6.2.1. Introduction

The earliest models of psychological treatment for anorexia nervosa were psychodynamic in nature, albeit with few attempts to study them systematically (for review see Dare & Crowther, 1995; Herzog & Hartmann, 1997; Kaplan, 2002).

From the 1960s onwards, behaviour therapy for anorexia nervosa became increasingly popular, with many articles reporting on the use of operant conditioning techniques (for review see Bemis et al., 1987; Schmidt, 1989). The basic operant paradigm consisted of isolating patients from social and material reinforcers that were subsequently delivered contingent on weight gain or caloric intake. For a time, this technique became part of many inpatient regimes, because of its efficacy in encouraging weight gain in the short term. However, operant conditioning approaches have been criticised as coercive and controlling (for review see Bemis, 1987), and their influence has waned in recent years.

The seminal – though controversial – work of Minuchin and colleagues (1975) stimulated much interest in the use of family interventions in the treatment of anorexia nervosa. Initially, the rationale for this approach was rooted in the notion that families have a key causal role in the development of anorexia nervosa (‘the anorexogenic family’). However, it is now widely agreed that family interventions are best viewed as treatments that mobilise family resources rather than treating family dysfunction, for which there is no empirical evidence (Eisler et al., 2003). The first treatment trial of family therapy was published in 1987 (Russell et al., 1987), studying patients who had undergone a period of weight restoration in a specialist eating disorder inpatient unit prior to starting outpatient psychotherapy. This study showed that in 21 adolescents with a short duration of illness, family therapy was superior to individual supportive counselling in maintaining weight gained. The findings of this study stimulated three further RCTs into different types of family interventions for adolescents with anorexia nervosa (Le Grange et al., 1992; Eisler et al., 2000; Geist et al., 2002). In addition there has been one further comparison of family therapy with individual therapy although the findings are difficult to interpret (Robin et al., 1999). The original Maudsley model of family therapy has since been manualised for therapists (Lock et al., 2001).

A handful of controlled trials, mainly in adults with anorexia nervosa, have evaluated the efficacy of specific individual psychotherapies, such as cognitive behaviour therapy (Channon et al., 1989; Serfaty et al., 2002; Pike et al., in press; MacIntosh et al., submitted); cognitive analytic therapy (Treasure et al., 1995; Dare et al., 2001), focal analytical psychotherapy (Dare et al., 2001) and interpersonal psychotherapy (McIntosh et al., submitted).

More recently there has been interest in the use of motivational interventions in the engagement and treatment of people with anorexia nervosa (Treasure & Ward, 1997; Vitousek et al., 1998), however, RCTs in this area are as yet lacking.

Overall, the body of research into the treatment of anorexia nervosa is small and inconsistent in methodological quality. The conclusions that can be drawn are limited because many studies have no follow-up data, lack the statistical power necessary to detect real effects, and use different study entry criteria and outcome measures.

6.2.2. Current practice

There is wide variability in the availability of psychological therapies for patients with anorexia nervosa. There is no uniform or agreed approach to the psychological treatment or management of anorexia nervosa in adults, either in terms of types of treatment offered, their duration, intensity or the setting in which treatment is provided.

In the treatment of anorexia nervosa in children and adolescents, family interventions are usually offered. These may vary in approach and not all of them will resemble the evidence-based family interventions that have a focus on eating behaviours. Specialist eating disorder services may offer a range of individual psychological therapies including cognitive behaviour therapy, psychodynamic psychotherapy, motivational enhancement therapy and family interventions.

6.2.3. Outpatient psychological treatments (first episode and later episodes)

This section focuses on psychological treatments given as the main or only treatment to patients who present during a first or later episode of anorexia nervosa.

6.2.4. Outpatient psychological treatments after weight restoration in hospital

Inpatient treatments aim to return body weight to a healthy level but even when this occurs patients remain very vulnerable to subsequent weight loss. Outpatient psychological treatments are offered to prevent this.

6.2.5. Different types of psychological inpatient treatment regime

There has been some interest in the question of whether different types of inpatient regimes are more efficient than others in terms of achieving short-term weight restoration.

6.2.6. Psychological treatments as adjuncts to inpatient treatment

Specialist inpatient treatment programmes for anorexia nervosa typically consist of multiple components, with the aim of providing comprehensive package of inpatient care. The relative importance and efficacy of these different components has so far received little research attention.

6.2.7. Additional considerations in the management of children and adolescents

There is a small but consistent evidence base, which indicates that family-based treatments are important in the treatment of adolescents with anorexia nervosa. Consensus as to what constitutes the best form of family intervention has not been achieved but two factors stand out as potentially important:

• Family interventions should have a focus on the eating disorder and how this impacts on family relationships, emphasising in the early stages of treatment the necessity for parents to take a central role in supporting their child’s efforts to eat.
• Both separated (parents and patient meet separately with the therapist) and conjoint forms (parents and patient together with therapist) of family therapy may be beneficial.

