The importance of individualised care, good communication and trust for reducing nasogastric tube feeding under physical restraint: qualitative multi-informant study.

BACKGROUND: Nasogastric tube (NGT) feeding against a patient's consent is an intervention that clinicians working in specialist mental health in-patient units may need to implement from time to time. Little research has explored clinician, patient and carer perspectives on good practice. AIMS: To use qualitative data from people with lived experience (PWLE), parents/carers and clinicians, to identify components of best practice when this intervention is required. METHOD: PWLE and parents/carers were recruited via BEAT UK's eating disorder charity. Clinicians were recruited via a post on The British Eating Disorders Society's research page. Semi-structured interviews were administered, transcribed and thematically analysed. RESULTS: Thirty-six interviews took place and overlapping themes were identified. Participants spoke in relation to three themes: first, the significance of individualised care; second, the importance of communication; third, the impact of staff relationships. Sub-themes were identified and explored. CONCLUSIONS: Good care evolved around positive staff relationships and individualised care planning rather than standard processes. The centrality of trust as an important mediator of outcome was identified, and this should be acknowledged in any service that delivers this intervention.

Nasogastric tube feeding under restraint: understanding the impact and improving care.

BACKGROUND: Nasogastric tube feeding under physical restraint is an intervention that clinicians working in specialist mental health in-patient units may need to implement. AIMS: To examine the impact of this intervention on people with lived experience, carers and staff. METHOD: People with lived experience and parents and/or carers were recruited via UK eating disorder charity Beat. Clinicians were recruited via the British Eating Disorders Society's research forum. Qualitative semi-structured interviews were conducted and transcribed, and the results were thematically analysed. RESULTS: Thirty-six participants took part, and overlapping themes were identified. All participants spoke in relation to four themes: (a) the short-term impact on the patient; (b) the impact on those around the patient; (c) the long-term impact; and (d) the positive impact. Subthemes were identified and explored. CONCLUSION: This lifesaving intervention can also negatively affect patients, parents and carers, peers and staff. Further research is needed to understand how interactions and environmental modifications can mitigate the negative impacts.

Effects of the COVID-19 pandemic on the mental health of clinically extremely vulnerable children and children living with clinically extremely vulnerable people in Wales: a data linkage study.

OBJECTIVES: To determine whether clinically extremely vulnerable (CEV) children or children living with a CEV person in Wales were at greater risk of presenting with anxiety or depression in primary or secondary care during the COVID-19 pandemic compared with children in the general population and to compare patterns of anxiety and depression during the pandemic (23 March 2020-31 January 2021, referred to as 2020/2021) and before the pandemic (23 March 2019-31 January 2020, referred to as 2019/2020), between CEV children and the general population. DESIGN: Population-based cross-sectional cohort study using anonymised, linked, routinely collected health and administrative data held in the Secure Anonymised Information Linkage Databank. CEV individuals were identified using the COVID-19 shielded patient list. SETTING: Primary and secondary healthcare settings covering 80% of the population of Wales. PARTICIPANTS: Children aged 2-17 in Wales: CEV (3769); living with a CEV person (20 033); or neither (415 009). PRIMARY OUTCOME MEASURE: First record of anxiety or depression in primary or secondary healthcare in 2019/2020 and 2020/2021, identified using Read and International Classification of Diseases V.10 codes. RESULTS: A Cox regression model adjusted for demographics and history of anxiety or depression revealed that only CEV children were at greater risk of presenting with anxiety or depression during the pandemic compared with the general population (HR=2.27, 95% CI=1.94 to 2.66, p<0.001). Compared with the general population, the risk among CEV children was higher in 2020/2021 (risk ratio 3.04) compared with 2019/2020 (risk ratio 1.90). In 2020/2021, the period prevalence of anxiety or depression increased slightly among CEV children, but declined among the general population. CONCLUSIONS: Differences in the period prevalence of recorded anxiety or depression in healthcare between CEV children and the general population were largely driven by a reduction in presentations to healthcare services by children in the general population during the pandemic.

