Shining the light on eating disorders, incidence, prognosis and profiling of patients in primary and secondary care: national data linkage study.

BACKGROUND: Diagnosing eating disorders can be difficult and few people with the disorder receive specialist services despite the associated high morbidity and mortality. AIMS: To examine the burden of eating disorders in the population in terms of incidence, comorbidities and survival. METHOD: We used linked electronic health records from general practitioner and hospital admissions in Wales, UK within the Secure Anonymised Information Linkage (SAIL) databank to investigate the incidence of new eating disorder diagnoses. We examined the frequency of comorbid diagnoses and prescribed medications in cases and controls in the 2 years before and 3 years after diagnosis, and performed a survival analysis. RESULTS: A total of 15 558 people were diagnosed with eating disorders between 1990 and 2017. The incidence peaked at 24 per 100 000 people in 2003/04. People with eating disorders showed higher levels of other mental disorders (odds ratio 4.32, 95% CI 4.01-4.66) and external causes of morbidity and mortality (odds ratio 2.92, 95% CI 2.44-3.50). They had greater prescription of central nervous system drugs (odds ratio 3.15, 95% CI 2.97-3.33), gastrointestinal drugs (odds ratio 2.61, 95% CI 2.45-2.79) and dietetic drugs (odds ratio 2.42, 95% CI 2.24-2.62) before diagnosis. These excess diagnoses and prescriptions remained 3 years after diagnosis. Mortality was raised compared with controls for some eating disorders, particularly in females with anorexia nervosa. CONCLUSIONS: Incidence of diagnosed eating disorders is relatively low in the population but there is a major longer term burden in morbidity and mortality to the individual.

Consent and confidentiality in clinical work with young people.

Consent and confidentiality are increasingly important in clinical practice. However, the dilemmas faced by mental health practitioners can be highly complex and difficult to resolve. This difficulty is compounded by the fact that consent and confidentiality are subject to several different types of legislation based on different principles, and many of the policies which are formulated for general medical practice may not fit well with the mental healthcare context. The ethical principles, evidence base, legal context, developmental considerations and clinical context relevant to each situation must all be integrated, in consultation with children and adolescents and their parents, in order to arrive at a treatment plan which is sensitive to the views of all, developmentally appropriate for the children and adolescents, and responsive to changes in the situation or attitudes. We offer some practical approaches, including clinical practice algorithms, to consider the issues of consent and confidentiality in the child and adolescent mental healthcare setting.

Deep Brain Stimulation in Anorexia Nervosa: Hope for the Hopeless or Exploitation of the Vulnerable? The Oxford Neuroethics Gold Standard Framework.

Neurosurgical interventions for psychiatric disorders have a long and troubled history (1, 2) but have become much more refined in the last few decades due to the rapid development of neuroimaging and robotic technologies (2). These advances have enabled the design of less invasive techniques, which are more focused, such as deep brain stimulation (DBS) (3). DBS involves electrode insertion into specific neural targets implicated in pathological behavior, which are then repeatedly stimulated at adjustable frequencies. DBS has been used for Parkinson's disease and movement disorders since the 1960s (4-6) and over the last decade has been applied to treatment-refractory psychiatric disorders, with some evidence of benefit in obsessive-compulsive disorder (OCD), major depressive disorder, and addictions (7). Recent consensus guidelines on best practice in psychiatric neurosurgery (8) stress, however, that DBS for psychiatric disorders remains at an experimental and exploratory stage. The ethics of DBS-in particular for psychiatric conditions-is debated (1, 8-10). Much of this discourse surrounds the philosophical implications of competence, authenticity, personality, or identity change following neurosurgical interventions, but there is a paucity of applied guidance on neuroethical best practice in psychiatric DBS, and health-care professionals have expressed that they require more (11). This paper aims to redress this balance by providing a practical, applied neuroethical gold standard framework to guide research ethics committees, researchers, and institutional sponsors. We will describe this as applied to our protocol for a particular research trial of DBS in severe and enduring anorexia nervosa (SE-AN) (https://clinicaltrials.gov/ct2/show/NCT01924598, unique identifier NCT01924598), but believe it may have wider application to DBS in other psychiatric disorders.

Qualities of a good Singaporean psychiatrist: Qualitative differences between psychiatrists and patients.

