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Background: Hypothermic machine organ perfusion (HMP) offers opportunity to manipulate grafts with pharmacological agents prior to transplantation. Pretreating organs with novel cytotopic anticoagulant peptides that localize to endothelial cell membranes could ameliorate microvascular thrombotic sequelae posttransplantation. We describe experiments testing thrombalexin (TLN), a novel cell binding thrombin inhibitor, using porcine and unused human kidneys in a series of ex vivo normothermic hemoreperfusion models., Methods: Thirty-eight porcine kidneys were used. Control kidneys underwent pretreatment via HMP with either unmodified perfusion solution (n = 15) or solution with inactive-TLN (absent anticoagulant effect, n = 4). Test kidneys were perfused with TLN-treated solution (n = 19). All kidneys then underwent hemoreperfusion. Two unused human kidneys underwent a similar protocol., Results: Hypothermic machine perfusion pretreatment facilitated delivery and tethering of TLN in the organ microvasculature. Hemoreperfusion challenge demonstrated improved perfusion in TLN-treated kidneys compared with controls: 26.4% superior flow (30.6 vs. 23.1 mL/min per 100 g, P = 0.019) and 28.9% higher perfusion flow indices (0.43 vs. 0.32 mL/min per 100 g mm Hg, P = 0.049). Orthogonal polarization spectral imaging demonstrated superior microvascular capillary perfusion in TLN-treated organs versus controls (9.1 vs 2.8 pl/s per mm, P = 0.021). Rapid-sampling microdialysis for cortical [lactate] as a marker of tissue ischemia/metabolism detected lower levels in TLN-treated kidneys. Perfusate analysis demonstrated reduced fibrin generation in TLN-treated kidneys correlating with perfusion data., Conclusions: Our data suggest that HMP graft pretreatment with cytotopic anticoagulants is feasible and ameliorates perfusion deficits seen in ex vivo hemoreperfusion models. There is potential for further development and application of this translational strategy to deliver locally active anticoagulants directly within grafts and decrease microvascular thrombotic sequelae, while avoiding systemic anticoagulation and its associated risks.

Objective: The study aimed to examine caregiving burden and levels of distress, accommodating behaviours, expressed emotion (EE) and carers' skills, in parents of adolescents with anorexia nervosa., Method: A semi-structured interview assessed the objective burden (time spent across caregiving tasks) in parents (n = 196) of adolescents (n = 144) receiving outpatient treatment for anorexia nervosa. Subjective burden (carers' distress), accommodating behaviours, EE and carers' skills were measured by self-report., Results: Mothers, on average, spent 2.5 h/day of care, mainly providing food and emotional support, compared with 1 h/day by fathers. The level of distress and accommodating behaviour was significantly lower in fathers than in mothers. Accommodating behaviours mediated the relationship between objective burden and subjective burden in mothers, whereas EE and carers' skills did not mediate this relationship for either parent., Discussion: The objective burden for most mothers is high. In order to reduce subjective burden, it may be helpful to target accommodating behaviours., Trial Registration: ISRCTN83003225 - Expert Carers Helping Others (ECHO). Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association., (Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.)