Establishing a collaborative working relationship with families with a young person with anorexia nervosa presents a particular challenge that requires time and expertise to balance the competing needs of different family members. However, whilst there is an emphasis on family interventions the young person’s individual rights and responsibilities should not be overlooked. Issues such as confidentiality and consent must be considered carefully and not simply overridden by clinicians or parents. For this reason, young people should be offered individual appointments with a therapist separate from those with their family members or carers. For children and adolescents it is also particularly important to ensure adequate physical monitoring and rapid commencement of treatment.

6.2.8. Clinical summary

Various forms of psychological treatment are associated with improvements in terms both of weight gain and recovery by the end of treatment compared to ‘standard care’ for certain populations. However, the long-term benefits may not be sustained. For patients not requiring emergency admission to hospital, outpatient psychological treatment may be as, or more, effective than admission. For those admitted to hospital, no particular psychological treatment regime, either as a central component of the treatment programme or as an adjunct has been shown to have beneficial effects.

There is limited evidence that family interventions focused explicitly on eating disorders may be of specific benefit to younger people, but there is insufficient evidence to determine whether conjoint (i.e. patient and parents meet together) or separated forms of family therapy (i.e. therapist meets patient and parents separately) are more effective.

6.2.9. Clinical practice recommendations

6.3.1. Introduction

A diverse network of neurotransmitters and neurohormones are involved in the central and peripheral control of appetite and satiety. A variety of drugs that act on various receptors within these pathways have been examined in the treatment of anorexia nervosa.

6.3.2. Current practice

Antidepressant drugs are often used to treat the depressive symptoms in anorexia nervosa and their effects on weight gain have also been studied. Medications are also used to treat comorbid conditions such as major depressive disorder and obsessive-compulsive disorder. Antipsychotic drugs or minor tranquillisers or antihistamines are frequently used symptomatically to reduce the high levels of anxiety present with anorexia nervosa, but are not recommended for the promotion of weight gain.

However, an evidence base for current practice is lacking. There are few studies on which to base clinical decisions and the studies are of low statistical power. There is also doubt about generalising from the patient samples studied. Drugs are not as acceptable or as well tolerated as psychotherapy in this patient group (Treasure, 1998). Only short-term effects have been studied and the outcome measures used are often not comparable to those used in psychotherapy studies. Compromised nutritional status may also affect the mechanism of drug action and this is rarely considered in studies. For example, there is some evidence that antidepressants have lower efficacy in the context of low levels of oestrogen (Halbreich & Kahn, 2000). They may be also less effective if tryptophan levels are altered.

Because of the complications of starvation, vomiting, dehydration and over hydration in this clinical group, there may be problems in terms of pharmacokinetics (i.e. drug absorption and toxicity). Extremely malnourished patients and those with electrolyte abnormalities are at risk of cardiac complications. Drugs with cardiac side effects should be used with caution.

6.3.3. Pharmacological treatment

The aim of pharmacological treatment in people with anorexia nervosa is to produce weight gain and improve their quality of life or to alleviate some of the comorbidity such as depression, anxiety or obsessive-compulsive features. Three main classes of drugs have been considered in the treatment of anorexia nervosa, these are antidepressants, antihistamines and antipsychotics.

6.3.4. Additional considerations in the management of children and adolescents

It is uncertain whether any of the above findings can be generalised to children and adolescents. In general there are safety data available for sertraline and amisulpride used for other conditions in the under 18 group, but these drugs have not been studied in anorexia nervosa. There is no evidence specifically addressing the use of drugs in the child and adolescent age group.

6.3.5. Clinical summary

There is no evidence that drug treatment (antidepressants [tricyclics and SSRIs]), conventional antipsychotics and antihistamines) has additional benefit on weight gain in people undergoing multi-faceted inpatient treatment. There is limited preliminary evidence from one small trial that fluoxetine may reduce the likelihood of deterioration after inpatient weight restoration. It remains to be established whether or not new compounds (e.g. atypical antipsychotics) or new settings (e.g. day hospitals as a supplement to outpatient therapy) or new specifications (matching drug to clinical phenotype or endophenotype) will be of benefit. A further complication in interpreting these studies is that a number of the secondary features of anorexia nervosa that may respond to medication may also improve as the patient gains weight (e.g. depressed mood).

6.3.6. Clinical practice recommendations

6.3.6.1.

Medication should not be used as the sole or primary treatment for anorexia nervosa. [C]

6.3.6.2.

Caution should be exercised in the use of medication for comorbid features such as depressive or obsessive-compulsive features as they may resolve with weight gain alone. [C]

6.3.6.3.

When medication is used to treat people with anorexia nervosa, the side effects of drug treatment (in particular, cardiac side effects), should be carefully considered because of the compromised cardiovascular function of many people with anorexia nervosa. [C]

6.3.6.4.

Health care professionals should be aware of the risk of drugs that prolong the QTc interval on the ECG: for example, antipsychotics, tricyclic antidepressants, macrolide antibiotics, and some antihistamines. In patients with anorexia nervosa at risk of cardiac complications, the prescription of drugs with side effects that may compromise cardiac function should be avoided. [C]

6.3.6.5.

If the prescription of medication that may compromise cardiac functioning is essential, ECG monitoring should be undertaken. [C]

6.3.6.6.

