Department of Psychiatry, Guys Hospital, London
Institute of Psychiatry, London
St Georges Hospital, London, UK
Correspondence: Professor Janet Treasure, Department of Psychiatry, 5th Floor, Thomas Guy House, Guys Campus, London SE1 9RT, UK. E-mail: j.treasure{at}iop.kcl.ac.uk
Declaration of interest All authors were members of the NICE guideline development group for the clinical guideline on eating disorders.
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ABSTRACT |
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INTRODUCTION |
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The eating disorders have notable psychiatric and medical comorbidities and sequelae. Anorexia nervosa has the highest mortality of all psychiatric conditions; this is a result of both physical ill health and suicide. In recognition of these risks the NICE guideline states:
The level of risk to the patients mental and physical health should be monitored as treatment progresses because it may increase for example following weight change or at times of transition between services in cases of anorexia nervosa (National Collaborating Centre for Mental Health, 2004).
We explore the implications of these risks for psychiatrists.
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THE PROBLEMS |
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On the basis of Grade A evidence (at least one randomised controlled trial as part of a body of literature of overall good quality and consistency), the NICE guideline recommends that out-patient cognitivebehavioural therapy should be provided for bulimia nervosa, usually over a 6-month period. In contrast, there are no Grade A recommendations for anorexia nervosa and only one Grade B (well-conducted clinical studies but no randomised clinical trials on the topic of recommendation):
Family interventions that directly address the eating disorder should be offered to children and adolescents with anorexia nervosa (National Collaborating Centre for Mental Health, 2004).
Eating disorders are now commonly managed within mental health services, with the addition of medical/paediatric services for those with high medical risk. Treatment may need to be divided between services near the family and those at the place of higher education. Simultaneously patients may move from adolescent to adult services and away from parental involvement in treatment. The current organisation of the health service does not take the needs of older adolescents into account.
Thus the admixture of risks, problems and age at presentation of these patients raises questions about transitions between services involved in the care of people with eating disorders. Tiers of intensity/skills within different organisational structures and links between them have to be negotiated:
We will discuss the difficulties that this entails and suggest some tentative solutions.
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WHERE ARE EATING DISORDERS MANAGED WITHIN HEALTH SERVICES? |
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The setting of services for people with eating disorders also varies between cultures; in Germany, for example, they are frequently managed within the specialty of psychosomatic medicine.
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TRANSITIONS: BRIDGING THE GAPS |
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Where management is shared between primary and secondary care, there should be clear agreement among individual healthcare professionals onthe responsibility for monitoring patients with eating disorders. This agreement should be in writing and should be shared with the patient and, where appropriate, their families and carers (National Collaborating Centre for Mental Health, 2004).
Secondary and tertiary care
Transition between tiers of services can be problematic, particularly for
adult services. Community mental health teams sometimes argue that they lack
the skills to manage such cases or that eating disorders fall outside their
remit of managing severe mental illness. This raises questions about the
definition of severe mental illness and the core competencies required by
these teams. Goldberg & Gournay
(1997) suggested that anorexia
nervosa fulfils several defining criteria of severe mental illness:
... unlikely to remit spontaneously; associated with major disability;... whose care will usually involve both the primary and the community mental health team;... have grossly elevated standardised mortality rate.. .will need at least a brief admission.
Some individuals with bulimia nervosa have serious comorbidity such as major depression and/or personality disorders. It is beyond the resources of specialist eating disorders units to manage these complex cases single-handedly.
Family home and student abode
Services are linked to primary care at the place of the familys
residence. The idea of a patient having lengthy but flexible care from two
teams while they are students is an anathema to many service providers who
prefer to remove patients from their books if they are out of
the area for a period. Treatment for eating disorders cannot be easily
compartmentalised to fit within academic terms or holidays.
The recent report The Mental Health of Students in Higher Education (Royal College of Psychiatrists, 2003) provides a useful framework for resolving the difficulties posed. Its list of recommendations includes:
Local mental health teams and counselling and medical services in HEIs [Higher Education Institutions] to work more closely together when jointly supporting those with severe mental health difficulties; to develop frameworks and clear protocols for cross-referral which take account of local mental health and counselling provision and expertise. Student counselling services to participate in the care programme approach (CPA) for students when necessary, although it must be recognised that student counsellors are not mental health workers and cannot fulfil the role of CPA care coordinator.
and
An enabling policy to allow students to move smoothly between home and university, to ensure continuity of NHS treatment (including CPA) and without arguments about which Trust should pay (Royal College of Psychiatrists, 2003: p. 55).
Child and adolescent mental health and adult psychiatry
The move between CAMHS and adult services is not well defined. The timing
of the transition is variable and sometimes depends upon the complexity of the
case. The links are unclear should CAMHS link to community mental
health teams or to tertiary eating disorder services? There is often no
procedure for managing this transfer, or local protocols dictate a pathway
that is not always in the best interest of the patient. A sudden change in
treatment ethos, towards increased individual responsibility, can be
bewildering and dangerous for patients and their families. Parents can
subsequently find that they are excluded from decisions about care.