Background: The cognitive interpersonal model predicts that parental caregiving style will impact on the rate of improvement of anorexia nervosa symptoms. The study aims to examine whether the absolute levels and the relative congruence between mothers' and fathers' care giving styles influenced the rate of change of their children's symptoms of anorexia nervosa over 12 months., Methods: Triads (n=54) consisting of patients with anorexia nervosa and both of their parents were included in the study. Caregivers completed the Caregiver Skills scale and the Accommodation and Enabling Scale at intake. Patients completed the Short Evaluation of Eating Disorders at intake and at monthly intervals for one year. Polynomial Hierarchical Linear Modeling was used for the analysis., Results: There is a person/dose dependant relationship between accommodation and patients' outcome, i.e. when both mother and father are highly accommodating outcome is poor, if either is highly accommodating outcome is intermediate and if both parents are low on accommodation outcome is good. Outcome is also good if both parents or mother alone have high levels of carer skills and poor if both have low levels of skills., Limitations: Including only a sub-sample of an adolescent clinical population; not considering time spent care giving, and reporting patient's self-reported outcome data limits the generalisability of the current findings., Conclusion: Accommodating and enabling behaviours by family members can serve to maintain eating disorder behaviours. However, skilful behaviours particularly by mothers, can aid recovery. Clinical interventions to optimise care giving skills and to reduce accommodation by both parents may be an important addition to treatment for anorexia nervosa., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: Viability assessment during preservation is imperative to avoid unnecessary discard of marginal organs maximizing graft outcomes in kidney transplantation. To address this need, we have developed a novel system based on a rapid sampling microdialysis (rsMD) analyzer allowing continuous tissue monitoring and measurement of metabolic markers of cell damage. Our aim was to develop a tool that allows for accurate assessment of tissue metabolism and organ viability in the preservation period., Methods: Twenty-two porcine kidneys subjected to 15 min of warm ischemia underwent either 24 h of static cold storage (SCS) or 10 h of hypothermic machine perfusion (HMP). After preservation, tissue temperature was allowed to passively increase to ambient temperature as an ischemic challenge. Cortical and medullary metabolism was monitored throughout with online measurements of lactate concentrations made every 60 s., Results: On commencement of monitoring, lactate concentrations were successfully detected within 15 mins. During the initial 1.5 h, lactate concentrations were similar during SCS (65 μM) and HMP (124 μM, P > 0.05) but lower after 10 h of SCS (SCS: 68 μM versus HMP: 230 μM, P < 0.001). Warming data suggest a resilience of HMP kidneys to subsequent temperature induced ischemia compared to SCS kidneys., Conclusions: This preliminary study provides the baseline ischemic profile for porcine kidneys while validating the technique of rsMD as a tool for organ viability assessment during preservation. The data characterize metabolic differences between SCS and HMP preserved allografts and can help elucidate why HMP is clinically superior to SCS allowing development of interventions to augment these benefits., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to develop and validate a new questionnaire designed to measure caregiver skills that, in line with the interpersonal component of the cognitive interpersonal maintenance model (Schmidt and Treasure, J Br J Clin Psychol, 45, 343-366, 2006), may be helpful in the support of people with anorexia nervosa (AN). A further aim is to assess whether this scale is sensitive to change following skills-based caregiver interventions., Method: The Caregiver Skills (CASK) scale was developed by a group of clinicians and caregivers. Preliminary versions of the scale devised for both caregivers and parents were given at baseline and at follow-up after two studies of caregiver interventions (a clinical trial of the effectiveness of guided self-help and training workshops). Exploratory and confirmatory factor analyses (CFA) were used to test the factorial structure of the CASK scale. Cronbach's alpha was used to measure internal consistency of the CASK scales., Results: Exploratory Factor Analysis suggested a six component solution (Bigger Picture, Self-Care, Biting-Your-Tongue, Insight and Acceptance, Emotional Intelligence and Frustration Tolerance) and this model was confirmed with CFA. Significant clinically relevant correlations were found between the CASK scales and other standardised measures of caregivers' attitudes and behaviours. Furthermore, greater improvements on abilities measured by the CASK scale were found in caregivers who received skills-training than caregivers assigned to a 'treatment as usual' condition., Discussion: The CASK scale is a measure of the fidelity of interventions based on the cognitive interpersonal maintenance model and is sensitive to the intensity of the intervention provided., (© 2014 Wiley Periodicals, Inc.)

