8.1. What are the primary care (PC) and specialised care interventions for eating disorders? Other resources?
8.2. In eating disorders, what clinical criteria may be useful to assess referral amongst the health care resources available in the NHS?
8.3. In eating disorders, what clinical criteria may be useful to assess complete hospitalisation (inpatient care) in healthcare resources available in the NHS?
8.4. In eating disorders, what clinical criteria may be useful to assess discharge in health care resources available in the NHS?
The management model proposed, in which patients are referred from one management resource to another, is bound by protocols, recommendations and guidelines elaborated with clinical criteria for which there is little evidence that guides decisions regarding where to perform the intervention (See question 8.2. in this chapter).
Primary care is carried out in primary care centres, the first level of access to health care. At this level interventions are focused on:
Initiating nutritional restoration by means of adequate renutrition or refeeding (See question 9.1. chapter 9, “Treatment”) and performing nutritional education (nutritional counselling) (See question 9.2. chapter 9, “Treatment”).
Eating disorder patients are provided with specialised care, the second and third levels of access to health care, in the form of inpatient care resources (psychiatric and general hospital), specialised outpatient practices (mental health centres for adults and children), day hospitals for day care (centres specialised in eating disorders and general mental health centres), emergency services, medical services pertaining to general hospitals and specific units (for eating disorders, borderline personality disorder and toxicology).
The degree of nutritional deterioration, along with the presence or absence of complications, determine the selection of access and feeding route, as well as the location where nutritional follow-up must be performed.
The day care treatment programme includes meal monitoring, and patients must complete a survey on the foods they ingest in 24 hours, including on weekends when they are away from the centre. Each patient must be medically and nutritionally assessed at least once a week, weight and related medical symptoms must be monitored, requested blood work must be assessed if necessary, and the dietary survey and objectives must be reviewed. In inpatient care, nutritional support with artificial nutrition must be strictly monitored to avoid or manage the onset of the refeeding syndrome.
Mutual help groups (MHG) are groups of people who meet voluntarily with the aim of helping each other. They are generally comprised of individuals who share the same problem or who find themselves in a similar difficult situation. The MHG emphasises personal interaction and each member’s capacity to assume responsibilities. It tends to provide emotional help and promote values that help members strengthen their own sense of self. These groups provide assistance and emotional support to families and patients, facilitating the success of the corresponding therapy. Groups are guided by facilitators (people who have experienced the same problem or situation as the participants) and are periodically aided by a professional who supervises the intervention and provides instruments to improve group dynamics (See Annex 3.2. Support associations for patients with eating disorders and their families).
Counselling consists of performing a series of personal interviews with patients and relatives to inform and educate on the disease and its main health, family and social consequences, as well as to provide guidance on the current situation of health care, legal, economic and social resources, with the objective of reassuring and assisting the patient and/or family.
Day centres are public sociosanitary resources that accommodate patients with different long-term disorders, including cases of chronic eating disorders and cases with psychiatric comorbidity. These centres provide, amongst other activities and interventions, rehabilitation (tertiary prevention). In our setting there are no public day centres aimed exclusively at patients with eating disorders.
Therapeutic apartments (assisted or not) constitute another public network resource that enables social reinsertion of patients suffering from different disorders. In our public network there are no apartments specifically for eating disorder patients.
Criteria for referral from primary care to mental health services (CSMA and CSMIJ) are as follows:
Criteria for referral from primary care to emergency hospitalisation (Emergency service of a general hospital) to receive emergency medical treatment are as follows:
Criteria for referral from primary care to emergency psychiatric assessment (at a hospital’s Psychiatry Service) are as follows:
These are not absolute criteria and, depending on their intensity, day care may be indicated (partial hospitalisation).
There are other psychopathological disorders that prevent outpatient treatment:
In order to pursue complete hospitalisation, the judge’s authorisation is required. In the case of minors, it is advisable though not indispensable to have the parents’ authorisation as well as the judge’s, and in the case of over-age patients, to have judicial authorisation (see chapter 12, “Legal Aspects”).