All patients with a diagnosis of anorexia nervosa should have an alert placed in their prescribing record concerning the risk of side effects. [C]

6.4.1. Introduction

Identification of those patients with short-term risk of serious harm or death is clearly important in clinical practice. Recommendations as to how to assess, what to monitor and when to intervene are, therefore, vital.

The vast majority of longer-term follow-up studies indicate that people with anorexia nervosa have an almost 10-fold risk of dying compared to healthy people the same age and sex. Standardised mortality rates range between 4.71 and 12.82 (Nielsen et al., 1998). Mortality in eating disorders is predominately related to malnutrition, methods of weight control and suicide. Among studies in which cause of death is documented, 54 per cent died of eating disorder complications, 27 per cent committed suicide and the remaining 19 per cent died of unknown or other causes (Nielsen, 2001).

6.4.2. Current practice

There is limited evidence as to how and where risk should be managed. Opinion and practice varies between (and within) countries, centres and clinicians. This is the case both in terms of threshold for hospital admission and the goals of the admission. For example, the APA guidelines (American Psychiatric Association, 2000) recommend admission to hospital when a BMI is less than 16 kg/m² or weight loss greater than 20 per cent. In both the US and Australia, patients are generally admitted for short-term medical stabilisation on a medical or paediatric ward. In the UK, patients at low weight are frequently managed in an outpatient setting in specialist eating disorder services. In these instances there is a higher threshold for inpatient treatment with admission often not occurring until the patient’s BMI falls below 13 kg/m². However, managing these low weight patients in an outpatient setting can be hazardous and should rarely be done without specialist advice. In the majority of inpatient specialist services in the UK, the goal is full weight recovery and so admissions are longer term. Admission to either a medical/paediatric or general psychiatric unit may occur but this varies with availability of services.

6.4.3. Physical risk reduction and monitoring

Applying information about the best evidence to a specific patient’s problem is not easy as the clinical picture is diverse physically, psychologically and socially. The patient’s problems have to be clearly defined and placed within the context of a clinical risk assessment. This needs to include an assessment both of the acute risk and the longer-term prognosis.

Decisions on short-term risk involve a combined assessment of the physical risk and the person’s psychological capacity to consent to treatment, taking into account the possible resources of motivation and psychosocial support. A diagram is provided (see Appendix 7) as a simple guide to medical practitioners and other members of the multidisciplinary team as a decision aid when evaluating this acute risk. Body mass index is a better marker than weight alone as a proxy measure of physical risk but a rigid cut off point is less good for the extremes of height as the relationship is non-linear. Children have smaller fat stores than mature women and so medical complications occur with less weight loss. Bulimic features or refusal to drink also increase the risk. In turn, these medical markers interact with a variety of clinical and psychosocial factors. High physical risk is often associated with an impairment of capacity for the consent to treatment.

Because of the paucity of data and the nature of the issue under review, the GDG chose to use an informal consensus process (see Chapter 3, Section 3.4.7. for details) to address questions related to risk reduction and monitoring. The review team conducted a systematic search for all available evidence relating to the issue. A number of studies met the GDG’s eligibility criteria, including two systematic reviews of anorexia nervosa and mortality, and outcome at follow-up (Nielsen, 2001; Steinhassuen, 2002). Long-term follow-up studies on patients suffering from anorexia nervosa were also considered, and where possible predictors and causes of death were noted. This is an area in which there is limited research. Exact causes of death are rarely described. The majority of studies documented cause of death as being as a result of starvation in anorexia nervosa. In those studies where death certificates were examined, again the exact precipitant of death was not always established. There are few post-mortem results documented.

Physical factors associated with higher mortality include severity of weight loss, over-activity and vomiting, bulimia and purging (Nielsen, 2000; Steinhausen, 2002). A BMI less than 13 kg/m² in adults is of prognostic significance as it indicates a greater risk for mortality (Casper, 1996; Hebebrand et al., 1997). In the latter study, only seven out of the 14 patients with a BMI of 11 kg/m² at referral survived (Hebebrand, 1997). Data on malnourished females in famine indicate that with a BMI less than 11 kg/m², risk of mortality increases sharply (Collins, 1995). Prolonged QT intervals may predispose a person to life-threatening arrhythmias, and might be responsible for cases of sudden death. Furthermore, prolonged QT intervals in ECG were recorded seven days before sudden death (Isner, 1985). Abnormally low serum albumin levels and low weight are the best variables to predict a lethal course (Herzog et al., 1997).

In the studies documenting mortality in patients with anorexia nervosa, causes of death vary. Causes include dehydration, electrolyte (particularly hypokalaemia) and metabolic complications, infections (bronchopneumonia and sepsis) and cardiac complications (see Neumarker, 1997, for review). Comorbid alcoholism has also been shown to be associated with increased mortality (Keel et al., 2003). Rupture/perforation of the gastrointestinal tract has been less frequently described (Zipfel, 2000)

Few studies have reported exclusively on the mortality in adolescents. There is a suggestion that the mortality rate is lower. This may reflect the fact that chronicity and mortality increase with increasing age (Steinhausen, 2002). BMI measures in children and younger adolescents are an inadequate reflection of physical reserve. Weight centiles or percentage weight for height give a more accurate guide to the degree of weight loss. Rapid weight loss in children is potentially more dangerous than in adults, and children are known to dehydrate more quickly (Irwin, 1984). Clinical judgement and physical examination may be a better indicator than serum electrolyte levels as to the need for rehydration (Nicholls & Stanhope, 2000).