Background: There may be a link between anorexia nervosa and autism spectrum disorders. The aims of this study were to examine whether adolescents with anorexia nervosa have autism spectrum and/or obsessive-compulsive traits, how many would meet diagnostic criteria for autism spectrum disorder, and whether these traits are shared by parents., Methods: A total of 150 adolescents receiving outpatient treatment for anorexia nervosa or subthreshold anorexia nervosa and their parents completed the autism spectrum disorder and eating disorder sections of the Development and Well-being Assessment. Patients also completed the Children Yale-Brown Obsessive-Compulsive Scale and other measures of psychiatric morbidity, and parents completed the short Autism Quotient and Obsessive-Compulsive Inventory Revised., Results: Adolescents with anorexia nervosa had a below average social aptitude (19% below cut-off) and high levels of peer relationship problems (39% above cut-off) and obsessive-compulsive symptoms (56% above cut-off). Six cases (4%, all females) were assigned a possible (n = 5) or definite (n = 1) diagnosis of autism spectrum disorder. Parental levels of autism spectrum and obsessive-compulsive traits were within the normal range., Conclusions: This study suggests that adolescents with anorexia nervosa have elevated levels of autism spectrum traits, obsessive-compulsive symptoms, and a small proportion fulfil diagnostic criteria for a probable autism spectrum disorder. These traits did not appear to be familial. This comorbidity has been associated with a poorer prognosis. Therefore, adaptation of treatment for this subgroup may be warranted., Trial Registration: Controlled-trials.com: ISRCTN83003225. Registered on 29 September 2011.

Experienced Carers Helping Others (ECHO) is an intervention for carers of people with eating disorders. This paper describes the theoretical background and protocol of a pilot multicentre randomised controlled trial that will explore the use of two variants of ECHO for improving outcomes for adolescents with anorexia nervosa (AN) referred for outpatient care. Adolescent patients and their carers (typically parents and close others in a supportive role) will be recruited from 38 eating disorder outpatient services across the UK. Carers will be randomly allocated to receive 'ECHOc' guided self-help (in addition to treatment as usual), 'ECHO' self-help only (in addition to treatment as usual) or treatment as usual only. Primary outcomes are a summary measure of the Short Evaluation of Eating Disorders at 6- and 12-month follow-ups. Secondary outcomes are general psychiatric morbidity of AN patients and carer, carers' coping and behaviour, and change in healthcare use and costs at 6- and 12-month follow-ups. Therapist effects will be examined, and process evaluation of ECHOc will be completed. The findings from this pilot trial will be used in preparation for executing a definitive trial to determine the impact of the preferred variant of ECHO to improve treatment outcomes for AN., (Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.)

Aims and Methods: This study aims to explore perceptions of eating disorder service strengths and to develop a clearer picture of improvements clinicians would like to see occur in the services they lead. A survey designed by the Royal College of Psychiatrists' Section of Eating Disorders was completed by 83 lead clinicians in both public and private sector services in the UK and Eire. Content analysis was performed, and common themes were identified., Results: Five main strengths of a service were identified as follows: quality of treatment (n = 36), staff skills (n = 21), continuity of care (n = 15), family involvement (n = 12) and accessibility and availability (n = 11). These themes also arose when clinicians evaluated areas they wished to develop and improve., Conclusions: Service providers' views were congruent with each other, NICE guidelines and quality standards as proposed by the Royal College. Although clinicians feel that their service fulfils many practice guidelines, there remains areas in which adherence is felt to be lacking., (Copyright © 2011 John Wiley & Sons, Ltd and Eating Disorders Association.)

