The use of guardianship legislation for anorexia nervosa: a report of 15 cases

Involuntary treatment in patients with anorexia nervosa: utilization patterns and associated factors

BACKGROUND

A subgroup of patients with anorexia nervosa (AN) undergoing involuntary treatment (IT) seems to account for most of the IT events. Little is known about these patients and their treatment including the temporal distribution of IT events and factors associated with subsequent utilization of IT. Hence, this study explores (1) utilization patterns of IT events, and (2) factors associated with subsequent utilization of IT in patients with AN.

METHODS

In this nationwide Danish register-based retrospective exploratory cohort study patients were identified from their first (index) hospital admission with an AN diagnosis and followed up for 5 years. We explored data on IT events including estimated yearly and total 5-year rates, and factors associated with subsequent increased IT rates and restraint, using regression analyses and descriptive statistics.

RESULTS

IT utilization peaked in the initial few years starting at or following the index admission. A small percentage (1.0%) of patients accounted for 67% of all IT events. The most frequent measures reported were mechanical and physical restraint. Factors associated with subsequent increased IT utilization were female sex, lower age, previous admissions with psychiatric disorders before index admission, and IT related to those admissions. Factors associated with subsequent restraint were lower age, previous admissions with psychiatric disorders, and IT related to these.

CONCLUSIONS

High IT utilization in a small percentage of individuals with AN is concerning and can lead to adverse treatment experiences. Exploring alternative approaches to treatment that reduce the need for IT is an important focus for future research.

Influence of eating disorder psychopathology and general psychopathology on the risk of involuntary treatment in anorexia nervosa

PURPOSE

We explored associations between clinical factors, including eating disorder psychopathology and more general psychopathology, and involuntary treatment in patients with anorexia nervosa. Our intention was to inform identification of patients at risk of involuntary treatment.

METHODS

This was a retrospective cohort study combining clinical data from a specialized eating disorder hospital unit in Denmark with nationwide Danish register-based data. A sequential methodology yielding two samples (212 and 278 patients, respectively) was adopted. Descriptive statistics and regression analyses were used to explore associations between involuntary treatment and clinical factors including previous involuntary treatment, patient cooperation, and symptom-level psychopathology (Eating Disorder Inventory-2 (EDI-2) and Symptom Checklist-90-Revised (SCL-90-R)).

RESULTS

Somatization (SCL-90-R) (OR = 2.60, 95% CI 1.16-5.81) and phobic anxiety (SCL-90-R) (OR = 0.43, 95% CI 0.19-0.97) were positively and negatively, respectively, associated with the likelihood of involuntary treatment. Furthermore, somatization (HR = 1.77, 95% CI 1.05-2.99), previous involuntary treatment (HR = 5.0, 95% CI 2.68-9.32), and neutral (HR = 2.92, 95% CI 1.20-7.13) or poor (HR = 3.97, 95% CI 1.49-10.59) patient cooperation were associated with decreased time to involuntary treatment. Eating disorder psychopathology measured by the EDI-2 was not significantly associated with involuntary treatment.

CONCLUSIONS

Clinical questionnaires of psychopathology appear to capture specific domains relevant to involuntary treatment. Poor patient cooperation and previous involuntary treatment being associated with shorter time to involuntary treatment raise important clinical issues requiring attention. Novel approaches to acute anorexia nervosa care along with unbiased evaluation upon readmission could mitigate the cycle of repeat admissions with involuntary treatment.

LEVEL OF EVIDENCE

Level III, cohort study.

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.

What distinguish patients with compulsory treatment for severely undernourished anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is a mental disorder potentially leading to severe malnutrition and life-threatening complications, with high mortality rates and dropouts from treatment. In the most severe cases, treatment refusal associated with acute nutritional disorders may require compulsory admission in specialised units. The aim of this study was to investigate clinical and nutritional parameters associated with the use of compulsory treatment for severely ill AN patients requiring intensive nutritional care.

METHODS

This retrospective, single-centre study performed in a unit of specialised nutritional care compared severely undernourished inpatients, compulsorily admitted for AN, with a population of sex- and age-matched voluntarily admitted patients. Socio-demographic and clinical variables were collected for univariate comparison and logistic regression.

