Beruflich Dokumente
Kultur Dokumente
December 2012
Inside this issue
Time has passed quickly again since our last newsletter and this time round we will
be focussing again on the Annual conference held in November 2012.
Congratulations and many thanks again to Frances Connan for another amazing
conference where we were able to listen to many renowned speakers and also to
catch up with friends and colleagues.
It was great to hear a lot of positive feedback about the conference and especially
from Jane Morris who told us about two very inspired and enthralled students from
Aberdeen who are thinking about psychiatry electives!
We thank AED president Dasha Nichols who has agreed to provide news from AED
as a standing item in our newsletter.
Jacinta Tan, senior research fellow and an empirical medical ethicist has written for
us a great article on assessing decision-making capacity in patients with eating
disorders. Can we remind you again that we would welcome any issues that
members would like to be included in the newsletter.
The bursary winners of a place at this years annual academic meeting, were Peter
Sellars, E Barrett, J Theivendran, K Jawahar and Jessica Wright. Peter and
Gemma have both written articles for this newsletter which are well worth a read.
Dr Golnar Aref-Adibs poster presentation won this year and makes interesting
comments in the present climate of a wish for early discharges by various
commissioning bodies.
Dr Irene Yi
Editor
Irene.Yi@sabp.nhs.uk
Dr Rebecca Cashmore
Co-Editor
Rebecca.cashmore@leicspart.nhs.uk
Dear Colleagues,
We are pleased to be bringing you another issue of the Sections newsletter, with
wide ranging contributions on many subjects that should be interesting and
enlightening.
Trainees continue to be actively involved in the Section, with high quality and
competitive submissions for the Section Poster Prize. This prize was established to
encourage interest in Eating Disorders psychiatry and research in the specialism,
and we are fortunate to attract high calibre submissions, as well as an increasing
number of Bursaries to attend the Section Annual Meeting.
Our Annual Conference was held on 2 November 2012, at the Cavendish
Conference Centre, London. Thanks are especially due to Frances Connan for her
indefatigable enthusiasm. The conference was acclaimed by attendees, and covering
a wide-range of clinically relevant topics, in relation to medical and treatment
issues.
Our Executive Committee has welcomed a number of new members and bade
farewell to some old friends. We maintain our primary focus on ensuring quality of
treatments around the UK, engaging proactively with new processes of
commissioning and carving out our special expertise as a subspecialty of
psychiatry.
The issue of ensuring high quality services remains a key concern, and our UKwide quality assurance network of eating disorders services is germinating nicely.
Finally, we look forward to 2013 with all its promises and pitfalls. As the Health
and Social Care Act puts competition between services at its heart, we are
committed to putting quality and collaboration at the centre of our own philosophy.
With kind regards
John
Dr John Morgan
Chair EDSECT
In the last EDSECT newsletter I told you a bit about the AED, who we are, and
debunked a few myths. If you missed it, here is the link to the last newsletter (see
section 7). [link to
http://www.rcpsych.ac.uk/members/sections/eatingdisorders.aspx ]
This time I thought Id tell you a bit about some things the AED have been up to
recently that might be of interest to EDSECT.
Firstly, the AED has recently published the long awaited Residential and Inpatient
standards https://www.aedweb.org/AED_Inpatient_Standards.htm . The purpose
of the guidelines is to promote high quality residential and inpatient treatment for
eating disorders. Specifically they are intended to (a) safeguard patients and
families who seek eating disorder residential and inpatient treatment; (b) review
and improve the quality of care offered by residential and inpatient treatment
programs; and (c) provide a quality of care benchmark for third party payers in the
development of comprehensive models of care and its reimbursement, where
applicable. Like the QED standards, the recommendations are intended for use in
clinical governance, quality assurance and/or the development of key performance
indicators. In the USA they will also be used as a guide for credentialing of
treatment programs.
