Involuntary admission: the case of anorexia nervosa

Longitudinal investigation of patients receiving involuntary treatment for extremely severe anorexia nervosa

INTRODUCTION

Involuntary treatment may be a life-saving option for extremely severe anorexia nervosa (AN) in the context of life-threatening conditions and refusal of care. The long-term outcomes of patients undergoing involuntary treatment for AN are poorly understood. This study aims to explore quality of life, long-term outcomes and attitudes towards involuntary treatment in patients involuntarily treated for extremely severe AN.

METHODS

23 patients involuntarily admitted for extremely severe AN (I-AN), and 25 voluntarily admitted patients (V-AN) were compared for body mass index (BMI), residual symptoms, quality of life, and attitudes towards treatment almost four years after discharge. In I-AN, clinical variables were also compared between admission and follow-up.

RESULTS

At follow-up, weight restoration was higher in V-AN (p = 0.01), while differences in quality of life, BMI, and mortality rates were not significant between I-AN and V-AN (p > 0.05). In I-AN, BMI increased and weight-controlling strategies decreased at follow-up (p < 0.05). Despite negative experiences of involuntary treatment, the perception of the necessity of treatment increased from admission to follow-up (p < 0.01) and became comparable to V-AN (p > 0.05).

DISCUSSION

Involuntary treatment for AN does not appear to be a barrier to weight gain and clinical improvement, nor to long-term attitudes towards treatment.

Involuntary treatment: A qualitative study from the perspectives of individuals with anorexia nervosa

OBJECTIVE

Involuntary treatment for anorexia nervosa (AN) is sometimes necessary and lifesaving but can be experienced negatively by some individuals. The purpose of this qualitative study was to better understand participants' perceptions about their experience with involuntary treatment for AN.

METHOD

Thirty adult participants, who had been treated involuntarily for AN in the past, completed self-report measures and qualitative interviews. Interview transcripts were coded using thematic analysis.

RESULTS

Three themes were identified: (1) mixed perceptions about involuntary treatment, (2) the impact of involuntary treatment on external factors, including relationships, education, and employment, and (3) lessons learned from the experience. Participants who endorsed a positive shift in perspective regarding the need for involuntary treatment also reported favorable changes in their eating disorder recovery, whereas individuals whose perspective about their involuntary treatment remained negative, showed no changes in their recovery post-treatment.

CONCLUSIONS

Involuntary treatment for AN was recognized, in retrospect, as being beneficial by individuals with AN who were doing well, but individuals who continued to struggle with their eating disorder reported negative consequences.

Clinical and Ethical Dilemmas in the Involuntary Treatment of Anorexia Nervosa

LEARNING OBJECTIVES

After completing this activity, practitioners will be better able to:• Discuss the growing body literature emphasizing moderation and harm-reduction in patients with severe and enduring anorexia nervosa (SE-AN)• Outline and discuss the legal, ethical, and medical challenges inpatient providers face when treating patients with SE-AN.

ABSTRACT

Patients with severe and enduring anorexia nervosa (SE-AN) present numerous clinical and ethical challenges for the hospital psychiatrist. Patients typically come to the hospital in a state of severe medical compromise. Common difficulties in the period of acute medical stabilization include assessment of decision-making capacity and the right to decline treatment, as well as legally complex decisions pertaining to administering artificial nutrition over the patient's objection. Following acute medical stabilization, the psychiatric consultant must decide whether psychiatric hospitalization for continued treatment is indicated, and if so, whether involuntary hospitalization is indicated. The standard of care in these situations is unclear. Pragmatic issues such as lack of appropriate facilities for specialized treatment are common. If involuntary hospitalization is not approved or not pursued, there may be difficulty in determining whether, when, and how to involve palliative care consultants to guide further management. These cases are complex and largely reside in a medico-legal and ethical gray area. This article discusses the difficulties associated with these cases and supports a growing body of literature emphasizing moderation and harm-reduction in patients with SE-AN. Physician-assisted dying (PAD) is also discussed.

