Management of anorexia nervosa revisitedBMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7438.479 (Published 26 February 2004) Cite this as: BMJ 2004;328:479
- Janice Russell, clinical associate professor and medical director ()
Early intervention can help—but some cases still need tertiary inpatient care
A recent review of outcome in anorexia nervosa pessimistically stated that the 20th century has seen no apparent improvement1: half the patients still never fully recover, overall mortality remains at 5%, and 20% of patients stay chronically ill. Is treatment efficacy really this bad? And where does this leave the clinician?
Early intervention might be expected to exert a positive effect, and indeed this was evident in the 21 year follow up by Zipfel et al of 84 patients.2 More support comes from a recently published prevalence study of 208 patients that reported no excess mortality at 27 year follow up.3 The high rate of anorexia of 0.48% in the study on which this was based suggests that mild or early cases may have been included, though safer management of medically compromised patients might also have been a factor.
The concept of treating patients with eating disorders as hospital inpatients has its detractors, and some have claimed that treatment in general makes no difference to outcome.4 However, the study that purported to show this was flawed and could not have been considered a treatment outcome study.5 Only a minority of the 220 patients received treatment which would have been generally considered to be adequate, there was no form of randomisation, and the chronicity and relatively high weights of the anorexia nervosa group made these unlikely to be representative. A multicentre, naturalistic study of 524 patients with anorexia nervosa followed for 2.5 years after admission to one of 43 hospitals in Germany has subsequently shown better outcomes with extended admission for older patients, while those who were younger and less ill benefited from a variety of treatment settings.6 So perhaps therapeutic nihilism isn't warranted.
Patients with anorexia nervosa are often seen by individual practitioners and by healthcare systems in a negative way—and not without reason. These patients' denial, hostility, and uncertain motivation for treatment; the concerned family and friends; the spectre of medical compromise; the comorbid conditions; confidentiality issues; and the challenge of behavioural containment are not for the fainthearted. The clinician's role needs to embrace engagement, exposition (having everyone tell their story), clinical evaluation and monitoring, nutritional education, non-judgmental support, and unfailing encouragement. Continued efforts must be made to keep the patient engaged, enlist help from those around, re-evaluate progress, and to seek advice or refer on if necessary. Is it as daunting as it sounds? It must be said that some patients recover with fairly minimal help, while others instil continuing anxiety, frustration, impotence, despair, and ultimately demoralisation in their medical carers. This is particularly likely to be the case if adequate tertiary support and treatment is not available
So what is out there to help the beleaguered clinician? Evidence for any therapeutic intervention in anorexia nervosa is difficult to come by given the patients' non-acceptance of randomisation, issues around privacy and compliance, and the fact that clinicians' questions often require a more naturalistic approach than that afforded by randomised controlled trials.6 7 Good enough evidence supports the imperative of adequate nutritional rehabilitation for bone, endocrine, brain integrity, and survival.8 This entails containment—that is, getting the patient to eat and to desist from weight losing behaviours so as to achieve and maintain an appropriate body weight—medical and psychiatric integration, and a multidisciplinary approach.
Medication has been proffered as a magic wand. A recent open clinical trial of the novel antipsychotic agent olanzepine (a benzodiazepine with multiple receptor affinities including selective binding to mesolimbic dopaminergic neurons) gave cause for optimism with demonstrated enhancement of weight gain and a lack of extrapyramidal side effects.9 My own clinical experience would add reduction of anorexic preoccupations, anxiety, quasipsychotic symptoms, and hyperactivity, even at very small doses. The selective serotonin reuptake inhibitors have been proposed to prevent relapse, and are useful in reducing depressive and obsessive compulsive symptoms. However, recent genetic studies which showed an association with polymorphism in the novel norepinephrine transporter gene promoter polymorphic region in restricting anorexia nervosa lend support to early use of the antidepressants reboxetine, a selective norepinephrine reuptake inhibitor, and venlafaxine, which inhibits both serotonin and norepinephrine reuptake.10
However, medication, even if the patient is willing it take it (many are not), remains only an adjunct to nutritional rehabilitation conducted through a variety of psychological treatments. Controlled trials of psychotherapies in anorexia nervosa are few, though benefit has been shown for family therapy in younger patients with shorter duration of illness.11 Clinicians are often comfortable with supportive, psychoeducational, and even cognitive behavioural and motivational techniques. Referral to psychologists or dietitians may be possible, but the problem is more often one of time—in particular, time to see the patient often enough. Being able to listen well and sit with the predicament of the patient and the family will not only nourish all concerned but might avoid perpetuation of past abuses by minimising the need for compulsory treatment, life saving and unavoidable though this can sometimes be.
But some patients need the attention of specialist inpatient treatment under the care of a specialist multidisciplinary team: how can expertise of this level be accessed? Innovations such as continuing medical education, telemedicine, travelling consultants, shared care, computer based techniques, guided self help, rehabilitative hostels, day and intensive outpatient programmes still cannot entirely obviate the need for properly resourced tertiary in patient treatment places—which shrinking health budgets may no longer support. Appreciation of the diversity of anorexia nervosa might permit better matching of patients to treatments, although promising research insights have thus far only partly delivered. Sadly it is often easier to treat the osteoporosis of chronic anorexia nervosa than to provide containment for the recently ill without funds for private inpatient care. Sometimes, the best treatment clinicians can offer is to be an advocate for patients and their carers for an appropriate level of specialist care.
Competing interests JR is medical director of a privately funded inpatient facility and consultant to a publicly funded day programme.