6.4.4. Clinical summary

Low weight (BMI less than 13 kg/m²), dehydration and electrolyte abnormalities indicate an increased risk of mortality. Cardiac arrhythmias and low serum albumin and glucose are of particular concern.

6.4.5. Clinical practice recommendations

6.4.6. Long-term risk and its management

Apart from the concern of immediate physical risk in patients with anorexia nervosa, the long-term physical consequences are considerable. For the purposes of this section, the GDG chose to focus on the effects on the skeletal system, on reproduction and the associated hormonal abnormalities, including low oestradiol, low IGF-I, and high serum cortisol that may contribute to the bone loss. Gastrointestinal and dental complications are largely as a result of vomiting and laxative abuse. These are described in the chapter on bulimia nervosa. It should be noted however that many of these complications are exacerbated in patients with low weight and muscle weakness. Other consequences have also been described (e.g. cardiac, dermatological, haematological), but these will not be covered in this guideline.

The development of osteopenia and osteoporosis is a serious and long-term consequence of starvation. Oestrogen deficiency, malnutrition, low body mass and hyperactivity all play a part in this development. This section will consider evidence for the effect of weight gain and medication in the management of this complication. In children and adolescents, weight loss has particularly serious implications. Sixty per cent of bone accretion occurs during puberty (Golden, 1992). Gain in bone mass is most pronounced between 11 and 14 years of age and falls significantly after 16 years of age (Soyka et al., 2002). Therefore, it would be expected that the failure of bone mineral accrual in girls with anorexia nervosa would differ depending on the maturation age.

Failure of this accretion thus compounds bone loss in children and adolescents with anorexia nervosa. Growth retardation is a further complication in children and adolescents (Russell, 1985; Danziger, 1994) and failure to grow may indicate nutritional deficiencies. It is thought that with weight gain ‘catch-up growth’ can occur up until fusion of the epiphyses (Nicholls & Stanhope, 2000). Regular monitoring of height as well as weight is important in children and adolescents with anorexia nervosa. Recommended weight ranges have to be regularly adjusted to take into account changes in height and age. Hormonal treatments, although used, have not been evaluated in adolescents with anorexia nervosa. There is a risk that oestrogen administration may cause premature epiphyseal fusion and growth stunting (Nicholls & Stanhope, 2000).

With regard to the reproductive system, there are several areas of concern: infertility, persistent amenorrhoea and oligomenorrhoea, and polycystic ovaries. In adolescent anorexia nervosa there is a risk of pubertal delay and ultimately arrested pubertal development (Russell, 1985). The effect on fertility and pregnancy will be described below.

Dental erosion is the most common oral problem in patients with eating disorders who engage in self-induced vomiting. A discussion of the issues concerning dental complications can be found in the chapter on bulimia nervosa (Section 7.5.2).

6.4.7. Clinical summary

Bone loss is a serious problem in anorexia nervosa with serious long-term consequences. Weight restoration is associated in adolescents with important gains in bone density. Oral oestrogen and oral DHEA do not appear to have a positive impact on bone density and hormone replacement therapy is not recommended in children and adolescents as it may cause premature fusion of the bones. High impact exercise is associated with an increased risk of fracture in anorexia nervosa. rhIGF-I, alone or in combination with an oral contraceptive, is associated with improvements in bone metabolism and bone mineral density but intensive clinical monitoring is necessary and this treatment should only be given in specialist centres with appropriate skills and knowledge. The long-term effect is uncertain.

6.4.8. Clinical practice recommendations

6.4.8.1.

Oestrogen administration should not be used to treat bone density problems in children and adolescents as this may lead to premature fusion of the epiphyses. [C]

6.4.9. Other physical interventions

Malnutrition is a core feature of anorexia nervosa. Refeeding is a necessary component of treatment but is not sufficient. The approach to refeeding varies between centres and countries. There is debate about the setting, means and rate of weight gain and limited evidence to support different views. In some centres the calorie deficit is made up with food, given as normal, albeit larger, meals or snacks. In other centres liquid foods can be used to supplement or replace some or all of the meals. An alternative, which is not used frequently within the UK, is nasogastric feeding. Rarely percutaneous endoscopic gastrostomy (PEG) or total parenteral nutrition (TPN) has been used. These interventions are only used when patients are not able to co-operate with oral refeeding and there is concern about physical risk. In these circumstances legal and ethical considerations need to be addressed.