Nasogastric tube feeding under physical restraint: comprehensive audit and case series across in-patient mental health units in England.

AIMS AND METHOD: To identify the clinical characteristics of patients receiving nasogastric tube (NGT) feeding under physical restraint. Clinicians participated via professional networks and subsequent telephone contact. In addition to completing a survey, participants were invited to submit up to ten case studies. RESULTS: The survey response rate from in-patient units was 100% and 143 case studies were submitted. An estimated 622 patients received NGT feeding under restraint in England in 2020-2021. The most common diagnosis was anorexia nervosa (68.5-75.7%), with depression, anxiety and autism spectrum disorder the most frequent comorbidities. Patients receiving the intervention ranged from 11 to 60 years in age (mean 19.02 years). There was wide variation in duration of use, from once to daily for 312 weeks (mode 1 week; mean 29.1 weeks, s.d. = 50.8 weeks). CLINICAL IMPLICATIONS: NGT feeding under restraint is not uncommon in England, with variation in implementation. Further research is needed to understand how the high comorbidity and complexity contribute to initiation and termination of the intervention.

Recognising and managing eating disorders in the emergency department.

Compared with other mental health conditions or psychiatric presentations, such as self-harm, which may be seen in emergency departments, eating disorders can seem relatively rare. However, they have the highest mortality across the spectrum of mental health, with high rates of medical complications and risk, ranging from hypoglycaemia and electrolyte disturbances to cardiac abnormalities. People with eating disorders may not disclose their diagnosis when they see healthcare professionals. This can be due to denial of the condition itself, a wish to avoid treatment for a condition which may be valued, or because of the stigma attached to mental health. As a result their diagnosis can be easily missed by healthcare professionals and thus the prevalence is underappreciated. This article presents eating disorders to emergency and acute medicine practitioners from a new perspective using the combined emergency, psychiatric, nutrition and psychology lens. It focuses on the most serious acute pathology which can develop from the more common presentations; highlights indicators of hidden disease; discusses screening; suggests key acute management considerations and explores the challenge of mental capacity in a group of high-risk patients who, with the right treatment, can make a good recovery.

Recognising and managing eating disorders in the emergency department.

Compared with other mental health conditions or psychiatric presentations, such as self-harm, which may be seen in emergency departments, eating disorders can seem relatively rare. However, they have the highest mortality across the spectrum of mental health, with high rates of medical complications and risk, ranging from hypoglycaemia and electrolyte disturbances to cardiac abnormalities. People with eating disorders may not disclose their diagnosis when they see healthcare professionals. This can be due to denial of the condition itself, a wish to avoid treatment for a condition which may be valued, or because of the stigma attached to mental health. As a result their diagnosis can be easily missed by healthcare professionals and thus the prevalence is underappreciated. This article presents eating disorders to emergency and acute medicine practitioners from a new perspective using the combined emergency, psychiatric, nutrition and psychology lens. It focuses on the most serious acute pathology which can develop from the more common presentations; highlights indicators of hidden disease; discusses screening; suggests key acute management considerations and explores the challenge of mental capacity in a group of high-risk patients who, with the right treatment, can make a good recovery.

Decision-making and best practice when nasogastric tube feeding under restraint: multi-informant qualitative study.

BACKGROUND: Clinicians working in mental health in-patient settings may have to use nasogastric tube feeding under physical restraint to reverse the life-threatening consequences of malnutrition when this is driven by a psychiatric condition such as a restrictive eating disorder. AIMS: To understand the decision-making process when nasogastric tube feeding under restraint is initiated in mental health in-patient settings. METHOD: People with lived experience of nasogastric tube feeding under restraint and parents/carers were recruited via the website of the UK's eating disorder charity BEAT. Eating disorder clinicians were recruited via an online post by the British Eating Disorders Society. Semi-structured interviews were administered to all participants. RESULTS: Themes overlapped between the participant groups and were integrated in the final analysis. Two main themes were generated: first, 'quick decisions', with the subthemes of 'medical risk', 'impact of not eating' and 'limited discussions'; second, 'slow decisions', with subthemes of 'threats', 'discussions with patient', 'not giving up' and 'advanced directives'. Benefits and harms of both quick and slow decisions were identified. CONCLUSIONS: This research offers a new perspective regarding how clinical teams can make best practice decisions regarding initiating nasogastric feeding under restraint. In-patient mental health teams facilitating this clinical intervention should consider discussing it with the patient at the beginning of their admission in anticipation of the need for emergency intervention and in full collaboration with the multidisciplinary team.