The AED does not see its role as accrediting organisations or individuals, but
rather using our expertise to collate and distil information to produce best practice
guidance based on evidence, where available. The initial steps for this venture
preceded QED, and indeed may have influenced it, since both Janet Treasure and
Tony Jaffa were part of the process. The complexities and political sensitivities of
US health care has made progress towards standards that are likely to have a
acceptability in the US, never mind applicable globally, a slow and challenging task.
Nonetheless, we are delighted that the basic elements of good care for people with
eating disorders have been laid out succinctly and specifically in a way that will be
of use to those seeking treatment as well as those delivering it. We are now in
discussions about developing standards for individual eating disorders
practitioners.
Finally, we are in the throes of making plans for next years International
Conference on Eating Disorders (ICED) in Montreal. If you havent been, Montreal
really is the best amalgam of North American and European culture. The
conference promises to be great too. Our own Nadia Micali, together with Bryn
Austin from Harvard, has been jointly responsible for putting the conference
programme together and overseeing the scientific committee. Caroline Meyer has
also been part of the programme planning team, all accountable to Glenn Waller as
Director for Annual Meetings. So quite a strong UK presence! The theme for the
2013 ICED is Crossing Disciplinary Boundaries in Eating Disorders. There will be
sessions on BED and Obesity, Biology and Medical Complications, Body Image and
Prevention, Children and Adolescents, Comorbidity, Course and Consequences of
Eating Disorders, Diagnosis, Classification and Measurement, Epidemiology,
Gender, Ethnicity, and Culture, Personality and Cognition, Risk Factors and Eating
Disorders in Underserved Populations, Risk Factors for Eating Disorders and
Treatment of Eating Disorders. There will also be special interest sessions, a
session dedicated to research-practice integration, and welcome, closing and award
ceremonies. If you havent been to an AED conference, I would be delighted if you
would join me there.
Until next time, wishing you all a very Merry Christmas and Happy New Year.
Dasha Nicholls
President, AED
Great Ormond Street Eating Disorders Team
Address:
The College of Health and Human Sciences, Swansea University, SA2 8PP, United
Kingdom
In two recent legal cases in Wales and England, judges have reached different
conclusions as to whether compulsory treatment was in the best interests of
patients suffering from severe and life threatening eating disorders.(1, 2) i Both
judges, however, found that these patients lacked capacity to make decisions about
their treatment. In the case of Re E, Justice Jackson found that although E could
understand the information and communicate a decision, the anorexia nervosa
made her unable to use and weigh the information and she therefore lacked
capacity. These rulings make it clear that capacity in eating disorders can be a
problematic issue.
As mental disorders, eating disorders falls under both the scope of both mental
health and mental capacity legislation in England, Scotland and Wales. On the one
hand the Mental Health Act 2007 could be used to deliver treatment of a mental
disorder (but not of other unrelated medical conditions) without a patients consent
if there is a significant risk posed to the individual (or others), without reference to
capacity.(3) The Mental Health Act Commission has clarified that re-feeding
constitutes treatment of an eating disorder under the meaning of the Mental Health
Act.(4) On the other hand, the Mental Capacity Act 2005 and Adults with
Incapacity (Scotland) Act 2000 allow decision-making by others regarding treatment
and other aspects of life in the best interests of a person, if that person lacks
capacity.(5, 6) Where there is no mental capacity legislation, for example in
Northern Ireland, case law suggests patients who lack capacity should similarly be
treated in their best interests.
With the availability of mental health legislation, why would we need to assess
capacity? There are (at least) three scenarios where this might be useful:
1. Where the disorder is considered by clinicians to be untreatable and they
need to decide whether to accept patient refusal of treatment, nutrition or
life-sustaining measures;
2. Where the disorder may be treatable but there is doubt in the clinical team
about whether formal compulsory treatment is appropriate, so knowing
capacity status can guide the team as to how much weight they should give
to patient decisions which may not be in their own best interests;
3. Contentious cases, for instance prolonged use of mental health legislation,
where the assessment of capacity may help inform clinical and tribunal
decisions.