Implications of Involuntary Psychiatric Admission: Health, Social, and Clinical Effects on Patients

Involuntary psychiatric admission is an increasing, widespread practice adopted throughout the world; however, its legal regulation and practice are still under debate, and it is subject to criticism from the human rights point of view. Only a few studies have strictly focused on the outcomes and subsequent treatment implications of this practice. To perform a scoping review of the literature on involuntary psychiatric admission and systematize and summarize its outcomes and implications for adult psychiatric inpatients.Four overarching issues emerged from the studies: a) symptomatological repercussions, b) impacts on treatment before discharge, c) impacts on treatment after discharge, and d) implications on patients' attitudes, behavior, and functioning. The overall evidence suggested correlations between involuntary psychiatric admission and several implications: length of stay, aggressive behavior, occurrence of psychopathologies, uses of coercive measures, psychiatric service activations after discharge, emotive reactions, and quality of life. The proposal presented here is the major involvement of the patient and of all the other actors involved during the entire treatment process to promote a shift from a delegation perspective to a negotiation perspective in the management of involuntary psychiatric admission.

Reconsidering the ethics of compulsive treatment in light of clinical psychiatry: A selective review of literature

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It provides contradictory evidence on how patients experience CT and its impact on their mental health and treatment programs, also which are main reasons for the use of CT and what efforts in psychiatry have been made to reduce, replace and refine it.

Reconsidering the ethics of compulsive treatment under the light of clinical psychiatry

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It focuses on how patients experience CT and its impact on their mental health and treatment programs, the reasons for the use of CT versus voluntary treatment and what efforts have been made to reduce, replace and refine the presence of CT in psychiatry.

Reconsidering the ethics of compulsive treatment in light of clinical psychiatry: A selective review of literature

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It provides contradictory evidence on how patients experience CT and its impact on their mental health and treatment programs, also which are main reasons for the use of CT and what efforts in psychiatry have been made to reduce, replace and refine it.

Compulsory treatments in eating disorders: a systematic review and meta-analysis

INTRODUCTION

The aims of this systematic review and meta-analysis are to provide a summary of the current literature concerning compulsory treatments in patients with eating disorders (ED) and to understand whether compulsorily and involuntarily treated patients differ in terms of baseline characteristics and treatment outcomes.

METHODS

Relevant articles were identified following the PRISMA guidelines by searching the following terms: "treatment refusal", "forced feeding", "compulsory/coercive/involuntary/forced treatment/admission", "eating disorders", "feeding and eating disorders", "anorexia nervosa", "bulimia nervosa". Research was restricted to articles concerning humans and published between 1975 and 2020 in English.

RESULTS

Out of 905 articles retrieved, nine were included for the analyses allowing the comparisons between 242 compulsorily and 738 voluntarily treated patients. Mean body mass index (BMI) was slightly lower in patients compelled to treatments. Mean illness duration, BMI at discharge and BMI variation showed no significant differences between the two groups. Average length of hospitalization was 3 weeks longer among compulsory-treated patients, but this did not result in a higher increase in BMI. No significant risk difference on mortality was estimated (three studies).

CONCLUSIONS

Compulsory treatments are usually intended for patients having worse baseline conditions than voluntary ones. Those patients are unlikely to engage in treatments without being compelled but, after the treatments, albeit with longer hospitalisations, they do achieve similar outcomes. Therefore, we can conclude that forcing patients to treatment is a conceivable option.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis.

Practitioners' perspectives on ethical issues within the treatment of eating disorders: Results from a concept mapping study

OBJECTIVE

Treating patients with eating disorders (EDs) is associated with an array of ethical concerns, including balancing patients' health and autonomy, access to care, and use of harm-reduction versus recovery-oriented treatment models. The primary aim of the current study is to gain a better understanding of ethical issues faced by ED practitioners by using a concept mapping, or Q-sort, approach.

METHOD

A total of 12 practitioners completed the brainstorming phase and generated statements regarding ethical issues they faced while treating patients with EDs. A subsequent 38 practitioners completed a sorting task, where they created and labeled piles, into which they grouped each statement. Of those 38 participants, 30 rated both the frequency with which they encountered each ethical issue and its impact on patient care.