Objective: To evaluate the clinical effectiveness and cost-effectiveness of inpatient compared with outpatient treatment and general (routine) treatment in Child and Adolescent Mental Health Services (CAMHS) against specialist treatment for young people with anorexia nervosa. In addition, to determine young people's and their carers' satisfaction with these treatments., Design: A population-based, pragmatic randomised controlled trial (RCT) was carried out on young people age 12 to 18 presenting to community CAMHS with anorexia nervosa., Setting: Thirty-five English CAMHS in the north-west of England co-ordinated through specialist centres in Manchester and Liverpool., Participants: Two hundred and fifteen young people (199 female) were identified, of whom 167 (mean age 14 years 11 months) were randomised and 48 were followed up as a preference group., Interventions: Randomised patients were allocated to either inpatient treatment in one of four units with considerable experience in the treatment of anorexia nervosa, a specialist outpatient programme delivered in one of two centres, or treatment as usual in general community CAMHS. The outpatient programmes spanned 6 months of treatment. The length of inpatient treatment was determined on a case-by-case basis on clinical need with outpatient follow-up to a minimum of 6 months., Main Outcome Measures: Follow-up assessments were carried out at 1, 2 and 5 years. The primary outcome measure was the Morgan-Russell Average Outcome Scale (MRAOS) and associated categorical outcomes. Secondary outcome measures included physical measures of weight, height, body mass index (BMI) and % weight for height. Research ratings included the Health of the National Outcome Scale for Children and Adolescents (HoNOSCA). Self report measures comprised the user version of HoNOSCA (HoNOSCA-SR), the Eating Disorder Inventory 2 (EDI-2), the Family Assessment Device (FAD) and the recent Mood and Feelings Questionnaire (MFQ). Information on resource use was collected in interview at 1, 2 and 5 years using the Child and Adolescent Service Use Schedule (CA-SUS). Satisfaction was measured quantitatively using a questionnaire designed for the study and qualitative (free) responses on it. The questionnaire data were supplemented by qualitative analysis of user and carer focus groups., Results: Of the 167 patients randomised, 65% adhered to the allocated treatment. Adherence was lower for inpatient treatment (49%) than for general CAMHS (71%) or specialist outpatient treatment (77%) (p = 0.013). Every subject was traced at both 1 and 2 years, with the main outcome measure completed (through contact with the subject, family members or clinicians), by 94% at 1 year, 93% at 2 years, but only 47% at 5 years. A validated outcome category was assigned for 98% at 1 year, 96% at 2 years and 60% at 5 years. There was significant improvement in all groups at each time point, with the number achieving a good outcome being 19% at 1 year, 33% at 2 years and 64% (of those followed up) at 5 years. Analysis demonstrated no difference in treatment effectiveness of randomisation to inpatient compared with outpatient treatment, or, specialist over generalist treatment at any time point, when baseline characteristics were taken into account. Generalist CAMHS treatment was slightly more expensive over the first 2 years of the study, largely because greater numbers were subsequently admitted to hospital after the initial treatment phase. The specialist outpatient programme was the dominant treatment in terms of incremental cost-effectiveness. Specialist treatments had a higher probability of being more cost-effective than generalist treatments and outpatient treatment had a higher probability of being more cost-effective than inpatient care. Parental satisfaction with treatment was generally good, though better with specialist than generalist treatment. Young people's satisfaction was much more mixed, but again better with specialist treatment, including inpatient care., Conclusion: Poor adherence to randomisation (despite initial consent to it), limits the assessment of the treatment effect of inpatient care. However, this study provides little support for lengthy inpatient psychiatric treatment on clinical or health economic grounds. These findings are broadly consistent with existing guidelines on the treatment of anorexia nervosa, which suggest that outpatient treatments should be offered to the majority, with inpatient treatment offered in rare cases, though our findings lend little support to a stepped-care approach in which inpatient care is offered to outpatient non-responders. Outpatient care, supported by brief (medical) inpatient management for correction of acute complications may be a preferable approach. The health economic analysis and user views both support NICE guidelines, which suggest that anorexia nervosa should be managed in specialist services that have experience and expertise in its management. Comprehensive general CAMHS might, however, be well placed to manage milder cases. Further research should focus on the specific components of outpatient psychological therapies. Although family-based treatments are well established, trials have not established their effectiveness compared with good-quality individual psychological therapies and the combination of individual and family approaches is untested. Further research is needed to establish which patients (if any) might respond to inpatient psychiatric treatment when unresponsive to outpatient care, the positive and negative components of it and the optimum length of stay., Trial Registration: NRR number (National Research Register) N0484056615; Current Controlled Trials ISRCTN39345394.