Nasogastric tube feeding under physical restraint on paediatric wards: ethical, legal and practical considerations regarding this lifesaving intervention.

Eating disorders have the highest mortality rate of any psychiatric condition. Since the COVID-19 pandemic, the number of patients who have required medical stabilisation on paediatric wards has increased significantly. Likewise, the number of patients who have required medical stabilisation against their will as a lifesaving intervention has increased. This paper highlights a fictional case study aiming to explore the legal, ethical and practical considerations a trainee should be aware of. By the end of this article, readers will be more aware of this complex issue and how it might be managed, as well as the impact it can have on the patient, their family and ward staff.

Nasogastric tube feeding under restraint: practical guidance for children's nurses.

The number of children and young people admitted to children's wards with an eating disorder has increased significantly since the start of the coronavirus disease 2019 (COVID-19) pandemic. In the most extreme cases, those with severe malnutrition may need to be fed via a nasogastric tube without their consent. Children's nurses working on hospital wards may therefore care for children and young people who need to receive nasogastric tube feeding under physical restraint. This article offers an overview of eating disorders and their detrimental effects as well as practical advice for children's nurses, supporting them to provide safe, compassionate and person-centred care to their patients.

Remote mental health services: a mixed-methods survey and interview study on the use, value, benefits and challenges of a national video consulting service in NHS Wales, UK.

Social distancing laws during the first year of the pandemic, and its unprecedented changes to the National Health Service (NHS) forced a large majority of services, especially mental health teams to deliver patient care remotely. For many, this approach was adopted out of necessity, rather than choice, thus presenting a true 'testing ground' for remote healthcare and a robust evaluation on a national and representative level. OBJECTIVE: To extract and analyse mental health specific data from a national dataset for 1 year (March 2020-March 2021). DESIGN: A mixed-methods study using surveys and interviews. SETTING: In NHS mental health services in Wales, UK. PARTICIPANTS: With NHS patients and clinicians across child and adolescent, adult and older adult mental health services. OUTCOME MEASURES: Mixed methods data captured measures on use, value, benefits and challenges of video consulting (VC). RESULTS: A total of 3561 participants provided mental health specific data. These data and its findings demonstrate that remote mental health service delivery, via the method of VC is highly satisfactory, well-accepted and clinically suitable for many patients, and provides a range of benefits to NHS patients and clinicians. Interestingly, clinicians working from 'home' rated VC more positively compared with those at their 'clinical base'. CONCLUSIONS: Post 1-year adoption, remote mental health services in Wales UK have demonstrated that VC is possible from both a technical and behavioural standpoint. Moving forward, we suggest clinical leaders and government support to sustain this approach 'by default' as an option for NHS appointments.

Identifying and managing eating disorders in type 1 diabetes mellitus: An all-Wales study.

BACKGROUND: Co-morbid diabetes and eating disorders have a particularly high mortality, significant in numbers and highly dangerous in terms of impact on health and wellbeing. However, not much is known about the level of awareness, knowledge and confidence amongst healthcare professionals regarding co-morbid Type 1 Diabetes Mellitus (T1DM) and eating disorders. AIM: To understand the level of knowledge and confidence amongst healthcare professionals in Wales regarding co-morbid T1DM and eating disorder presentations, identification and treatment. RESULTS: We conducted a survey of 102 Welsh clinicians in primary care, diabetes services and eating disorder services. 60.8% expressed low confidence in identification of co-morbid T1DM and eating disorders. Respondents reported fewer cases seen than would be expected. There was poor understanding of co-morbid T1DM and eating disorders: 44.6% identified weight loss as a main symptom, 78.4% used no screening instruments, and 80.3% consulted no relevant guidance. The respondents expressed an awareness of their lack of knowledge and the majority expressed willingness to accept training and education. CONCLUSION: We suggest that priority must be given to education and training of all healthcare professionals in primary care, diabetes services and mental health services who may see patients with co-morbid T1DM and eating disorders.

