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Objective: Studies of quality of life among individuals with eating disorders have relied almost exclusively on clinical samples. We examined impairment in quality of life in a community sample of women with eating disorders recruited as part of an epidemiological study.Methods: Measures of health-related quality of life (Medical Outcomes Study 12-item Short-Form Physical and Mental Component Summary scales) and subjective well-being (WHOQOL-BREF Psychological Functioning and Social Relationships subscales) were completed by women with eating disorders ( n = 159), primarily variants of bulimia nervosa and binge eating disorder, and a comparison group of healthy women ( n = 232).Results: When compared with healthy women, women with eating disorders reported substantial impairment in aspects of quality of life relating to mental health, although item-level analysis indicated considerable variation in the extent to which specific aspects of emotional well-being were affected. Impairment in social relationship and in physical health was less pronounced and due, at least in part, to between-group differences in age, body weight and demographic characteristics. Impairment in certain aspects of perceived physical health was, however, apparent among women with eating disorders, even after controlling for between-group differences in body weight.Conclusions: Community cases of women with eating disorders experience marked impairment in quality of life as this relates to mental health functioning and at least some impairment in physical health functioning. Personality characteristics and ego-syntonic aspects of eating-disordered behaviour may complicate the interpretation of findings relating to impairment in specific aspects of quality of life.

We sought to further explore the validity of the distinction between objective bulimic episodes (OBEs) and subjective bulimic episodes (SBEs) in the study of bulimic-type eating disorders. Drawing on data obtained at the second, interview phase of a large-scale epidemiological study, we identified mutually exclusive subgroups of women with bulimic-type eating disorders who engaged in regular OBEs but not SBEs (n = 37) or regular SBEs but not OBEs (n = 52). These subgroups were compared on a wide range of outcomes, including socio-demographic characteristics, current levels of eating disorder psychopathology, general psychological distress and impairment in role functioning, current and lifetime impairment in quality of life specifically associated with an eating problem, (self)-recognition of an eating problem, health service utilization and use of psychotropic medication. The only difference between groups was that participants who reported regular OBEs were heavier than those who reported regular SBEs. The findings converge with those of previous research in suggesting that bulimic-type eating disorders characterized by regular SBEs, but not OBEs, do not differ in any clinically meaningful way from those characterized by regular OBEs, but not SBEs. Inclusion of bulimic-type eating disorders characterized by regular SBEs as a provisional category requiring further research in DSM-V appears warranted.

Attitudes and beliefs concerning the nature and treatment of bulimia nervosa (BN) were compared among young adult women at low risk of an eating disorder (n = 332), at high risk (n = 83), or already showing symptoms (n = 94). Participants completed a self-report questionnaire that included a measure of eating disorder symptoms. A vignette of a fictional person suffering from BN was presented, followed by a series of questions addressing the nature and treatment of the problem described. High-risk and symptomatic participants were more likely than low-risk participants to report that they would not approach anyone for advice or help, were they to have BN or a similar problem, because they would not want anyone to know. Symptomatic participants were more likely to believe that someone with BN would be discriminated against, more likely to consider bulimic behaviors to be acceptable, and more likely to view BN as being common among women in the community, than low-risk participants, participants in the high-risk group being intermediate on each of these questions. The findings suggest that the attitudes and beliefs of individuals with eating disorder symptoms differ systematically from those of individuals at high risk, but who do not yet have symptoms, and from those at low risk. They also indicate specific attitudes and beliefs that may need to be addressed in prevention and early intervention programs. The potential benefits of assessing individuals' attitudes and beliefs concerning the nature and treatment of eating-disordered behaviour and tailoring program content accordingly may be worthy of investigation.

Variables associated with the use of health services were examined in a prospective, community-based study of women with bulimic-type eating disorders who did (n = 33) or did not (n = 58) receive treatment for an eating problem during a 12-month follow-up period. Participants who received treatment for an eating problem differed from those who did not in several respects, including higher body weight, higher levels of eating disorder psychopathology, general psychological distress, and impairment in role functioning, deficits in specific aspects of coping style, greater awareness of an eating problem, and greater likelihood of prior treatment for a problem with weight. However, the variables most strongly associated with treatment seeking were greater perceived impairment in role functioning specifically associated with an eating problem and greater perceived inability to suppress emotional difficulties. These were the only variables that were significantly associated with treatment seeking in multivariable analysis. The findings suggest that individuals' recognition of the adverse effects of eating-disordered behavior on quality of life may need to be addressed in prevention and early intervention programs for eating disorders.

Background and Aims: Attitudes and beliefs concerning the eating disorder bulimia nervosa (BN) were examined in a community sample of women (n = 158) with BN-type eating disorders.Method: A vignette was presented describing a fictional person meeting diagnostic criteria for BN. Participants gave their opinions on a range of issues concerning the nature and treatment of the problem described.Results: Most participants believed that BN would be difficult to treat and that relapse would be likely, were initial treatment successful. Primary care practitioners, psychologists, counsellors and close friends were perceived as helpful in the treatment of BN by the vast majority of participants. Lifestyle changes, including taking vitamins and minerals, were also highly regarded, whereas participants were ambivalent about the benefits of psychiatrists and antipathetic towards the use of prescription medication. Most participants believed that BN is common among women in the community and many had occasionally or of...

