Ulrike Schmidt’s research while affiliated with King's College London and other places

Background Eating disorders are severe psychiatric conditions associated with high mortality rates, particularly among young people. These disorders often co-occur with self-harm and suicidal ideation, yet the temporal dynamics between these variables remain poorly understood. Aims This study aims to elucidate the longitudinal associations between eating disorder symptoms, self-harm, and suicidal ideation using structural equation modelling. Method Repeated measures of these phenotypes were used to construct a hypothetical model that includes cross-path analyses within and between the variables in two cohorts: the Twins Early Development Study (TEDS; ages 16, 21 and 26; N=5,196), representing a general population sample, and the Covid-19 Psychiatry and Neurological Genetics study (COPING; data collected between June 2020 and July 2021; N=490), which focused on individuals with a history of anxiety or depression. In the TEDS cohort, symptoms of eating disorders, self-harm, and suicidal ideation showed limited continuity across adolescence and young adulthood, with peak symptom severity at age 21. Results Cross-domain associations revealed that both self-harm and suicidal ideation at age 21 were more strongly associated with eating disorders at 26 than the reverse. In contrast, the COPING cohort exhibited more stability in symptoms over time but showed minimal cross-domain effects. Conclusions The effects of self-harm and suicidal ideation on eating disorders in early adulthood are stronger than the influence of disordered eating on suicidality.

Eating disorders, including anorexia nervosa, bulimia nervosa and binge eating disorder, are psychiatric conditions associated with high mortality rates, particularly due to suicide. Although eating disorders are strongly associated with suicidal ideation, attempts, and fatalities, the precise relationship between these conditions remains poorly understood. While substantial genetic influences have been identified for both eating disorders and suicidality, the shared genetics contributing to their co-occurrence remain unclear. In this study, we utilized a multivariate approach to examine the shared genetic architecture of eating disorder symptoms, suicidal thoughts and behaviors in ~20,000 participants from the COVID-19 Psychiatry and Neurological Genetics (COPING) study. We applied individual-level structural equation modeling to explore the factor structure underlying eating disorder symptoms and suicidal ideation, followed by genetic correlation analyses. We modeled the general factor of susceptibility to eating disorders and suicidal ideation that was as strongly genetically influenced as both conditions, with mean SNP heritability of 9%. Importantly, despite the frequent co-occurrence of eating disorders with other psychiatric conditions, our findings highlight the specificity of the relationship between eating disorders and suicidality, independent of other co-occurring psychopathology, such as depression and anxiety. This specificity highlights the need for targeted approaches in understanding the shared susceptibility factors.

Background Individuals with marginalised social characteristics (e.g. by race/ethnicity, gender, body weight) report experiencing eating disorder (ED) symptoms but do not proportionally access treatment. There may be unique factors experienced by individuals with multiple marginalised social characteristics which are not included in our current understanding of help-seeking for EDs. The present review sought to examine the extent of evidence exploring help-seeking and service utilisation for (EDs) by people with more than one marginalised social characteristic or identity. Main A systematic scoping review was conducted in accordance with the Joanna Briggs Institute guidelines for scoping reviews. Four databases (PsycINFO, PubMED, Embase, Medline) were searched for papers explicitly examining help-seeking or service utilisation for people with more than one marginalised social characteristic or identity (e.g. race/ethnicity, sexual orientation, weight status). Included studies underwent qualitative synthesis employing an existing model of help-seeking adapted for this review. The most common ED investigated was binge eating disorder (BED) and the most frequently reported marginalised characteristics were overweight/obesity and race/ethnicity. Other intersectional characteristics identified included socioeconomic status (SES), gender, and sexual orientation. People with marginalised social identities such as race/ethnicity or gender were more likely to seek help for BED when they also experienced a higher BMI. There was consensus across studies included in this review that help-seeking rates are low for people with an ED. Conclusion Mental health literacy and cultural beliefs about help-seeking are important factors affecting the experiences of people with intersectional identities and this may impact their likelihood to seek help. Results suggest that future studies should consider the interaction between social characteristics and identities in their analyses of outcomes in EDs as this is an emerging area of research, extension of our findings is also needed. The protocol for this review is registered via PROSPERO number CRD42024525849.

