Health service utilization for eating disorders: findings from a community-based study

BACKGROUND: Prior use of health services was examined in a community sample of women with bulimic-type eating disorders. METHOD: Participants (n = 159) completed a structured interview for the assessment of eating disorder psychopathology as well as questions concerning treatment-seeking and type of treatment received. RESULTS: Whereas a minority (40.3%) of participants had received treatment for an eating problem, most had received treatment for a general mental health problem (74.2%) and/or weight loss (72.8%), and all had used one or more self-help treatments. Where treatment was received for an eating or general mental health problem, this was from a primary care practitioner in the vast majority of cases. Only half of those participants who reported marked impairment associated with an eating problem had ever received treatment for such a problem and less than one in five had received such treatment from a mental health professional. CONCLUSION: Women with bulimic-type eating disorders rarely receive treatment for an eating problem, but frequently receive treatment for a general mental health problem and/or for weight loss. The findings underscore the importance of programs designed to improve the detection and management of eating disorders in primary care.     

Diabetes and eating disorders in primary care

OBJECTIVE: To determine the relationship between diabetes and eating disorders among primary care patients. METHOD: Data on 3,000 patients were obtained from eight primary care and family practice settings, including the PRIME-MD Patient Health Questionnaire (PHQ), self-reported physical illness, and social functioning information. Multivariate logistic regression analyses were used to determine the association between diabetes and eating disorders. RESULTS: Diabetes was associated with an increased likelihood of eating disorders [OR = 2.3 (1.4, 3.9)], after adjusting for differences in demographic characteristics and comorbid mental disorders. This effect was specific to diabetes. Eating disorder was the only mental disorder associated with a significantly increased risk of diabetes, odds ratio (OR) = 2.4 (1.4, 4.0), after adjusting for demographic characteristics and comorbid mental and physical disorders. Patients with both diabetes and eating disorders had significantly higher levels of comorbid anxiety, panic attacks, and alcohol use disorders, compared with those with one but not both. DISCUSSION: Consistent with reports from community-based samples, these data suggest that diabetes may be associated with an increased likelihood of eating disorders among patients in primary care. Clinicians who treat patients with diabetes, a common condition in primary care, should screen for eating disorders. In addition, patients with eating disorders may be at risk for the development of diabetes. Further work is needed to determine the generalizability of these findings and to understand the mechanism of this association.     

Help seeking and barriers to treatment in a community sample of Mexican American and European American women with eating disorders

OBJECTIVE: The study examined treatment seeking for eating disorders in Mexican American and European American women. METHOD: One hundred forty-five women with eating disorders (76 Mexican American, 69 European American) were diagnosed using the Structured Clinical Interview for DSM-IV-TR (SCID-IV) and Eating Disorder Examination (EDE). RESULTS: Only 28% of the sample reported having sought treatment for their eating problems and only 17% had received treatment. Both groups were equally likely to believe they have significant eating problems and to want help. However, Mexican Americans were less likely to have sought treatment and, having sought help, were less likely to have been diagnosed or treated. European Americans were more likely to have utilized psychotherapists, psychiatrists, and psychotropic medications, whereas Mexican Americans largely had sought help from general practitioners for weight concern. The two groups endorsed similar barriers to treatment seeking. CONCLUSION: Results support clinical impressions that eating disorders largely go undetected and untreated. Nonspecialists may be likely to fail to detect eating disorders.     

The interaction of personality disorders and eating disorders: a two-year prospective study of patients with longstanding eating disorders

OBJECTIVE: The current study aimed to investigate the relation between personality disorders and symptoms of both eating disorders and general psychopathology over time. METHOD: Seventy-four patients, with a mean age of 30 years and admitted to a hospital for treatment of a chronic eating disorder, were assessed using the Eating Disorder Inventory (EDI), the Eating Disorder Examination (EDE), the Symptom Check List-90-Revised (SCL-90-R), and the Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II) at admission, and after 1 and 2 years. RESULTS: At the 2-year follow-up, there was considerable reduction in both personality and symptoms (effect size = 0.83-0.94). Panel modeling using structural equation modeling techniques indicated that symptomatic changes generally preceded changes in the personality disorder. DISCUSSION: Eating disorder symptoms and general symptomatology had direct effects on a dimensional personality disorder index. Thus, personality disorders may be at least partially a consequence of general symptomatology in chronic eating disorders. Symptom improvement appears to precede changes in personality in this sample of patients with chronic eating disorders.     