RESULTS

Compulsory treatment in AN was mainly associated with lower socio-economic status (p < 0.01), history of lower weight (p < 0.05), more frequently prescribed psychotropic medication (p = 0.02), more previous admissions for AN, longer hospitalisations (p < 0.01) and binge eating/purging subtype (p = 0.02). Binge eating/purging subtype and the number of past admissions showed the strongest odds of compulsory treatment in multivariate analysis.

CONCLUSION

The knowledge of factors associated with compulsory treatment may help practitioners of all fields to better evaluate its pertinence and indications in AN.

Involuntary Treatment and Quality of Life

The issues centering on the involuntary treatment of severe and enduring anorexia nervosa are daunting. There is a general consensus that people with this illness are likely to have high levels of disability, be underemployed/unemployed, and receive welfare. Anorexia nervosa shows a similar degree of impairment to those with depression or schizophrenia on quality-of-life measures. It is possible to mount a cogent argument as to why a rehabilitation model of care needs to be considered for those with persistent eating disorders. In such cases, harm minimization and improved quality of life should be prioritized and involuntary treatment used judiciously.

When Does the “Duty to Protect” Apply with a Client Who has Anorexia Nervosa?

Individuals with eating disorders, especially those with anorexia nervosa, have the potential to experience significant harm and even death as a result of behaviors related to their condition. Because of this risk, the authors argue that there is a duty to protect (i.e., an obligation to take some action when a person is engaging or considering engaging in a behavior that may lead to self-harm) when a client's anorexia-related behavior has progressed to the point of medical jeopardy—that is, her or his life is in danger. This article reviews information on anorexia, including mortality data; ethical and legal issues when a client is believed to be a harm-to-self; and the literature related to involuntary hospitalization and compulsory treatment of clients with anorexia. The article concludes with a set of guidelines for when the duty to protect when a client has anorexia nervosa begins and with suggestions for interventions.

Compulsory treatment in anorexia nervosa: a review

OBJECTIVE

Compulsory in-patient refeeding of patients with severe anorexia nervosa (AN) has caused considerable controversy. The effects of such treatment on longer-term outcome are not well known. The objective of this article is to review the evidence on the outcome of compulsory treatment for AN.

METHOD

Three large databases were searched for studies regarding compulsory treatment in AN.

RESULTS

Detained patients have more severe symptoms and comorbidity and a longer duration of inpatient stay. In the short term compulsory refeeding in AN appears to be beneficial, but the longer term effects remain uncertain. Clinicians report no worsening of the therapeutic relationship after compulsory treatment.

DISCUSSION

In severe cases of AN where the patient refuses life-saving treatment compulsory treatment needs to be considered. Future research should focus on the longer term effects of compulsory treatment and also on questions related to mental capacity in AN.

A systematic review of the frequency, duration, type and effect of involuntary treatment for people with anorexia nervosa, and an analysis of patient characteristics

OBJECTIVE

Involuntary treatment of anorexia nervosa is controversial and costly. A better understanding of the conditions that determine involuntary treatment, as well as the effect of such treatment is needed in order to adequately assess the legitimacy of this model of care. The aim of the present study was to investigate the frequency and duration of involuntary treatment, the characteristics of this group of patients, the kind of involuntary actions that are applied and the effect of such actions.

REVIEW

Relevant databases were systematically searched for studies investigating the involuntary treatment of individuals diagnosed with anorexia nervosa.

RESULTS

The studies included in the review contained people treated in an inpatient setting for severe or severe and enduring anorexia nervosa. People that were treated involuntarily were characterised by a more severe psychiatric load. The levels of eating disorder pathology between involuntary and voluntary groups were similar and the outcome of involuntary treatment was comparable in terms of symptom reduction to that of voluntary treatment.

CONCLUSION

Despite inconsistent findings, the comparable levels of eating disorder pathology observed between involuntary and voluntary patient-groups together with findings of higher co-morbidity, more preadmissions, longer duration of illness and more incidences of self-harm for involuntary patients suggest that involuntary treatment is not a reaction to the severity of eating disorder symptoms alone, but is most likely a response to the complexity of the patient's situation as a whole.

Psychological treatment for anorexia nervosa: a meta-analysis of standardized mean change

BACKGROUND

For the German treatment guidelines for eating disorders, the literature on psychological treatment of anorexia nervosa (AN) was reviewed systematically. As a common meta-analysis of randomized clinical trials proved to be impossible, a review of all available clinical trials was conducted, statistically integrating standardized mean change scores. Research questions comprised differential effects of therapeutic techniques and settings as well as determining which weight gains could be expected.

