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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.

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. Multicenter Efficacy. Bulimic Nervosa CBT Non-responders. Background.

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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.

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  1. 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

  2. Multicenter Efficacy Bulimic Nervosa CBT Non-responders

  3. Background 1. CBT best established psychotherapy for BN 2. IPT may also work (2 studies) 3. Antidepressants benefit many patients - Fluoxetine best established

  4. Questions 1. What therapy works best for CBT non-responders: medication or IPT? 2. Do additional visits prevent relapse in responders?

  5. CBT Assess Secondary F/U Assess F/U Assess | | | | | | | | -2 0 16 17 33 34 60 80 16 wk 1 wk

  6. Measures

  7. 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.

  8. Rapid Interv. F/U | | Remit F/U F/U | | CBT | IPT F/U | | Symp. Fluox.  Desip. F/U | | Week 34 Week 60 Week 17

  9. Recruitment Number screened 847 Number screened out 591 Number interviewed 258 Number interviewed out 66 Number started CBT 194

  10. Enter CBT N = 194 Dropout CBT N = 54 (28%) Abstinent after CBT = 76 (54%) Symptomatic after CBT = 64 (46%)

  11. Dropouts

  12. 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.

  13. Conclusions 1. Priorities for further research a. improve initial treatment “packages” b. identify likely non-responders early in treatment and shift/ enhance therapy then.

  14. 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)

  15. Multicenter Effectiveness Bulimia Nervosa Self-Help CBT MEDS CBT

  16. Long-Term Follow-Up • Bulimia Nervosa 10-15 years • Gastric Bypass 13-15 years

  17. Participants • Females • Evaluated 1981 - 1987 • Participated in: • Imipramine/CBT Treatment Trial • 2 - 5 Year Follow-Up

  18. 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

  19. 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

  20. 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

  21. Follow-up Gastric Bypass Patients

  22. 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

  23. Follow-up Gastric Bypass Patients

  24. 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

  25. Follow-up Gastric Bypass Patients

  26. 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)

  27. Follow-up Gastric Bypass Patients

  28. Change in BMI

  29. International Eating DisordersStandardized 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)

  30. Costs

  31. IEDSDB Eating Disorder Institute 412 U. of South Florida 41 Med. College Ohio 276

  32. Other Technology Development • Palm Pilots - Monitoring (EMA: Ecological Momentary Assessment) • Palm Pilots - Therapy Extenders • Palm Pilots - Therapy Self-Help • Telemedicine - Therapy (CBT for BN)

  33. EMA • Interval Contingent Recording (e.g., end of day) • Signal Contingent Recording (e.g., randomly) • Event Contingent Recording (e.g., prior to binge eating)

  34. New Models of Service Delivery • Self-help • Supervised self-help • Internet-based • Phone-based • Computer adjunct • Computer-based • Telemedicine

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