Background:   Psychotropic drugs are not recommended for child and adolescent eating disorders, though they are used empirically for symptomatic treatment and co-morbid conditions. Little is known about rates of prescribing or the beneficial and adverse effects., Objective:   To ascertain rates and outcomes of psychotropic drug prescribing in child and adolescent eating disorder services., Method:   Retrospective case note study of eating disorder cases (n = 308), seen in one year in seven specialist UK services, covering indications, response to treatment, beneficial and adverse effects., Results:   Drugs were prescribed for 27%, (mainly anorexia nervosa), 12% before referral to specialist services. The most commonly prescribed drugs were fluoxetine and olanzapine, but 26 different drugs were used. The most common indications were depression, anxiety and 'pseudo-psychotic' concerns about weight. Drugs were generally well tolerated, but their effectiveness was uncertain., Conclusions:   Non-specialists commonly prescribe psychotropic medication to this vulnerable group without reference to specialist services. Specialists prescribe regularly on empirical grounds, without apparent undue consequences, though these may be under-reported. A prospective clinical trial would further clarify risks and benefits., (© 2009 Association for Child and Adolescent Mental Health.)

Background: Common mental health problems impose substantial challenges to patients, carers, and health care systems. A range of interventions have demonstrable efficacy in improving the lives of people experiencing such problems. However many people are disadvantaged, either because they are unable to access primary care, or because access does not lead to adequate help. New methods are needed to understand the problems of access and generate solutions. In this paper we describe our methodological approach to managing multiple and diverse sources of evidence, within a research programme to increase equity of access to high quality mental health services in primary care., Methods: We began with a scoping review to identify the range and extent of relevant published material, and establish key concepts related to access. We then devised a strategy to collect - in parallel - evidence from six separate sources: a systematic review of published quantitative data on access-related studies; a meta-synthesis of published qualitative data on patient perspectives; dialogues with local stakeholders; a review of grey literature from statutory and voluntary service providers; secondary analysis of patient transcripts from previous qualitative studies; and primary data from interviews with service users and carers.We synthesised the findings from these diverse sources, made judgements on key emerging issues in relation to needs and services, and proposed a range of potential interventions. These proposals were debated and refined using iterative electronic and focus group consultation procedures involving international experts, local stakeholders and service users., Conclusions: Our methods break new ground by generating and synthesising multiple sources of evidence, connecting scientific understanding with the perspectives of users, in order to develop innovative ways to meet the mental health needs of under-served groups.

