Depression is a common disabling condition with a prevalence of 4–8%. There is significant morbidity, mortality and huge personal, family and economic costs, including problems of stigma and discrimination. The National Institute for Health and Clinical Excellence (NICE) recently updated[1] its 2004 guidelines[2] on the treatment of depression while the Scottish Intercollegiate Guideline Network (SIGN) is developing a guideline for the non-pharmacological treatment of mild to moderate depression in primary care.[3,4] Since 2004 NICE has recommended a stepped care approach based on the severity, duration, history and impact of the depression. Recommendations for mild depression include active monitoring, guided self help, computerised cognitive behaviour therapy (CBT), exercise and brief psychological interventions such as counselling, problem-solving therapy and brief CBT. Antidepressants are not recommended because the risk–benefit ratio is poor. For moderate depression, CBT, medication or both are options, taking patient preference into account. In severe depression, treatment resistance or recurrent depression, CBT should be offered in combination with medication. Interpersonal therapy (IPT) or couples therapy should also be considered. Further research is needed to address the issues of efficacy, efficiency and acceptability of the stepped care approach. ####Specific psychological interventions #####Cognitive behavioural therapy Now used in a wide range of disorders, CBT developed from the finding that depressed patients had consistently negative views about themselves, the world and the future, which drove unhelpful behaviours and maintained depressed mood. Cognitive behavioural therapy is structured and time-limited, with typically 16–20 one-hour sessions. Treatment goals are agreed and the patient develops a series of skills, which include identifying and challenging negative thoughts, altering unhelpful behaviours and problem solving. Guided discovery is used rather than debate or persuasion. Homework tasks are agreed as the patient practises the therapy in everyday life. The focus of therapy is in the here and now, with background information gathered to help identify dysfunctional beliefs developed earlier in life. These are addressed later in the therapy to reduce vulnerability to further episodes. Cognitive behavioural therapy is as effective as therapeutic doses of antidepressants, with remission rates of around 50%.[5] There is evidence of benefit over treatment as usual, waiting list controls and persistent benefit at two-year follow-up. There is evidence of benefit of combining medication with CBT, although further research is needed. There is also evidence for small group CBT. There are some criticisms of the CBT evidence, including that the median sample size was only 30, only 70% of studies were randomised and only 20% monitored adherence to therapy for CBT.[3] However, with a large number of randomised controlled trials – NICE reviewed 66 – and systematic reviews, the evidence is robust and consistent. Cognitive behavioural therapy is not more effective in the treatment of depression than other systematic psychological therapies, for example IPT or behavioural activation, but there are considerably more studies of CBT and the range of applications is wider, which may explain why the recommendations for CBT are broader. Mindfulness-based CBT has the best evidence in relapse prevention. This group intervention incorporates meditation and helps patients to focus more on the present (focusing on the body, breathing, seeing thoughts as objects of awareness) and less on regrets from the past or worries about the future. #####Interpersonal therapy Interpersonal therapy focuses on the links between the patient’s current interpersonal relationships and symptoms of depression. The goals are to reduce symptoms by learning to cope with or resolve interpersonal problems such as interpersonal conflicts, role transitions, grief and loss and social skills. There is no writing or homework required. Treatment duration is similar to CBT. Interpersonal therapy is as effective as CBT and medication, with fewer studies but of high quality.[2] There is also evidence of benefit over treatment as usual, waiting list controls, placebo and of persistent benefit. Evidence for benefit combined with medication also requires more study. Monthly maintenance IPT sessions can be effective in delaying relapse of depression. #####Couple-focused therapies The couple-focused therapies reviewed by NICE[1] were based on CBT, IPT or behavioural interventions. There is a small body of evidence of equal benefit to individual CBT or IPT and it is an option where relationship factors are relevant. #####Guided self help and computerised CBT Cognitive behavioural therapy and IPT therapists require considerable training and ongoing supervision and are an expensive and currently insufficient resource. The CBT model has lent itself to self help approaches which may be more acceptable to some patients, improve access and make more efficient use of therapists' time. Patients learn skills using books, self help manuals or interactive computer packages. Effect sizes of 0.4–0.8 are found, with greater effectiveness associated with a supportive therapist monitoring and guiding progress.[6] ‘Blue Pages’, a written course of psycho-education with minimal therapist input, and the computerised CBT (cCBT) programme ‘Mood Gym’ were found to be effective in depression.[7] The cCBT package ‘Beating the Blues’ was found to be ‘clinically superior to treatment as usual, at negligible additional cost’.[8] Questions remain for this and similar packages regarding compliance, relapse rates and costs. #####Behavioural activation Behavioural activation and problem-solving therapy are based on CBT techniques and could be delivered by less highly trained therapists. Behavioural activation focuses on an agreed scheduling of activities to encourage patients to approach activities they have been avoiding and also on analysing the function of rumination (going over and over past regrets) that serves as a form of avoidance. There is strong evidence of benefit equal to CBT.