METHODS

After an extensive literature search, studies were selected, rated by 3 independent raters. Weight gain as the main outcome criterion was transformed into standardized mean change scores. Effect sizes were checked for homogeneity.

RESULTS

57 studies containing 84 treatment arms and 2,273 patients could be integrated. Studies differed considerably in quality. The strongest bias identified was reporting selectively on completers or failures, versus intention-to-treat samples. No significant differences between effect sizes could be identified concerning treatment setting, technique or patient characteristics. If treatment time is taken into account, inpatient treatment produced a faster weight gain than outpatient treatment.

CONCLUSION

The study describes weight gains which can be reached in outpatient and inpatient settings. It yielded no salient results speaking for a certain therapy technique, setting or procedure. Treatment guidelines for psychological treatment of AN still have to rely on lower level evidence.

Psychiatrists' attitudes towards autonomy, best interests and compulsory treatment in anorexia nervosa: a questionnaire survey

BACKGROUND

The compulsory treatment of anorexia nervosa is a contentious issue. Research suggests that psychiatrists have a range of attitudes towards patients suffering from anorexia nervosa, and towards the use of compulsory treatment for the disorder.

METHODS

A postal self-completed attitudinal questionnaire was sent to senior psychiatrists in the United Kingdom who were mostly general adult psychiatrists, child and adolescent psychiatrists, or psychiatrists with an interest in eating disorders.

RESULTS

Respondents generally supported a role for compulsory measures under mental health legislation in the treatment of patients with anorexia nervosa. Compared to 'mild' anorexia nervosa, respondents generally were less likely to feel that patients with 'severe' anorexia nervosa were intentionally engaging in weight loss behaviours, were able to control their behaviours, wanted to get better, or were able to reason properly. However, eating disorder specialists were less likely than other psychiatrists to think that patients with 'mild' anorexia nervosa were choosing to engage in their behaviours or able to control their behaviours. Child and adolescent psychiatrists were more likely to have a positive view of the use of parental consent and compulsory treatment for an adolescent with anorexia nervosa. Three factors emerged from factor analysis of the responses named: 'Support for the powers of the Mental Health Act to protect from harm'; 'Primacy of best interests'; and 'Autonomy viewed as being preserved in anorexia nervosa'. Different scores on these factor scales were given in terms of type of specialist and gender.

CONCLUSION

In general, senior psychiatrists tend to support the use of compulsory treatment to protect the health of patients at risk and also to protect the welfare of patients in their best interests. In particular, eating disorder specialists tend to support the compulsory treatment of patients with anorexia nervosa independently of views about their decision-making capacity, while child and adolescent psychiatrists tend to support the treatment of patients with anorexia nervosa in their best interests where decision-making is impaired.

Coercion is coercion? Reflections on trends in the use of compulsion in treating anorexia nervosa

OBJECTIVE

This paper explores similarities and differences between formal coercion and other forms of 'strong persuasion' in clinical decision-making about medical management of patients with severe anorexia nervosa.

METHOD

The paper builds on findings from analysis of data from 117 successive admissions to an eating disorder facility, where an eating disorder was the primary diagnosis.

RESULTS

The study implications of particular interest in this paper are the findings that legal coercion into treatment was associated with three main indicators: the patient's past history (number of previous admissions), the complexity of their condition (the number of other psychiatric comorbidities), and current health risk (measured either by body mass index or the risk of re-feeding syndrome).

CONCLUSIONS

We conclude that clinicians use legal coercion very sparingly in treating severe anorexia nervosa, distinguishing legal coercion from other forms of close clinical management of patients. While we agree with Monahan et al. and others that there are similarities between legal coercion and other forms of strong clinical management (or power), our results suggest that clinicians recognize the importance of maintaining, rather than blurring that distinction.

Self-liking and self-competence: relationship to symptoms of anorexia nervosa

Self-esteem has been hypothesised to play a pivotal role in the development and treatment, and outcome of anorexia nervosa (AN). Though this relationship is typically investigated by considering self-esteem as a unitary construct, research suggests that this comprises of two related but distinct components of self-liking and self-competence. This study investigates the association between self-liking, self-competence, and symptomatology of AN through the course of a defined treatment episode in 77 women. Self-liking was significantly associated with laxative abuse. Self-competence was significantly associated with elevated ineffectiveness, perfectionism and interpersonal distrust. Although self-competence and eating disturbance severity significantly improved over the treatment episode, one in three participants reported a reduced self-like or self-competence. Changes in both self-competence and self-liking at the end of treatment was associated with changes in drive for thinness. Such findings have implications for treatment models concerned with improving self-esteem.