A number of complications can occur during refeeding. This is a high-risk period for biochemical abnormalities. People at most risk are those with a BMI less than 12 kg/m², those who vomit, abuse laxatives and binge, and those with concurrent physical conditions. Physical monitoring is necessary during periods of refeeding. A range of electrolyte disturbances can occur during refeeding, which are sometimes referred to collectively as the ‘refeeding syndrome’. Hypophosphataemia may develop rapidly during refeeding; if severe, it can cause cardiac and respiratory failure, delirium and fits. Ingestion of large quantities of carbohydrates, during rapid refeeding, may result in a precipitate drop in serum phosphate levels. Therefore, in the first few days of refeeding patients who have had very low or absent intakes for long periods, no attempt should be made to achieve net weight gain. Instead they should receive energy and protein provision at levels at or less than their estimated basal requirements with generous provision of balanced multi-vitamins and minerals especially thiamine, potassium, magnesium and phosphate.

Certain vitamin or mineral deficits have come under close scrutiny. For example, the similarity between some of the symptoms of zinc deficiency and the symptoms of anorexia nervosa has led to an interest in zinc replacement. A proportion of patients with anorexia nervosa may be deficient in thiamine, riboflavin, Vitamin C and Vitamin D. The clinical significance of many of these deficiencies is unclear but it is usual for there to be a general rather than a specific deficit and therefore a multi-vitamin/multi-mineral supplement in oral form (e.g. suitable preparations include Sanatogen Gold [non-NHS], Forceval 1–2 or Seravit capsules daily). Care should be taken to prevent the risk of vitamin A and D toxicity from excessive use of supplements.

There has been some research into the nutritional management of anorexia nervosa but all of the studies on nutritional approaches are quasi-experimental and small, and the studies on zinc are small.

There is controversy, but little evidence, about the appropriate time course used to achieve the goals of treatment. Some argue that it is important to restore normal weight as soon as possible, others argue for a slower increase in weight. The standard rate of weight gain in the UK is 0.5 to 1 kg per week. The majority of people with anorexia nervosa are treated as outpatients but for the small number who require admission most specialist eating disorder inpatient units aim to discharge people once weight is fully recovered. However, there is an alternative view that full weight recovery can be achieved by outpatient or day patient interventions following brief inpatient refeeding, and that discharge at an intermediate weight may provide an alternative.

There is also the argument that weight gain is only one outcome of interest. Another goal is to ensure that eating behaviour is normalised and maintained after discharge, that abnormal weight and shape cognitions are normalised and that there is improved quality of life in people with anorexia nervosa.

Physical therapies have been used in some European countries (e.g. Belgium and Norway), which have a long tradition of integrating physical therapies into psychotherapy. Physical rehabilitation programmes including riding, climbing, for example, have been used. This has not been the tradition in the UK. Indeed in many programmes in the UK exercise is restricted and bed rest is prescribed.

6.4.10. Clinical summary

Nasogastric feeding can confer some benefit in terms of increased rate of weight gain or actual weight gain, as part of a treatment programme. There was insufficient evidence that either TPN or zinc supplementation confer any benefit in terms of weight gain. TPN appears to be associated with more adverse events in one small study. Some limited benefit, on symptoms but not on weight gain, has also been identified from one small trial investigating massage.

6.4.11. Clinical practice recommendations

6.4.11.1.

Total parenteral nutrition should not be used for people with anorexia nervosa, unless there is significant gastrointestinal dysfunction. [C]

6.4.12. Concurrent physical conditions

6.4.13. Clinical practice recommendations

6.5.1. Introduction

The majority of people with eating disorders present first in primary care. However, it is probable that most patients presenting with anorexia nervosa are referred on to secondary care usually within mental health services, including both general mental health services and specialist eating disorder services. Specialist eating disorder services for anorexia nervosa are distributed patchily (Royal College of Psychiatrists, 2001). A substantial proportion of such tertiary provision, in particular inpatient care, is in the private sector and many NHS patients are treated in private hospitals.

6.5.2. Current practice

Most patients with anorexia nervosa receive treatment solely on an outpatient basis. However, a substantial minority receive inpatient treatment. The style and content of inpatient programmes for anorexia nervosa varies widely. Hospital admission may be aimed at ameliorating the effects of the illness on the patient’s physical state or at achieving progress toward full recovery. The former sometimes involves admission to general medical settings. The latter is usually attempted within psychiatric hospitals. It is generally held that it is preferable for admission to be to settings where the staff are experienced in the treatment of the disorder. Furthermore, the setting needs to be appropriate to the age of the patient. Special day programmes are being developed as an alternative mode of intensive treatment for anorexia nervosa.

6.5.3. Effective service configurations

Although there is considerable variation in the pattern of service delivery there is a limited evidence base on which to develop effective patterns of service delivery. However, the principle that the right treatments should be offered to the right patients in the right setting if services are to be effective and cost-effective, should guide service development.

This review seeks to examine whether any particular level of service provision is associated with better outcomes in anorexia nervosa. In addressing this issue it may be useful to differentiate between two types of hospital admission.

First, inpatient treatment of anorexia nervosa may be aimed at the stabilisation and rectification of the patient’s physical state. It is widely believed that such treatment can at times be life-saving. However, such management has not been the subject of systematic comparative research and is unlikely to be.

Second, inpatient treatment aimed at helping the patient to progress toward full recovery is widely practiced and is more amenable to study.