Aim: We hypothesize that a reason for the infrequent uptake of treatments by people with eating disorders is poor knowledge about treatments and outcomes for eating disorders (ED-Mental Health Literacy; ED-MHL). Our aim was to test putative health benefits of a brief ED-MHL intervention. Methods: In a community-based two-phase survey, 122 young women (mean age 28.5 SD 6.3 years) with ED symptoms meeting DSM-IV criteria for clinical severity were randomized to receive either a brief ED-MHL intervention (comprising information about efficacious treatments, reputable self-help books and where to go for further information and/or services) or information about local mental health services only. All were given feedback on their scores on measures of ED symptoms and quality of life. ED-MHL, ED symptoms and health-related quality of life were assessed prior to the intervention and at 6- and 12-month follow-up. Results: One hundred and two participants (84%) completed follow-up at 12 months. Symptomatic improvement and changes in specific aspects of ED-MHL, namely, less pessimism about how difficult EDs are to treat and improved recognition and knowledge, as well as increased help seeking, were observed in both groups. Differences between groups were uncommon but compared with control participants, those in the intervention group had improved health-related quality of life. Conclusions: A brief community-based intervention aimed to improve knowledge and beliefs about EDs and their treatments may be a valuable first step in improving health-related outcomes for people with ED, but more research is needed.

MOND, JONATHAN M., BRYAN RODGERS, PHILLIPA J. HAY, ANITA DARBY, CATHY OWEN, BERNHARD T. BAUNE, AND R. L. KENNEDY. Obesity and impairment in psychosocial functioning in women: the mediating role of eating disorder features. Obesity. 2007;15: 2769–2779. Objective: The objective was to test the hypothesis that, in women, the association between obesity and impairment in psychosocial functioning is mediated by levels of weight and shape concerns and/or binge-eating frequency. Research Methods and Procedures: Self-report measures of eating disorder psychopathology, mental health functioning, subjective quality of life in the psychological and social domains, and days “out-of-role” associated with any (physical or mental) health problem, were completed by a community sample of women classified as obese (BMI 30 kg/m 2 , n 639) or non-obese (BMI 30 kg/m 2 , n 4253). For each of the dependent measures, regression models were used to test the hypothesis of mediation by comparing the strength of the relationship between independent and dependent variables with and without inclusion of the putative mediator in the regression model. Results: On each measure, the conditions for perfect mediation were satisfied when weight or shape concerns acted as the putative mediator, indicating that there was no association between obesity and functional impairment after controlling for weight or shape concerns. In contrast, associations between obesity and impairment in psychosocial functioning remained highly significant when binge-eating frequency was the putative mediator. Discussion: The findings suggest that in women, weight and shape concerns are an important mediator of the relationship between obesity and impairment in psychosocial functioning, whereas binge eating may not be of primary importance. A greater focus on body acceptance in obesity treatment may be indicated.

Objective: To examine levels of eating disorder behaviours and cognitions of young women with obesity in the Australian Capital Territory, Australia and assess the impact upon psychological status. Design: General population cross-sectional survey. Subjects: A total of 4891 young women from the community aged 18–42 years, of which 630 were in the obese weight range. Measurements: Body mass index (BMI), eating disorder psychopathology (eating disorder examination questionnaire), and psychological distress (K-10). Results: Women with obesity had significantly higher levels of dietary restraint, eating concern, weight concern, shape concern, binge eating, misuse of diuretics, use of diet pills and fasting compared to other women in the community. These eating disorder cognitions and behaviours were associated with increased levels of psychological distress. In women with obesity, eating concern, weight concern, shape concern, dietary restraint and decreased age predicted psychological distress in a multivariate model. Among other women in the community, behaviours such as laxative misuse, 'hard' exercise and subjective bulimic episodes also contributed to the model predicting psychological distress. Conclusion: As disordered eating psychopathology is high in young obese women and negatively impacts upon psychological status, obesity prevention and treatment should consider eating disorder psychopathology and mental health outcomes.

This research examined the “mental health literacy” of adolescents concerning eating-disordered behavior. A vignette describing a fictional 16-year old female meeting diagnostic criteria for bulimia nervosa was presented to 522 female high school students, followed by a series of questions concerning treatment of and treatment-seeking for the problem described. Results indicated that primary care practitioners, mothers and close female friends were most highly regarded as potential sources of help. Self-help interventions, including the use of vitamins and minerals, were also highly regarded, whereas participants were less positive about the benefits of mental health specialists and ambivalent about the use of anti-depressant medication. Most participants believed that the problem described would be difficult to treat, and that relapse was likely even given appropriate treatment. An additional finding of note was that among participants with a high level of eating disorder symptoms (n=36, 6.9%), recognition of an eating problem was poor. We conclude that beliefs likely to be conducive to low and/or inappropriate treatment-seeking for eating problems may be common among adolescent girls. In addition, the findings suggest that prevention programs for the eating disorders need to target not only at-risk individuals, but also individuals in their immediate social environment.

In order to establish norms for the Eating Disorder Examination Questionnaire (EDE-Q) among young adult women, the questionnaire was administered to a large general population sample of women aged 18-42 yr in the Australian Capital Territory (ACT) region of Australia. Normative data were derived for EDE-Q subscales and for the occurrence of specific eating disorder behaviours, for each of five age bands (18-22, 23-27, 28-32, 33-37, 38-42 yr). Mean scores (SDs) for the Restraint, Eating Concern, Weight Concern and Shape Concern subscales for the total sample (n = 5,255) were, respectively, 1.30 (1.40), 0.76 (1.06), 1.79 (1.51) and 2.23 (1.65). The mean global score was 1.52 (1.25). The regular occurrence of objective and subjective overeating episodes was reported by 10.6% and 12.7% of participants, respectively. The regular use of self-induced vomiting, laxative misuse, and use of diuretics, was reported by 1.4%, 1.0%, and 0.3%, of participants, respectively, while 2.2% of participants reported regularly using diet pills. "Extreme dietary restraint" and "excessive exercise" were reported by 3.4% and 4.9% of participants, respectively. Both attitudinal and behavioural features of eating disorder psychopathology tended to decrease with increasing age. These data will inform researchers intending to use the EDE-Q in epidemiological studies.

