Written evidence submitted by Dr Dasha Nicholls MBBS MRCPsych MD FAED, Consultant Child and Adolescent Psychiatrist and Honorary Senior Lecturer; Past President of the Academy for Eating Disorders (CMH0105)
Feeding and Eating Disorders Service, Department of Child and Adolescent Mental Health, Great Ormond Street Hospital, London WC1N 3JH,: d.nicholls@ucl.ac.uk
These comments are submitted by me as an individual, arising from discussions with the principal providers of care for young people with eating disorders across London, leading to the development of the standards for London for Eating Disorders Inpatient care.
Key Points:
- Anorexia nervosa is the third commonest chronic illness of adolescence and has the highest morbidity and mortality of all psychiatric disorders
- Eating disorders onset in early/mid adolescence in the majority of cases, and the best evidence based treatments are outpatient treatments.
- Despite this, the majority of resources for eating disorders are directed towards inpatient care and adult services, both in the NHS and independent sector
- Eating disorders is one of the, if the not the, commonest reasons for CAMHS inpatient admission1.
- The number of young people under age 14 hospitalised for an eating disorder has more than doubled over the past 10 years [Hospital Episode Statistics data].
- Hospitalisation is necessary to manage both medical and psychiatric risk during the course of treatment in a significant number of cases. However, randomised controlled trials show that hospitalisation:
- is no more effective than outpatient treatment2
- Is no better and is more expensive than day patient care3
- Is as effective if admission is brief (for stabilisation) as when admission is longer (for weight restoration)[1]
- Studies also show that specialist child and adolescent eating disorders services (CAEDS) are better at detecting cases early and offering continuity of care, thus reducing the need for hospitalisation 4
- Currently
- the majority of young people are not managed by CAEDS
- the separation of inpatient services (so called Tier 4) from outpatient services results in discontinuity of care and thus is not conducive to brief admissions
- the poor integration of paediatric services with CAMHS is not conducive to managing high risk patients and early intervention
- Data from areas where there are specialist services support findings from the literature on treatment response i.e.
- around 60% respond to first line evidence based interventions5
- where paediatric services are integrated with specialist eating disorders care, transitions to and from outpatient care are more rapid and admission lengths are reduced
- Treatment can be offered more intensively and without discontinuity of care within a CAEDS for treatment resistant cases
- We propose an evidence based stepped care model for child and adolescent eating disorders (below) which aims to:
- Offer rapid detection and early intervention (see 6 for rationale)
- Review treatment response in a timely way and revise treatment accordingly,
- Minimise the duration of ineffective treatments
- Stipulate treatments to be offered, thus minimising geographical and idiosyncratic variation in treatment availability
- CYP-IAPT goes some way to addressing the problems of access to evidence based treatment, but does not provide the comprehensive multidisciplinary training, including medical care, necessary to prevent the considerably morbidity and mortality of this patient group.
- I suggest a national body be established/mandated to facilitate the establishment of CAEDS for all regions, including developing recommendations for staffing and skill mix, and to develop a training agenda equipping paediatric and CAMHS staff to effectively treat early onset cases.
Reference List
(1) Department of Health. National Inpatient Child and Adolescent Psychiatric Survey (NICAPS). England: HMSO; 2002.
(2) Gowers SG, Clark AF, Roberts C, Byford S, Barrett B, Griffiths A et al. A randomised controlled multicentre trial of treatments for adolescent anorexia nervosa including assessment of cost-effectiveness and patient acceptability - the TOuCAN trial. Health Technol Assess 2010; 14(15):1-98.
(3) Herpertz-Dahlmann B, Schwarte R, Krei M, Egberts K, Warnke A, Wewetzer C et al. Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervosa (ANDI): a multicentre, randomised, open-label, non-inferiority trial. Lancet 2014.
(4) House J, Schmidt U, Craig M, Landau S, Simic M, Nicholls D et al. Comparison of specialist and nonspecialist care pathways for adolescents with anorexia nervosa and related eating disorders. Int J Eat Disord 2012; 45(8):949-956.
(5) Lock J, le GD, Agras WS, Moye A, Bryson SW, Jo B. Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry 2010; 67(10):1025-1032.
(6) Nicholls DE, Yi I. Early intervention in eating disorders: a parent group approach. Early Interv Psychiatry 2012.