The literature contains many descriptions of special inpatient treatment regimes for anorexia nervosa, and some outcome data are available (e.g. Bowers & Anderson, 1994). However, comparison between centres is difficult because of the likelihood that the case mix varies widely across studies. There is less data available about outpatient or day patient approaches. (Particular outpatient therapies are described elsewhere.) There is very little on the comparison between outpatient and day or inpatient treatment or on the integration of different forms of care.

The St. George’s study (Crisp, Norton, Gowers, Halek, Yeldham, Levett & Bhat, 1991) is alone in attempting a comparison within a randomised controlled trial of hospital admission and two forms of outpatient treatment. (There was also an assessment only condition but many participants went on to receive treatment elsewhere thereby confounding the comparison.)

The study lacked power and had other difficulties. However, it did demonstrate that many patients made progress with fairly modest outpatient treatment over one year (Gowers, Norton, Halek & Crisp 1994). Such outpatient treatment is widely practiced but poorly documented. In one study of a specialised secondary service nearly three-quarters of adults with anorexia nervosa were managed without hospital admission (Palmer, Gatward, Black & Park, 2000).

Specialised day patient treatment for anorexia nervosa has been described in this country and abroad and positive outcomes are documented at least in the short term (Birchall, Palmer, Waine, Gadsby & Gatward, 2002; Gerlinghof, Backmund & Franzen, 1998; Olmsted, McFarlane, Molleken & Kaplan, 2001; Robinson, 2003; Zipfel et al., 2002). However, it is uncertain whether the patients described might otherwise have been admitted as inpatients or managed as outpatients. There are no randomised comparisons. One study suggests that the addition of a day programme may reduce the use of inpatient beds (Birchall, Palmer, Waine, Gadsby & Gatward, 2002). It is unlikely that day care could ever abolish the need for inpatient treatment altogether. Indeed, the relative effectiveness and cost-effectiveness of the two forms of more intensive treatment have yet to be adequately studied.

It is widely believed that there may be benefits in the treatment of severe anorexia nervosa which has not responded to less intensive treatments within a specialised tertiary eating disorders service compared with less specialised secondary services. Both competence and confidence tend to develop in settings where such treatment is a regular and ongoing activity. However, there is a lack of studies that might provide evidence to support these views. One study of mortality in patients treated in two contrasting services suggested that there might be advantages associated with greater specialisation (Crisp, Callender, Halek & Hsu, 1992).

A single systematic review of inpatient versus outpatient treatment of anorexia nervosa was inconclusive because of lack of evidence (Meads, Gold & Burls, 2001).

6.5.4. Clinical summary

In a minority of patients, admission to hospital may at times be necessary to stabilise the physical state or even save the life of severely physically impaired patients. Inpatient treatment aimed at recovery usually leads to weight gain at least where admission has been to a unit where such treatment is a regular activity. Such treatment may have lasting effects although weight loss is common after discharge. There is no unequivocal evidence that inpatient treatment confers long-term advantage except as a short-term life-saving intervention in patients at high risk. However, inpatient treatment may well be a rational option for patients who have failed to respond to apparently adequate outpatient treatment. The place of day care as an alternative option in these circumstances has yet to be fully evaluated but seems promising.

6.5.5. Satisfaction with service setting/configuration and adherence to treatment

The area of patient and carer perceptions has been the focus of some research in the area of eating disorders. Much of this work has been focused on perceptions of inpatient treatment for anorexia nervosa or on mixed or poorly defined populations of people with eating disorders, therefore it should be treated with caution. This area of research is potentially informative when considering the relative merits of different service configurations although the major focus of such work has been on improving the acceptability of services, which may have benefits in terms of improved attendance rates and increased involvement with and effectiveness of programmes and treatments prescribed (Matoff & Matoff, 2001; Swain-Campbell et al., 2001). Taking account of user and carer perceptions when designing and delivering services may also facilitate help seeking over a prolonged period in people with recurrent mental health problems (Buston, 2002). This in turn may contribute to reduced morbidity.

Individuals with eating disorders, and anorexia nervosa in particular, are often described as being ambivalent about seeking treatment. Unlike most other psychiatric conditions, core features of eating disorders can be highly valued by the patient. In addition, the hospital environment can contribute to a sense of passivity and vulnerability, which can be linked to an increased sense of loss of control, one of the central characteristics of an eating disorder (Eivors et al., 2003). Such factors can contribute to a degree of reluctance to engage fully in interventions, resulting in relatively high levels of treatment refusal and premature drop-out, with related implications for long-term recovery and health care costs (Kahn & Pike, 2001; Swain-Campbell et al., 2001). Some centres report that up to 50 per cent of patients prematurely cease contact after assessment at an eating disorders service (Button et al., 1997; Vandereycken & Pierloot, 1993). Yager et al. (1989) draw attention to the fact that studies from many eating disorders centres suggest that drop-out rates for virtually all types of treatment are considerable, suggesting relatively high levels of patient dissatisfaction with services and treatments offered. Noordenbos et al. (1988) suggest that in people with a long-standing eating disorder, patients’ dissatisfaction may be compounded by clinicians’ beliefs about ‘chronic’ or ‘untreatable’ presentations.