Inpatient management (complete hospitalisation) can be carried out in a general hospital (or one specialised in eating disorders), the psychiatric hospital being the most recommended resource in special cases such as chronicity and severe mental disorders (delirium, repeated self-aggression, cognitive deterioration, etc.).
Specific eating disorder units are found in general hospitals and depend on the psychiatry service (although in some alienated cases they depend on the endocrinology service). Amongst other functions, they tackle especially resistant cases. These specific units are in contact with other hospital services such as Internal Medicine, Gynaecology, etc. and perform interventions on complications derived from eating disorders.
In order to refer to outpatient care (adult or children MHCs):
For hospital admission:
Discharge criteria will depend on the ITP.
The process will end when clinical improvement is evident and enables the patient to resume normal daily life, verifying that during a period of time greater than two years the following criteria are being fulfilled:
|D||8.1.||Individuals with eating disorders should be treated in the appropriate care level based on clinical criteria: outpatient care, day care (day hospital) and inpatient care (general or psychiatric hospital).|
|D||8.2.||Health care professionals without specialist experience in eating disorders or who are faced with uncertain situations should seek the advice of a trained specialist when emergency inpatient care is deemed the most appropriate option for a patient with an eating disorder.|
|D||8.3.||The majority of patients with BN can be treated on an outpatient basis. Inpatient care is indicated when there is risk of suicide, self-inflicted injuries and serious physical complications.|
|D||8.4.||Health care professionals should assess patients with eating disorders and osteoporosis and advise them to refrain from performing physical activities that may significantly increase the risk of fracture.|
|D||8.5.||The paediatrician and the family physician must be in charge of the management of eating disorders in children and adolescents. Growth and development must be closely monitored.|
|D||8.6.||Primary care centres should offer monitoring and management of physical complications to patients with chronic AN and repeated therapeutic failures who do not wish to be treated by mental health services.|
|D||8.7.||Family members, especially siblings, should be included in the individualized treatment plan (ITP) of children and adolescents with eating disorders. The most common interventions involve sharing of information, advice on behavioural management of eating disorders and improving communication skills. The patient’s motivation to change should be promoted by means of family intervention.|
|D||8.8.||Where inpatient care is required, it should be carried out within a reasonable distance to the patient’s home to enable the involvement of relatives and carers in treatment, to enable the patient to maintain social and occupational links and to prevent difficulties between care levels. This is particularly important in the treatment of children and adolescents|
|D||8.9.||Patients with AN whose disorder has not improved with outpatient treatment must be referred to day patient treatment or inpatient treatment. For those who present a high risk of suicide or serious self-inflicted injuries, inpatient management is indicated.|
|D||8.10.||Inpatient treatment should be considered for patients with AN whose disorder is associated with high or moderate risk due to common disease or physical complications of AN.|
|D||8.11.||Patients with AN who require inpatient treatment should be admitted to a centre that ensures adequate re-nutrition, avoiding the re-feeding syndrome, with close physical monitoring (especially in the first few days), along with the appropriate psychological intervention.|
|D||8.12.||The family physician and paediatrician should take charge of the assessment and initial intervention of patients with eating disorders who attend primary care.|
|D||8.13.||When management is shared between primary and specialised care, there should be close collaboration between health care professionals, patients and relatives and carers.|
|√||8.14.||Patients with confirmed diagnosis or clear suspicion of an eating disorder will be referred to different health care resources based on clinical and age criteria.|
|√||8.15.||Referral to adult or children mental health centres (CSMA/CSMIJ) by the family physician or paediatrician should consist of integrated care with shared responsibilities.|
|√||8.16.||Cases referred to adult or children mental health centres (CSMA/CSMIJ) still require different levels to work together and short- and mid-term monitoring of patients, to avoid complications, recurrences and the onset of emotional disorders, and to detect changes in the patient’s environment that could influence the disease.|
|√||8.17.||The need to prescribe oestrogen treatment to prevent osteoporosis in girls and adolescents with AN should be carefully assessed, given that this medication can hide the presence of amenorrhoea.|
|√||8.18.||In childhood, specific eating disorder treatment programmes designed for these ages will be required.|
Latest update: January 2010