Background: Current policy in the UK and elsewhere places emphasis on the provision of mental health services in the least restrictive setting, whilst also recognising that some children will require inpatient care. As a result, there are a range of mental health services to manage young people with serious mental health problems who are at risk of being admitted to an inpatient unit in community or outpatient settings., Objectives: 1. To assess the effectiveness, acceptability and cost of mental health services that provide an alternative to inpatient care for children and young people. 2. To identify the range and prevalence of different models of service that seek to avoid inpatient care for children and young people., Search Strategy: Our search included the Cochrane Effective Practice and Organisation of Care Group Specialised Register (2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, issue 4), MEDLINE (1966 to 2007), EMBASE (1982 to 2006), the British Nursing Index (1994 to 2006), RCN database (1985 to 1996), CINAHL (1982 to 2006) and PsycInfo (1972 to 2007)., Selection Criteria: Randomised controlled trials of mental health services providing specialist care, beyond the scope of generic outpatient provision, as an alternative to inpatient mental health care, for children or adolescents aged from five to 18 years who have a serious mental health condition requiring specialist services beyond the capacity of generic outpatient provision. The control group received mental health services in an inpatient or equivalent setting., Data Collection and Analysis: Two authors independently extracted data and assessed study quality. We grouped studies according to the intervention type but did not pool data because of differences in the interventions and measures of outcome. Where data were available we calculated confidence intervals (CIs) for differences between groups at follow up. We also calculated standardised mean differences (SMDs) and 95% CIs for each outcome in terms of mean change from baseline to follow up using the follow-up SDs. We calculated SMDs (taking into account the direction of change and the scoring of each instrument) so that negative SMDs indicate results that favour treatment and positive SMDs favour the control group., Main Results: We included seven randomised controlled trials (recruiting a total of 799 participants) evaluating four distinct models of care: multi-systemic therapy (MST) at home, specialist outpatient service, intensive home treatment and intensive home-based crisis intervention ('Homebuilders' model for crisis intervention). Young people receiving home-based MST experienced some improved functioning in terms of externalising symptoms and they spent fewer days out of school and out-of-home placement. At short term follow up the control group had a greater improvement in terms of adaptability and cohesion; this was not sustained at four months follow up. There were small, significant patient improvements reported in both groups in the trial evaluating the intensive home-based crisis intervention using the 'Homebuilders' model. No differences at follow up were reported in the two trials evaluating intensive home treatment, or in the trials evaluating specialist outpatient services., Authors' Conclusions: The quality of the evidence base currently provides very little guidance for the development of services. If randomised controlled trials are not feasible then consideration should be given to alternative study designs, such as prospective systems of audit conducted across several centres, as this has the potential to improve the current level of evidence. These studies should include baseline measurement at admission along with demographic data, and outcomes measured using a few standardised robust instruments.

Clinician-rated measures are in extensive use as routine outcome measures in child and adolescent mental health services. We investigated cross-national differences and inter-rater reliability of the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), the Children's Global Assessment Scale (CGAS) and the Global Assessment of Psychosocial Disability (GAPD). Thirty clinicians from 5 nations independently rated 20 written vignettes. The national groups afterwards established national consensus ratings. There were no cross-national differences in independent scores, but there were differences in national consensus scores, which were also more severe than independent scores. The ICC for the HoNOSCA total score was 0.84, for the CGAS 0.61 and for the GAPD 0.54. These measures may usefully contribute to cross-national comparison studies.

Background:   Research suggests that the routine measurement of treatment outcomes is a neglected area of clinical practice within mental health care settings. Still it is not clear to what extent such findings apply to child and adolescent mental health services (CAMHS). A cross-sectional survey of UK CAMHS revealed that although quantitative clinical measures are commonly used within these services, there is little uniformity in the instruments utilised, and they rarely inform a system of routine outcome measurement. However, in general, respondents did not have a philosophical or scientific objection to the practice of routinely measuring outcomes, but rather felt that they lacked the necessary resources to facilitate such initiatives.

Although eating disorders in children and adolescents remain a serious cause of morbidity and mortality, the evidence base for effective interventions is surprisingly weak. The adult literature is growing steadily, but this is mainly with regard to psychological therapies for bulimia nervosa and to some extent in the field of pharmacotherapy. This review summarises the recent research literature covering management in three areas, namely physical management, psychological therapies, and service issues, and identifies prognostic variables. Findings from the adult literature are presented where there is good reason to believe that these might be applied to younger patients. Evidence-based good practice recommendations from published clinical guidelines are also discussed. Suggestions for future research are made, focusing on 1) the need for trials of psychological therapies in anorexia nervosa, 2) applications of evidence-based treatments for adult bulimia nervosa to the treatment of adolescents, and 3) clarification of the benefits and costs of different service models.