People receiving inpatient treatment for anorexia nervosa have been found to be twice as likely to drop out of treatment compared to general psychiatric inpatients (Kahn & Pike, 2001). Reasons for drop out are likely to be varied and complex. One study found that drop out from adult inpatient treatment was modestly predicted by anorexia nervosa sub-type (being greater in the binge-purge sub-type) and length of illness (with associated higher number of previous hospitalisations) and not to severity of eating disorders symptomatology or associated psychopathology (Kahn & Pike, 2001). Another study concluded that very little of formal treatment is regarded by patients as essential to recovery in those who have been treated for and recovered from anorexia nervosa (Maine, 1985). Such findings suggested a complicated relationship between service setting, clinical outcome and patient experience that is difficult to tease out.

Models of service provision currently vary considerably. Newton (2001) reports that although various surveys have identified strengths and weaknesses in existing service provision, this information seems to have had little impact on service planning. Assessment of patient and carer satisfaction specifically in relation to service setting is rarely carried out. Similarly, patient adherence and drop out, specifically in relation to service setting is not usually investigated (Mahon, 2000). Information about patient and carer views tends to come from qualitative studies of service users, based on structured and semi-structured interviews (with data presented descriptively or, for example, using a type of thematic content analysis such as a grounded theory approach) or questionnaires. The latter are often used to measure characteristics of clinical presentation (rather than service setting), which are then correlated with, for example, satisfaction or drop out. In some cases forced choice responses about satisfaction or ratings of perceived helpfulness are used, but again these are rarely related specifically to service configurations. Research in the area of satisfaction surveys is particularly prone to bias.

This issue of satisfaction and adherence to treatment was considered across a number of different types of service setting (e.g. outpatient, inpatient, day patient, generalist, specialist, self-help; local, distant, etc.); and across different age groups (adults, adolescents, children).

The review team conducted a new systematic search for all relevant research. No studies were found that specifically investigated comparisons between types of service. Nevertheless, a number of studies provided useful data (Brinch, Isager & Tolstrup, 1988; Buston, 2002; Button et al., 1997; Button & Warren, 2001; Carnell, 1998; Deeble & Bhat, 1991; Eivors et al., 2003; Haigh & Treasure, 2003; Hsu, Crisp & Callender, 1992; Kahn & Pike, 2000; Kopec-Schrader et al., 1993; Le Grange & Gelman, 1998; Mahon, 2000; Maine, 1985; Malson et al., unpublished; Matoff & Matoff, 2001; Newton, 2001; Newton et al., 1993a; Noordenbos et al., 1988; Pettersen & Rosenvinge, 2002; Rosenvinge & Klusmeier, 2000; Sharkey-Orgnero, 1999; Stockwell et al., 1987; Sturmey, 1992; Swain Campbell, Surgenor & Snell, 2001; Tozzi et al., 2003; Vandereycken & Pierloot, 1983; Yager et al., 1989). Seven further studies were consulted, but not used directly (Bowers & Andersen, 1994; Greenwood et al., 1999; Lemberg & May, 1991; Neiderman et al., 2000; Newton, Hartley & Sturmey, 1993b; Wilhelm & Clarke, 1998; Zipfel et al., 2002).

The following findings emerged from the papers considered in this section:

• Greater treatment satisfaction is most commonly reported in relation to outpatient treatment (particularly regarding individual and group therapy) (Rosenvinge & Klusmeier, 2000; Newton et al., 1993a).
• Lengthy waiting times for outpatient treatment have been identified as a major reason for being dissatisfied with health care, and problems and delays in accessing medical or other appropriate help are associated with lower levels of satisfaction (Rosenvinge & Klusmeier, 2000; Buston, 2002).
• Carers and parents of adolescents have identified a lack of and need for support, involvement and education about eating disorders for themselves (Kopec-Schrader et al., 1993; Haigh & Treasure, 2003).
• Continuity of care with an individual professional has been found to be valued –this could be taken to support the notion of comprehensive services, which can be flexible in terms of intensity (Buston, 2002).
• People who perceive their therapists to be ‘experts on eating disorders’ have been found to be more satisfied with treatment. ‘Expert’ includes concepts of ‘understanding’ and having ‘knowledge of eating disorders’ with the former being rated as the more important therapist attribute (Rosenvinge & Klusmeier, 2000).
• Informal supportive social relationships outside the treatment setting and a supportive relationship with a partner have been identified as important in recovery in people with eating disorders (Maine, 1985; Pettersen & Rosenvinge, 2002; Tozzi et al., 2003).
• Surveys of self-help groups suggest that they are regarded by the majority of attendees as helpful, being positively associated with social involvement and supportive sharing. However, self-help groups can be experienced by some individuals as upsetting or promoting competitiveness in terms of weight loss and eating disorders behaviours (Deeble & Bhat, 1991).
• Some people who have received treatment for anorexia nervosa report a general negative perception of being treated as an illness or diagnosis rather than as a person (Brinch et al., 1988, Malson et al.). This may be associated with reduced likelihood of seeking psychiatric help later.
• Perceived negative staff attitudes, and an overemphasis on weight and weight restoration have been identified as unhelpful or harmful aspects of treatment by adults receiving inpatient treatment (Button & Warren, 2001). An overemphasis on weight gain has also been found to be associated with drop out from treatment (Newton et al., 1993a).
• The acceptability of inpatient treatment for anorexia nervosa in adolescence has been rated as low in regards to feeling pressured and watched, with authoritarian and restricting aspects of therapy causing anger and ambivalence (Brinch et al., 1988).
• Adolescents have reported a sense of lack of privacy and intrusiveness in the context of inpatient care (Buston, 2002).
• Parents of adolescents with anorexia nervosa have reported feeling blamed for their child’s eating disorder by clinicians providing treatment (Sharkey-Orgnero, 1999).

