Out-patients : a necessary evil ?

One of us was recently congratulated by their local primary care trust commissioner on having set up the first memory clinic in the UK. This was incorrect but that was the possible impression given in the first sentence of Dr Foy’s interesting survey (Psychiatr Bull 2008; 32: 467^9). The paper that she cites described the Maudsley Memory Clinic that we think was the second in the UK but the first based within a psychiatric service.We ought to have cited the excellent paper by van der Cammen et al that actually describes the first clinic at St Pancras Hospital but which had not been published at the time. Now that there is to be ’a memory clinic in every town’ we thought we had better set the record straight.

Recently, Magnes (Psychiatr Bull 2008; 32: 458^60) conducted a survey of patient attendance posing the question 'Are out-patient appointments a necessary evil?' The need for out-patient appointments was both queried 1 and robustly defended. 2 Frequently, when discussing the role of such appointments the focus is on attendance. 3,4 However, research addressing other aspects would greatly benefit psychiatry.
We believe that the following issues could be considered: what is the purpose of out-patient appointments? (possible responses: (a) review mental state, adherence, risk, etc.; (b) opportunity for the patients to ask questions; (c) update the GP and/or other services involved; (d) consider referral to other members of the multidisciplinary team or other services); how often should we see patients and for how long? Furthermore, guidance on appropriate discharge procedures would be very helpful.
Finally, we would like to echo Holloway's 2 suggestion that 'a more nuanced discussion' on that 'necessary evil' is urgently required.

Ambivalence in eating disorders
Ambivalence towards recovery is a common feature among individuals with eating disorders, 1,2 particularly those with anorexia. 3,4 The often valued and perversely positive role that an eating disorder (notably, anorexia) plays within a person's life 2 results in a fluctuating level of motivation to engage in therapy. This powerful degree of ambivalence plays a significant role in the high drop-out rates along the care pathway, 4 along with other factors identified in Waller et al's recent study. 5 It is surprising, therefore, that as yet there has been little research evaluating the impact of the different stages within the motivation cycle for change on treatment outcomes in individuals diagnosed with eating disorders. 2 A standardised assessment of a person's level of ambivalence and drive for recovery, such as the Readiness and Motivation Interview 1 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 their fluctuating level of motivation as they pass along the care pathway, allowing the therapist to tailor motivational techniques towards this. It would also enhance the quality of further outcome data relating to patient engagement with eating disorder services.
In Waller et al's study, 13% of individuals offered out-patient therapy following initial assessment failed to engage with treatment. The waiting period between acceptance into the service and commencement of out-patient 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 individuals. The aim of the course of five weekly evening sessions is to consolidate initial engagement and bridge the gap between assessment and treatment, by providing 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 those who attended for the initial session subsequently remaining engaged throughout the full 5-week course. On completion of the course, participants provided feedback on each topic covered on a ten-point Likert scale questionnaire (1, not at all useful; 10, very useful). Most of the ratings (89%) 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 individuals expressed a need 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 service users was that the group made them feel supported and less alone with their illness while awaiting treatment. We hope that this positive experience will help to perpetuate therapeutic engagement while they remain under the care of our service.
Improving the overall quality of a service user's experience when passing through the care pathway (as identified by Waller et al), with their direct involvement at all stages, from the booking of an initial appointment to a collaborative approach towards therapy, is essential in ensuring active engagement of service users with all psychiatric conditions. However, it is particularly important when attempting to support those whose illness has such strong egosyntonic qualities as anorexia in making a decision to pursue recovery.