An international collaborative database: its use in predicting length of stay for inpatient treatment of anorexia nervosa

OBJECTIVE

We describe the establishment of an Australasian multisite research database for inpatient treatment of anorexia nervosa (AN). Using this database, the second aim of this study is to investigate the extent to which length of stay (LOS) in participating facilities could be predicted at admission from patient, clinical, and site variables.

METHOD

Standardized demographic and clinical data were collated for 213 admission episodes involving 154 participants over a 20 month period from five Australian and one New Zealand specialist treatment centres.

RESULTS

While nine variables significantly predicted LOS on univariate analysis, linear regression determined that only body mass index, and having had 2-3 previous admissions made significant independent contributions to LOS.

DISCUSSION

Multisite databases offer a viable means by which to conduct clinical research, particularly in regard to low prevalence disorders such as AN. Their additional advantage is that of involving front-line practitioners recruiting participants more likely to be representative of cases seen across treatment centres. At just under a fifth of the total variance predicted by the best-fit model, LOS in hospital remains an aspect of AN treatment difficult to predict, and future studies need to explore variables other than the obvious demographic or clinical issues at admission. The clinical and planning implications are discussed.

Who owns the child in hospital? A preliminary discussion

AIM

To 'own' a person is considered an infringement of human rights, but we suggest that concepts of ownership influence interactions between parents and staff when a child is admitted to hospital. This paper aims to stimulate debate and contains an explanation of the exploration of the literature for research and discussion of ownership of the child.

METHOD

A wide variety of library indexes, databases and populist media were examined although it was impossible to examine all literature which may have contained references to this topic, and, apart from databases which contained abstracts in English, we could not include literature written in any language other than English, Swedish, and Icelandic.

FINDINGS

We found no research that examines how concepts of ownership of a child affects communication between health professionals and parents and, ultimately, the delivery of health care. This paper begins discussion on the issues.

DISCUSSION

Historical literature shows that ownership of humans has been a part of many cultures, and parents were once considered to own their children. Ownership of another has legal connotations, for instance in guardianship struggles of children during marriage breakup and in ethical debates over surrogacy and products of assisted conception. Within health care, it becomes a contentious issue in transplantation of body parts, in discourse on autonomy and informed consent, and for religious groups who refuse blood transfusions. In health care, models such as family centred care and partnership in care depend on positive communication between parents and staff. If a hospital staff member feels that he/she owns a child for whom he/she is caring, then conflict between the staff member and the parents over who has the 'best interests of the child' at heart is possible.

CONCLUSION

We encourage debate about concepts of who owns the hospitalized child - the parents or the staff? Should it be argued at all? Is the whole concept of ownership of another, be it adult or child, the ethical antithesis to modern beliefs about human rights? Comment on this issue is invited.

Is dementia a mental illness?

OBJECTIVE

To examine whether dementia is a mental illness.

METHOD

An analysis of decisions in the Supreme Court of New South Wales that dementia per se was not a mental illness in terms of the 1958 Mental Health Act. A brief review of the extrusion of other diseases from psychiatry.

RESULTS

Concepts in legislation are based on a dichotomy between mental infirmity and mental illness that has changed over time. This change is the result of shifting perceptions about the basis of illness and disease and the causation of mental symptoms. Mental health legislation is aimed as much at social control of feared behaviour as protecting the ill/incompetent. Guardianship legislation offers a more holistic response that better meets the patient's needs and could be extended to supplant mental health legislation.

CONCLUSIONS

Dementia's departure from mental illness reflects psychiatry's continuing marginalization within medicine on an outdated mind/body or illness/disease split. This underlines one of the psychiatrist's roles as the vehicle to 'medically' explain abnormal behaviour. This model means that behaviour, once explained in terms of disease as opposed to illness, can be moved from the direct responsibility of psychiatry into other areas of medicine. Paradoxically, this suggests that the future of psychiatry will be in a completely different direction from its current biological focus.