RESULTS

A total of six clusters emerged: Insufficient Level of Care, Lack of Evidence-Based Practice, Insurance Barriers, Family Involvement, Patient Autonomy, and Limited Access to Expertise. Lack of Evidence-Based Practice, Insurance Barriers, and Insufficient Level of Care was the most frequent problem faced by ED practitioners, whereas Insurance Barriers and Patient Autonomy had the greatest impact.

DISCUSSION

Findings outline frequent and impactful areas of ethical concern that arise when treating patients diagnosed with EDs. Practitioners most commonly reported that patient- and insurance-driven factors limited patient access to appropriate care. Regulations supporting the provision of evidence-based care should be emphasized in public health policy and advocacy efforts, given their impact in limiting the delivery of adequate patient care.

Medication assisted treatment (MAT) in criminal justice settings as a double-edged sword: balancing novel addiction treatments and voluntary participation

Medication-Assisted Treatment (MAT) provides an opportunity to address opioid addiction among justice-involved individuals, an often difficult to reach population. This potential has been increasingly recognized by agencies, policymakers and pharmaceutical companies. The result has been a marked increase in the number of drug courts, prisons and agencies in which MAT, notably with long-acting injectable medications, is offered. While this is a positive development, ensuring that vulnerable individuals are in a position voluntarily participation within the complex criminal justice environment is necessary. The unequal authority and agency inherent in the nature of these environments should be recognized. Therefore, rigorous protections, mirroring the goals of the consent processes required for medical or sociobehavorial research, should be employed when MAT is offered to protect individual autonomy.

Physicians' perspectives on the treatment of patients with eating disorders in the acute setting

BACKGROUND

Hospitalisation for an eating disorder is rare, however treatment in the acute medical setting can be a life-saving admission. While the multidisciplinary team delivers overall patient care, medical decisions are the responsibility of the treating physicians. Treatment decisions directly impact on patient care and outcomes. This study aimed to explore the considerations that influence the medical decisions of physicians when treating patients with eating disorders in the acute setting.

METHOD

Semi-structured interviews were conducted with ten medical physicians who had previously treated eating disorders on a general medical unit in two Australian tertiary hospitals. An interview schedule, based on the literature and four relevant domains from the Consolidated Framework for Implementation Research, was developed. Interviews were audio recorded, transcribed verbatim and analyzed thematically. Coding and interim themes and sub-themes were developed by two dietitian researchers; these were further refined through researcher discussion and triangulation with two additional dietitian researchers.

RESULTS

Ten doctors were interviewed (3 consultants (1 adult general medical and 2 paediatricians: 13-16 years medical experience), 2 registrars (4-7 years experience), 1 resident (1 year experience), and 4 interns (< 1 year experience). Doctors described memorable patient cases, related to hospital stays over several weeks. Interviews ranged in length from 58 min to 91 min. Four themes (with five sub-themes) were developed: 1) navigating uncertainty (focusing on processes and goals and seeking information), 2) being "the good doctor" (doing the right thing), 3) seeing the big picture (depending on key players and considering short and long-term), and 4) involving family and patient.

CONCLUSIONS

Non-specialist physicians described challenges in the treatment of eating disorders in the inpatient setting. They take a holistic approach that considers both short and longer-term goals, relying on specialist colleagues, the wider multidisciplinary team and sometimes family members to guide treatment decisions during admissions on general medical wards. Additional support, education and training centered on the key themes may increase physicians' confidence and ability to make effective treatment decisions for this patient group. The results are relevant to all health professionals working in this field to better understand the priorities of medical physicians and to support them to achieve positive outcomes in the inpatient treatment of patients with eating disorders.

Therapeutic alliance, anorexia nervosa and the inpatient setting: A mixed methods study

AIMS

The aim of this study was to understand the context of the inpatient setting for the treatment of anorexia nervosa and the implications for the therapeutic alliance between nurses and consumers.

BACKGROUND

The nature of the therapeutic alliance is dependent on the contextual factors that influence interactions. The inpatient setting for the treatment of anorexia nervosa is one such setting where the therapeutic alliance is operative, yet challenging and poorly understood.

DESIGN

A two-phase explanatory sequential design was employed. Descriptive statistics from phase one informed phase two interviews. Phase two data were analysed through thematic analysis.