Objective and Method: To inform the classification of bulimic-type eating disorders not meeting formal diagnostic criteria for bulimia nervosa (BN), levels of eating disorder psychopathology and functional impairment associated with subjective and objective bulimic episodes (SBEs and OBEs) and purging and nonpurging methods of weight control were examined in a large community-based sample of women (n = 5,232). Results: Participants who reported recurrent bulimic episodes had significantly higher levels of eating disorder psychopathology and functional impairment than those who did not and this was the case whether the episodes were objective or subjective. Similarly, participants who reported the use of extreme weight control behaviors had higher levels of eating disorder psychopathology and functional impairment than those who did not, and this was the case whether purging or nonpurging behaviors were employed. The combination of bulimic episodes and extreme weight control behaviors was associated with particularly high levels of eating disorder psychopathology and functional impairment. Conclusion: The combination of bulimic episodes, objective or subjective, and extreme weight control behaviors, purging or nonpurging, is significant in terms of impairment in psychosocial functioning among individuals affected by eating disorders not meeting formal diagnostic criteria for BN. The combination of SBEs and extreme weight control behaviors, in particular, warrants further investigation.

Background and objectives The effects of questionnaire length and mode of delivery on response rates were examined in an epidemiological study of eating-disordered behavior. Methods Short (8 pages) and long (14 pages) questionnaires were posted or hand-delivered to a community sample of 802 women. Nonrespondents who received the first questionnaire by hand delivery received a reminder letter and replacement questionnaire by post; those who received the initial questionnaire by post were further randomized to receive the first reminder by hand delivery or by post, in short or long form. A second reminder letter and questionnaire (in short or long form) were posted to all remaining nonrespondents. Results The overall response rate was 52.9%. This is a conservative estimate of true response, because in a substantial proportion of cases (12.2%) individuals were no longer resident at the listed address. There was a significant effect of mode of delivery on response, favoring hand delivery, at both the initial mailout and first reminder. There was no effect of questionnaire length on response to the initial mailout, although overall response was significantly higher for the longer form. It was estimated that an overall response of 58.0% would have been achieved had first reminders been hand-delivered to all nonrespondents who received the initial mailout by post. Conclusions Delivery of questionnaires by hand may be an effective way to increase response rates in epidemiological research, but little is to be gained by reducing questionnaire length.

Objective To examine relationships between exercise behaviour, eating-disordered behaviour and quality of life in a community sample of women. Method Self-report measures of frequency of exercise, obligatoriness of exercise and motivation for exercise, and of eating disorder psychopathology and quality of life, were completed by 169 women aged 18–45 who engaged in regular exercise. Results Exercising to improve appearance or body tone, and feelings of guilt following the postponement of exercise, were the exercise variables most strongly associated with elevated levels of eating disorder psychopathology and, in turn, reduced quality of life. There was no association between exercise behaviour and quality of life independent of the effects of eating disorder psychopathology. Conclusions Operational definitions of ‘excessive exercise’ might usefully include reference to the use of exercise to improve appearance or body tone and the experience of guilt following postponement of exercise. Inclusion of such information in prevention programmes for eating disorders may also be of benefit. ‘Excessive exercise’ is unlikely to be associated with impairment in psychosocial functioning in the absence of eating disorder psychopathology. Copyright © 2004 John Wiley & Sons, Ltd and Eating Disorders Association.

In order to examine the concurrent and criterion validity of the questionnaire version of the Eating Disorders Examination (EDE-Q), self-report and interview formats were administered to a community sample of women aged 18-45 (n = 208). Correlations between EDE-Q and EDE subscales ranged from 0.68 for Eating Concern to 0.78 for Shape Concern. Scores on the EDE-Q were significantly higher than those of the EDE for all subscales, with the mean difference ranging from 0.25 for Restraint to 0.85 for Shape Concern. Frequency of both objective bulimic episodes (OBEs) and subjective bulimic episodes (SBEs) was significantly correlated between measures. Chance-corrected agreement between EDE-Q and EDE ratings of the presence of OBEs was fair, while that for SBEs was poor. Receiver operating characteristic (ROC) analysis, based on a sample of 13 cases, indicated that a score of 2.3 on the global scale of the EDE-Q in conjunction with the occurrence of any OBEs and/or use of exercise as a means of weight control, yielded optimal validity coefficients (sensitivity = 0.83, specificity = 0.96, positive predictive value = 0.56). A stepwise discriminant function analysis yielded eight EDE-Q items which best distinguished cases from non-cases, including frequency of OBEs, use of exercise as a means of weight control, use of self-induced vomiting, use of laxatives and guilt about eating. The EDE-Q has good concurrent validity and acceptable criterion validity. The measure appears well-suited to use in prospective epidemiological studies.

Objective: To examine trends in the use of oral conventional, depot and atypical antipsychotic medications in Australian States and Territories between 1995 and 2001. Methods: For each 6 month interval between July 1995 and December 2001, prescription data obtained were converted into a measure of drug utilization expressed as the number of defined daily doses per thousand population per day (DDDs/1000/day). Data concerning the major specialty of the prescriber were available for the period 1996–2000. Results: In each State and Territory, use of atypical antipsychotic medications increased markedly while use of oral conventional and depot medications declined. Between July 2001 and December 2001, the proportion of total prescriptions for antipsychotic medications accounted for by prescriptions for atypical medications varied from 63.1% in South Australia to 76.1% in the Australian Capital Territory (ACT). Relative use of atypical medications was higher in the ACT than in other regions, while relative use of depot medications was higher in the Northern Territory than in other regions. During the year 2000, the proportion of prescriptions for oral conventional and depot medications written by general practitioners (GPs) exceeded 75% in all regions other than the ACT. Between 1996 and 2000, the proportion of prescriptions for atypical medications written by GPs increased markedly in all regions but remained lower than for oral conventional and depot medications. Conclusions: Atypical antipsychotic medications have replaced conventional medications as the first-line pharmacological treatment for psychotic disorders in all regions of Australia. Continued expansion of programmes designed to foster collaboration between GPs and mental health services will be essential in achieving optimal prescribing of antipsychotic medications.