[9] The Scottish Intercollegiate Guidelines Network reviewed two meta-analyses involving 22 studies and found an effect size of 0.7–1.2; it plans to recommend behavioural activation. ####Problem-solving therapy This involves helping the patient develop skills to break down problems into manageable tasks. The evidence for problem-solving therapy is less convincing, based on a small number of suitable studies. #####Counselling Counselling involves professional guidance in resolving personal conflicts and emotional problems. The National Institute for Health and Clinical Excellence advises non-directive person-centred models of 6–10 sessions. The evidence base is less developed. The Scottish Intercollegiate Guidelines Network considers that there is sufficient evidence to recommend counselling, but it point out that many of the studies have mixed populations and do not address use in depression specifically. There is evidence that antidepressants act more quickly than counselling. Some studies show no benefit over usual care and others show that benefits are not sustained. In the 2009 guideline NICE suggests counselling only if other low-intensity interventions or group CBT are declined, and recommends that the practitioner should explain ‘uncertainty of effectiveness in depression’. This has proved highly controversial, with some challenging the evidence NICE included to reach its conclusions. #####Psychodynamic therapy There is a greater emphasis on the therapy relationship and the role of unconscious mechanisms in psychodynamic therapy (PDT) than in other interventions. Therapy is non-directive and the patient is not taught specific skills. Instead, the therapist interprets and helps the patient to develop self awareness and understand how patterns from the past are re-enacted in the present. There is some evidence of equal benefit to CBT or medication. However, few studies focus specifically on depression and some categorised PDT with IPT, leading to difficulty interpreting results. The Scottish Intercollegiate Guidelines Network concluded that further good quality randomised controlled trials are needed but recommends PDT in mild to moderate depression. The NICE 2009 guidline recommends PDT for moderate depression where CBT or IPT have not been beneficial or declined but again advises patients be informed about uncertainty of efficacy.[1] Again, these recommendations have proved controversial. #####Psychological interventions with insufficient evidence Psychological interventions with insufficient evidence include music therapy, art therapy, neurolinguistic programming, thought field therapy and emotional freedom therapy. ####Other interventions #####Exercise Supervised, structured exercise programmes are recommended by both NICE and SIGN as an evidence-based effective treatment. Due to some inconsistencies in earlier meta-analyses, the SIGN group carried out a systematic review of the literature and found good-quality evidence for the benefits of exercise in depression, with reduction in depressive symptoms in a range of settings and age groups of equal efficacy to antidepressants (about 45%), with similar drop-out rates (20–40%) and effect persisting for one year.[3] One study showed similar efficacy to CBT. Study limitations included small sample sizes and the use of volunteers who may have higher motivation levels than usual patients. Studies have tried to determine the required ‘dose’ of exercise, with one study finding a minimum of 30–40 minutes three days per week, others a required energy expenditure of 70–80% of heart rate reserve. The National Institute for Health and Clinical Excellence specifies an average of three sessions per week, lasting 45 minutes to one hour over an average of 12 weeks, tailored to the individual to maximise adherence. #####St John’s wort (*Hypericum*) This herbal supplement has been extensively studied,[1] with robust evidence of benefit in mild and moderate depression, with superiority over placebo and no difference or greater efficacy than synthetic antidepressants. St John’s wort is less effective than low-dose antidepressants in severe depression. It appears as acceptable as placebo and more acceptable than tricyclic antidepressants in particular. It is recommended by SIGN in its draft guideline.[3] However, it is not without important side effects and interactions including with the oral contraceptive pill, warfarin and anticonvulsants. There are also issues with the amounts of active ingredients (there are at least ten potential contributors) in different preparations as St John’s wort is not subject to pharmacoregulation. It is important therefore to check if patients are taking St John’s wort and alert them to these issues. In contrast to the draft SIGN recommendations, NICE recommends that practitioners neither prescribe nor advise patients to take St John's wort due to these concerns.[1] No other herbal supplements currently have sufficient evidence of benefit in depression. #####Complementary therapies With as many as 46% of people using some form of complementary therapy in their lifetime, patients with depression are also likely to consider their use. The Scottish Intercollegiate Guidelines Network looked at the evidence for the benefits of homeopathy, acupuncture, yoga, reiki, aromatherapy, reflexology and t'ai chi in depression. It found a paucity of good-quality randomised controlled trials, poor methodology and reporting and insufficient evidence to recommend any of these complementary therapies. ####Special groups #####Co-morbid physical illness The National Institute for Health and Clinical Excellence has developed a separate guideline in this area.[10] A lower threshold for intervention is suggested where depression complicates the care of the physical health problem. Group-based peer support programmes are recommended in addition to the above range of interventions. The provision of psychological therapy as part of general medical care can be effective and may improve acceptability and access to treatments. #####Elderly There is also good evidence for the benefits of psychological treatments for depression in older adults. Further work is needed to clarify whether this is also true for patients with more severe depression and the older old. #####Depression in pregnancy and postnatal period With higher effect sizes and the changing risk–benefit ratio for psychotropic medication in pregnancy and lactation, NICE recommends more rapid access to the standard range of psychological treatments. Non-directive counselling at home and telephone support are also recommended. #####Children and young people There are specific problems with a lack of efficacy for most selective serotonin reuptake inhibitors (SSRIs) in this group. Non-pharmacological interventions are recommended for children and young people regardless of the severity of depression. ####Which therapy for which patient? More research is required to determine which patients may benefit most from which intervention and what treatments to offer if the initial choices are ineffective. The therapeutic alliance, therapist competence and adherence to the treatment model all have significant effects on clinical outcome. Interventions may cause harm. Ongoing supervision for therapists is essential and the issue of therapist competency in real-life practice requires further study. 2009-06-16T10:18:37Z None declared. 109 2009-11-11T00:00:00Z 2009-11-11T00:00:00Z non-pharmacological-management-of-depression 2009-06-22T00:00:00Z

In recent years there has been a growth in interest in non-pharmacological treatments for depression from patients, professionals and government, with concern about the rising use of antidepressants alongside questions about antidepressant efficacy and a stronger evidence base for some non-pharmacological interventions. In this companion article to our popular article on [the pros and cons of SSRI anti-depressants,](http://behindthemedicalheadlines.com/articles/the-pros-and-cons-of-ssri-antidepressants)Consultant psychiatrist Eleanor Halloran looks at the available options.