The definition of incapacity varies between different legal jurisdictions (see box for
current definitions applying to the United Kingdom). Grisso and Appelbaum in the
USA developed the MacCAT-T instrument of competence which conceptualises
capacity as: Understanding, Retention, Appreciation, and Reasoning (comparative
and consequential).(7) Importantly, the mental capacity laws applying in England,
Wales and Scotland require that incapacity arises from disturbances of mind,
which includes mental disorder. Studies have shown that there are high rates of
incapacity amongst inpatients in acute general medical and psychiatric wards.(8, 9)
Worse, however, physicians often fail to detect patients incapacity.(8)
In some cases of mental disorder, it would be evident that a person lacks capacity,
for example if a patient is extremely thought disordered from schizophrenia or
severely cognitively impaired from dementia. In eating disorders, however, sufferers
typically have the ability to understand and retain information, and indeed many
possess an impressive knowledge of their illness and its risks. There are, however,
other ways in which eating disorders may affect the ways in which, or the reasons
for which, people with eating disorders might make decisions about whether or not
to accept treatment. Any assessment of capacity therefore needs to be both
thorough and nuanced to pick up more subtle but significant difficulties in
decision-making. The application of the Mental Capacity Act in the two law cases
suggests that the main difficulties are generally categorised under the broad
criterion ability to use and weigh information. This criterion, however, is poorly
defined and gives little guidance to the clinician. A suggested format for assessment
which should help clinicians to perform a full assessment of factors which may
affect capacity is given below.
some patients to decide, even after they have weighed up the options, not to have
treatment because they would rather die than gain weight.(12)
Conclusion
There are several ways in which eating disorders can affect decision-making. This
does not mean, however, that all patients who have eating disorders lack capacity.
It also does not mean that all patients who have eating disorders should be
compelled to have treatment, though it should be borne in mind that patients
themselves favour compulsory treatment to save life.(16, 17) Capacity must always
be assessed at the time for the decision at hand. The assessment of capacity
requires a careful and systematic approach, but as the MacCAT-T instrument
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acknowledges, even with formal instruments, in the end the judgement of the
presence or absence of capacity is a clinical, global judgement.(7)
acting; or
making decisions; or
communicating decisions; or
understanding decisions; or
retaining the memory of decisions.(6)
11
References:
1.A Local Authority v E [2012] EWHC 1639 (COP).
2.
http://www.legislation.gov.uk/ukpga/2007/12/pdfs/ukpga_20070012_en.pdf.
4.
treatment of anorexia nervosa under the Mental Health Act 1983. London: HMSO;
1997.
5.
http://www.dca.gov.uk/menincap/legis.htm.
6.
http://www.legislation.gov.uk/asp/2000/4/pdfs/asp_20000004_en.pdf.
7.
12
13.
Braun DL, Sunday SR, Halmi KA. Psychiatric comorbidity in patients with
E.R. 819.
At the time of writing, the legal ruling is not yet available in the public domain and
the only information available is from newspaper reports.
well as Psychiatrists. This painted a multidimensional image of the service and the
professionals closely working together to look after the patients in their care. As an
ex-neuroscientist I may be slightly biased in mentioning the presentation by
Professor Kringelbach on pleasure centres involved in food intake and the
implications of reward pathways on eating disorders. I found this to be of particular
interest personally as the neurological pathways described are shared by many
other conditions. Whilst this research may still be in its infancy, it may help to
direct more targeted management for these conditions in the future.
The general atmosphere of the conference was very friendly and I was struck by
how approachable the other delegates were. When it came to patient management I
learnt as much by talking to the attending consultants as I did from the insightful
post presentation discussions. I thoroughly enjoyed the manner in which each
consultant, including the speakers shared their personal experiences for patient
management. I believe this very revealing of the heterogeneity of the subject and
each individual patient experience. I also believe this is perhaps the most important
point which I will take away with me from the conference.
I would like to thank the Royal College of Psychiatrists for this enriching
experience.