Towards a Stepped Care Model for Child and Adolescent Eating disorders
Nicholls D, Yeo J, Micali N, Lock J. In Preparation
Who is responsible for care? | Who is the focus? | What is the role? | Intervention arms? | Evidence available? |
Stage 1 Individuals, Public organizations, NHS. Interventions delivered by trained interventionists under supervision | General population for awareness and recognition. | Identify high risk individuals Provide information Advise on service access Refer as needed | Intervention programs such as healthy weight intervention programs, Dissonance-based intervention programs, Media literacy programs. | A great deal of study on Universal prevention programs. |
Stage 2 GPs, School health counsellors, or other named key professionals. Interventions delivered by trained interventionists under supervision | High risk individuals Females>15 years old with body image concerns and eating disturbances. High risk groups e.g. athletes, dancers. Carers of high risk groups such as coaches and parents. Children of parents with EDs. | Recognise emerging cases Assess Risk Refer to stage 3 or above | Dissonance-based intervention programs, Healthy weight intervention programs, Internet-based interventions (eBody Project, Body Project). | A great deal of research has addressed interventions for high risk individuals (mainly females). Little research has targeted parents, carers, coaches and mothers with EDs. |
Stage 3 GPs, Primary care team, Primary Mental Health workers, Family support team or other named key professionals under training or guidance from CAEDS[2] | Young person or parents/carers of newly diagnosed young person to guide the management and initial treatment of EDs | Assess risk, diagnose Guide/deliver initial intervention if indicated Refer to stage 4 or above if high risk or no response within 4 weeks | Self-help, MET, GPT, FT[3], Guided self-help, Internet-based programs. | Emerging area; typically target parents of child newly diagnosed with ED or older adolescents. |
Stage 4 CAEDS if available or Mental Health Professional with expertise in EDS
| Young people diagnosed with ED. | Review diagnosis Offer treatment within 2-4 weeks Weekly appointments, including weighing Refer to stage 5 or CAEDS if no response within 6 weeks | AN: Good evidence: FT. Some evidence: AFT Less evidence: CBT, BFT, FGT. BN: CBT, FT, SPT. High family stress/conflict: SFT | Evidence of effective treatments for both AN and BN. Overall, more evidence available for AN. Less known about BED. |
Stage 5 CAEDS
| Diagnosed patients with high medical risk, severe ED symptoms, significant comorbidities, or long duration of illness. | Review diagnosis Reassess e.g. medical, neuropsychological, comorbidity Progress reviews incorporating an independent or MDT perspective Refer to stage 6 or second opinion if no response or deterioration within 6 months | Medical severity: Acute hospitalization, nutritional interventions. Severe ED symptoms: Intensive family approaches e.g. MFGDT, FDW; Consider medication e.g. Olanzapine, Risperidone, Quetiapine, or SSRI; Individual therapies such as MET, AFT, CRT. Significant comorbidities: CE, antidepressant such as mirtazapine. Long duration of illness: Paediatric review. Consider adult therapies e.g. CAT, SSCM, CBT, IPT, MANTRA. Complexity: Multiagency interventions for complex family circumstances, parental health concerns, unmet educational needs | Medical severity: Limited evidence; High consensus. Severe ED symptoms: More evidence for AN than BN and BED. Comorbidities: Limited evidence addressing comorbidities. Long duration: Based on adults, effects for adolescents unknown. |
Stage 6 Day treatment within CAEDS, partial hospitalization, inpatient care | Severe AN with risk to life or severe established illness unresponsive to first line treatments | Review diagnosis and comorbidity Seek second opinion if no response within 6 months | Multimodal treatment; brief inpatient/paediatric admission (~3 weeks) with day treatment program or partial hospitalization continuous with outpatient care. Inpatient psychiatric treatment under Mental Health Law, if suicidal, need for 24 hour care, or elective admission with specific goals. | Some evidence available. Comparably, more research on AN than BN and BED. |
Abbreviations
Terms used | Abbreviation | Terms used | Abbreviation | |
Adolescent Focused Therapy | AFT | Family Group Treatment/Psycho-education | FGT/P | |
Anorexia Nervosa | AN | Family Therapy | FT | |
Behavioral Family Therapy | BFT | Group Parent-Training | GPT | |
Binge Eating Disorder | BED | Individual Supportive Psychotherapy | ISP | |
Bulimia Nervosa | BN | Individual Therapies | IT | |
Child and Adolescent Eating Disorders Service | CAEDS | Interpersonal Psychotherapy | IPT | |
Cognitive Analytic Therapy | CAT | Maudsley Model for Treatment of Adult with AN | MANTRA | |
Cognitive Based Therapy | CBT | Media Literacy | ML | |
Cognitive Remediation Therapy | CRT | Motivational Enhancement Therapy | MET | |
Conjoint Family Therapy | CFT | Multi-Family Group Day Treatment | MFGDT | |
Cue Exposure | CE | Multi-Family Group Therapy | MFGT | |
Day Hospitalization Programs | DHP | Separated Family Therapy | SFT | |
Eating Disorders | EDs | Social Cognitive Theory | SCT | |
Expressed Emotion | EE | Supportive Psychotherapy | SPT | |
Family Based Treatment | FBT | Specialist Supportive Clinical Management | SSCM | |
Family Day Workshops | FDW |
|
| |
2 April 2014