2009-11-11T11:02:58Z

Eating disorders are abnormalities in eating habits, in the context of a person’s distorted view of their own body image. The common subtypes are anorexia nervosa (AN) and bulimia nervosa (BN). There is overlap in the symptom pattern. Some may have a clinical picture that is initially consistent with AN but becomes consistent with BN after a period of time. If all the diagnostic criteria are not fully met, the terms ‘atypical anorexia’, ‘atypical bulimia’ or ‘unspecified eating disorder’ may be used to describe the condition. The following article gives information about BN. Please refer to our [separate article](http://behindthemedicalheadlines.com/articles/eating-disorders-anorexia-nervosa) for more information on AN. ####How common is bulimia nervosa? The prevalence of BN is about 1%.[1,2] About 90% of those diagnosed with BN are women.[1] Contrary to a common misconception, eating disorders have not been shown to be more prominent in any particular social class.[3] ####What causes it? The cause of BN is probably multifactorial. In those who have BN, there is a higher rate of a history of physical or sexual abuse, obesity, parental obesity, mood disorder, substance misuse, low self-esteem, perfectionism, disturbed family dynamics, parental weight or shape concern and early first menstrual bleeding.[4] It is difficult to say whether these are causal relationships or whether they are associations. ####Why is it important to recognise and treat BN? It is important to treat and recognise BN since it can cause a high degree of morbidity. Bulimia nervosa can cause many physical problems, including teeth erosion, hoarseness, mouth ulcers, throat bleeding, swollen cheeks, acid reflux, tiredness, fits, fainting, blackouts, muscle twitching, numb fingers and toes, swollen feet and ankles, dry skin, dehydration, irregular menstrual periods, diarrhoea, chronic constipation, stomach perforation, irregular heart rhythms, palpitations, chest pain and kidney damage.[5] It is associated with emotional and cognitive problems, such as depression, anxiety, irritability and poor concentration. ####Diagnosis People with BN often try to hide their symptoms from family or friends, so initially it may be hard for others to notice the illness. People with BN often have a normal weight. The features of BN include a persistent preoccupation with eating, and an irresistible craving for food; the patient succumbs to episodes of overeating in which large amounts of food are consumed in short periods of time. People with BN attempt to counteract the ‘fattening’ effects of food by one or more of the following methods: self-induced vomiting; laxative abuse; alternating periods of starvation; and the use of drugs such as appetite suppressants, thyroid preparations or diuretics. People with BN have a dread of fatness. There is often a history of an earlier episode of AN.[6] Bulimia nervosa may present with depression, amenorrhoea (lack of menstrual periods), infertility or physical complications. Bulimia nervosa sufferers may present to gastroenterologists or gynaecologists. They can become pregnant even when they are amenorrhoeic. Weight gain and body shape changes during pregnancy can provoke extreme distress in those with BN. There is also a higher prevalence of BN and sub-threshold eating disorder in those with insulin-dependent diabetes.[7] Eating disorders are associated with insulin omission for weight loss and impaired metabolic control in those with diabetes.[7] ####Referral It is very important to prepare patients prior to a referral, to improve the attendance rate. Referrals should be made to the nearest eating disorder service. The referrer should provide height, weight and recent blood results. If an eating disorder service is not available locally, referrals should be made to a mental health service. A referral to a dietician with expertise in eating disorders should also be made. ####Investigations The following investigations should be made: * Height and weight; * A thorough physical examination (look for dry skin and signs of dehydration; check for erect and supine blood pressure, pulse, temperature; perform cardiovascular, respiratory, gastro-intestinal and neurological examinations); * Blood tests (full blood count, urea and electrolytes, calcium, albumin, magnesium, phosphate, liver function tests, glucose, erythrocyte sedimentation rate, thyroid function tests, vitamin B12 and folate); * Electrocardiogram (look for QT interval, arrhythmias or changes associated with abnormal electrolytes). ####Treatment It is important to provide education about the effects of BN and healthy eating principles. Some patients will benefit from an evidence-based self-help programme.[8] There are better outcomes when these programmes are guided (that is, with encouragement and support from a healthcare professional). There is a good evidence base for both cognitive-behavioural therapy and interpersonal therapy in the treatment of BN.[8] Concurrent conditions such as depression should also be treated. Antidepressants (for example, fluoxetine) may reduce bulimic symptoms and depressive symptoms.[1] A daily dose of 60 mg fluoxetine may be required. Antidepressants should be discontinued if there is no benefit, remembering that many of the BN population are of child-bearing age. ####Complications People with BN may suffer from the following complications: * Electrolyte abnormalities from purging; * Neurological complications, such as fits from purging; * Gastrointestinal complications, such as stomach perforation from repeated vomiting, are rare but possible; * Cardiac complications, such as arrhythmias from deranged electrolytes; * Dental erosion from self-induced vomiting. ####Illness course and prognosis About 50% of patients recover, 30% making a full recovery and 20% continuing to have some symptoms.[9] Symptoms tend to fluctuate over time. Indicators of good prognosis are a shorter duration of illness, younger age of onset, higher social class and a family history of alcoholism. Indicators of poor prognosis are substance misuse (including alcohol), premorbid obesity, paternal obesity and personality disorder.[1] ####Useful links * Royal College of Psychiatrists. [Eating disorders](http://www.rcpsych.ac.uk/mentalhealthinfoforall/problems/eatingdisorders/eatingdisorders.aspx) (an information leaflet on anorexia and bulimia) * Quality Improvement Scotland. [Eating disorders in Scotland – recommendations for management and treatment]( http://www.nhshealthquality.org/nhsqis/qis_display_findings.jsp?pContentID=3255&p_applic=CCC&p_service=Content.show) * National Institute of Clinical Excellence. [*Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders.*](http://www.nice.org.uk/CG009) * Self help websites: [Beat eating disorders](http://www.b-eat.co.uk) (B-EAT) and [Disordered eating](www.disordered-eating.co.uk/) 2009-10-01T10:48:35Z Dr Wong has received funding from Wyeth for the research project 'Functional Imaging Biomarkers of Cognitive Enhancer Efficacy', led by Prof. Stephen Lawrie. 114 2009-10-01T00:00:00Z 2009-10-19T08:53:32Z eating-disorders-bulimia-nervosa 2009-10-19T08:53:32Z

Bulimia nervosa is an eating disorder characterised by an intense dread of fat and an irrestible craving for food, resulting in a cycle of binges and purging. In the second of two linked article on eating disorders, Drs Dichelle Wong and Katharine Logan discuss the prevalence, causes, diagnosis and treatment of this condition.