Background: The Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) is an established outcome measure for child and adolescent mental health. Little is known of adolescent views on outcome., Aims: To develop and test the properties of an adolescent, self-rated version of the scale (HoNOSCA-SR) against the established clinician-rated version., Method: A comparison was made of 6-weekly clinician-rated and self-rated assessments of adolescents attending two services, using HoNOSCA and other mental health measures., Results: Adolescents found HoNOSCA-SR acceptable and easy to rate. They rated fewer difficulties than the clinicians and these difficulties were felt to improve less during treatment, although this varied with diagnosis and length of treatment. Although HoNOSCA-SR showed satisfactory reliability and validity, agreement between clinicians and users in individual cases was poor., Conclusions: Routine outcome measurement can include adolescent self-rating with modest additional resources. The discrepancy between staff and adolescent views requires further evaluation.

Western research suggests that life events contribute to childhood psychiatric disorder but no studies have examined this in developing countries. During a population-based study of 1,403 8-12 year old children in Kerala, South India, a life events schedule was administered to parents of children with ICD10 psychiatric disorders (n = 72) and controls. Life events were associated with lower social class, greater poverty, less educated parents, worse physical health and psychiatric disorder. Multivariate analysis confirmed the association of life events with psychiatric disorder, independent of indices of social adversity.

This study aimed to identify the prevalence and associations of childhood psychiatric disorder in Calicut District, South India. Among 1403 children aged 8 to 12 years selected by random cluster sampling, a projected prevalence of 9.4% (95% CI 7.9-10.8%) was found. Associations of disorder with male sex, the Muslim religion, lower social class, less parental education, school failure, and impaired reading and vocabulary were found, but not with malnutrition or perinatal problems. The similarity to associations of disorder in Western studies was noted. The discussion focuses on the validity of comparisons of prevalence across cultures.

Those who suffer from eating disorders often carry the added burden of stigmatizing attitudes from the lay public and the medical profession. These attitudes not only restrict the opportunities for effective treatment but also confer additional handicaps. To some extent, stigmatizing beliefs are based on partial truths about these disorders, namely their dangerousness, their sometimes poor response to treatment, the sufferers' part in their maintenance, and difficulties in communication. This review explores the truth of these beliefs and suggests ways in which a more positive approach to the management of eating disorders might help to reduce the stigma. This includes empathy with the patient's predicament and an approach to treatment in which the patient's wishes are paramount.

Objective: To determine whether continuation of cognitive-behavioral therapy (CBT-C) could prevent relapse in adolescent psychiatric patients who had remitted from major depressive disorder (MDD)., Method: Seventeen patients who continued to have CBT-C for 6 months after remission from MDD were compared with a historical control group of 12 cases who had no further treatment after remission., Results: Only 1 of the 17 cases who continued with CBT-C dropped out. The cumulative relapse risk during CBT-C was significantly lower (0.2) than it had been in the historical control group (0.5)., Conclusions: CBT-C warrants further investigation in a randomized, controlled trial.

Ninety subjects with DSM-III-R anorexia nervosa were randomly allocated to four treatment options, one inpatient, two outpatient, and one comprising an assessment interview only. Twenty were thus offered a package of outpatient individual and family psychotherapy. At 2-year follow-up, 12 of the 20 were classed as well, or very nearly well, according to operationally defined criteria. Statistically significant improvements over time were obtained for weight, mean body mass index (BMI), and also for psychological, sexual, and socioeconomic adjustments. Weight and BMI changes were significantly better than for the assessment only group, some of whom had received extensive treatment elsewhere. The style of the outpatient therapy and compliance with it are described in some detail and prognostic indicators for the treated and untreated groups presented. Lower weights at presentation and vomiting were associated with poorer outcome, although age and length of history were not.

A retrospective analysis of referrals to a regional adolescent psychiatric service over two years was conducted, focusing on selected social and family variables, to identify areas of potential unmet need and the relationship between these factors and clinical variables. Social and family disadvantage was well represented in our patients, but few were over the age of 17 and fewer from ethnic minority backgrounds. Associations between social, family factors, diagnostic and treatment variables are presented and their implications discussed.