6.5.6. Relationship between service setting and risk of death, suicide and self-harm

Anorexia nervosa is associated with an increased mortality (Nielsen, 2001). People at risk of death because of their extreme physical state are likely to be considered –appropriately – for admission to hospital. However, there is unlikely to be systematic evidence to support such practice. Furthermore, people suffering from anorexia nervosa may be at increased risk of self-harm and suicide (Favaro & Santonastaso, 2000). This is especially so with respect of the binge-purging sub-type of anorexia nervosa.

6.5.7. Compulsory admission and treatment

A decision to compulsorily treat people with eating disorders occurs infrequently but does raise debate amongst professionals working in the field, the individuals they treat and their families. People with anorexia nervosa often differ from others with mental health problems in that the central characteristics of the illness are perceived as functional and valued by the individual. The individual can be perceived as ambivalent about recovery and resistant to intervention. In (eating disorders) treatment an emphasis is placed on developing a collaborative therapeutic relationship with the individual. Under conditions of compulsion this may be more difficult. However individuals who have undergone such treatment report contrasting positive and negative views when asked to comment later.

Treatment in this context refers to inpatient treatment of anorexia nervosa in adults, children and adolescents. However in the case of children and adolescents compulsory treatment can take place on an outpatient basis under parental authority, under the Mental Health Act 1983 and more rarely, with specific Court Orders.

There are no reports of compulsory admission for the specific treatment of bulimia nervosa or binge eating disorder (BED) in the UK.

Compulsory admissions and treatment for adults are carried out using the Mental Health Act (MHA) 1983. The Mental Health Act Commission (Guidance note number 3) provides guidance on the use of the Act in anorexia nervosa. Practice with children and adolescents, varies throughout the country. The issues of the ‘assessment of competence (in children/adolescents) and capacity (in adults)’ are complex. Legislation used with this population includes the Mental Health Act 1983 and the Children Act 1989.

Individuals with anorexia nervosa may be ambivalent about their treatment and can experience treatment as compulsory whatever their legal status. Often there are no differences between treatment programmes for those admitted and treated compulsorily and those who are not. Patients with eating disorders are sometimes admitted compulsorily for treatment of comorbid conditions.

For the purpose of this guideline, compulsory admission and treatment will be defined as that carried out using the legal powers available under the Mental Health Act 1983 or the Children Act 1989 or the authority of the court.

A further aim of employing compulsion under the MHA 1983 is to offer the individual the protection that is provided for them in the Act. It is important to remember that compulsory treatment does not equate with ‘feeding against the will of the person’ or ‘force feeding’. It is helpful to hold in mind the distinction between treatment carried out under the legislation with which the individual complies (for whatever reason) and that which the individual resists.

6.5.8. Clinical practice recommendations

6.5.8.1.

Most people with anorexia nervosa should be treated on an outpatient basis. [C]

6.5.8.2.

Inpatient treatment or day patient treatment should be considered for people with anorexia nervosa whose disorder has not improved with appropriate outpatient treatment, or for whom there is a significant risk of suicide or severe self-harm. [C]

6.5.8.3.

Inpatient treatment should be considered for people with anorexia nervosa whose disorder is associated with high or moderate physical risk. [C]

6.5.8.4.

Where inpatient management is required, this should be provided within a reasonable travelling distance to enable the involvement of relatives and carers in treatment, to maintain social and occupational links and to avoid difficulty in transition between primary and secondary care services. This is particularly important in the treatment of children and adolescents. [C]

6.5.8.5.

People with anorexia nervosa requiring inpatient treatment should normally 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. [C]*

6.5.8.6.

Health care professionals without specialist experience in eating disorders, or in situations of uncertainty, should consider seeking advice from an appropriate specialist when contemplating a compulsory admission for a patient with anorexia nervosa regardless of the age of the patient. [C]

6.5.8.7.

Health care professionals managing patients with anorexia nervosa, especially those with the binge-purging sub-type, should be aware of the increased risk of self-harm and suicide, particularly at times of transition between services or service settings. [C]

6.6.1. Clinical practice recommendations

6.6.1.1.

People with eating disorders should be assessed and receive treatment at the earliest opportunity. [C]

6.6.1.2.

Early treatment is particularly important for those with or at risk of severe emaciation and such patients should be prioritised for treatment. [C]