2009-10-19T08:53:32Z

Eating disorders are abnormalities in eating habits, in the context of a person’s distorted view of their body image. The common subtypes are anorexia nervosa (AN) and bulimia nervosa (BN). There is overlap in the symptom pattern. Some sufferers may have a clinical picture that is initially consistent with AN but becomes consistent with BN after a period of time. If all the diagnostic criteria are not fully met, the terms ‘atypical anorexia’, ‘atypical bulimia’ or ‘unspecified eating disorder’ may be used to describe the condition. The following article gives information about AN. Please refer to our separate article for [more information on BN](http://behindthemedicalheadlines.com/articles/eating-disorders-bulimia-nervosa). ####How common is anorexia nervosa? The prevalence of AN is 0.3% (three in 1,000) of young women,[1] and 80–90% of sufferers are women.[1] Anorexia nervosa has also been identified in non-Western societies.[2] ####Common myths * ‘Anorexia nervosa only affects women.’ In reality, up to 10% of people with AN are men. * ‘Anorexia nervosa only affects teenage girls.’ Anorexia nervosa is more common in younger age but can develop in all ages. * ‘Anorexia nervosa is a disorder of a higher social class.’ In reality, eating disorders are not shown to be more prominent in any particular social class,[3] but those that attend treatment tend to be from a higher social class. * ‘Anorexia nervosa is caused by families.’ In reality, lots of problems or difficulties in families arise due to looking after a person with AN. A study looking at family functioning in families with an AN or cystic fibrosis sufferer revealed that both groups showed higher emotional over-involvement than households who did not have sufferers of a chronic condition.[4] * ‘Anorexia nervosa is caused by trying to be thin, or is due to dieting that has gone out of control.’ In reality, the cause of AN is probably multifactorial. The majority of people that go on a diet do not develop AN. * ‘Anorexia nervosa is not serious.’ Anorexia nervosa can be difficult to treat, and can be life-threatening. Anorexia nervosa causes the highest mortality rate within psychiatric disorders. It is a serious condition. * ‘People with AN do not like food.’ In reality, people with AN are often preoccupied with food. They may spend lengthy periods of time preparing food for others, but do not eat a lot themselves. ####What causes it? The cause of AN is probably multifactorial. Anorexia nervosa can be found in families with obsessive, perfectionist and competitive traits. However, within the same family, there can be members that are affected by AN and others that are not. This implies that a genetic predisposition makes people more vulnerable to develop AN but that other factors also play a role. Common stressors that may precipitate AN are the onset of puberty, transitions, family conflict, academic pressures and other factors.[1] Media influences may also play a part in affecting people’s perception of body image but are not the whole story. ####Why is it important to recognise and treat AN? Anorexia nervosa causes the highest mortality rate within psychiatric disorders. It is associated with premature death (standardised mortality rate of 3.3).[5] It also causes a high morbidity in physical, psychological and social well-being. There is a higher risk of death if there are more weight fluctuations, a very low body mass index (BMI), purging or concurrent substance misuse, including alcohol.[1,5] ####Diagnosis People with AN often try to hide their symptoms from family or friends, so initially it may be hard for others to notice the illness. Anorexia nervosa is characterised by a distorted body image of oneself. Sufferers impose a low weight threshold on themselves. They dread being fat or putting on weight. They self-induce weight loss by different methods, for example avoiding food that they deem to be ‘fattening’; restricting the quantity of food they eat; purging with laxatives; the use of appetite suppressants, diuretics or slimming pills; excessive exercise; or self-induced vomiting. The body weight of people with AN is at least 15% below expected, or the BMI is 17.5 or less.[6] The hypothalamic-pituitary-gonadal axis is affected; this manifests in women as amenorrhoea (lack of menstruation) and in men as a loss of sexual interest and potency. Anorexia nervosa may cause delayed puberty, failure to achieve target height and osteoporosis.[7] The severity of AN is indicated by low or rapidly falling BMI and physical complications. In children, the use of BMI is less reliable than calculating the expected weight for a child’s height. Anorexia nervosa may present with depression, obsessive behaviour, amenorrhoea, infertility and gastrointestinal symptoms.[1] Sufferers may present to gastroenterologists or gynaecologists. It is important to recognise that AN sufferers can become pregnant even when they are amenorrhoeic or when they have a low BMI. Weight gain and body shape changes during pregnancy can provoke extreme distress in those with AN. There is also a higher prevalence of eating disorders and sub-threshold eating disorders in those with insulin-dependent diabetes.[8] Starvation alone can lead to physical and psychological symptoms. In a study using healthy volunteers, starvation led to many physical and psychological symptoms similar to those experienced by people with AN.