The limited availability and high cost of 7 Tesla (7T) structural MRI hinder its widespread application despite its superior imaging quality. This study introduces a High Frequency-Generative Adversarial Network (HF-GAN) to predict three-dimensional 7T-equivalent (P7T) images from standard 3T structural MRI scans, offering a cost-effective alternative. HF-GAN was trained on paired 3T and 7T MRI data and validated on external datasets, including STRATIFY/ESTRA (N=671) and ADNI2 (N=643), covering psychiatric and neurodegenerative disorders. Results indicate that P7T images generally exhibit enhanced contrast and better preservation of fine structural details compared to 3T, with improved sensitivity in detecting disease-related differences in key brain regions such as the thalamus, caudate, putamen, and frontal cortical areas. The partial η^2 values revealed that P7T explained a higher proportion of variance compared to 3T in most comparisons, highlighting its improved sensitivity to disease-related structural changes. These findings demonstrate that HF-GAN effectively enhances 3T MRI data quality, providing a scalable solution for research and clinical applications in neurodegenerative and psychiatric disorders. Additional validations in brain and other organ systems are warranted to further advance clinical translation.

Background Early intervention gives young people the best chance to recover from eating disorders (EDs). An important focus of early intervention is shortening the time between a person first developing symptoms and starting treatment (duration of untreated eating disorder; DUED). Patient-related factors (e.g. poor mental health literacy and help-seeking difficulties) are strongly associated with DUED. The aims of our study are to co-design and test the feasibility of FREED-Mobile (FREED-M), an online intervention tool for young people with early-stage EDs. This tool aims to improve knowledge about EDs, increase motivation to seek treatment and teach early steps towards change or recovery, thus reducing DUED. Methods We will carry out a randomised controlled feasibility trial comparing the FREED-M tool with a control intervention where individuals are sign-posted to an ED charity website. The objectives of the proposed trial are to establish/estimate: (a) attrition rates at follow-up (primary feasibility outcome); (b) participant recruitment; (c) intervention uptake, completion rates and acceptability; (d) intervention effect sizes and standard deviations for outcomes to inform the sample size calculation for a large-scale randomised controlled trial (RCT); (e) stakeholder views on the intervention. We aim to recruit 116 participants (young people, aged 16–25, with first episode ED) from primary care, schools and universities, ED services and social media. Online assessments will be carried out at baseline, end of intervention and follow-up (weeks 0, 4 and 12 post-randomisation, respectively). Outcomes will include motivation and readiness to change, attitudes and intentions towards help-seeking, ED symptoms, mood and social functioning, and health-related quality of life. Additionally, we will carry out a qualitative evaluation of participants’ views of the intervention and study design. Discussion The results of this feasibility trial will inform adaptations to the intervention as needed, as well as the study design (e.g. sample size, primary outcomes) of a future large-scale RCT to assess the effectiveness of the FREED-M intervention. If effective, this novel, online intervention has the potential for wide dissemination and for substantially reducing DUED to improve long-term patient outcomes. Trial registration ISRCTN, ISRCTN15662055. Registered 27 July 2022, https://www.isrctn.com/ISRCTN15662055.

Background A substantial proportion of anorexia nervosa patients require intensive treatments, commonly inpatient or day-patient treatment. The relative merits of these treatments for adults with anorexia nervosa are unknown. Therefore, a trial investigating the clinical effectiveness and cost-effectiveness of inpatient treatment-as-usual versus a stepped-care day-patient approach in adults with anorexia nervosa (DAISIES) was commissioned. This trial terminated prematurely due to poor recruitment, mainly resulting from COVID-19’s impact on service provision. Objective We describe the rationale, methods and available outcomes of the DAISIES trial. Reasons behind the trial’s failure and implications for future research are investigated. Design A two-arm multicentre open-label parallel-group non-inferiority randomised controlled trial, evaluating the effectiveness, acceptability and cost-effectiveness of two intensive treatments for adults with severe anorexia nervosa. Setting Specialist eating-disorder services in the United Kingdom with inpatient and/or day-patient treatment facilities. Participants Adults (age 17 +) with severe anorexia nervosa (body mass index ≤ 16 kg/m ² ) requiring intensive treatment and (optionally) their carers. Intended sample size: 386. Interventions Inpatient treatment-as-usual and a stepped-care day-patient treatment approach (with the option of initial inpatient treatment for medical stabilisation). Main outcome measures The primary outcome was body mass index at 12 months post randomisation. Qualitative interviews conducted during the trial included semistructured interviews to investigate patients’, families’ and clinicians’ views on treatments. Results During the 16-month recruitment period (November 2020 to March 2022), 53 patients were approached. Of these, 15 were enrolled and randomly allocated to the inpatient treatment-as-usual ( n = 7) or day-patient treatment ( n = 8) treatment arms. All participants were female with a mean (standard deviation) age of 24.8 (9.1) years and a mean (standard deviation) body mass index of 14.4 (1.6) kg/m ² . Patients’ body mass indexes had increased similarly in both groups at 12 months. Participants perceived the stepped-care day-patient treatment approach to be more acceptable than inpatient treatment-as-usual. Qualitative interviews with patients, carers and clinicians suggested valued (e.g. multidisciplinary provision of care) and disliked (e.g. perceived over-focus on weight gain) aspects of treatment. Investigation of the reasons behind the trial’s failure revealed strong treatment preferences among patients as the most common reason for non-participation, alongside the impact of COVID-19 on service provision. Limitations The main trial questions could not be answered due to low participant numbers. Conclusions No conclusions can be drawn concerning the clinical and cost-effectiveness of inpatient treatment-as-usual or stepped-care day-patient treatment. The day-patient treatment approach was perceived more positively by patients and carers. Service-related (e.g. reduced clinician time for research), patient-related (e.g. treatment preferences) and wider systemic factors (e.g. reduced service capacity and patient throughput nationally during COVID-19) seem to have contributed to the failure of the DAISIES trial. Future work Despite the trial’s failure, the need to investigate the effectiveness and experience of intensive treatments of adult anorexia nervosa remains. Alternative trial designs incorporating patient preferences and investigating community-based intensive treatment options have potential to improve acceptability and recruitment. Funding This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number HTA 17/123/03.