METHODS

A convenience sample of nurses and consumers were recruited from six wards, in five hospitals. Phase one involved the completion of a survey (N = 128) that measured the strength of the therapeutic alliance, as well as other elements of ward context. Phase two interviews (N = 54) were focused on the therapeutic alliance between nurses and consumers and the implications of the inpatient setting. Data collection occurred between May 2014 - February 2015.

RESULTS

Anorexia nervosa as an illness carries destructive implications for the quality of the therapeutic alliance. Nurses' intimate position in the inpatient setting and interpersonal capacity is influential in overcoming the obstacles that impede the therapeutic alliance.

CONCLUSION

Nurses' capacity for developing therapeutic alliances is in part dependent on a supportive ward organization and the adequacy of resources to permit meaningful interactions with consumers with anorexia nervosa. Understanding the contextual factors specific to the inpatient setting enhances nurses' ability to develop therapeutic alliances.

Caring for Patients With Severe and Enduring Eating Disorders (SEED): Certification, Harm Reduction, Palliative Care, and the Question of Futility

Anorexia nervosa is a serious mental illness with a high mortality rate. The body image distortion inherent to this disorder and the impaired judgment and cognition due to malnutrition frequently result in patients refusing treatment. Treatment is most effective if patients are treated early in the course of their illness and undergo a full course of treatment. Involuntary treatment may therefore be both life-saving and critical to recovery. Between April 2012 and March 2016, 109 patients (5.2% of patients admitted to the Eating Recovery Center in Denver, CO) were certified, 39% of whom were transferred from the ACUTE Center for Eating Disorders at Denver Health Medical Center. Of these 109 certified patients, 31% successfully completed treatment, and 42% returned for a further episode of care; 24% of the certifications were terminated as involuntary treatment was not found to be helpful. Conclusions supported by these data are that patients with anorexia nervosa who are the most medically ill often require involuntary treatment. In addition, although many patients who are certified successfully complete treatment, involuntary treatment is not helpful approximately 25% of the time. Many of the patients for whom certification is ineffective are those who suffer from a lifetime of illness that is severe and enduring. Patients with severe and enduring eating disorders (SEED) typically undergo cyclical weight restoration and weight loss. Many of these patients question the value of serial treatments, especially when they have few (if any) illness-free intervals. Patients, families, and treating physicians often wish to explore other models of care, including harm reduction and palliative care. In addition, patients with SEED may also contemplate whether a compassionate death would be better than an ongoing lifetime of suffering. In this review, we outline arguments for and against the concept of futility in SEED, and explore whether (or when) patients are competent to make the decision to die.

Perceived coercion in inpatients with Anorexia nervosa: Associations with illness severity and hospital course

OBJECTIVE

The use of coercion in the treatment for anorexia nervosa (AN) is controversial and the limited studies to date have focused on involuntary treatment. However, coercive pressure for treatment that does not include legal measures is common in voluntarily admitted patients with AN. Empirical data examining the effect of non-legal forms of coerced care on hospital outcomes are needed.

METHOD

Participants (N = 202) with AN, Avoidant/Restrictive Food Intake Disorder (ARFID), or subthreshold AN admitted to a hospital-based behavioral specialty program completed questionnaires assessing illness severity and perceived coercion around the admissions process. Hospital course variables included inpatient length of stay, successful transition to a step-down partial hospitalization program, and achievement of target weight prior to program discharge.

RESULTS

Higher perceived coercion at admission was associated with increased drive for thinness and body dissatisfaction, but not with admission BMI. Perceived coercion was not related to inpatient length of stay, rate of weight gain, or achievement of target weight although it was predictive of premature drop-out prior to transition to an integrated partial hospitalization program.

DISCUSSION

These results, from an adequately powered sample, demonstrate that perceived coercion at admission to a hospital-based behavioral treatment program was not associated with rate of inpatient weight gain or achieving weight restoration, suggesting that coercive pressure to enter treatment does not necessarily undermine formation of a therapeutic alliance or clinical progress. Future studies should examine perceived coercion and long-term outcomes, patient views on coercive pressures, and the effect of different forms of leveraged treatment.