Howard Steiger’s research while affiliated with McGill University and other places

Objective To determine the extent to which anorexia nervosa is associated with premature mortality. Method We carried out a matched cohort study of 7332 male and female patients with anorexia nervosa and 73,215 patient controls who were admitted between 1989 and 2023 in hospital centers of Quebec, Canada. We tracked the patients longitudinally over time to identify premature deaths before age 75 years and determined the cause of death. We used stratified Cox regression models adjusted for patient characteristics to estimate hazard ratios ( HR ) and 95% confidence intervals ( CI ) for the association between anorexia nervosa and premature mortality. Results Overall, 186 (2.5%) patients with anorexia nervosa and 615 (0.8%) matched controls died before age 75 years. Compared with no anorexia, anorexia nervosa was associated with 3.02 times the risk of premature mortality among females (95% CI 2.50–3.65) and 2.23 times the risk among males (95% CI 1.35–3.70). Patients with a first anorexia nervosa admission between age 20 and 29 years were most at risk of premature mortality ( HR 8.00, 95% CI 4.30–14.88), as were patients hospitalized ≥ 3 times for anorexia nervosa ( HR 4.72, 95% CI 3.25–6.84). Anorexia nervosa was associated with premature mortality due to metabolic and other endocrine disorders, suicide, and a range of other causes. Discussion Anorexia nervosa is associated with an elevated risk of premature mortality from metabolic disorders, suicide, and other causes. Patients who are female, hospitalized as young adults, or have repeated admissions for anorexia nervosa are most at risk.

Background: Phenomenology in anorexia nervosa (AN) appears to be subject to epigenetic regulation via DNA methylation. The micronutrients B12 and betaine contribute directly to DNA methylation and have been shown to be abnormally elevated in blood samples from people with AN. Methods: We measured plasma B12 and betaine levels, as well as leukocyte DNA methylation levels, among women with active AN (AN-active group), those in 1-year remission from AN (AN-remitted group), and those who had never experienced an eating disorder (NED group). We compared the groups on micronutrient levels and on the strength of association between micronutrients and methylation. Results: We included 64 women in the AN-active group, 49 in the AN-remitted group, and 49 in the NED group. Relative to those with NED (B12: mean 339.6 [standard deviation (SD) 224.3] μmol/L; betaine: mean 33.74 [SD 17.10] μmol/L), participants with active AN showed high B12 and betaine (B12: mean 571.0 [SD 505.2] μmol/L; betaine: mean 43.73 [SD 22.50] μmol/L); AN-remitted participants had elevated B12 alone (B12: mean 588.2 [SD 379.9] μmol/L; betaine: mean 33.50 [SD 19.20] μmol/L). There were also group-based differences in the strength of association between B12 and site-specific DNA methylation at genes regulating insulin function, glucose metabolism, cell regulation, and neurotransmitter function. These associations between B12 and methylation levels were generally stronger among those without an ED than among those with either active or remitted AN. Limitations: The extent to which plasma nutrient levels provide a meaningful proxy to cellular processes affecting DNA methylation is uncertain and the sample size limits the stability of results. We included only biological females in this investigation. Conclusion: Elevated B12 levels in AN resemble elevations reported among people with autoimmune, neoplastic, or other disorders. Such elevations imply that plasma B12 levels may misrepresent nutritional status among people with AN. Observed associations between levels of B12 and methylation at certain gene regions have ambiguous importance, but may indicate an influence of nutritional status on epigenetic mechanisms or may be the coincidence of separate processes that independently affect levels of micronutrients and DNA methylation.

Objective The Eating Disorder Examination Questionnaire (EDE‐Q) is a widely‐used measure of eating‐disorder symptoms. However, inconsistent replication of the subscale structure raises concern about validity. To provide a rigorous test of the EDE‐Q's dimensionality and item‐quality, we applied modern and classical test theory approaches to data obtained from a large, transdiagnostic sample of people with clinical eating disorders. Method We analyzed data from 1197 individuals ( M age = 27.9 years, SD = 10.08, 95% female) with various eating disorders, who had been assessed for treatment at a specialized program. Exploratory analyses (including Parallel Analyses), Confirmatory Factor Analyses (CFA) and graded‐response Item Response Theory (IRT) analyses, were conducted with Mplus. Results Factor analyses showed inappropriate fit to the original EDE‐Q subscales, as well as for alternative 1,2,3, and 4‐factor solutions. Parallel analyses suggested a one‐dimensional structure as best fit. IRT analyses showed substantial variability in EDE‐Q‐item quality and indicated that five items (fear of weight gain, feeling fat, desire to lose weight, importance of weight, importance of shape) were most pertinent to determining severity. The construct validity of the five EDE‐Q items was confirmed by a CFA, showing excellent fit. Discussion Our results suggest that EDE‐Q scores are best interpreted as spanning a one‐factor continuum. IRT results suggest that some items are more pertinent than others for determining eating‐disorder severity. Results could be useful for establishing short EDE‐Q versions, such as a five‐item version, which, in turn, would be helpful for measurement‐based clinical practice and for data‐collection in epidemiological and experimental studies.