[9] ####Referral It is very important to prepare patients prior to a referral, to improve the attendance rate. Referrals should be made to the nearest eating disorder service. The referrer should provide height, weight (ideally at least two weights over time to show the rate of weight change) and recent blood results. If an eating disorder service is not available locally, referrals should be made to a mental health service. A referral to a dietician with expertise in eating disorders should also be made. ####Investigations The following investigations should be made: * Height and repeated weights; * A thorough physical examination (look for skin breakdown and purpuric rash; check for erect and supine blood pressure, pulse, temperature; perform cardiovascular, respiratory, gastro-intestinal and neurological examinations); * Sit up and squat tests (is the person with AN able to sit up without using their arms as leverage? Is the patient able to squat and get up without using their arms for balance?); * Blood tests (full blood count, urea and electrolytes, calcium, albumin, magnesium, phosphate, liver function tests, creatine kinase, glucose, erythrocyte sedimentation rate, thyroid function tests, vitamin B12 and folate); * Electrocardiogram (look for QT interval, arrhythmias or changes associated with abnormal electrolytes); * A bone scan may be needed to look for osteoporosis. ####Treatment The management of AN is complex and often requires a multidisciplinary approach. People with AN should be advised against harmful activities such as purging, or activities that consume energy, such as exercising. Most treatment takes place in the outpatient setting. This usually involves gradual refeeding with dietician input, psychotherapy and medical assessments of the patient’s physical state. Weight gain is aimed at 0.5 kg per week in the outpatient setting, and 0.5–1 kg per week in the inpatient setting.[10] People with AN often have bradycardia, low white cell count and neutropenia. They are more at risk of infections when they have a low white cell count. However, those with a low white cell count do not always require hospital admission since there is a risk of hospital-acquired infections. White cell counts improve with refeeding and weight gain. Infections should be treated vigorously without delay. There are many types of psychotherapies that may be useful for AN, with no clear evidence-based best treatment. Commonly used types of psychotherapy are cognitive-behavioural therapy, interpersonal therapy, cognitive analytical therapy and family therapy.[10] Patients may need to be hospitalised if there are physical complications. Sometimes the use of Mental Health Act legislation may be required to detain patients when the situation is life-threatening, if they are not willing to engage in treatment voluntarily or if they do not make progress with outpatient treatment. ####Complications People with AN may suffer from the following complications: * Electrolyte disturbance (for example, low potassium) from purging; * Neurological complications, such as fits from purging; * Cardiac complications, such as arrhythmias due to prolonged corrected QT interval from low weight, exacerbated by deranged electrolytes; * Overwhelming infection secondary to a compromised immune system, due to low neutrophil count; * Dental erosion from self-induced vomiting; * Osteoporosis; * Renal failure; * Hypothermia; * Death. ####Illness course and prognosis Treatment is lengthy. Fifty per cent of patients do not recover completely and have a fluctuating course.[11,12,13] Recovery can take six years from the time of diagnosis.[11,12] Anorexia nervosa is usually managed in the outpatient setting. However, for those who are very ill with complications, hospital admissions can be life-saving. ####Advice to family members or carers Family arguments often happen surrounding the symptoms of AN and the difficulties caused by condition. It is important to get involved in the care plan of the person with AN, and provide firm and assertive care together. Do bear in mind that recovery can take years. ####Useful links * Royal College of Psychiatrists. [Eating disorders](http://www.rcpsych.ac.uk/mentalhealthinfoforall/problems/eatingdisorders/eatingdisorders.aspx) (an information leaflet on anorexia and bulimia) * Quality Improvement Scotland. [Eating disorders in Scotland – recommendations for management and treatment]( http://www.nhshealthquality.org/nhsqis/qis_display_findings.jsp?pContentID=3255&p_applic=CCC&p_service=Content.show) * National Institute of Clinical Excellence. [*Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders.*](http://www.nice.org.uk/CG009) * Self help websites: [Beat eating disorders](http://www.b-eat.co.uk) (B-EAT) and [Disordered eating](www.disordered-eating.co.uk/) 2009-10-01T13:02:09Z Dr Wong has received funding from Wyeth for the research project 'Functional Imaging Biomarkers of Cognitive Enhancer Efficacy', led by Prof. Stephen Lawrie. 115 2009-10-01T00:00:00Z 2009-10-19T08:51:51Z eating-disorders-anorexia-nervosa 2009-10-19T08:51:51Z

Anorexia nervosa is an eating disorder characterised by a distorted body image, resulting in a self-imposed low-weight threshold. In the first of two linked articles on eating disorders, Drs Dichelle Wong and Katharine Logan review this serious and potentially life-threatening illness, and discuss common myths surrounding the condition, as well as its causes, diagnosis, treatment and prognosis.