Objective: The aim of this review was to examine the level of evidence supporting the assumed link between a positive therapeutic alliance among patients and case managers and effective outcome for patients with a mental illness who are managed in community mental health services. Method: MedLine, PsychINFO and Social Sciences Index search of articles from 1986 to 2001 returned 84 articles and two texts. Inclusion criteria were the use of validated measures and relevance to psychiatry and community case management. Results: A definite correlation exists in the psychotherapy literature between the therapeutic relationship and improved outcomes, with its potential as a prognostic indicator acknowledged. Attempts to apply the concept to patients outside the field of psychotherapy have been slow, although expansion of the concept to other forms of change-inducing therapy was a current trend. Issues of definition, quantification and measurement of the relationship caused rigorous debate in the literature. Case management research demonstrating the importance of the therapeutic relationship and ‘goodness-of-fit’ between patients and case managers was sparse with no published Australian studies. Conclusions: The level of evidence supporting the link between the therapeutic alliance of patients with mental illness and improved outcomes although sparse is encouraging. It indicates the potential of the alliance as a predictor of outcome for patients engaged in case management services in community mental health. Research to determine the role and effectiveness of the alliance in the patient/case manager dyad is needed to define this potential. Effectiveness of clinical practice in the case management field could be enhanced if research findings confirmed the genesis and value of the alliance in case management. Focus on relationship strategies as a clinical tool gives the clinician and service provider a potential vehicle for promoting partnerships with the seriously mentally ill person in managing their illness and optimizing their strengths in the community.

The authors have provided a visiting psychiatric service to the Macquarie region of NSW for a number of years after the resignation of the sole resident psychiatrist (and ongoing failure to recruit a replacement). The purpose of this paper is to chronicle from a clinical perspective the satisfactions and challenges of this particular brand of rural psychiatry. It is hoped that an-insight into what constitutes a ‘Day in the country’ will spur other psychiatrists to consider spending some time providing distant services.

The focus of the present study was to examine the extent of noncompliance in psychiatric aftercare in an integrated hospital and community mental health service. Characteristics of those patients who were noncompliant were explored in order to facilitate the prediction of treatment noncompliance at the point of discharge from hospital. A consecutive cohort of patients discharged from an acute psychiatric general hospital unit into an integrated community mental health service provided data regarding demography, disease state, attitude to treatment and actual treatment availed in aftercare. At six months follow-up 36% of the initial cohort of 128 patients had met the study criteria of noncompliance in psychiatric aftercare. A number of demographic and clinical criteria distinguished this group including the engagement in skilled employment and the presence of an anxiety rather than psychotic disorder. Noncompliant patients were less symptomatic with more disturbed behavior than those patients remaining in treatment. Noncompliant patients were significantly more likely to have a case manager of lesser experience, to have committed serious crimes and to have predicted their default from treatment at the time of discharge. Noncompliance in psychiatric aftercare persists (despite the availability of integrated hospital and community mental health services) raising the question of the goodness of fit between patient need and service provision.

The purpose of this study was twofold: to examine the patient characteristics at discharge from an acute psychiatric unit that were associated with an increased likelihood of rehospitalization within the following six months, and to examine the relationship between rehospitalization and the nature of psychiatric aftercare in a well-integrated hospital and community based psychiatric service. The study reviewed the extent of psychiatric rehospitalization following the closure of large numbers of institutional psychiatric beds. At six months after discharge 38% of the patients had been readmitted to an institution, most commonly a hospital. Despite the provision of an integrated hospital and community health service with excellent welfare support, dissatisfaction with finances independently exerted an influence on the risk of readmission. Implications for future research and treatment planning are discussed focussing on the complex integration of health and welfare services.

Background: In order to elucidate the individual and community health burden of body dissatisfaction (BD), we examined impairment in quality of life associated with BD in a large, general population sample of women. Methods: Self-report measures of BD, health-related quality of life (SF-12 Physical and Mental Component Summary scales) and subjective quality of life (WHOQOL-BREF Psychological Functioning and Social Relationships subscales) were completed by 5,255 Australian women aged 18 to 42 years. Results: Most participants (86.9%) reported some level of dissatisfaction with their weight or shape and more than one third (39.4%) reported moderate to marked dissatisfaction. Higher levels of BD were associated with poorer quality of life for all items of both quality of life measures, the degree of impairment being proportional to the degree of BD. Associations were strongest for items tapping mental health and psychosocial functioning, although greater BD was associated with substantially increased risk of impairment in certain aspects of physical health even when controlling for body weight. Post-hoc analysis indicated that the observed associations between BD and quality of life impairment were not accounted for by an association between BD and eating disorder symptoms. Conclusions: In women, BD is associated with marked impairment in aspects of quality of life relating to mental health and psycho-social functioning and at least some aspects of physical health, independent of its association with body weight and eating disorder symptoms. Greater attention may need to be given to BD as a public health problem. The fact that BD is “normative” should not be taken to infer that it is benign.