INTRODUCTION: Pilot studies in Singapore established four themes (personal values, professional, relationship, academic-executive) relating to the qualities of a good psychiatrist, and suggested potential differences of opinion between patients and psychiatrists. We sought to explore differences between patients and psychiatrists regarding the qualities of a good psychiatrist. METHODS: Qualitative analysis of interviews using a modified grounded theory approach with 21 voluntary psychiatric inpatients and 18 psychiatrists. RESULTS: One hundred thirty-one separate qualities emerged from the data. The qualities of a good psychiatrist were viewed in the context of motivations, functions, methods, and results obtained, mirroring the themes established in the pilot studies. Patients and psychiatrists mostly concurred on the qualities of a good psychiatrist, with 62.6% of the qualities emerging from both groups. However significant differences existed. Patient-specific qualities included proof of altruistic motives, diligence, clinical competence, and positive results. What the psychiatrist represented to patients in relation to gender, culture, and clinical prestige also mattered to patients. Psychiatrist-specific qualities related to societal (e.g. public protection) and professional concerns (e.g. boundary issues). DISCUSSION: The results of this study demonstrate that patients and psychiatrists have different views about the qualities of a good psychiatrist. Patients may expect proof of care, diligence, and competence from the psychiatrist, along with positive results. In addition, psychiatrists should be mindful of what they represent to patients and how that can impact the doctor-patient relationship.

Attitudes of patients with anorexia nervosa to compulsory treatment and coercion.

BACKGROUND: The compulsory treatment of anorexia nervosa is a contentious issue. Research suggests that patients are often subject to compulsion and coercion even without formal compulsory treatment orders. Research also suggests that patients suffering from anorexia nervosa can change their minds in retrospect about compulsion. METHODS: Qualitative interviewing methods were used to explore the views of 29 young women concerning compulsion and coercion in the treatment of anorexia nervosa. The participants were aged between 15 to 26years old, and were suffering or had recently suffered from anorexia nervosa at the time of interview. RESULTS: Compulsion and formal compulsory treatment of anorexia nervosa were considered appropriate where the condition was life-threatening. The perception of coercion was moderated by relationships. What mattered most to participants was not whether they had experienced restriction of freedom or choice, but the nature of their relationships with parents and mental health professionals. CONCLUSIONS: People with anorexia nervosa appear to agree with the necessity of compulsory treatment in order to save life. The perception of coercion is complex and not necessarily related to the degree of restriction of freedom.

Psychiatrists' attitudes towards autonomy, best interests and compulsory treatment in anorexia nervosa: a questionnaire survey.

BACKGROUND: The compulsory treatment of anorexia nervosa is a contentious issue. Research suggests that psychiatrists have a range of attitudes towards patients suffering from anorexia nervosa, and towards the use of compulsory treatment for the disorder. METHODS: A postal self-completed attitudinal questionnaire was sent to senior psychiatrists in the United Kingdom who were mostly general adult psychiatrists, child and adolescent psychiatrists, or psychiatrists with an interest in eating disorders. RESULTS: Respondents generally supported a role for compulsory measures under mental health legislation in the treatment of patients with anorexia nervosa. Compared to 'mild' anorexia nervosa, respondents generally were less likely to feel that patients with 'severe' anorexia nervosa were intentionally engaging in weight loss behaviours, were able to control their behaviours, wanted to get better, or were able to reason properly. However, eating disorder specialists were less likely than other psychiatrists to think that patients with 'mild' anorexia nervosa were choosing to engage in their behaviours or able to control their behaviours. Child and adolescent psychiatrists were more likely to have a positive view of the use of parental consent and compulsory treatment for an adolescent with anorexia nervosa. Three factors emerged from factor analysis of the responses named: 'Support for the powers of the Mental Health Act to protect from harm'; 'Primacy of best interests'; and 'Autonomy viewed as being preserved in anorexia nervosa'. Different scores on these factor scales were given in terms of type of specialist and gender. CONCLUSION: In general, senior psychiatrists tend to support the use of compulsory treatment to protect the health of patients at risk and also to protect the welfare of patients in their best interests. In particular, eating disorder specialists tend to support the compulsory treatment of patients with anorexia nervosa independently of views about their decision-making capacity, while child and adolescent psychiatrists tend to support the treatment of patients with anorexia nervosa in their best interests where decision-making is impaired.

Capacity and competence in child and adolescent psychiatry.

Capacity and competence in the field of child and adolescent psychiatry are complex issues, because of the many different influences that are involved in how children and adolescents make treatment decisions within the setting of mental health. This article will examine some of the influences which must be considered, namely: developmental aspects, the paradoxical relationship between the need for autonomy and participation and the capacity of children, family psychiatry, and the duty of care towards children and adolescents. The legal frameworks relevant to consideration of consent and competence will be briefly considered, as well as some studies of children's consent, participation and competence. A case vignette will be used as a focus to consider the complexity of the issue of competence in child and adolescent psychiatry, in the particular mental disorder of anorexia nervosa.