more effective than medications for purging behaviors, but no other distinction between the two interventions could be made.

Virtually no evidence exists to suggest that CBT is better than other forms of psychotherapy. There was no evidence on whether the interventions improved quality of life.

Fluoxetine is already Food and Drug Administration-approved at 60 mg per day for the treatment of bulimia nervosa, based on 6- to 18-week trials showing that it reduced binge eating, purging, and associated psychological features, even though the results were “pretty weak because of the high dropout rates,” said Dr. Russell Marx, medical director of the eating disorders program at the University Medical Center at Princeton (N.J.).

Dialectical behavior therapy has shown preliminary evidence of being effective for bulimia.

In binge eating disorder, short-term trials of selective serotonin reuptake inhibitors have reduced the severity of illness as well as eating, psychiatric, and weight symptoms, compared with placebo.

BETHESDA, MD. – The release this year of American Psychiatric Association guidelines on treating eating disorders and two analyses of the available evidence to support such treatments have highlighted the dearth of effective, evidence-based interventions for the disorders.

The lack of such data and the funding to support eating disorders research show that much remains to be accomplished before the disorders get the recognition they deserve from the medical community and insurers, said speakers and attendees at the annual conference of the National Eating Disorders Association. At least 5 million Americans have the disorders, and anorexia nervosa has the highest premature mortality of any mental illness.

The National Institute of Mental Health is funding 10 extramural studies on eating disorders at outside locations (seven of which are in New York), but none of the institutes within the National Institutes of Health are conducting any intramural studies on the disorders. In comparison, the NIMH and other NIH institutes are funding 12 intramural studies on schizophrenia and 14 on bipolar disorder, in addition to many more extramural studies, said Dr. Pauline S. Powers of the department of psychiatry at the University of South Florida, Tampa. The total NIMH/NIH funding for schizophrenia, which affects 3 million Americans, is estimated to be $291 million, while about $30 million is spent on eating disorders research, Dr. Powers said.

Efforts aimed at spreading the word about the high prevalence, morbidity, and mortality of eating disorders to legislators may be the best bet for greater funding of eating disorders, which in turn may attract greater interest from researchers to submit research grant proposals, said Dr. Thomas R. Insel, director of the NIMH.

While the lack of research funding has made it difficult to discern which treatments are best for particular eating disorders, the APA's new guidelines will still be helpful for clinicians who “are not real familiar with the kinds of things that you see as complications in patients with eating disorders,” said Dr. Powers, who was a member of the APA work group on eating disorders that wrote the guidelines.

For providers to make the best judgment of the level of care and specific type of treatment that a patient needs, the APA guidelines stress the assessment of physical complications and laboratory tests that may be relevant in patients with anorexia nervosa or bulimia nervosa (Am. J. Psychiatry 2006;163[suppl.]:1–54). For different organ systems, the guidelines list symptoms and signs to look for and particular laboratory tests that may help to diagnose the problem.

“Almost everyone seeing patients with eating disorders should at least know the symptoms and then be able to choose how they're going to work with those particular problems–either by themselves, or [by] consult with a primary care doctor or a specialist,” Dr. Powers advised.

Bulimia nervosa patients may have many of the same symptoms as anorexia nervosa patients because they have a past history of anorexia.

According to the guidelines, basic laboratory tests for bulimia and anorexia patients should include urinalysis for ketones and blood tests for electrolytes, urea nitrogen, creatinine, thyroid-stimulating hormone, a complete blood count, liver enzymes, and erythrocyte sedimentation rate.

Other tests may be necessary in certain circumstances, such as dual-energy x-ray absorptiometry in anorexic patients who haven't had a menstrual period for more than 6 months, Dr. Powers said. At her center, clinicians also routinely order an electrocardiogram, a 24-hour urine creatinine clearance test, and a test for level of complement 3, which is an immune system protein that often drops to low levels early in anorexic patients.

It also may be easier to make a case for insurance coverage with reviewers if you have baseline values for laboratory tests, she noted.

The guidelines recommend placing patients at different levels of care (outpatient, intensive outpatient, partial hospitalization, residential treatment center, inpatient hospitalization) according to categories that are used to assess the severity of their illness, even though there is little evidence to substantiate such placements.

The independent, nonprofit health services research agency ECRI (formerly the Emergency Care Research Institute) conducted a meta-analysis of 48 unique randomized clinical trials on bulimia nervosa.

The report found weak to moderate evidence supporting the effectiveness of medications in reducing bingeing and purging behaviors, as well as anxiety and depression. Except for moderate evidence suggesting some benefit of cognitive-behavioral therapy (CBT) on purging, little data were available to support its effectiveness on bingeing and anxiety or depression.

Weak evidence suggests that CBT may be more effective than medications for purging behaviors, but no other distinction between the two interventions could be made.

Virtually no evidence exists to suggest that CBT is better than other forms of psychotherapy. There was no evidence on whether the interventions improved quality of life.

Fluoxetine is already Food and Drug Administration-approved at 60 mg per day for the treatment of bulimia nervosa, based on 6- to 18-week trials showing that it reduced binge eating, purging, and associated psychological features, even though the results were “pretty weak because of the high dropout rates,” said Dr. Russell Marx, medical director of the eating disorders program at the University Medical Center at Princeton (N.J.).

