mitchell by qingyunliuliu

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									     James Mitchell, M.D.
   Steve Wonderlich, Ph.D.
      Ross Crosby, Ph.D.
   James Roerig, Pharm. D.
   Martina de Zwaan, M.D.

     Neuropsychiatric Research Institute
University of North Dakota School of Medicine
Project                    Successful? Example
Multicenter Efficacy           ++         BN
Multicenter                    +/-        BN
Effectiveness
Multicenter Naturalistic                AN, BN
   Baseline                     +
   Prospective                  -
Long Term Follow-up            ++      BN, GBP
    Multicenter Efficacy
Bulimic Nervosa CBT Non-responders
              Background
1.   CBT best established psychotherapy
      for BN
2.   IPT may also work (2 studies)
3.   Antidepressants benefit many patients
     - Fluoxetine best established
               Questions
1.   What therapy works best for CBT
     non-responders: medication or IPT?
2.   Do additional visits prevent relapse in
     responders?
     Assess       CBT          Assess       Secondary Assess        F/U        F/U
 |            |           |             |            |         |          |          |
                  16 wk        1 wk
-2        0               16            17          33         34         60         80
                     Measures
        EATING                 PSYCHOPATHOLOGY/
                                    OTHER
       BE/V Recall                       SCID I

 EDE (Eating Disorders                   SCID II
     Examination)
BES (Body Esteem Scale)                   Beck

 BTQ (Bulimic Thoughts      I.I.P. (Inventory of Interpersonal
     Questionnaire)                      Problems)
EDE-Q (EDE-Questionnaire)              MPQ – Impul.

TFEQ (Three Factor Eating             Self-Efficacy
    Questionnaire)
                                       Rosenberg

                             HRQ (Helping Relationship
                                   Questionnaire)
                            SAS (Social Adjustment Scale)

                               YBC (Yale-Brown-Cornell)
                     Centers
Clinical - Univ. of Minnesota - J. Mitchell, M.D.,
                                S. Crow, M.D.

Clinical - Cornell University - K. Halmi, M.D.

Clinical - Rutgers University - T. Wilson, Ph.D.

Data    - Stanford University - S. Agras, M.D.,
                               H. Kraemer, Ph.D.
                           Rapid Interv.       F/U
                                           |            |
                 Remit

                               F/U             F/U
                                           |            |
    CBT
|
                               IPT             F/U
                                           |            |
                 Symp.


                         Fluox.  Desip.       F/U
                                           |            |
          Week                        Week           Week
           17                          34             60
      Recruitment

Number screened          847
Number screened out      591
Number interviewed       258
Number interviewed out    66
Number started CBT       194
Enter CBT             N = 194
Dropout CBT           N = 54 (28%)
Abstinent after CBT   = 76 (54%)
Symptomatic after CBT = 64 (46%)
35    32
30                          IPT
25
20
15                10
10
                                  4
 5
 0
     IPT        Drop-       Remission
            out/Withdrawn

35    32
30                          Med Mgmt.
25
20
                  15
15
10
                                  3
 5
 0
     Meds       Drop-       Remission
            out/Withdrawn
         Dropouts

         IPT   Meds   Total

Site 1   9%    55%    31%

Site 2   36%   29%    32%

Site 3   50%   83%    67%

Total    29%   48%    39%
             Conclusions
1.   With sequencing, attrition unacceptably
     high:    first intervention 28%
              second intervention 39%

2.   Response to secondary treatments
     unacceptably low.

      •
3.   • • Sequencing of little/no utility.
             Conclusions
1.   Priorities for further research

     a.   improve initial treatment
          “packages”
     b.   identify likely non-responders
          early in treatment and shift/
          enhance therapy then.
   Signal Detection Analysis
Post 4 weeks (6 sessions)
      Purging < 70%        Non-responders
                 Sensitivity 86%
                 Specificity 69%
     74% get correct treatment
      4% unnecessary treatment
      22% not get needed treatment (add later)
Multicenter Effectiveness
       Bulimia Nervosa


                  Self-Help


 CBT               MEDS


                    CBT
   Long-Term Follow-Up

• Bulimia Nervosa   10-15 years
• Gastric Bypass    13-15 years
        Participants
• Females

• Evaluated 1981 - 1987

• Participated in:
  – Imipramine/CBT Treatment Trial

  – 2 - 5 Year Follow-Up
            Assessments
• SCID I
• Ham-D
• Eating Disorders Questionnaire - Version 6
  (EDQ-VI)
• Body Shape Questionnaire (BSQ)
• Weissman Social Adjustment (WSAS-SR)
• Multidimensional Personality
  Questionnaire - Scale 8 (MPQ-8)
• Reproductive History
• N = 222