The use of guidelines for dissemination of "best practice" in primary care of patients with eating disorders

OBJECTIVE: A number of sets of clinical guidelines have been developed for the treatment of eating-disordered patients. This study aimed to measure adherence to such guidance among family physicians working in primary care settings. METHOD: In the wake of the publication of national guidelines for "best practice," family physicians in a large but diverse geographical region of the UK (population of 6.4 million) were approached and asked to complete a two-stage survey. RESULTS: Only 4% of these clinicians report using published guidelines or protocols, and none used the national guidelines that were available. Nor were these clinicians using the spirit of the guidelines, as there was little correspondence between recommended and actual treatment behavior. CONCLUSION: These findings suggest that specialist eating disorders services should not rely on guidelines to ensure the dissemination of best practice for these patients in primary care. Alternative means of dissemination are needed, and suggestions are made.     

Is there an increased clinical severity of patients with eating disorders under managed care?

Objectives: We sought to examine possible differences in medical status at presentation in 1996, compared to 1991, of adolescents with eating disorders (EDs) at a hospital-based multidisciplinary care program to reflect the increasing market penetration of managed care.

Design: Charts were reviewed for all new patients scheduled in a hospital-based outpatient ED program in 1996 and 1991. The 92-item standardized data extraction form included information on demographics, indicators of illness severity at the first visit, and subsequent hospitalization. The need for primary care referral was verified using billing records. Data were analyzed with Student’s t-test, Chi-square, Fisher’s exact, and Mann–Whitney U tests using SPSS 7.5.

Results: Of the 153 total patients, 133 kept their intake appointment and 130 (98%) of these had charts available for review. The age, racial/ethnic characteristics, and average length of disordered eating behaviors were not significantly different over the 5-year period. Referral from a primary care clinician was more commonly required in 1996 than 1991 (59% vs. 11%; p < .0001). Eighteen percent of the patients seen in 1996 were admitted from the initial appointment for medical stabilization, compared to 1.5% in 1991 (p = .002). Comparing 1996 to 1991, a similar number of patients had symptoms consistent with anorexia nervosa, whereas fewer patients in 1996 gave a history of bingeing and purging (22% vs. 40%; p = .027). There were no significant differences in indicators of illness severity, treatment by primary care clinician prior to referral, or hospitalization rates for those patients with and without managed care.

Conclusions: Patients in 1996 were more likely to require referrals, were less likely to have symptoms consistent with bulimia nervosa, and were more likely to be admitted for medical stabilization. There were no differences in patient presentation characteristics or initial hospitalization rates based on their managed care status. Further research is needed to investigate the changes in illness severity at presentation and to assess the role that managed care plays in the treatment of patients with eating disorders.     

Fluid Intake in patients with eating disorders

OBJECTIVES: The current study examined the fluid intake of patients with eating disorders and factors that may influence the amount and type of fluid consumed. Subjects comprised 81 inpatients with eating disorders. METHODS: A 7-day semi-standardized, retrospective fluid history was taken by a dietitian when the subjects were admitted to an eating disorder unit. Total fluid consumed per day was measured, which included all energy-free, energy-containing, and caffeine-containing fluids (all in milliliters per kilogram). Age, body mass index (BMI), and eating disorder behaviors (purging, binge eating, and excessive exercise) were also evaluated. RESULTS: Fluid intakes ranged from 250 ml to >6 L per day, with an average of 2.7 L. Only 17% of patients had fluid intakes in the recommended range. The most commonly consumed beverage was water followed by diet cola, coffee, juice, and tea. The lower the BMI and the older the patient, the greater the fluid intake. CONCLUSIONS: Fluid intake is variable and should be part of the clinical assessment of the eating disorder patient.     

Alexithymia and facial emotion recognition in patients with eating disorders

OBJECTIVE: Patients with anorexia or bulimia nervosa are reported to show high levels of alexithymia and to have difficulties recognizing facially displayed emotions. The current study tested whether it could be that facial emotion recognition is a basic skill that is independent from alexithymia. METHOD: We assessed emotion recognition skills and alexithymia in a group of 79 female inpatients with eating disorders and compared them with a group of 78 healthy female controls. Instruments used were the Toronto Alexithymia Scale, the Facially Expressed Emotion Labeling (FEEL) test, and the revised Symptom Check List (SCL-90-R). RESULTS: There were no significant differences between patients and controls in their emotion recognition scores, but patients with eating disorders displayed significantly more alexithymia and psychopathology. Emotion recognition in patients was not related to alexithymia, psychopathology, or clinical symptoms. CONCLUSION: We suggest that the reported alexithymia of patients with eating disorders is complex and independent from basic facial emotion recognition.     