2009-10-19T08:51:51Z

####Background Methadone was developed in Germany during the Second World War. It was not commercially produced until the USA took over the patent after the war. At first doctors thought methadone would be a revolutionary new painkiller, but by the early 1950s it was hardly being used at all. In 1964, two doctors from New York, Marie Nyswander and Vincent Dole, were looking for drugs to help heroin users. They found methadone helped their patients to stop using heroin and that tolerance was slow to develop – the methadone maintenance treatment was born. ####What is methadone? Methadone is an effective evidence-based medication used for the treatment of opioid dependence, most commonly street heroin. Methadone’s usefulness in the treatment of opioid dependence is the result of several factors. It has cross-tolerance with other opioids, including heroin and morphine, and a long duration of effect, which means methadone is effective in preventing patients from experiencing an opioid withdrawal syndrome. At high doses (60–80 mg +), methadone may reduce the euphoric effects of heroin and morphine, allowing patients on adequate doses to reduce or stop illicit opioid use. ####Maintenance treatment The evidence base for treating opioid-dependent patients with methadone has been well established and it has been proven to reduce illicit methadone use, reduce criminal behaviour and reduce risk-taking behaviour associated with its use.[1,2,3,4,5] A total of 22,000 adults in Scotland are on methadone, costing at least £25 million per year. Methadone is suitable for those who wish to stop using illicit opioids but who do not feel they can achieve total abstinence initially. It is also suitable for those who are motivated to detoxify from all opioids and achieve abstinence. Aspirations about patient progress within treatment (for which methadone is just a part) are outlined in the Scottish Government's *Road to Recovery* document,[6] which describes the treatment as ‘a process through which an individual is enabled to move on from their problem drug use towards a drug-free life and become an active and contributing member of society’. The most powerful evidence base for methadone is for long-term maintenance, with retention in treatment being an indicator of better outcomes.[7,8] Patients do not respond favourably to non-mutually agreed reductions in methadone or enforced detoxification regimes.[9,10] ####Methadone preparations The types of methadone available in the UK include methadone oral solution, methadone tablets and methadone injectable formulations. In Scotland, only methadone oral solution is used in maintenance programmes. This solution is a green liquid and 1 mg/ml is the formulation licensed for the treatment of opioid dependence. It is effective in alleviating withdrawal symptoms and can be administered in solution as a once-a-day dose (blood levels can be kept stable, thus eliminating post-dose euphoria and pre-dose withdrawal). Sugar-free formulations have been introduced in an attempt to reduce secondary dental caries. However, it is likely that the acidity rather than the sugar is responsible for the increased incidence of teeth decay. Good oral hygiene is required. ####Side effects The side effects of methadone are those associated with all opioids, including nausea, vomiting, constipation and drowsiness. Larger doses cause respiratory depression and hypotension. Sweating, dry mouth, headache and decreased libido may also occur. Some patients complain of aching muscles about 24 hours after dosing and this may signify a breakthrough withdrawal effect associated with low plasma levels of methadone. ####Methadone metabolism Oral use is detected (in blood) at 15–45 minutes, with peak plasma concentration at 2.5–4 hours. However, there is an up to 17-fold variation of peak concentration for a given dosage. Methadone is highly bound to plasma proteins, free fraction typically at 13%, but again with wide interindividual variation. Final bioavailability is 75% (range 36–100%). Plasma elimination half-life is 40 hours (range 5–130 hours), affected by the genetic activity of cytochrome P450 (CYP) 3A4 and co-administered drug enzyme induction or inhibition effects.[11] Recommended doses are between 60 and 120 mg,[12] but optimal doses reflect the dose relationship with effectiveness and vary widely in clinical practice. Genetic expression accounts for much of the variability and some patients may benefit for splitting the dose to twice daily or using an alternative opiate replacement (e.g. buprenorphine). ####Prescribing The UK guidelines on the treatment of drug problems recommend flexible doses of methadone rather than fixed doses. This approach is supported by many randomised trials that have examined the link between methadone dose and retention in treatment. Results showed that flexible doses (as opposed to fixed doses) significantly raised retention of patients in treatment over a one-year period, firstly by prescribing adequate doses for patients and secondly by determining dose according to individual patient response. Retention in treatment is associated with better health and crime outcomes for both patients and society.[13] ####Drug screening Screening can be carried out using oral swabs, urine samples or hair testing. Oral testing is least invasive and most convenient. Hair testing is more often used in employment or criminal cases, where abstinence needs to be demonstrated. In a urine sample, a maintenance methadone dose will be evident for seven to nine days, whereas heroin will be evident in urine for up to 48 hours. Over-the-counter preparations such as co-codamol or codeine phosphate can give a positive opioid result. False negatives can also occur with low doses and in pregnancy. ####Risk The national treatment guidelines outline the risks of overdose in relation to the commencement of methadone, specifically during its induction.[14] There is an increased risk of overdose and death during induction into methadone treatment. Sedative drugs such as alcohol and benzodiazepines potentiate the effects of opioids (respiratory depression and hypoventilation). Too high an initial dose of methadone can also lead to methadone toxicity that is often delayed for hours (maximum absorption occurs at four hours) or even days (steady state blood levels taking four to five days to establish). This is because of methadone’s slow oral absorption and long half-life. ####Drug interactions Methadone may be a risk factor for QT prolongation and *torsades de pointe* with a possible dose-dependent action. A QTc interval beyond the normal limits (440 ms for men and 470 ms for women) is associated with increased risk of cardiac arrhythmias and sudden death, especially above 500 ms. The Medicines and Healthcare Products Regulatory Agency recommends QT monitoring for patients on high-dose methadone (>100 mg daily). Screening before commencing methadone is not mandatory but needs consideration, and any QT prolongation requires investigation. Drug interactions can also slow or speed methadone metabolism. Medicines that increase opioid blood levels by an inhibition of the CYP3A4 enzyme include cimetidine, fluvoxamine, ciprofloxacin and erythromycin. Doses of methadone may need to be decreased to prevent withdrawal symptoms and increased to prevent withdrawal symptoms when the enzyme inducer is stopped. Anticonvulsants (e.g. phenytoin and carbamazepine), human immunodeficiency virus (HIV) medicines (e.g. efavirenz, nevirapine), rifampicin and St John’s wort have the opposite effect, decreasing blood levels of methadone by the induction of the CYP3A4 enzyme. Additionally, certain medicines such as tricyclic antidepressants and antipsychotics in combination with methadone can lead to *torsades de pointes* via prolongation of the QTc interval, so caution should be used with these combinations. ####Use of methadone in patients with co-existing psychiatric conditions Methadone is also used in patients with co-existing psychiatric illness. A third of opioid users suffer from mental health problems including depression and anxiety and, because of this, interactions of methadone with psychotropic drugs should always be borne in mind.[13] Pain management in drug users presents a particular challenge for doctors. Pharmacological intervention is only one aspect of pain management and non-pharmacological interventions, for example cognitive behavioural therapy, should be considered. Acute pain requires full analgesic management in patients dependent on opioids. These patients may have a lower tolerance of pain, together with a higher tolerance of opioid analgesic effects. For opioid-dependent patients with chronic pain, the development of joint working arrangements across services to assess this population is desirable. Advice on good practice in pain management and addiction medicine can be found in *Pain and substance misuse: improving the patient experience*.[11] ####Methadone in pregnancy Engagement in treatment services is key. Even where pregnant women continue to use illicit substances, it has been shown that by engaging them in treament programmes their own health and the health of their unborn babies is better than those women who are not engaged in any treatment.[15] The objective of management is to achieve stability. Risks and needs should be assessed early and a treatment plan agreed between patient and clinician. It is important to screen for poly-substance misuse in pregnancy as there is evidence that other substances such as benzodiazepines and amphetamines may have more serious effects than heroin on the fetus. Clinicians need to be aware that some of the effects of different drugs of misuse during pregnancy are broadly similar and are, for the most part, non-drug specific. The national treament guidelines address the management of this special patient group.[14] ####Driving and methadone The Royal College Of General Practitioners, in its *Guidance for the use of methadone for the treament of opioid dependence in primary care*,[16] outlines the legal responsibility of patients prescribed methadone: 'Patients have a responsibility to inform the DVLA [the UK's Driver and Vehicle Licensing Agency] that they are receiving a prescription for methadone. They can then drive for personal reasons while prescribed oral methadone after undergoing a short independent medical examination and a urine screen for drugs. The licence is issued for a year at a time and needs to be supported by a favourable medical report. Patients will be subject to revocation of their licence where it is shown that there has been persistent use of or dependency on heroin, morphine, methadone and/or cocaine.' 2009-09-28T13:22:45Z None declared 113 2009-09-28T00:00:00Z 2009-10-19T13:51:10Z methadone-for-the-treatment-of-opioid-dependence 2009-10-19T13:51:10Z

Methadone has been in use since the 1960s as an effective medication for opioid dependency - particularly heroin. In this article Dr Malcolm Bruce and Dr Siobhan Morris look at the treatment regimes for methadone, together with its side effects, interactions with other drugs and risks.