Objective The study sought to identify the types of housing preferred by people with psychiatric disabilities seeking accommodations through a community mental health service in Sydney, Australia. Methods Housing options available in the mental health service's catchment area were identified, and the extent of demands on residents' behavior that was associated with each option was assessed using an established measure. Clients examined descriptions of each housing option and rank-ordered the options based on their preferences. Clients' current levels of functioning and symptoms were also assessed. Results Clients most preferred environments that ensured living alone in settings of low behavioral demand. Living in one's own home was the most preferred option, followed by living in government-subsidized housing, For-profit boarding houses were preferred over psychiatric group homes, and homelessness, long-term hospitalization, and crisis accommodations were least preferred. Shelter, privacy, food, and safety were highly valued housing attributes. Demographic characteristics, level of functioning, and severity of psychiatric symptoms did not predict accommodation preferences. Conclusion Consumers' resistance to psychiatric group housing with high levels of behavioral demand is unrelated to consumer characteristics and should be considered in planning suitable accommodations for persons with psychiatric disabilities.

One hundred patients with cancer were interviewed regarding their attitude to a range of final life events in both their current real and hypothetical future circumstances. Patients who anticipated a future possible role for the more passive options of wishing death to come early or ceasing all treatment, were more hopeless and had a reduced quality of life. Patients however who anticipated a role for the more active options of suicide and/or euthanasia were less fatalistic and did not report a reduced quality of life. The desire for suicide was particularly positively related to younger age, a personal psychiatric past history, and a number of treatment-related variables reflecting increased patient autonomy.

Objective: To outline the processes involved in establishing an integrated perinatal mental health service in a public mental health setting. Conclusions: The Australian Capital Territory (ACT) Mental Health Services established a perinatal mental health service based on coordinated, evidence-based treatments. One of the treatment approaches introduced into the service was Interpersonal Psychotherapy, a time-limited, empirically validated therapy for postnatal depression.

There is evidence that psychological treatments for postnatal depression are effective in the short-term; however, whether the effects are enduring over time remains an important empirical question. The aim of this study was to investigate the depressive symptoms and interpersonal functioning of participants in a randomised controlled trial (RCT) of group interpersonal psychotherapy (IPT-G) at 2 years posttreatment. The study also examined long-term trajectories, such as whether participants maintained their recovery status, achieved later recovery, recurrence or persistent symptoms. Approximately 2 years posttreatment, all women in the original RCT (N = 50) were invited to participate in a mailed follow-up. A repeated measures analysis of variance assessed differences between the treatment and control conditions on depression and interpersonal scores across five measurement occasions: baseline, mid-treatment, end of treatment and 3-month and 2-year follow-up. Chi-square tests were used to analyse the percentage of participants in the four recovery categories. Mothers who received IPT-G improved more rapidly in the short-term and were less likely to develop persistent depressive symptoms in the long-term. Fifty seven percent of IPT-G mothers maintained their recovery over the follow-up period. Overall, IPT-G participants were significantly less likely to require follow-up treatment. Limitations include the use of self-report questionnaires to classify recovery. The positive finding that fewer women in the group condition experienced a persistent course of depression highlights its possible enduring effects after treatment discontinuation. Further research is needed to improve our long-term management of postnatal depression for individuals who are vulnerable to a recurrent or chronic trajectory.

Impairment in mental health associated with eating-disorder features was examined in a large, general population sample of women aged 18 to 42 years. Participants (n = 5255) completed self-report measures of eating-disordered behaviour, mental health functioning, height and weight and socio-demographic information.The most common eating-disorder features were extreme concerns about weight or shape (14.6%), subjective overeating (12.7%), objective overeating (10.6%) and extreme concerns about dietary intake (10.4%). In multivariable analysis, in which mental health functioning was regressed on eating-disorder features, while also controlling for age and body weight, objective overeating (β = -0.07), subjective overeating (β = -0.07), extreme dietary restriction (β = -0.06) and extreme concerns about eating (β = -0.04) showed small, but statistically significant associations with mental health impairment, whereas extreme weight or shape concerns showed a very strong association (β = -0.24).From a clinical perspective, the findings are consistent with the importance attached to the "over-evaluation" of weight or shape as a core component of eating-disorder psychopathology. From a public health perspective, the findings indicate the need to conceive of body dissatisfaction as a target for health promotion in its own right.

One hundred oncology and hematology cancer patients from a major teaching hospital and their treating doctors were studied regarding their attitudes toward cardiopulmonary resuscitation (CPR). A descriptive approach was used, incorporating semistructured interviews of patients and medical staff and established questionnaire measures, examining knowledge of and attitudes toward disease and treatment, and projected attitude toward CPR and current psychological functioning. One-third of the patient sample anticipated a time when they would not consent to cardiopulmonary resuscitation. This was significantly associated with good disease prognosis. Patients with a psychiatric past history were also overrespresented. It appears that patient attitude to treatment withdrawal and refusal of CPR is related to disease progression and likely to change over time. This supports a dynamic and evolving model of advance directives rather than any fixed decree. Medical staff reported that they planned to provide half the sample with intensive medical treatment (including Intensive Care support in the event of their cardiac arrest), and 32% were designated for ward-based resuscitation only. Eighteen percent would not be resuscitated. These patients were older, had more treatment side effects, and a poorer quality of life. Those patients with either a psychiatric past history or higher ratings of depressive affect were also overincluded in the doctors' "Do-Not-Resuscitate" (DNR) group. These results suggest that there are other qualitative factors (e.g., current psychological functioning and past psychiatric history) that contribute to DNR decisions beyond the usual disease-based criteria seen in formal DNR protocols.