A recent intercollegiate report highlighted this issue. One recommendation was that
For young people with mental health problems specific services should be available for those in the1619 gap... (Intercollegiate Working Party on Adolescent Health, 2003: p. 40).
The need for young peoples services to bridge this important developmental interface has been recognised for people with psychosis. It is lamentable that this has not yet been addressed in many eating disorder services.
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CORE COMPETENCIES FOR PSYCHIATRISTS IN EATING DISORDERS |
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Knowledge of the care required for acute medical risk, if necessary using compulsory treatment, is crucial.
Acute risk
A simple guide to the assessment of medical risk in anorexia nervosa is
available in appendix 7 of the NICE guideline
(National Collaborating Centre for Mental
Health, 2004). The criteria for in-patient admission are given in
the Australian and New Zealand guidelines
(Beumont et al, 2004).
The management of high-risk cases is difficult and usually requires specialist
expertise.
Long-term prognosis
Skilled early intervention has a profound beneficial effect on the course
of anorexia nervosa. A randomised controlled trial showed that 90% of patients
given an effective treatment (family therapy) within 3 years of illness onset
had a good outcome at 5 years (Eisler
et al, 1997). Only 20% of cases have a good outcome when
treatment is given after 3 years of illness. The Australian and New Zealand
guidelines summarise the predictors of outcome at first referral
(Beumont et al, 2004).
Good outcome is associated with minimal weight loss (body mass index > 17
kg/m2), absence of medical complications, strong motivation to
change behaviour, and supportive family and friends who do not condone the
abnormal behaviour. Poor outcome is indicated by vomiting in emaciated
patients, onset in adulthood, coexisting psychiatric or personality disorder,
disturbed family relationships and a long duration of illness.
Matching risk with intensity of care
The NICE guideline (appendix 7) includes an evaluation of both the acute
and long-term risk and a summary of services required to match patient needs.
For example, people with severe unremitting anorexia nervosa (in common with
other severe psychiatric conditions) may require social help, long-term
psychotherapy, and crisis support for self-harm and rehabilitation. Emergency
admissions are needed when there is acute medical risk. The NICE guidelines
recommend that:
People with anorexia nervosa requiring inpatient treatment should be admitted to a setting that can provide the skilled implementation of refeeding with careful physical monitoring (particularly in the first few days of refeeding) and in combination with psychosocial interventions (National Collaborating Centre for Mental Health, 2004).
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CONCLUSION |
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Services need to clarify treatment policies for anorexia nervosa and to liaise with medical colleagues about protocols for the management of those at high risk. A clear understanding of the problems is necessary and good collaboration and communication between services are paramount. Finally, there needs to be an acceptance that anorexia nervosa is a severe and enduring mental illness with a high morbidity and mortality warranting consideration throughout psychiatric services.
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REFERENCES |
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Eisler, I., Dare, C., Russell, G. F., et al (1997) Family and individual therapy in anorexia nervosa. A 5-year follow-up. Archives of General Psychiatry, 54, 1025 1030.[Abstract]
Goldberg, D. & Gournay, K. (1997) The General Practitioner, the Psychiatrist and the Burden of Mental Health Care. Maudsley Discussion Paper No. 1. London: Institute of Psychiatry. http://admin.iop.kcl.ac.uk/maudsley-publications/maudsley-discussion-papers/mdp01.pdf
Intercollegiate Working Party on Adolescent Health (2003) Bridging the Gaps: Health Care for Adolescents. London: Royal College of Paediatrics and Child Health. http://www.rcpsych.ac.uk/publications/cr/council/cr114.pdf
National Collaborating Centre for Mental Health (2004) Eating Disorders. Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders. National Clinical Practice Guideline. No. 9. Leicester & London: British Psychological Society & Gaskell. http://www.nice.org.uk/pdf/cg009niceguidance.pdf
OHerlihy, A., Worrall, A., Lelliott, P., et al
(2003) Distribution and characteristics of in-patient child
and adolescent mental health services in England and Wales. British
Journal of Psychiatry, 183, 547
551.
Royal College of Psychiatrists (2003) The Mental Health of Students in Higher Education (Council Report CR112). London: Royal College of Psychiatrists.
Sell, L. & Robson, P. (1998) Perceptions of college life, emotional wellbeing and drug and alcohol use among Oxford undergraduates. Oxford Review of Education, 24, 235 243.
Turnbull, S., Ward, A., Treasure, J., et al (1996) The demand for eating disorder care. An epidemiological study using the general practice research database. British Journal of Psychiatry, 169, 705 712.[Abstract]
Received for publication February 4, 2004. Revision received January 24, 2005. Accepted for publication April 19, 2005.
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