The Welsh Eating Disorder Service Review 2018, Scottish Eating Disorder Service Review 2021 and recommendations of best practice in comorbid eating disorders and diabetes.

BACKGROUND: Diabetes and eating disorders are frequently comorbid. This particular comorbidity is not only often poorly recognised, but is difficult to treat and has a high mortality. METHOD: In this article, we will briefly review the relationship between diabetes and eating disorders. We will review the current NICE and other guidance and reports concerning both diabetes and eating disorders in the United Kingdom. We will then describe the recommendations of the 2018 Welsh Government Eating Disorder Service Review and the 2021 the Scottish Government Eating Disorder Service Review regarding diabetes and eating disorders, which will lead to service change. CONCLUSIONS: We conclude that this is a relatively underdeveloped but important area where there needs to be further service development and more collaboration between diabetes and eating disorder services.

Clinical management and mortality risk in those with eating disorders and self-harm: e-cohort study using the SAIL databank.

BACKGROUND: Individuals with eating disorders who self-harm are a vulnerable group characterised by greater pathology and poorer outcomes. AIMS: To explore healthcare utilisation and mortality in those with a record of: self-harm only; eating disorders only; and both co-occurring. METHOD: We conducted a retrospective whole population e-cohort study of individuals aged 10-64 years from 2003 to 2016. Individuals were divided into: record of self-harm only; eating disorders only; both self-harm and eating disorders; and no record of self-harm or eating disorders. We used linked routinely collected healthcare data across primary care, emergency departments, hospital admissions and out-patient appointments to examine healthcare contacts and mortality. RESULTS: We identified 82 627 individuals: n = 75 165 with self-harm only; n = 5786 with eating disorders only; n = 1676 with both combined. Across all groups and settings significantly more individuals attended with significantly more contacts than the rest of the population. The combined group had the highest number of contacts per person (general practitioner, incident rate ratio IRR = 3.3, 95% CI 3.1-3.5; emergency department, IRR = 5.2, 95% CI 4.7-5.8; hospital admission, IRR = 5.2, 95% CI 4.5-6.0; out-patients, IRR = 3.9, 95% CI 3.5-4.4). Standardised mortality ratios showed the highest excess mortality overall in the self-harm only group (SMR = 3.2, 95% CI 3.1-3.3), particularly for unnatural causes of death (SMR = 17.1, 95% CI 16.3-17.9). SMRs and years of life lost showed an increased risk of mortality in younger age groups in the combined group. Adjusted hazard ratios showed increased mortality across all groups (self-harm only, HR = 5.3, 95% CI 5.2-5.5; eating disorders only, HR = 4.1, 95% CI 3.4-4.9; combined group, HR = 6.8, 95% CI 5.4-8.6). CONCLUSIONS: Individuals in all groups had higher healthcare service utilisation than the general population. The increased mortality risk in young people with a record of both eating disorders and self-harm highlights the need for early specialist intervention and enhanced support.

Model for ethical triaging of electroconvulsive therapy patients during the COVID-19 pandemic.

Electroconvulsive therapy (ECT) is an essential treatment for severe mental illnesses such as depression with suicidality and catatonia. However, its availability is being threatened by resource limitations and infection concerns due to the COVID-19 pandemic. This may necessitate the triage of patients for ECT but there is no established ethical framework to prioritise patients. We offer an application of an ethical framework for use of scare medical resources in the ECT setting.

A visual step-by-step guide for clinicians to use video consultations in mental health services: NHS examples of real-time practice in times of normal and pandemic healthcare delivery.