One hundred oncology patients from a major teaching hospital were asked about their attitudes to a number of final life events including active withdrawal from treatment, the refusal of cardiopulmonary resuscitation, suicide and euthanasia. A descriptive approach was used incorporating semi-structured interviews and established questionnaire measures. One third of the patient sample anticipated some role for taking active steps to end their own lives. This was not restricted to those currently psychologically disturbed nor to any particular demographic subgroup. Patients with more severe illness or poor prognosis did not express interest in suicide and euthanasia. A positive past psychiatric history increased the potential for seeing suicide as an option. The results have significant implications for the establishment of patient care protocols in final life events.

Objective and Methods: Agreement between self-report and interview assessment of purging behaviours was examined in a community sample of women with a high level of eating disorder symptoms (n = 324) who completed both the Eating Disorder Examination (EDE) and Eating Disorder Examination Questionnaire (EDE-Q). Results: Of 46 individuals who reported any use of self-induced vomiting or laxative misuse on the questionnaire, 19 (41.7%) denied these behaviours when subsequently questioned in a face-to-face interview. These individuals had lower levels of eating disorder psychopathology, functional impairment and general psychological distress, than participants who reported purging on both the questionnaire and at interview (n = 27). Conclusions: The assumption of interview superiority in the assessment of specific aspects of eating disorder psychopathology should not be uncritically accepted. Caution should be exercised in drawing conclusions concerning the level of agreement between self-report and interview assessment of purging based on research in clinical samples.

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. © 2007 by Wiley Periodicals, Inc. Int J Eat Disord 2007

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.

Levels of eating disorder psychopathology, impairment in psycho-social functioning and use of health services were compared among probable cases of binge eating disorder (BED) with and without extreme weight or shape concerns ("undue influence of weight or shape on self-evaluation") recruited from a large community sample of women. Data for obese non-binge eaters (n=457), also recruited from the community sample, and for a clinical sample of eating disorder patients (n=128), recruited separately, were included for comparative purposes. BED cases who reported extreme weight or shape concerns (n=51, 46.4%) had significantly higher levels of eating disorder psychopathology and functional impairment than those who did not report such concerns (n=59), after controlling for between-group differences in age and body weight. In addition, BED cases who reported extreme weight or shape concerns were more likely to have sought treatment for an eating or weight problem than those who did not. Whereas levels of eating disorder psychopathology and functional impairment were markedly elevated among BED cases with extreme weight or shape concerns, BED cases who did not report extreme weight or shape concerns resembled obese non-binge eaters in most respects. The findings support the inclusion of an undue influence of weight or shape on self-evaluation as a diagnostic criterion for BED. In the absence of this influence, eating disorders that otherwise resemble BED do not appear to be "clinically significant".

The correlates of self-induced vomiting and laxative misuse were examined in a large community sample of young adult women (N = 5255). Scores on measures of eating disorder psychopathology, general psychological distress, functional impairment, as well as the use of health services for an eating or weight problem were compared among participants who reported regular self-induced vomiting, but not laxative misuse (N = 59), and those who reported regular misuse of laxatives, but not vomiting (N = 39). Individuals who misused laxatives were older, perceived poorer physical health, and were less likely to have sought treatment specifically for a problem with eating than those who engaged in self-induced vomiting. In all other respects, the groups were similar. However, individuals who regularly engaged in both forms of purging (N = 8) had particularly high levels of eating disorder and comorbid psychopathology. The perception among women of normal weight that only syndromes involving the use of self-induced vomiting constitute an eating disorder may need to be addressed in prevention programs. The combination of self-induced vomiting and laxative misuse may indicate a particularly severe psychiatric disturbance.

Objective The current study informed the definition of excessive exercise by examining relations between exercise behavior, eating-disordered behavior, and quality of life (QOL) in a community sample of women. Method Self-report measures of frequency of exercise, obligatory exercise and motivation for exercise, and of eating disorder psychopathology and QOL, were completed by 3,472 women aged 18-42 years who engaged in regular exercise. Results The extent to which exercise is intended to influence weight or shape and the degree to which guilt is experienced when exercise is postphoned were the exercise variables most strongly associated with elevated levels of eating disorder psychopathology and reduced QOL. Subgroups of participants who reported exercising solely for weight and shape reasons (n = 322 [9.3%]), intense guilt after postponement of exercise (n = 136 [3.9%]), or both (n = 116 [3.3%]), had markedly elevated levels of eating disorder psychopathology. There was no association between excessive exercise and reduced QOL after the effects of eating disorder psychopathology were statistically controlled. Conclusion The findings suggest that exercise is excessive when its postponement is accompanied by intense guilt or when it is undertaken solely to influence weight or shape. Operational definitions of excessive exercise might usefully include reference to these terms. The findings may also be of benefit in informing the content of prevention programs, which address dysfunctional exercise behavior. Excessive exercise is unlikely to be associated with impairment in psychosocial functioning in the absence of eating disorder psychopathology. It may, however, be a useful indicator of such psychopathology.