Peter Sellars
As a CT1 in psychiatry, with my only prior experience in the field being a few weeks
in an inpatient unit during my elective, I was a little unnerved that the content
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would be heavily focused on the minutiae of eating disorders and would, therefore,
go over my head.
To my delight, I found the whole experience thoroughly enjoyable. The lecture hall
was packed, the food was good and the conference centre staff were very helpful.
The programme was varied and interesting, with medically orientated lectures on
bone health and fertility to psychology based ideas such as CBT as used in irritable
bowel syndrome. It was evident how these could link in with management of
patients with eating disorders, and spawned much discussion around the topics
after the lectures.
Two highlights were the presentation on the pleasure of food intake by Professor
Kringelbach, and the results of a study on Multi Family Therapy by Professor Eisler,
the proposal of which had been presented at a previous Eating Disorder Annual
section meeting.
Jemma Theivendran
15
Background
Whilst working as core psychiatry trainee on Phoenix Eating
Disorder Unit the first three patients I admitted had a BMI
ranging from 9 to 10. I was alarmed and surprised at the
severity
of
the
cases
and
the
team
commented
that
Under the supervision of the consultant I worked with a team of medical students
and a psychology trainee to determine whether there was a trend for discharge from
hospital to occur at a lower BMI over the course of the last 6 years and whether
this was leading to a higher readmission rate.
16
It is
The unit provides comprehensive treatment for all types of eating disorders that
includes inpatient treatment (Phoenix Wing,15 beds), a residential stepped down
facility (Acacia House 5 beds) and a day service (Russell Unit, 8 places).
Aim
To determine whether new constraints in commissioning were
associated with:
Method
The analysis comprised of a retrospective case note review of all inpatient
admissions from 2006 to 2011 to The Phoenix Wing Eating Disorder Unit. Data
regarding primary diagnosis, admission and discharge BMI, length of stay, mode of
discharge, MHA section status, and transfer to Acacia House were obtained from
the hospital database (RiO) and checked against the discharge summaries
completed by ward doctors. The data were all anonymised and each patient was
assigned a number, to cross reference in the event of readmission.The data was
entered in Excel and analysed using GraphPad Prism.
Results:
There have been 278 admissions since January 2006, with 240 of these having a
primary diagnosis of anorexia nervosa, 17 with severe bulimia nervosa and 21 with
atypical eating disorders. Mean age at admission was 30 years (median 27.5), with
17
95% of admissions being female. The average number of patients on MHA section
each year was 7 (range 4-9).
The average length of stay was 132 days and there was no significant variation over
the period from 2006 to 2011.
whole,
mean
BMI
upon
discharge
18
From 2006 to 2011 there was a rise in both the absolute and relative number of
readmissions of these patients.
Conclusion
These data confirm that patients are being discharged at lower BMIs with a poorer
psychiatric outcome and higher readmission rate.
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6- Other News
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Member
Year of joining
Position
Dr Agnes Ayton
2012 (C)
Co-opted Member
Dr John Morgan
2011 (E)
Chair
Dr Jane Shapleske
2007 (E)
Financial Officer
Dr Carol Wilson
2012 (A)
Dr Rebecca Cashmore
2011 (E)
Elected Member
Dr Frances Connan
2007 (E)
Elected Member
Dr Philip Crockett
2011 (E)
Elected Member
Elected Member
Dr Philippa Hugo
2011 (E)
Vice Chair
Ms Veronica Kamerling
2011 (C)
Co-opted Member
Dr Nikola Kern
2011 (E)
Academic Secretary
Dr Adrienne Key
2007 (E)
Elected Member
Dr Jessica Morgan
2011 (E)
Elected Member
Dr Elizabeth Morris
2011 (E)
Elected Member
Dr Sandeep Ranote
2011 (C)
Co-opted Member
Dr Lorna Richards
2007 (E)
Elected Member
Ms Susan Ringwood
2008 (C)
Co-opted Member
Dr Paul Robinson
2007 (E)
Elected Member
Dr Christine Vize
2011 (E)
Elected Member
Dr Irene Yi
2011 (C)
Co-opted Member
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