Patients with diminished mental ability respond more poorly in treatment.
Many genetic, psychosocial, and interpersonal factors work against treatment success in patients with anorexia nervosa (AN). These patients are often very reluctant to enter treatment, and impaired decision-making could further complicate this situation. According to a group in the Netherlands, people with AN with diminished mental capacity appear to do even less well in treatment and have poorer ability to make decisions than do patients without mental health problems. This does not improve with weight restoration (B J Psych Open. 2017; 3: 147. doi:10.1192/bjpo.bp.116.003905).
Isis F.M. Elzakkers, MD, and colleagues at the Eating Disorders Unit, Altrecht Mental Institute, Zeist, The Netherlands, examined decisional capacity at baseline and 1 and 2 years later. The Dutch group designed a longitudinal study of 70 adult female patients with severe AN. At baseline, psychiatrists established mental capacity, and clinical and neuropsychological data (especially regarding decision-making capacity) were collected. Then, after one and two years, clinical and neuropsychological tests were repeated, and admission and remission rates recalculated.
Participants completed the Eating Disorder Examination Questionnaire (EDEQ) and their body mass index (BMI, kg/m2) was established. The participant’s’ medical record provided information about admissions, treatments, and social functioning. Full remission was defined as weight in the normal range (BMI: 18.5 to 25.0), resumption of menses, and having no disabling anorectic cognitions. Clinicians with ED treatment experience used the MacArthur Competence Assessment Tool-Treatment (MacCAT-T), a semi-structured interview, to determine the level of mental capacity to consent to treatment. The Iowa Gambling Task (IGT) was also used to further assess each individual’s decision-making capacity.
One year later
After a year, 56 of the original group of 70 women (80%) agreed to continue on in the study, and at 2 years, 50 (71%) took part. At 1 year, 82% of the original group was still in treatment. After 2 years, 48 women, or 69%, were still receiving regular care. Only one participant in this study was held under the Mental Health Act at baseline, not due to his eating disorder but to comorbid alcohol dependence. One patient died of AN-related complications; a second patient died after the second follow-up. Both patients had been judged to have diminished mental capacity to consent to treatment at baseline, and both had BMIs below 15 kg/m2.