Objective Previous studies have indicated that virtual treatments for eating disorders (EDs) are roughly as effective as are in‐person treatments; the present nonrandomized study aimed to expand on the current body of evidence by comparing outcomes from a virtual day treatment program with those of an in‐person program in an adult ED sample. Method Participants were 109 patients who completed at least 60% of day treatment sessions ( n = 55 in‐person and n = 54 virtual). Outcome measures included ED and comorbid symptoms, and motivation. Results Linear mixed models showed that global EDE‐Q scores decreased during treatment (AIC = 376.396, F = 10.94, p = 0.002), irrespective of treatment modality ( p = 0.186). BMI significantly increased over time (AIC = 389.029, F = 27.97, p < 0.001), with no effect of treatment modality ( p = 0.779). Discussion Our findings suggest that the virtual delivery of day treatments produces comparable outcomes to those obtained using in‐person formats, and that virtual formats may represent a pragmatic treatment option, especially in situations in which access to in‐person care is limited.

Objective: To determine the association between adolescent hospitalization for suicide attempts and the subsequent risk of eating disorder hospitalization. Method: This was a cohort study of 162,398 adolescent girls in Quebec, Canada, including 7741 with suicide attempts before 20 years of age, matched to 154,657 adolescents with no attempt between 1989 and 2019. The main exposure measure was suicide attempt hospitalization. The main outcome measure was hospitalization for an eating disorder up to 31 years later, including anorexia nervosa, bulimia nervosa, and other eating disorders. We used adjusted Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between adolescent suicide attempts and eating disorder hospitalization. Results: Adolescent girls admitted for a suicide attempt had 5.55 times the risk of eating disorder hospitalization over time (95% CI 3.74-8.23), compared with matched controls. Suicide attempt was associated with anorexia nervosa (HR 3.57, 95% CI 1.78-7.17) and bulimia nervosa and other eating disorders (HR 8.55, 95% CI 5.48-13.32). Associations were pronounced in girls with repeated suicide attempts. Girls who attempted suicide through self-poisoning had an elevated risk of anorexia nervosa, whereas girls who used violent methods such as cutting or piercing had a greater risk of bulimia nervosa and other eating disorders. Suicide attempt was strongly associated with eating disorder hospitalization in the year following the attempt, but associations persisted throughout follow-up. Discussion: Suicide attempt admission is associated with the long-term risk of eating disorder hospitalization in adolescent girls. Public significance: This study of adolescent girls suggests that suicide attempt admission is associated with the long-term risk of hospitalization for eating disorders. The risk is greatest in the year after the attempt, but persists over time. Adolescents who present with a suicide attempt may benefit from screening for eating disorders and long-term follow-up to help prevent the exacerbation or development of eating disorders.

Background Given limited availability of informed treatments for people affected by eating disorders (EDs), there has been increasing interest in developing self-administered, technology-based ED interventions. However, many available interventions are limited to a specific ED diagnosis or assume that participants are ready to change. We developed a digital self-help application (called ASTrA) that was explicitly designed to be transdiagnostic and to help increase motivation for change. The aim of the present study was to describe the development and examine the psychometric properties, user satisfaction and rated potentials for practical use of our application. Methods The content of our application was based on concepts derived from self-determination theory, the transtheoretical model of change, and cognitive theory. The application was developed by a multidisciplinary team of clinicians, researchers, staff members and individuals with lived ED experience, each being involved in all steps of the application’s development. We tested validity, reliability, satisfaction and perceived feasibility for clinical implementation in an independent sample of 15 patients with an ED and 13 clinicians specialized in ED treatment. Psychometric properties were evaluated using descriptive statistics, correlations, content validity indices and intraclass coefficients. Differences in satisfaction ratings and perceived potential for clinical implementation of the application between clinicians and patients were examined using Mann–Whitney U tests. Results The digital application showed excellent validity (mean i-CVI: .93, range: .86–.96) and internal reliability (all Cronbach alpha’s > .88). Patients and clinicians both considered the application acceptable, appropriate, and feasible for use in clinical practice. Conclusions Findings suggest that our transdiagnostic interactive application has excellent psychometric properties. Furthermore, patients and clinicians alike were positive about the possible use of the application in clinical practice. The next step will be to investigate the application's effectiveness as an intervention to promote autonomous motivation and to facilitate remission in people on the waitlist for specialized ED treatment.