Background Rates of trauma and Posttraumatic Stress Disorder (PTSD) were examined in order to compare the profile in clients of an Australian Public Mental Health Service with that reported in the international literature for clients with major mental illness and to explore the effect of this on client health outcomes. Potential factors contributing to increased levels of trauma/PTSD in this group of clients and the issue of causality between PTSD and subsequent mental illness was also explored. Methods A convenience sample of 29 clients was screened for trauma and PTSD using the Posttraumatic Stress Diagnostic Scale™ (PDS) and selected outcome measures. Paired and independent samples t-test and ANOVA were applied to the data. Results High levels of undocumented trauma and PTSD were found. Twenty clients, (74%) reported exposure to multiple traumatic events; 33.3% (9) met DSM IV diagnostic criteria for PTSD. Significant difference was found for PTSD symptomatology, severity and impairment and for client and clinician-rated scores of Quality of Life (QOL) outcomes in the PTSD group. No effect for PTSD symptomatology on the Working Alliance (WA) was found. Factors that may influence higher rates of PTSD in this group were identified and included issues associated with the population studied, the predominance of assaultive violence found, and vulnerability and risks factors associated with re-traumatisation within the social and treating environments. Conclusion A similar trauma and PTSD profile to that reported in the international literature, including greater levels of trauma and PTSD and a poorer QOL, was found in this small sample of clients. It is postulated that the increased levels of trauma/PTSD as reported for persons with major mental illness, including those found in the current study, are primarily related to the characteristics of the population that access public mainstream psychiatric services and that these factors have specific implications for service delivery, and raise issues of efficiency and effectiveness of resource use in achieving successful outcomes in public mental health services for clients with co-morbid PTSD. Further research with a more rigorous design is needed to test these preliminary findings within Australian Community Mental Health Services.

Objective: To examine quality of life among subgroups of eating disorder patients. Method: Self-report questionnaires which included two quality of life measures were completed by 87 individuals referred for treatment to the Australian Capital Territory Eating Disorders Day Program. Health-related quality of life, as measured by the Medical Outcomes Study 12-item Short Form Mental Component Summary scale, and subjective quality of life, as measured by subscales of the World Health Organization Brief Quality of Life Assessment Scale (WHOQOL-BREF), were compared among individuals who received the diagnosis of anorexia nervosa purging subtype (n=15), anorexia nervosa restricting subtype (n=19), bulimia nervosa (n=40) and binge eating disorder (n=10), and among a general population sample of young adult women employed as a control group (n=495). Results: Eating disorder patients, when considered together, showed marked impairment in both health-related and subjective quality of life relative to normal control subjects. However, in both domains, restricting anorexia nervosa patients reported significantly better quality of life than other patient groups, after controlling for levels of general psychological distress. Scores on the Social Relationships subscale of the WHOQOL-BREF among individuals in this subgroup were similar to those of normal control subjects. Conclusions: Reliance on any one instrument is likely to be misleading in assessing the quality of life of eating disorder patients. Careful consideration needs to be given to the assessment of restricting anorexia nervosa patients in particular.

Objective: to examine disability associated with community cases of the more commonly occurring eating disorders and with particular eating disorder behaviours. Method: self-report questionnaires, which included measures of eating disorder symptoms and impairment in everyday functioning, were completed by 495 female residents of the Australian Capital Territory region aged between 18 and 45 years. A structured interview for the assessment of eating disorders was completed by a subgroup (n=208) of participants. Discriminant function analysis was used to identify cases of eating disorders in the total sample (n=495) based on the characteristics of individuals interviewed. Impairment in functioning, as measured by the Medical Outcomes Study Short Form, was compared among eating disorder cases and non-cases, among subgroups of participants engaging in particular eating disorder behaviours, and among community cases of anxiety and affective disorders identified from the Australian National Survey of Mental Health and Well-Being. Results: community cases of eating disorders (n=31; 6.3%) were associated with substantial impairment in functioning, comparable with that of community cases of anxiety and affective disorders. Among eating disorder behaviours, the use of extreme weight-control behaviours, in particular self-induced vomiting, was associated with the highest levels of impairment, although the occurrence of regular episodes of overeating was also associated with considerable impairment. Conclusions: the burden on the community of the more commonly occurring eating disorders may be substantial. Improving women's recognition of the adverse effects of eating disordered-behaviour on functioning, as well as their knowledge of effective treatments, will be important in reducing this burden.

Objective To examine the beliefs of women concerning the helpfulness of various possible interventions for bulimia nervosa. Method Face-to-face interviews were conducted with a community sample of 208 women aged 18–45 years. Respondents were presented with a vignette describing a fictional person meeting diagnostic criteria for bulimia nervosa and were asked to indicate whether various persons, treatments, medications, and self-help activities would be helpful, harmful, or neither helpful nor harmful for the person described. Results Respondents indicated that seeing a general practitioner (GP), counselor, or dietitian was more likely to be helpful than seeing either a psychologist or a psychiatrist. GPs were perceived as the individuals likely to be most helpful for the problem described, and most likely to be approached first, whereas counseling was regarded as the most helpful treatment. Self-help interventions, including the use of vitamins and minerals, were also highly regarded, while a minority of participants believed that anti-depressant medication would be helpful. Conclusions Information concerning treatments that are effective for eating disorders should be included in prevention programs. Collaborations between mental health specialists and primary health providers are vital to ensure the optimal treatment of eating-disordered behavior. © 2004 by Wiley Periodicals, Inc. Int J Eat Disord 36: 62–68, 2004.

Few studies have examined attitudes towards eating-disordered behaviour among women in the general population. A vignette describing a fictional person meeting diagnostic criteria for bulimia nervosa (BN) was presented to a community sample of women aged 18–45. Respondents (n = 208) were asked a series of questions concerning the severity and prevalence of the problem described. Most respondents viewed BN as a distressing condition whose sufferers are deserving of sympathy. However, more than one-third of respondents had at some stage believed that it ‘might not be too bad’ to be like the person described in the vignette. Most respondents believed that the prevalence of the problem described among women in the community was likely to be between 10 % and 30 % (48.6%) or between 30% and 50 % (23.1 %). Individuals with a clinically significant eating disorder (n = 13, 6.3%) were more likely to perceive the symptoms of BN as being acceptable, and its prevalence higher, than individuals with no eating disorder diagnosis. Information concerning the medical and psychological sequelae of BN and other eating disorders might usefully be incorporated in prevention programmes. Prospective community-based research is required to elucidate the nature of the relationship between perceived acceptability of eating disorder symptoms and actual eating disorder psychopathology. Extension of the present research to examine the views of women in other cultures would also be of interest.

