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Problems across care pathways in specialist adult eating disorder services

  • Glenn Waller (a1), Ulrike Schmidt (a2), Janet Treasure (a3), Katie Murray (a4), Joana Aleyna (a4), Francesca Emanuelli (a5), Jo Crockett (a6) and Maria Yeomans (a7)...

Abstract

Aims and Method

Despite considerable knowledge of outcomes for patients who complete treatment for eating disorders, less is known about earlier stages in the treatment journey. This study aimed to map the efficiency of the anticipated patient journey along care pathways. Referrals to specialist eating disorder services (n=1887) were tracked through the process of referral, assessment, treatment and discharge.

Results

The patient mortality rate was low. However, there were serious problems of attrition throughout the care pathways. of the original referrals where a meaningful conclusion could be reached, in approximately 35% the person was never seen, only half entered treatment and only a quarter reached the end of treatment.

Clinical Implications

This study demonstrates considerable inefficiency of resource utilisation. Suggestions are made for reducing this inefficiency, to allow more patients the opportunity of evidence-based care.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

References

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Agras, W. S., Crow, S. J., Halmi, K. A., Mitchell, J. E., Wilson, G.T. & Kraemer, H. C. (2000) Outcome predictors for the cognitive behavioral treatment of bulimia nervosa: data from a multisite study. American Journal of Psychiatry, 157, 13021308.
Coker, S., Vize, C., Wade, T. & Cooper, P. J. (1993) Patients with bulimia nervosa who fail to engage in cognitive behavior therapy. International Journal of Eating Disorders, 13, 3540.
Crisp, A. (2006) Death, survival and recovery in anorexia nervosa: a thirty five year study. European Eating Disorders Review, 14, 168175.
Fairburn, C. G. (2008) Cognitive Behavior Therapy and Eating Disorders. Guilford.
Fairburn, C. G. & Harrison, P. J. (2003) Eating disorders. Lancet, 361, 407416.
Geller, J. (2002) What a motivational approach is and what a motivational approach isn't: reflections and responses. European Eating Disorders Review, 10, 155160.
Linehan, M. (1993) Cognitive–Behavioural Treatment of Borderline Personality Disorders. Guilford.
Mahon, J. (2000) Dropping out from treatment for eating disorders: what are the issues? European Eating Disorders Review, 8, 198216.
National Institute for Health and Clinical Excellence (2004) Eating Disorders. Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders. NICE.
Nielsen, S. & Bará-Carril, N. (2003) Family, burden of care and social consequences. In Handbook of Eating Disorders (2nd edn) (eds Treasure, J., Schmidt, U. & van Furth, E.), pp.191206. Wiley.
Treasure, J., Smith, G., & Crane, A. (2007) Skills-based Learning for Caring for a Loved One with an Eating Disorder. the New Maudsley Method. Routledge.
Waller, G., Cordery, H., Corstorphine, E., et al (2007) Cognitive–Behavioral Therapy for the Eating Disorders. A Comprehensive Treatment Guide. Cambridge University Press.

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Problems across care pathways in specialist adult eating disorder services

  • Glenn Waller (a1), Ulrike Schmidt (a2), Janet Treasure (a3), Katie Murray (a4), Joana Aleyna (a4), Francesca Emanuelli (a5), Jo Crockett (a6) and Maria Yeomans (a7)...
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eLetters

Ambivalence in Eating Disorders

Sara L Adshead, Specialist Registrar, General Adult Psychiatry
10 February 2009

Ambivalence towards recovery is a common feature amongst patients with Eating Disorders1,2, particularly those with Anorexia Nervosa3,4.

The often valued and perversely positive role that an Eating Disorder(notably Anorexia Nervosa) plays within a patient’s life2 results in a fluctuating level of motivation to engage in therapy. This powerful degreeof ambivalence plays a significant role in the high drop out rates along the care pathway4, along with other factors identified in Waller et al’s recent study.

It is surprising therefore that as yet there has been little researchevaluating the impact of the different stages within the motivation cyclefor change on treatment outcomes in patients suffering from Eating Disorders2 .

A standardised assessment of a patient’s level of ambivalence and drive for recovery, such as the Readiness and Motivation Interview1 or similar would not only provide guidance to the therapist as to an individual’s likely initial level of engagement, but also facilitate a picture of a patient’s fluctuating level of motivation as they pass along the care pathway, allowing the therapist to tailor motivational techniquestowards this. It would also enhance the quality of further outcome data relating to patient engagement with Eating Disorder Services.

I note that in Waller et al’s study, 13% of those patients offered outpatient therapy following initial assessment failed to engage with treatment. I would suggest that the waiting period between acceptance intothe service and commencement of outpatient treatment is a critical stage in the care pathway, as a loss of ‘momentum’ through the service at this stage carries a significant risk of disengagement.In an attempt to counter this effect, the Birmingham Eating Disorder Service has recently introduced an ‘Awareness Group’. Designed specifically for newly assessed and diagnosed patients, the aim of the course of five weekly evening sessions is to consolidate initial engagement and bridge the gap between assessment and treatment, via the provision of information on Eating Disorders, treatment options, and the structure of the service.

Although in its early stages, initial outcome for the group has proved positive, with 97% of patients who attended for the initial sessionsubsequently remaining engaged throughout the full five week course.On completion of the course, patients provided feedback on each topic covered by means of a ten-point Likert Scale ranging from 1 (not at all useful), to 10 (very useful). 89% of ratings were 7 or above, with the physical consequences of Eating Disorders, comorbid psychological disorders, and the effects of laxatives/vomiting rated as the three most highly relevant topics covered.Additionally, several patients highlighted a desire for guidance and support in informing relatives and friends of their Eating Disorder, and one suggestion was that the final session be opened to such significant others for education. (A separate carers’ group is already available within our service). A common response from the majority of patients was that the group made them feel supported and less alone with their illness,whilst awaiting treatment. It is hoped that this positive experience will serve to perpetuate therapeutic engagement whilst they remain under the care of our service.

Improving the overall quality of a patient’s experience when passing through the care pathway (as identified by Waller et al), with the direct involvement of the patient at all stages, from the booking of an initial appointment to a collaborative approach towards therapy, is essential in ensuring active engagement of patients with all psychiatric conditions, but particularly when attempting to support patients suffering from an illness with such strong egosyntonic qualities as Anorexia Nervosa in making a decision to pursue recovery.

Dr Sara AdsheadSpecialist Registrar General Adult Psychiatry

References

1)Geller, J; Zaitsoff, S; Srikameswaran, S ‘Tracking readiness and motivation for change in individuals with eating disorders over the courseof treatment’

Cognitive Therapy and Research, October 2005, 29/5 (611-625)

2)Beato-Fernandez, L; Rodriguez-Cano, T ‘Eating disorders and stagesof change: Prognostic influence on eating psychopathology’

Eating Disorders (New Research), 2006 (245-263)

3)Zeeck,A; Hartmann, A; Buchholz, C ‘Drop outs from in-patient treatment of anorexia nervosa’ Acta Psychiatrica Scandinavica 2005, 111 (29-37)

4)Guarda, A.S ‘Treatment of anorexia nervosa: Insights and obstacles’

Physiology and Behaviour, April 2008, 94/1, (113-120)

Author details:

Dr Sara L AdsheadSpecialist Registrar General Adult PsychiatryEating Disorder ServiceThe Barberry Centre, 25 Vincent Drive, Edgbaston, Birmingham B15 2FG

Sara.adshead@bsmhft.nhs.uk

Tel: 0121 301 2420

Fax: 0121 301 2411
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Conflict of interest: None Declared

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