Now in its fourth edition, the acclaimed Oxford Textbook of Psychopathology aims for both depth and breadth, with a focus on adult disorders and special attention given to personality disorders. It provides an unparalleled guide for professionals and students alike. Esteemed editors Robert F. Krueger and Paul H. Blaney selected the most eminent researchers in abnormal psychology to provide thorough coverage and to discuss notable issues in the various pathologies which are their expertise. This fourth edition of the Oxford Textbook of Psychopathology is fully updated and also reflects alternative, emerging perspectives in the field (e.g., the National Institute of Mental Health’s Research Domain Criteria Initiative [RDoC, the Hierarchical Taxonomy of Psychopathology [HiTOP]). The Textbook exposes readers to exceptional scholarship, the history and philosophy of psychopathology, the logic of the best approaches to current disorders, and an expert outlook on what researchers and mental health professionals will be facing in the years to come. This volume will be useful for all mental health workers, including clinical psychologists, psychiatrists, and social workers, and as a textbook focused on understanding psychopathology in depth for anyone wishing to be up to date on the latest developments in the field.

Background We studied the effect of the Covid‐19 pandemic on child eating disorder hospitalizations in Quebec, Canada. Quebec had one of the strictest lockdown measures targeting young people in North America. Methods We analyzed eating disorder hospitalizations in children aged 10–19 years before and during the pandemic. We used interrupted time series regression to assess trends in the monthly number of hospitalizations for anorexia nervosa, bulimia nervosa, and other eating disorders before the pandemic (April 2006 to February 2020), and during the first (March to August 2020) and second waves (September 2020 to March 2021). We determined the types of eating disorders requiring hospital treatment and identified the age, sex and socioeconomic subgroups that were most affected. Results Hospitalization rates for eating disorders increased during the first (6.5 per 10,000) and second waves (12.8 per 10,000) compared with the period before the pandemic (5.8 per 10,000). The increase occurred for anorexia nervosa as well as other types of eating disorders. The number of girls and boys aged 10–14 years admitted for eating disorders increased during wave 1. Wave 2 triggered an increase in eating disorder admissions among girls aged 15–19 years. Hospitalization rates increased earlier for advantaged than disadvantaged youth. Conclusions The Covid‐19 pandemic affected hospitalizations for anorexia nervosa as well as other eating disorders, beginning with girls aged 10–14 years during wave 1, followed by girls aged 15–19 years during wave 2. Boys aged 10–14 years were also affected, as well as both advantaged and disadvantaged youth.

Purpose: To determine if suicide attempts increased during the first year of the pandemic among young adolescents in Quebec, Canada. Methods: We analyzed children aged 10-14 years who were hospitalized for a suicide attempt between January 2000 and March 2021. We calculated age-specific and sex-specific suicide attempt rates and the proportion of hospitalizations for suicide attempts before and during the pandemic and compared rates with patients aged 15-19 years. We used interrupted time series regression to measure changes in rates during the first (March 2020 to August 2020) and second (September 2020 to March 2021) waves and difference-in-difference analysis to determine if the pandemic had a greater impact on girls than boys. Results: Suicide attempt rates decreased for children aged 10-14 years during the first wave. However, rates increased sharply during the second wave for girls, without changing for boys. Girls aged 10-14 years had an excess of 5.1 suicide attempts per 10,000 at the start of wave 2, with rates continuing to increase by 0.6 per 10,000 every month thereafter. Compared with the prepandemic period, the increase in the proportion of girls aged 10-14 years hospitalized for a suicide attempt was 2.2% greater than that of boys during wave 2. The pattern seen in girls aged 10-14 years was not present in girls aged 15-19 years. Discussion: Hospitalizations for suicide attempts among girls aged 10-14 years increased considerably during the second wave of the pandemic, compared with boys and older girls. Young adolescent girls may benefit from screening and targeted interventions to address suicidal behavior.