Dialectical behavior therapy has shown preliminary evidence of being effective for bulimia.

In binge eating disorder, short-term trials of selective serotonin reuptake inhibitors have reduced the severity of illness as well as eating, psychiatric, and weight symptoms, compared with placebo.

BETHESDA, MD. – The release this year of American Psychiatric Association guidelines on treating eating disorders and two analyses of the available evidence to support such treatments have highlighted the dearth of effective, evidence-based interventions for the disorders.

The lack of such data and the funding to support eating disorders research show that much remains to be accomplished before the disorders get the recognition they deserve from the medical community and insurers, said speakers and attendees at the annual conference of the National Eating Disorders Association. At least 5 million Americans have the disorders, and anorexia nervosa has the highest premature mortality of any mental illness.

The National Institute of Mental Health is funding 10 extramural studies on eating disorders at outside locations (seven of which are in New York), but none of the institutes within the National Institutes of Health are conducting any intramural studies on the disorders. In comparison, the NIMH and other NIH institutes are funding 12 intramural studies on schizophrenia and 14 on bipolar disorder, in addition to many more extramural studies, said Dr. Pauline S. Powers of the department of psychiatry at the University of South Florida, Tampa. The total NIMH/NIH funding for schizophrenia, which affects 3 million Americans, is estimated to be $291 million, while about $30 million is spent on eating disorders research, Dr. Powers said.

Efforts aimed at spreading the word about the high prevalence, morbidity, and mortality of eating disorders to legislators may be the best bet for greater funding of eating disorders, which in turn may attract greater interest from researchers to submit research grant proposals, said Dr. Thomas R. Insel, director of the NIMH.

While the lack of research funding has made it difficult to discern which treatments are best for particular eating disorders, the APA's new guidelines will still be helpful for clinicians who “are not real familiar with the kinds of things that you see as complications in patients with eating disorders,” said Dr. Powers, who was a member of the APA work group on eating disorders that wrote the guidelines.

For providers to make the best judgment of the level of care and specific type of treatment that a patient needs, the APA guidelines stress the assessment of physical complications and laboratory tests that may be relevant in patients with anorexia nervosa or bulimia nervosa (Am. J. Psychiatry 2006;163[suppl.]:1–54). For different organ systems, the guidelines list symptoms and signs to look for and particular laboratory tests that may help to diagnose the problem.

“Almost everyone seeing patients with eating disorders should at least know the symptoms and then be able to choose how they're going to work with those particular problems–either by themselves, or [by] consult with a primary care doctor or a specialist,” Dr. Powers advised.

Bulimia nervosa patients may have many of the same symptoms as anorexia nervosa patients because they have a past history of anorexia.

According to the guidelines, basic laboratory tests for bulimia and anorexia patients should include urinalysis for ketones and blood tests for electrolytes, urea nitrogen, creatinine, thyroid-stimulating hormone, a complete blood count, liver enzymes, and erythrocyte sedimentation rate.

Other tests may be necessary in certain circumstances, such as dual-energy x-ray absorptiometry in anorexic patients who haven't had a menstrual period for more than 6 months, Dr. Powers said. At her center, clinicians also routinely order an electrocardiogram, a 24-hour urine creatinine clearance test, and a test for level of complement 3, which is an immune system protein that often drops to low levels early in anorexic patients.

It also may be easier to make a case for insurance coverage with reviewers if you have baseline values for laboratory tests, she noted.

The guidelines recommend placing patients at different levels of care (outpatient, intensive outpatient, partial hospitalization, residential treatment center, inpatient hospitalization) according to categories that are used to assess the severity of their illness, even though there is little evidence to substantiate such placements.

The independent, nonprofit health services research agency ECRI (formerly the Emergency Care Research Institute) conducted a meta-analysis of 48 unique randomized clinical trials on bulimia nervosa.

The report found weak to moderate evidence supporting the effectiveness of medications in reducing bingeing and purging behaviors, as well as anxiety and depression. Except for moderate evidence suggesting some benefit of cognitive-behavioral therapy (CBT) on purging, little data were available to support its effectiveness on bingeing and anxiety or depression.

Weak evidence suggests that CBT may be more effective than medications for purging behaviors, but no other distinction between the two interventions could be made.

Virtually no evidence exists to suggest that CBT is better than other forms of psychotherapy. There was no evidence on whether the interventions improved quality of life.

Fluoxetine is already Food and Drug Administration-approved at 60 mg per day for the treatment of bulimia nervosa, based on 6- to 18-week trials showing that it reduced binge eating, purging, and associated psychological features, even though the results were “pretty weak because of the high dropout rates,” said Dr. Russell Marx, medical director of the eating disorders program at the University Medical Center at Princeton (N.J.).

Dialectical behavior therapy has shown preliminary evidence of being effective for bulimia.

In binge eating disorder, short-term trials of selective serotonin reuptake inhibitors have reduced the severity of illness as well as eating, psychiatric, and weight symptoms, compared with placebo.