2009-10-19T13:51:10Z

####Background Cigarette smoking is the single largest preventable cause of death and illness in the industrialised world.[1] Each year more than 100,000 people in the UK[2] and 4.9 million people worldwide die due to smoking-related causes.[3] Tobacco contributes to a wide range of diseases that cause death and disability. One in two regular smokers will die prematurely because of their habit.[4] Without effective intervention, it is estimated that cigarette smoking will have caused the deaths of more than 520 million people worldwide by 2050. #####Smoking prevalence In the UK, approximately 9.4 million adults are smokers, 21% of the total population. Rates among men are slightly higher than among women (22% and 20% respectively).[5] Prevalence is higher in less affluent groups and communities; smoking prevalence is currently 29% in routine and manual occupations, compared with 15% in managerial and professional groups.[5] #####Smoking cessation Around 70% of smokers want to stop smoking.[6] A recent survey in England suggested that 30% of smokers endorsed the statement ‘I want to stop smoking’ and 25% endorsed the statement ‘I intend to stop smoking soon’. It also found that 43% of smokers reported having tried to quit in the past year and 56% of smokers reported trying to cut down.[7] Approximately 50% of quit attempts involve the use of smoking cessation aids, usually consisting of nicotine replacement therapy (NRT) bought over the counter. Varenicline is used by approximately 5% of quitters and only 3% of smokers access National Health Service (NHS) stop smoking services when trying to quit. Additionally, 19% of smokers reported using medication without behavioural support and a further 19% reported trying to quit without using any treatment.[7] #####Unaided quit attempts Most smokers attempt to quit without using medication or behavioural support. However, most unaided quit attempts are unsuccessful. A systematic review of the effectiveness of unaided quit attempts[8] suggested that most relapse occurs very early on in the quit attempt, with the majority of smokers relapsing within eight days of cessation. This review concluded that the main challenge posed by unaided cessation is not late relapse but initiating a period of abstinence. The authors concluded that ‘front loaded’ therapies that provide structured support to a smoker immediately prior to their quit attempt should be promoted.[8] The long-term prolonged abstinence rate of an unaided smoker ranges from 3–5%, considerably below that of a supported cessation attempt of 10–15%.[9] ####Interventions The UK is the only country in the world with a national, free at the point of use smoking treatment service. NHS stop smoking services were established from 1999 and are available in all parts of the UK, providing structured behavioural support and stop smoking medications (pharmacotherapy) to smokers who are motivated to stop smoking. #####Pharmacotherapy There are currently three main licensed medications for smoking cessation in the UK: NRT, bupropion (Zyban) and varenicline (Champix). Evidence from clinical trials suggests that, when used as directed, these medications can significantly increase a smoker’s chance of stopping smoking and remaining abstinent.[10] #####Nicotine replacement therapy Nicotine replacement therapy is the most common and widely available medication for smoking cessation. It is available on prescription and also sold over the counter. Nicotine replacement therapy use is normally initiated on the quit date and used for a further 8--12 weeks, depending upon the product. Nicotine replacement therapy is now licensed for use in the UK with pregnant women, people with cardiovascular disease and young people aged 12 years and over.[11,12] There are six types of NRT products: **Nicotine patch** The patch is applied to a hair-free, non-sensitive area of the body, usually the upper arm or leg. Nicotine is absorbed through the skin and a constant supply is received for 16 or 24 hours, depending upon the type of patch used. Nicotine levels rise very slowly, peaking at 4--8 hours. The patch is changed daily. Minimal side effects include skin irritation, sleep disturbance or a mild itch. **Nicotine gum** The gum is chewed following a ‘chew-rest-chew’ technique, different to normal chewing gum. Nicotine is slowly absorbed through the mouth, and nicotine levels peak after approximately 30 minutes. An estimated 10--15 pieces should be used daily. Minimal side effects include hiccups, gastric problems or jaw ache. **Lozenge** The lozenge is sucked slowly, dissolving in about 20 minutes, and the nicotine is absorbed through the mouth. Nicotine levels peak after about 20--30 minutes. A new lozenge can be sucked about every 1--2 hours, with a maximum of 25 per day. Mild side effects may include a stinging sensation in mouth with first use, gastric irritation and hiccups. **Microtab** The microtab is placed under the tongue and dissolves after approximately 20 minutes. Nicotine levels peak after 20--30 minutes. Approximately 15--30 tabs should be used per day. Side effects may include stinging or burning under the tongue with first use, gastric irritation or hiccups. **Inhalator** The inhalator is ‘smoked’ in a similar way to a cigarette, via shallow or deep puffing for about 20 minutes every hour. Nicotine is absorbed through the mouth and peak nicotine levels occur after about 20--30 minutes. This method of NRT provides a high sensory and behavioural replacement, e.g. the hand-to-mouth sensation. Side effects may include coughing and throat irritation; these, however, will disappear with continued use. **Nasal spray** The nasal spray is the fastest-acting NRT product, providing rapid relief from cravings. It is squirted into each nostril, about once per hour. Nicotine levels peak after about 5--10 minutes. Side effects may include nasal and throat irritation, stinging and a runny nose. The six products can be used individually or, alternatively, products can be used in combination (e.g. using the patch regularly, and supplementing this with the gum as and when needed). Recent evidence suggests that combination therapy is more effective than using a single product.[10,13] With NRT the numbers needed to treat (i.e. the number of smokers who smoke 15 or more per day who need to be treated in order to achieve one long-term (six months or more) quitter) is 13--20.[14] It is preferable for smokers to set a quit date and stop smoking completely. However, for some smokers, for a variety of reasons, this is not possible. In response, the product licence for NRT has recently been modified to allow it to be used while cutting down cigarette consumption with a view to quitting, usually over a two-week period.[10] #####Bupropion (Zyban) Bupropion was originally developed as an antidepressant. Early trials identified that, as an unexpected effect of the medication, it helped patients to stop smoking. When bupropion is used as an aid to smoking cessation, the dosage is lower and treatment does not rely on the medication's antidepressant action. The medication is started one week before the quit date to allow steady state levels to be reached in the blood. During this time the smoker is encouraged to continue smoking as normal. One tablet is taken per day for the first week, followed by two tables per day from the quit date for 7--11 weeks. After this time it is likely that individuals will have changed their habits and the behaviours they previously linked to smoking and the majority of withdrawal symptoms will have stopped. They should then be able to stop taking bupropion without starting to smoke again. Side effects of bupropion may include a dry mouth, sleeping difficulties and headache. Seizures have been reported, but they are rare (one in 1,000). Bupropion is thought to work by increasing the activity in the dopamine and noradrenaline pathways in the central nervous system; this reduces the severity of withdrawal symptoms and the motivation to smoke.[11,15] With bupropion the numbers needed to treat (i.e. the number of smokers who smoke 15 or more per day who need to be treated in order to achieve one long-term (six months or more) quitter) is 10--17.[14] #####Varenicline (Champix) Varenicline, known as Champix in the UK, was launched in December 2006 and is available only on prescription. It is a new medication, developed specifically for smoking cessation. Published trials report that varenicline is superior to placebo and to bupropion in supporting a smoker to stop.