Variables that influence diagnosis and treatment of the eating disorders within primary care settings: a vignette study

OBJECTIVE: This study examined the influence of clinical and nonclinical features of case presentation on the diagnosis and treatment of eating disorders in primary care. METHOD: Family physicians from a defined region of the UK were provided with two vignettes, characterizing eating disorder presentations in primary care. Case gender, ethnicity, weight status, and diabetes history were experimentally manipulated. Outcome variables included the primary diagnosis and the treatment course selected for each case. RESULTS: Female cases were more likely to receive an eating disorder diagnosis, even when their symptoms were identical to those of males. Nonclinical demographic variables also influenced treatment decisions. Weight status and physical comorbidity had a limited influence on treatment pathways. CONCLUSION: Nonclinical features of case presentations are used when making eating disorder diagnoses and in selecting treatment. Decision-making in primary care does not reflect recommendations from clinical guidance, and this disparity might increase the risk of complications in the care of sub-groups of eating-disordered patients.     

Self-recognition of disordered eating among women with bulimic-type eating disorders: A community-based study

OBJECTIVE: Self-recognition of eating-disordered behavior was examined in a community sample of young adult women (n = 158) with bulimic eating disorders. METHOD: A vignette was presented describing a fictional person meeting diagnostic criteria for bulimia nervosa. Participants were asked whether they might currently have a problem such as the one described. Scores on measures of eating disorder psychopathology, functional impairment and general psychological distress were compared between participants who recognized a problem with their eating and those who did not. RESULTS: Participants who recognized a problem with their eating (n = 86, 51.9%) had higher levels of eating disorder psychopathology and general psychological distress, were more likely to engage in self-induced vomiting, and tended to be heavier, than those who did not (n = 72, 48.1%). In addition, participants who recognized a problem were more likely to have received treatment for an eating or weight problem. In multivariate analysis, the occurrence of self-induced vomiting and higher body weight were the only variables significantly associated with recognition. CONCLUSION: Poor recognition of eating-disordered behavior may be conducive to low or inappropriate treatment seeking among individuals with bulimic- type eating disorders. The perception that only disorders involving self-induced vomiting are pathological may need to be addressed in prevention programs.     

Drug abuse in women with eating disorders

OBJECTIVE: Drug abuse in women with eating disorders has received relatively little attention. The frequency of drug use disorder (DUD) by specific drug type was examined in the current longitudinal study. METHOD: In a prospective study, women diagnosed with either anorexia nervosa (AN; n = 136) or bulimia nervosa (BN; n = 110), were interviewed and assessed for research diagnostic criteria (RDC) DUD every 6-12 months over 8.6 years. RESULTS: Forty-two (17%) women in the current longitudinal study had a lifetime history of DUD, with 19 prospective onsets over the course of the study (9 AN and 10 BN). The most commonly abused illicit drugs were amphetamines, cocaine, and marijuana, and rates of DUD did not differ between intake diagnoses of AN and BN. CONCLUSION: Drug abuse in women with eating disorders is an area of clinical concern and should be monitored routinely throughout the treatment process.     

Health care utilization of carpenters with substance abuse-related diagnoses

BACKGROUND: Persons in the construction trades in the US have high rates of alcohol and substance abuse. We had the unique opportunity to evaluate health care utilization through private insurance and workers' compensation for a group of carpenters at high risk of injury and substance abuse. METHODS: We identified a cohort of union carpenters. Their claims for medical care through union insurance and workers' compensation, and appropriate measures of time at risk were documented. Using methods of indirect standardization, we compared utilization and costs between carpenters with and without alcohol and substance-abuse related diagnoses (ASRD). RESULTS: Through private insurance, those with ASRD had 10% higher outpatient utilization and 2.1 times higher rates of hospitalizations for injury care; 2.6 times higher rates of outpatient care; and 2.9 times higher inpatient admissions for non-injury care. Individuals with ASRD had only modestly increased rates (10%) of outpatient utilization through workers' compensation. CONCLUSIONS: These findings support the need for alcohol and drug abuse prevention and treatment services for this workforce. Operationalizing this among highly mobile workforces, such as the construction trades, is a challenge. While not intending to minimize the problems of alcohol or substance abuse on the job among carpenters, the focus of prevention should not necessarily be in the workplace.