• N = 200 (90.1%)    located

• N = 179 (80.6%)    agreed to participate

• N = 19    (8.5%)   refused participation

• N=1       (0.5%)   deceased

• N=1       (0.5%)   severely disabled
   N = 176
   N = 20 (11.6% ) Full ED
   N = 81 (46.8%) Partial ED
   N = 72 (41.5%) Full Remission

Prediction
   Baseline Treatment c CBT predicted
   long-term outcome
 Follow-up Gastric Bypass Patients


18 months     Kolanowski, 1997
18 months     Choman, et al, 1999
5 years       Howard et al, 1995
7 years       Avinoch, et al, 1992
7 years       Smith, et al, 1995
10 years      Wolfe, et al, 1994
   Follow-up Gastric Bypass Patients


• Gastric bypass roux-en-y
• 100-125 cm roux limb
• Two applications of TA 90 B stapler  20-
  30 cc pouch
• Anastamosis of 12-14 mm diameter + O-
  Deklene suture
   Follow-up Gastric Bypass Patients


M-FED Interview     Eating behavior--
                    Psychopathology
SF-36               Health Status, Q.O.L.

AUDIT               ETOH Use

MeritCare Gastric   Health Status/Medical
Bypass              History
Questionnaire
Follow-up Gastric Bypass Patients

   N = 100

     70 Agreed to interview
     16 Initially refused (8 agreed later)
     8 Deceased
     6 Not located
     78 Interviewed
    + 8 Deceased
     86 Outcome Data
  Follow-up Gastric Bypass Patients


Interviewed 36 (47%) – 13 years post


             33 (42%) – 14 years post


             9 (12%) – 15 years post
   Follow-up Gastric Bypass Patients


                        BMI
       Pre-Surgery = 43.8 (32.1 - 57.2)
Minimum Post-surgery = 25.9 (18.4 - 38.0)
         Follow-up = 32.8 (22.7 - 49.5)
  Follow-up Gastric Bypass Patients

Involuntary Vomiting     52   69%

“Plugging”               33   43%

“Heartburn”              33   43%

Diarrhea                 24   32%
                              Largest Change from Pre-surgery Baseline
                              Current Change from Pre-surgery Baseline


                 0
                 -2
Change in BMI




                 -4
                 -6
                 -8
                -10
                -12
                -14
                -16
                -18
                      Never binged       Binged pre-surgery only   Binged pre- and post-
                             (n=36)              (n=25)                surgery (n=9)
                  Pre-Surgical BMI     Lowest BMI (post-surgery)        Current BMI


                  50
                  45
                  40
Body Mass Index




                  35
                  30
                  25
                  20
                  15
                  10
                   5
                   0
                        Never binged       Binged Pre-Surgery   Binged Pre- and Post-
                             (n=36)            Only (n=25)          Surgery (n=9)
International Eating Disorders
   Standardized Data Base
•   EDQ (8.7 Eating Disorder Questionnaire)
•   SF-36 (Social Finding-36)
•   EDE-Q4 (Eating Disorders Examination)
•   EDI-II (Eating Disorders Inventory)
•   QEWP-R (Questionnaire on Eating and
       Weight Patterns-Revised)
                   Costs
Scanner                       $6,000

Computer                      $2,000

Printer                    $900 (duplex)

Teleform Program              $3,070

IEDSDB Program                 N.C.
        IEDSDB
Eating Disorder Institute 412

U. of South Florida       41

Med. College Ohio        276
Methodology            Successful?
Paper/Pencil Testing       ++
Direct Entry               ++
Scramble Form Entry        ++
Entry via Palm Top         ++
Computers
Computer-Generated         ++
Evaluation
Computer-Generated         +/-
Reports
Internet Data Entry        +/-
 Other Technology Development

• Palm Pilots - Monitoring (EMA:
  Ecological Momentary Assessment)
• Palm Pilots - Therapy Extenders
• Palm Pilots - Therapy Self-Help
• Telemedicine - Therapy (CBT for BN)
                 EMA
• Interval Contingent Recording (e.g., end
  of day)
• Signal Contingent Recording (e.g.,
  randomly)
• Event Contingent Recording (e.g., prior
  to binge eating)
New Models of Service Delivery
       •   Self-help
       •   Supervised self-help
       •   Internet-based
       •   Phone-based
       •   Computer adjunct
       •   Computer-based
       •   Telemedicine
       Overall Conclusions
• CBT best treatment BN
• Secondary treatments/sequencing
  generally not helpful
• CBT associated with better long-term
  outcomes
• Gastric Bypass associated with good
  long-term outcome
• New methods of monitoring/therapy
  delivery developing
Doing OK         Not Doing OK/Goals
Efficacy         Naturalistic F/U
Effectiveness    Computer Reports
New Data Entry   Internet Entry
Methods
Long Term F/U    Therapist Feedback
Studies

Computer Evals

								
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