[16] Varenicline has a different mechanism of action from the other smoking cessation medications. It is a partial nicotine agonist, meaning that it binds to and triggers the ACh (nicotinic) receptors in the brain. It works by reducing the urge to smoke and by relieving craving and withdrawal symptoms. As with bupropion, smokers start by taking one varenicline tablet per day for a week before the quit date to build up the levels of the drug in the body. On the quit date they stop smoking and increase the dosage to two per day. When the course of treatment ends it is anticipated that the ex-smoker will be able to stop taking the medication, coming down to one tablet per day for the last week, without initiating smoking again. Side effects of varenicline may include nausea, abnormal dreams, headache and insomnia. Several stories appeared both in the US and the UK media at the end of 2007 and beginning of 2008 suggesting that varenicline was associated with suicidal ideation and suicide. However, there is no scientific evidence to support this link.[17] The varenicline summary of product characteristics currently states that depressed mood may be a symptom of nicotine withdrawal. Depression, rarely including suicidal ideation and suicide attempt, has been reported in patients undergoing a smoking cessation attempt, including those with varenicline. Treatment should be discontinued if agitation, depressed mood or changes in behaviour are a concern, or if the patient develops suicidal ideation or suicidal behaviour. With varenicline the numbers needed to treat (i.e. the number of smokers who smoke 15 or more per day who need to be treated in order to achieve one long-term (six months or more) quitter) is 5--11.[14] #####Behavioural interventions Behavioural interventions include brief advice and more intensive support. Brief advice lasts for up to five minutes and can be delivered by any health professional as part of regular consultation or patient interaction. Health professionals should ask about patients' smoking, advise them to stop, assess whether they are willing to stop, assist them with medication, provide a referral to specialist treatment if necessary and arrange a follow-up to check on their progress. Brief interventions can also include discussion, provision of self-help material and encouragement to quit or maintain abstinence.[10] In comparison, more intensive structured behavioural support is usually provided on a one-to-one basis, or as part of a group. In the UK, this type of support is provided by NHS stop smoking service staff or other professionals who have been trained as smoking cessation advisers. A pattern is often followed of one or two pre-quit sessions, followed by regular weekly post-quit sessions for four to six weeks. During these sessions discussion includes how smokers can prepare for the quit date, situations that they may find challenging, how to overcome these and how to deal with craving to avoid relapse. This behavioural support is usually combined with pharmacotherapy.[10] #####Self-help materials Self-help materials are an effective way of communicating sizable amounts of information to large audiences, at relatively low cost. There is evidence that smoking cessation self-help materials can help smokers to quit.[18] Materials that are individually tailored and aimed at specific groups have proved successful at aiding a quit attempt. The use of self help materials are recommended in the National Institute for Health and Clinical Excellence (NICE) smoking cessation guidelines.[10] #####Telephone counselling Telephone counselling, delivered by services such as the NHS smoking quit-line is also recommended in NICE smoking cessation guidance. Counsellors working for the quit-line provide encouragement and support to anyone who wants to quit, or who has recently quit and requires ongoing support. Quit-lines provide behavioural support over the phone rather than face to face, and counsellors have usually received similar training to NHS stop smoking service advisers.[10] ####Combined interventions Pharmacotherapy alone increases the likelihood of a successful quit attempt, as does behavioural support alone. However, it is the combination of the two that is most effective in helping smokers quit. Table 1 shows that a combination of medication and behavioural support can result in an increase in abstinence of 10--20% at six months, compared with unaided cessation, or a 5--10% increase in permanent abstinence.[9] West and Stapleton used previously collected data to estimate that for every 100,000 smokers, using only medication would save 3,750 life years, while using behavioural support and medication together would save between 7,500--15,000 life years.[9] #####Cost-effectiveness of behavioural support and medication It is estimated that smoking annually costs the NHS £2.7 billion. This figure covers the treatment of diseases caused by smoking, including the cost of hospital admissions, general practitioner consultations and prescription charges.[19] Effective smoking cessation aids and stop smoking services are highly cost-effective.[10] NICE guidelines conclude that brief advice, individual and group behavioural support, pharmacotherapy, self-help materials, telephone counselling and quit-lines are all cost-effective compared with no intervention.[10] While all stop smoking interventions are cost-effective, some are more cost-effective than others: * Group counselling is more cost-effective than individual counselling; * Brief advice and more intensive counselling, when combined with NRT or bupropion, are more cost-effective than when these types of behavioural support are provided alone; * NRT and bupropion, combined with counselling, are more cost-effective than NRT or bupropion alone; * Varenicline is cost-effective compared with bupropion, NRT or placebo.[10] ####Alternative interventions In addition to the effective smoking cessation treatments described above, other interventions are available. Many of these claim to be successful; however, the evidence to support these claims is limited. McRobbie et al. conducted a rapid review of alternative treatments for smoking cessation. They found inadequate evidence to recommend that any of the following interventions be offered by the NHS.[20] **Acupuncture** Evidence suggests that acupuncture does not improve long-term abstinence more than placebo; similarly this is true for acupressure, laser therapy and electro stimulation.[10,20] **Hypnotherapy** Evidence suggests that hypnotherapy does not improve long-term abstinence rates more than any other intervention which is as participant-intensive, such as individual counselling.[10,20] **St John’s wort** At the time of the review, there was no evidence of the effectiveness of St John's wort on long-term smoking cessation. **‘Rapid smoking’** Rapid smoking is a form of aversion therapy that involves a client smoking a large number of cigarettes in quick succession. There is some evidence that this method can improve abstinence rates, but it is not recommended in NICE guidance for smoking cessation, as it conflicts with smoke-free legislation regulations and can expose the practitioner to secondhand smoke.[10,20] McRobbie and colleagues also examined a number of other products, including NicoBloc, Nicobrevin and glucose, and concluded that these were not effective in increasing long-term abstinence rates, although glucose may increase the efficacy of other smoking cessation medications when used in combination.[20] ####Conclusion Stopping smoking is the single most important action smokers can take to improve their current and future health.[21] While most smokers try to stop unaided, using a combination of pharmacotherapy and behavioural support is what works best. Health professionals should ensure that smokers are aware of the effects of smoking, of the different types of support available and of the efficacy of different treatments. Smokers who are motivated to quit should be referred to local NHS stop smoking services to maximise their chances of becoming non-smokers. ####Further resources * National Institute for Health and Clinical Excellence. [Smoking cessation services.](http://guidance.nice.org.uk/PH10) * [NHS smoking cessation support](http://smokefree.nhs.uk/) * [Action on Smoking and Health (ASH)](http://www.ash.org.uk/) * [UK Centre for Tobacco Control Studies](http://www.ukctcs.org) 2009-09-08T14:22:49Z None declared. 112 2009-09-08T00:00:00Z 2009-09-16T12:07:41Z smoking-cessation 2009-09-16T12:07:41Z

Stopping smoking is the single most important action smokers can take to improve their health. In this article, Professor Linda Bauld and Ms Lucy Hackshaw from the UK Centre for Tobacco Control Studies review the available treatment options and their efficacy.

2009-09-16T12:07:41Z