Tuesday, April 7, 2015

Compulsory Treatment for Anorexia Nervosa Studies address difficult decisions in this area of continual debate.

Anorexia nervosa (AN) is, at times, addressed with compulsory treatment. Compulsory treatment has been somewhat controversial, but published evidence suggests there are benefits from it (Br J Psychiatry. 1999; 175:147). However, that particular article suggested that, after 5 years, mortality was increased in those receiving compulsory treatment compared to those receiving voluntary treatment. This is perhaps not surprising, but it is disappointing; one would hope that compulsory treatment might ameliorate long-term risks associated with AN, which are certainly high (and are well known to include mortality). 
In a recent article, Ward and colleagues reported on the roughly 20-year outcome of 81 participants (patients in the same study described in 1994 by Ramsey) compared to 81 matched patients receiving similar treatment (Int J Eat Disord. 2014; Dec 26. doi: 10.1002/eat.22377). Mortality over 20 years was examined using a national death register. The results showed that there were 12 deaths in the whole sample in the first 5 years, and that 15 more deaths occurred in the next 15 years. The overall standardized mortality ratio (the ratio of observed deaths in the study population to the expected number of deaths, based on age, gender, and ethnicity) after 25 years was 3.1. In other words, people with AN in this study were about three times more likely to have died than were people in the general population without AN. However, there were no significant differences in SMR between the compulsory and voluntary treatment patients.
In discussing the results, the authors state, “The findings of this study do not support the hypothesis that compulsory treatment itself has an effect on the longer-term mortality rate, including, as far as the evidence goes, that attributed to suicide.” This certainly is true regarding the concern sometimes raised that compulsory treatment might be associated with increased risk for suicide. In fact, given that mortality appeared elevated at five years, one might wonder if the opposite is true: that there may be long-term mortality reducing benefits of compulsory treatments in individuals with AN severe enough to warrant that compulsory treatment. 

Searching the databases for more information 

To provide a broad overview of research in this area, Isis F.F.M. Elzakkers, MD, and colleagues at Altrecht Medical Institute, Zeist, The Netherlands, searched articles in three large electronic databases (PubMed, Psychinfo, and Scopus) from the 1800s to April 2014 for studies on compulsory treatment for AN. The researchers hoped to find the frequency of hospitalization, the outcome, the risk factors, and finally feedback from AN patients who had undergone compulsory treatment (Int J Eat Disord. 2014; 47:845). 

Epidemiology and outcome

The authors found that compulsory treatment rates ranged from 1.5% to 11.6% of inpatients detained under the Mental Health Act (United Kingdom). They reported finding no “high-quality” data from the U.S. In one report, 28 AN patients out of 170 treated were legally committed over the course of 7 years (1991-1998) at the University of Iowa. In contrast, in an Australian study, 28% of persons admitted for treatment were treated compulsorily (Am J Psychiatry. 2000; 157:1806). 
Only 5 studies provided data on compulsory treatment, while two also had outcome and follow-up data. In one large study by Watson and colleagues, body mass index (BMI, kg/m2) at admission was relatively high in both the voluntary and compulsory groups (18.4 and 17.4, respectively), but they note that this was a diagnostically mixed group. When data from all 5 studies were analyzed, the authors found that patients in the compulsory treatment group had more severe symptoms of AN and other comorbidities (more previous admissions, more instances of self-harm, more common history of abuse, higher levels of depression, and longer duration of illness). Compulsory hospital stays were longer and weights at discharge were similar for both the voluntarily and compulsory treated groups. 
Dr. Elzakkers and colleagues report that little is known about the longer-term effects of compulsory treatment. Limited data suggest compulsory treatment may be associated with a tendency toward better outcome at one year. In addition, when they analyzed risk factors for compulsory treatment, the authors discovered that a higher severity or complexity of illness resulted in a higher likelihood of compulsory treatment.

How patients view compulsory treatment

Two qualitative studies have gathered patient feedback on compulsory treatment. When Tan et al. studied the attitudes of patients and parents toward compulsory treatment (Int J Law Psychiatry. 2003; 26:627 and 2010; 33:13), most patients reported that compulsory treatment was “self-evidently” the right thing to do because “no one was allowed to die from AN.” Many patients who had received compulsory treatment were grateful afterward, and many believed in retrospect that at extremely low weights they had impaired decision-making. 

More data are needed

The authors believe that long-term studies including at least 5 years of follow-up will be needed to gain a better view of the benefit of compulsory treatment for these patients. Results of such studies may also help clarify the fundamental psychological mechanisms underlying mental capacity, and help provide some guidelines for clinicians faced with the difficult decision of ordering compulsory hospitalization for this challenging population.

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