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"GOWERS, SIMON G"
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Clinical effectiveness of treatments for anorexia nervosa in adolescents: Randomised controlled trial
Treatment guidelines identify few adequately powered trials to guide recommendations for anorexia nervosa.
To evaluate the effectiveness of three readily available National Health Service treatments for adolescents (aged 12-18 years) with anorexia nervosa.
Multicentre randomised controlled trial of 167 young people comparing in-patient, specialist out-patient and general child and adolescent mental health service (CAMHS) treatment.
Each group made considerable progress at 1 year, with further improvement by 2 years. Full recovery rates were poor (33% at 2 years, 27% still with anorexia nervosa). Adherence to in-patient treatment was only 50%. Neither in-patient nor specialist out-patient therapy demonstrated advantages over general CAMHS treatment by intention to treat, although some CAMHS out-patients were subsequently admitted on clinical grounds. In-patient treatment (randomised or after out-patient transfer) predicted poor outcomes.
First-line in-patient psychiatric treatment does not provide advantages over out-patient management. Out-patient treatment failures do very poorly on transfer to in-patient facilities.
Journal Article
Economic evaluation of a randomised controlled trial for anorexia nervosa in adolescents
Young people with anorexia nervosa are often admitted to hospital for treatment. As well as being disruptive to school, family and social life, in-patient treatment is expensive, yet cost-effectiveness evidence is lacking.
Cost-effectiveness analysis of three treatment strategies for adolescents with anorexia nervosa.
UK multicentre randomised, controlled trial comparing in-patient psychiatric treatment, specialist out-patient treatment and general out-patient treatment. Outcomes and costs assessed at baseline, 1 and 2 years.
There were 167 young people in the trial. There were no statistically significant differences in clinical outcome between the three groups at 2 years. The specialist out-patient group was less costly over the 2-year follow-up (mean total cost 26 738 UK pounds) than the in-patient (34 531 UK pounds) and general out-patient treatment (40 794 UK pounds) groups, but this result was not statistically significant. Exploration of the uncertainty associated with the costs and effects of the three treatments suggests that specialist out-patient treatment has the highest probability of being cost-effective.
On the basis of cost-effectiveness, these results support the provision of specialist out-patient services for adolescents with anorexia nervosa.
Journal Article
Brief scale for measuring the outcomes of emotional and behavioural disorders in children
BackgroundFollowing the development of a child and adolescent version of the Health of the Nation Outcome Scales (HoNOSCA), field trials were conducted to assess their feasibility and acceptability in routine outcome measurement.AimsTo evaluate the reliability, validity and acceptability of HoNOSCA in routine outcome measurement.MethodFollowing training, 36 field sites provided ratings on 1276 cases at one time point and outcome data on 906. Acceptability was assessed by way of written feedback and at a debriefing meeting.ResultsHoNOSCA demonstrated satisfactory reliability and validity characteristics. It was sensitive to change and its ability to measure change accorded with the clinicians' independent rating. HoNOSCA was reasonably acceptable to clinicians' from a range of disciplines and services.ConclusionsProvided that training needs can be met, HoNOSCA represents a satisfactory brief outcome measure which could be used routinely in child and adolescent mental health services.
Journal Article
Development of weight and shape concerns in the aetiology of eating disorders
Although weight and shape concerns are considered to be integral to the psychopathology of anorexia and bulimia nervosa, uncertainties remain about developmental aspects of the aetiology of these concerns and their relationship to eating disorders.
To review the recent literature on weight and shape concern, with particular emphasis on aetiology, to identify a possible developmental pathway from weight concern through abnormal eating behaviour to disorder.
Literature review of Medline and Psychlit databases using the keywords 'eating disorder', 'weight concern', 'shape concern' and 'aetiology'. Inclusion criteria were based on the strength of quantitative research findings, originality of ideas and recent publication.
Weight and shape concerns follow a developmental pathway arising before the typical age for the development of eating disorders. The origins are multifactorial, with biological, family and sociocultural features predominating.
Although weight and shape concern seems commonly to underlie the development of eating disorders, an alternative pathway appears to exist through impulsivity and fear of loss of control. Prevention strategies may usefully focus on the attitudes and concerns that lead to dieting behaviour.
Journal Article
Parental high concern and adolescent-onset anorexia nervosa: A case-control study to investigate direction of causality
Robust evidence that anorexia nervosa is preceded rather than accompanied by high-concern (overprotective) parenting is limited.
To look for evidence of parental high concern occurring before any onset of disorder.
Forty consecutive referrals of adolescent girls with DSM-III-R anorexia nervosa were compared with matched controls using obstetric records and maternal interviews.
Index mothers reported higher rates of: near-exclusive child care (P = 0.02), infant sleep difficulties (P = 0.018), severe distress at first regular separation (P = 0.048), high maternal trait anxiety levels (P = 0.008) and later age for first sleeping away from home (P = 0.009). More index families had experienced a severe obstetric loss prior to their daughter's birth (P = 0.066).
This study lends evidence to the clinical contention that high-concern parenting in infancy is associated with the later development of anorexia nervosa. This may derive, in part, from aspects of unresolved grief.
Journal Article
Difficulties in family functioning and adolescent anorexia nervosa
BackgroundDifficulties in family functioning are often evident when an adolescent has anorexia nervosa, and the possible causative or contributory role of such difficulties in the illness is unclear.AimsTo elucidate the relationship between severity of anorexia nervosa and difficulties in family functioning and whether clinical improvement results in diminution of self-rated family difficulties.MethodThirty-five adolescents with anorexia nervosa and their mothers completed the Family Assessment Device (FAD) while clinicians administered the McMaster's Structured Interview of Family Functioning (McSIFF). Severity of anorexia nervosa was rated at baseline and at one year follow-up using the Morgan–Russell Schedule.ResultsClinicians and patients were more critical of the families' functioning than parents. There was an inverse association between the extent of family difficulties and severity of anorexia nervosa. Over time subjects improved clinically but this was not matched by improvement in family functioning.ConclusionsDifficulties in family functioning do not appear to be directly associated with severity of anorexia nervosa nor do these difficulties reduce with clinical improvement, in the short term.
Journal Article
The future of in-patient child and adolescent mental health services
Professor Simon Gowers, University of Liverpool Section of Adolescent Psychiatry, Academic Unit, 79 Liverpool Road, Chester CH2 1AW UK Although the majority of children with mental health problems are treated in community services, a comprehensive child and adolescent mental health service (CAMHS) needs access to highly specialised provision including in-patient facilities. A lack of monitoring has led to a situation in which little is known about the precise number, distribution and function of these services, hence the Department of Health's decision to commission the National In-patient Child and Adolescent Psychiatry Study (NICAPS). There are several variables to consider: the epidemiology of mental health problems in children and adolescents, comparisons with other developed countries, the views of referring CAMHS, and evidence of inappropriate admissions elsewhere. If we take 7.1% as a conservative estimate of the prevalence of mental health problems in this population, this would suggest that 1 in 1000 children with a mental health problem could be admitted to an in-patient unit at any time.
Journal Article