Objectives Mandatory nutrition labels for out-of-home food consumption have been introduced in several countries to curb rising obesity levels. However, concerns have been raised about the potential negative impacts of such policies on individuals with eating disorders. This review aimed to summarise the literature on the impact of out-of-home nutrition labels on individuals with eating disorders or disordered eating. Design A systematic search across eight databases was conducted on 11 October 2023. Data sources MEDLINE, EMBASE, APA PsycINFO, Web of Science, ProQuest Dissertations and Theses Global, Scopus and CINAHL. Unpublished studies were searched for on Google Scholar and PsyArXiv. Eligibility criteria Studies were included if they assessed the impact of out-of-home nutrition labelling policies on individuals with eating disorders or disordered eating. Data extraction and synthesis 538 studies were screened, of which 16 studies met inclusion criteria. Results The reviewed studies included five experimental/quasi-experimental studies, five cross-sectional studies and six qualitative/mixed-methods studies. Across studies, eating disorder pathology was associated with noticing labels more frequently, paying more attention to caloric intake and more frequent behaviour changes due to caloric values. The metasynthesis identified five themes based on the qualitative findings, being drawn to calories, facilitating the eating disorder, reassurance, social eating and frustration. Conclusions The current review summarised the existing literature on the impact of out-of-home nutrition label policies on individuals with eating disorders. The evidence suggests that there is cause for concern regarding negative impacts, particularly for those with restrictive eating disorders, which should be explored further by research and considered by policymakers when making decisions on public health policies.

Objective This study aimed to investigate the longitudinal bi-directional relationship between self-reported restrictive eating behaviours and sleep characteristics within a sample of UK adolescents from the Millennium Cohort Study (MCS). Method Using a Structural Equation Modelling approach, the present study investigated the prospective associations between individual sleep behaviours (e.g., sleep timing, sleep onset latency, social jetlag) at age 14 and restrictive eating behaviours at age 17. Moreover, the association between restrictive eating behaviours (age 14) and self-reported sleep quality (age 17) was tested. A mediation analysis was conducted to explore the role of depressive symptoms in these relationships. In total, N = 6,041 young people provided self-report data at both timepoints (sweep 6 & 7) and a subsample of N = 2,164 additionally provided diary data on their sleep behaviours over two separate 24 h periods. Results Sleep indicators at age 14 did not significantly predict changes in restrictive eating behaviours across time. However, engagement in restrictive eating behaviours at age 14 significantly predicted poorer self-perceived sleep quality three years later (β = 0.06, SE = 0.01, p <.01). Depressive symptoms fully mediated this relationship (indirect effect: β = 0.05, SE = 0.04, p <.001). Discussion The present study provides evidence for a prospective positive association between restrictive eating behaviours and subsequent poorer sleep quality in a large, general population sample. Findings of the mediation analysis suggest mood as a potential target for tertiary prevention when addressing restrictive eating behaviours as an eating disorder risk factor in adolescents.