Objective: A model of intermittent psychiatric service provision to rural and remote New South Wales communities by metropolitan psychiatrists and mental health professionals has been evaluated. The services provided included peer support to lone mental health and generic health workers, direct psychiatric care to clients in their own environment and skills development education sessions to general health staff and other professionals affiliated with health care (e.g. police and ambulance officers). Method: There were 10 visits of teams made up of a psychiatrist and another mental health professional to six rural and remote locations. Outcomes of the services delivered were examined including clinical services and teaching skills training sessions. Indirect outcome measures included changes to Pharmaceutical Benefits Scheme prescription patterns in areas serviced and data regarding transfer of clients for psychiatric care in regional centres. Difficulties in evaluation are discussed. Results: The feasibility of intermittent service provision was demonstrated. Education packages were well received and a positive change in workers' attitudes toward mental health practice was found. Conclusion: Intermittent psychiatric services in remote settings add value to health care delivery particularly when dovetailed with skills-based education sessions.

Background The aim of this study was to research the feasibility of training mental health consumers as tutors for 4th year medical students in psychiatry. Methods A partnership between a consumer network and an academic unit in Psychological Medicine was formed to jointly develop a training package for consumer tutors and a curriculum in interviewing skills for medical students. Student attitudes to mental health consumers were measured pre and post the program. All tutorial evaluation data was analysed using univariate statistics. Both tutors and students evaluated the teaching program using a 4 point rating scale. The mean scores for teaching and content for both students and tutors were compared using an independent samples t-test. Results Consumer tutors were successfully trained and accredited as tutors and able to sustain delivery of tutorials over a 4 year period. The study found that whilst the medical students started with positive attitudes towards consumers prior to the program, there was a general trend towards improved attitude across all measures. Other outcomes for tutors and students (both positive and negative) are described. Conclusions Consumer tutors along with professional tutors have a place in the education of medical students, are an untapped resource and deliver largely positive outcomes for students and themselves. Further possible developments are described.

To help predict aggressive and violent behaviors, the frequency and types of these behaviors in acute psychiatric inpatient settings were examined, and potential interactions between staffing and patient mix and rates of the behaviors were explored.Data on violent incidents were gathered prospectively in three adult acute psychiatric units in a general hospital and two units in a primary psychiatric hospital in Sydney, Australia. Staff recorded violent and aggressive incidents, which were ranked on an 8-level scale. They also completed weekly reports of staffing levels and patient mix. Poisson regression analysis was used to calculate relative rates, 95 percent confidence intervals, and p values.A total of 1,289 violent incidents were recorded over a seven-month period. Based on the scale, 58 percent of the incidents were serious. Seventy-eight percent were directed toward nursing staff. Complex relationships between staffing, patient mix, and violence were found. Relative risk increased with more nursing staff (of either sex), more nonnursing staff on planned leave, more patients known to instigate violence, a greater number of disoriented patients, more patients detained compulsorily, and more use of seclusion. The relative risk decreased with more young staff (under 30 years old), more nursing staff with unplanned absenteeism, more admissions, and more patients with substance abuse or physical illness. In total these factors accounted for 62 percent of the variance in violence.Violent incidents in psychiatric settings are a frequent and serious problem. Incidents appear to be underreported, and the seriousness of an incident does not guarantee it will be reported.

Background We sought to evaluate the hypothesis that mental health impairment in underweight women, where this occurs, is due to an association between low body weight and elevated levels of body dissatisfaction and/or eating-disordered behaviour. Methods Subgroups of underweight and normal-weight women recruited from a large, general population sample were compared on measures of body dissatisfaction, eating-disordered behaviour and mental health. Results Underweight women had significantly greater impairment in mental health than normal-weight women, even after controlling for between-group differences in demographic characteristics and physical health. However, there was no evidence that higher levels of body dissatisfaction or eating-disordered behaviour accounted for this difference. Rather, underweight women had significantly lower levels of body dissatisfaction and eating-disordered behaviour than normal-weight women. Conclusions The findings suggest that mental health impairment in underweight women, where this occurs, is unlikely to be due to higher levels of body dissatisfaction or eating-disordered behaviour. Rather, lower levels of body dissatisfaction and eating-disordered behaviour among underweight women may counterbalance, to some extent, impairment due to other factors.

Violent incidents in inpatient psychiatric settings were examined among a group of repeatedly violent patients to better understand the clinical and occupational health significance of repeated violence.Data on violent incidents were collected prospectively over seven months in five psychiatric units in Sydney, Australia. Recidivist patients--those responsible for more than 20 incidents of violence or aggression--and nonrecidivist violent patients were compared in terms of the nature of the incidents, warning signs, and staff responses to violence.Of the 174 patients involved in violent incidents, 20 (12 percent) were recidivists. These patients accounted for 69 percent of the 752 violent incidents identified. Recidivists were significantly older than nonrecidivist patients. Compared with nonrecidivists, the men recidivists were more likely to have an organic brain syndrome, and the women recidivists were more likely to have a personality disorder. When a recidivist patient was violent, staff members' response was significantly less likely to include institutional mechanisms for dealing with violence, such as contacting occupational health and safety officers, completing injury notification forms, and notifying police. Violence occurred among recidivists despite their giving more warning signs than nonrecidivists, suggesting that recidivists' threats were not taken seriously by staff, perhaps reflecting demoralization in the face of repeated violence.Even though this study focused only on serious incidents and defined recidivism narrowly, it found that recidivism of violence and aggression among psychiatric patients was a serious problem. The relative lack of response by staff members to the violent acts of recidivist patients is of concern.