Despite the increasingly widespread use of video consultations, there are very few documented descriptions of how to set up and implement video consultations in real-time practice. This step-by-step guide will describe the set-up process based on the authors' experience of two real-time National Health Service (NHS) examples: a single health board use (delivered in normal time), and an All-Wales National Video Consultation Service roll-out (delivered during an emergency pandemic as part of the COVID-19 response). This paper provides a simple visual step-by-step guide for using telepsychiatry via the remote use of video consultations in mental health services, and outlines the mandatory steps to achieving a safe, successful and sustainable use of video consultations in the NHS by ensuring that video consultations fit into existing and new NHS workflow systems and adhere to legal and ethical guidelines.

Debate: COVID crisis, natural capital and clinical care - 'building back better' for a new values-based CAMHS.

The COVID-19 pandemic has meant upheaval for child and adolescent mental health services and for children, young people and their families. We look at this disruption through the lens of values-based practice. We also briefly examine the concept of natural capital and the opportunity for 'Building Back Better' post-COVID. We suggest that as well as losses, there are also opportunities to rethink and reshape our practices to make them more value-based.

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.

Current eating disorder healthcare services - the perspectives and experiences of individuals with eating disorders, their families and health professionals: systematic review and thematic synthesis.

BACKGROUND: Eating disorders have the highest mortality rate of mental disorders and a high incidence of morbidity, but if diagnosed and treated promptly individuals can benefit from full recovery. However, there are numerous problems at the healthcare interface (i.e. primary and secondary care) for eating disorders. It is important to examine these to facilitate appropriate, seamless treatment and improve access to specialist care. AIMS: To examine the current literature on the experiences and perspectives of those across healthcare interfaces for eating disorders, to include individuals with eating disorders, people close to or caring for those with eating disorders such as family and friends, and health professionals. METHOD: To identify relevant papers, a systematic search of electronic databases was conducted. Other methods, including hand-searching, scanning reference lists and internet resources were also used. Papers that met inclusion criteria were analysed using a systematic methodology and synthesised using an interpretative thematic approach. RESULTS: Sixty-three papers met the inclusion criteria. The methodological quality was relatively good. The included papers were of both qualitative (n = 44) and quantitative studies (n = 24) and were from ten different countries. By synthesising the literature of these papers, three dominant themes were identified, with additional subthemes. These included: 'the help-seeking process at primary care'; 'expectations of care and appropriate referrals' and 'opposition and collaboration in the treatment of and recovery from eating disorders'. CONCLUSIONS: This review identifies both facilitators and barriers in eating disorder healthcare, from the perspectives of those experiencing the interface first hand. The review provides recommendations for future research and practice. DECLARATION OF INTEREST: None.

The Moral Obligation to Prioritize Research Into Deep Brain Stimulation Over Brain Lesioning Procedures for Severe Enduring Anorexia Nervosa.

Deep Brain Stimulation is currently being investigated as an experimental treatment for patients suffering from treatment-refractory AN, with an increasing number of case reports and small-scale trials published. Although still at an exploratory and experimental stage, initial results have been promising. Despite the risks associated with an invasive neurosurgical procedure and the long-term implantation of a foreign body, DBS has a number of advantageous features for patients with SE-AN. Stimulation can be fine-tuned to the specific needs of the particular patient, is relatively reversible, and the technique also allows for the crucial issue of investigating and comparing the effects of different neural targets. However, at a time when DBS is emerging as a promising investigational treatment modality for AN, lesioning procedures in psychiatry are having a renaissance. Of concern it has been argued that the two kinds of interventions should instead be understood as rivaling, yet "mutually enriching paradigms" despite the fact that lesioning the brain is irreversible and there is no evidence base for an effective target in AN. We argue that lesioning procedures in AN are unethical at this stage of knowledge and seriously problematic for this patient group, for whom self-control is particularly central to wellbeing. They pose a greater risk of major harms that cannot justify ethical equipoise, despite the apparent superiority in reduced short term surgical harms and lower cost.