Involuntary treatment in anorexia nervosa

It is difficult to predict, on first contact with patients with AN, whether a compulsory admission to hospital may become necessary to protect their lives and health. There are only tentative pointers so far to an entrenched avoidance of treatment: (1) components of a disordered personality associated with a history of childhood physical or sexual abuse or previous episodes of self-harm and (2) the presence of a more severe illness, suggested by numerous previous admissions. An involuntary admission is likely to be beneficial at least in the short term, as shown by a gratifying weight gain, although a longer period of inpatient stay may be necessary. Patients who have required compulsory detention are at a considerable risk in the long-term as shown by their high mortality rates. It is, therefore, essential to organize long-term observation for all patients who required involuntary admission for AN. A compulsory admission for AN does not require compulsory treatment, such as forced feeding by NGT or other intrusive methods. Clinicians who contemplate a compulsory admission for a seriously ill anorexic patient might therefore question the advantages provided by the detention. First, clinicians can be assured that it should be possible to induce a satisfactory weight gain through persistent nursing methods without running the risk of these patients discharging themselves. With inpatients, the goals are nearly always attained, although the admission may be longer than average. Not only do these patients' nutrition improve vastly, but also they are likely to show improvements in their mental state. Secondly, these patients are likely to learn that the professional staff, their families, and outside agencies take their illness very seriously, even if patients themselves do not seem to. This is particularly evident when patients appeal to a Mental Health Review Tribunal for release. They attend the proceedings and hear the evidence presented by their psychiatrists, the nursing staff, and their nearest relatives. The tribunal usually sustains the compulsory admission: the patient may be initially distressed, but in the long run the experience is generally therapeutic. Finally, compulsory admission permits more stringent forms of supervision. For example, patients who vomit may have legitimately restricted access to bathrooms. Patients addicted to exercise may be rationed to sensibly short periods of walking daily. Patients who are extremely anxious or overactive may be required to take appropriate tranquilizing or sedating drugs, such as one of the benzodiazepine drugs. Clinicians sometimes are reluctant to resort to compulsory admission because of a fear of damaging the therapeutic relationship with their patients. Clinical observations, however, point to the converse being the case, as shown in several studies. Tiller et al maintain: "Compulsory treatment may be an act of compassion: it shows that professionals recognize the severity of the illness and that they are prepared to contain the anxieties provoked by weight gain. Often the patients and their families are immensely relieved to hand over the responsibility, temporarily, to the professional team."

Compulsory treatment in anorexia nervosa. Short-term benefits and long-term mortality

BACKGROUND

Anorexia nervosa is a mental disorder with a high long-term mortality. Patients are ambivalent about treatment and often avoid it. Of necessity, compulsory treatment sometimes must be considered. A report from the Mental Health Act Commission has helped to reduce previous confusion.

AIMS

To identify the premorbid and clinical features that predisposed to compulsory admissions, the short-term benefits of the treatment and the long-term mortality rates (derived from the National Register).

METHOD

Eighty-one compulsory patients were compared with 81 voluntary patients.

RESULTS

Predisposing factors to a compulsory admission were a history of childhood sexual or physical abuse or previous self-harm. Detained patients had more previous admissions. Detained patients gained as much weight during admission as voluntary patients, but took longer. More deaths among compulsory than voluntary patients (10/79 v. 2/78) were found 5.7 years (mean) after admission.

CONCLUSIONS

Compulsory treatment is effective in the short term. The higher long-term mortality in the detained patients is due to selection factors associated with an intractable illness.

Civil commitment of the anorexic patient

Involuntary commitment appears to be an infrequently used intervention with anorexic patients, in part because of clinicians' uncertainty about its applicability to this population. In contrast to overtly suicidal patients, anorexic patients typically fail to express an intent to harm themselves, although their actions may result in severe harm. Examination of the language of civil commitment statutes, however, suggests that when the behavior of anorexic patients endangers their lives, they will usually be committable under grave disability standards. This appears to comport with the practices of experts in the treatment of anorexia, and with practices in other countries as well. Involuntary commitment should be used as an approach of last resort, when patients decline voluntary hospitalization and their physical safety is at risk. Moreover, civil commitment should probably also be limited to circumstances in which therapeutic gain is likely from hospitalization. Many severely ill anorexic patients will lack competence to make treatment decisions on their own behalf, allowing involuntary feeding and other procedures to take place, if necessary. Civil commitment is a tool that can legitimately be used in emergent situations with anorexic patients.