Anorexia Nervosa: When Should Patients Be Coerced to Have Treatment?

Involuntary admission for treatment of severe anorexia nervosa (AN) poses tremendous challenges for patients, parents and significant others, and clinicians alike. For clinicians, the risk of what may be a life-threatening illness balanced against the need to maintain a therapeutic relationship is often a clinical medicolegal tightrope where guidelines may be hazy. In addition, in some jurisdictions, such as Israel and until recently New South Wales in Australia, AN does not qualify as a mental illness warranting involuntary mental health admission and treatment. A team of researchers in Australia recently identified several criteria that might serve as guidelines for coerced admission for treatment of seriously ill AN patients (Isr J Psychiatry Relat Sci 2006; 43:159)

A 5-year review of admissions

Terry Carney, PhD, LLB, and colleagues in Sydney and Canberra, Australia recently reviewed all 177 admissions for treatment of AN to a specialist Australian AN program over nearly 5 years. The researchers divided the admissions into two groups, patients who agreed to hospitalization (informal admissions) and those who had been coerced into treatment.

Seventy-five patients accounted for 96 admissions, including some multiple admissions (up to 5 admissions to the unit) over the 5 years. Twenty-seven admissions resulted from mental health committals or adult guardianship orders. In 7 cases, admissions considered for coercion resulted in patients agreeing to informal admission, following a strategic confrontation and abandonment of resorting to the law. Slightly more than a third (36%) of admissions involved patients younger than 20, one-third were sole events within the sample periods, and three-fourths of those admitted were diagnosed with comorbid conditions. Approximately 40% of admissions were for less than 3 weeks, and the mean stay in the hospital was 49 days.

Four telling patient characteristics emerged

As the researchers continued their evaluation, certain characteristics emerged among those who had to be legally admitted for treatment of AN. These were: (1) young age at admission, (2) critically low body mass indexes (BMIs, or mg/kg2), (3) multiple prior admissions for treatment, and (4) comorbid mental health conditions.

Mental health comorbidity

The group that had to be coerced into treatment differed not only in the proportion of those who had comorbidity (85% vs. 75% among those who agreed to treatment) but in the number of cormorbid conditions. The coerced patients tended to have a much greater number of comorbid psychiatric diagnoses than did the informal treatment group.

Low presenting BMI

A critically low BMI was significantly associated with the likelihood of coerced admission (P = 0.05). Among the coerced patients, in 29% of admissions the patient had a BMI less than 12 at the time of admission. Nearly two-thirds (61.5%) had a BMI less than 14. In comparison, 8.6% of those who were voluntarily admitted had a BMI less tan 12. Although both groups had low BMIs, the composition of BMIs within the two groups was very distinctive: coerced patients had a lower BMI (10-12, in the very severely emaciated category) than did the informal patients.

Multiple admissions

Dr. Carney and colleagues also found that coerced patients were more likely than informal patients to have been admitted for treatment of AN or related conditions (80% vs. 57%, respectively). More than 1 in 3 of the coerced patients had been admitted 6 or more times previously, compared to only 1 in 10 of the informal patients.

Very young age at admission

Youth by itself did not prove to be statistically significant. However, 30.8% (8 patients) in the coerced admissions group were younger than 18 years of age, compared to 10% (7 patients) informally admitted to the unit. In addition there was a more marked trend for coercion to be used among for younger patients (under 18 years of age) with higher numbers of prior admissions to the unit. These patients tended to be better known to staff members in the unit and to have medically compromised weight (life-threatening BMIs of 10-12 kg/m2) and most developed the refeeding syndrome.

When first admissions were evaluated, the researchers found that patients who were coerced were statistically less likely to each as high a BMI on discharge as did the informal admissions group.

Wider implications of studies on coercion

In this study, the policy of the specialist treatment unit evolved to concentrating on preserving the physical integrity and safety of patients rather than on achieving acceptable BMIs or other goals.These cases also presented major dilemmas once features such as refeeding syndrome emerged. With neither family nor third parties (such as an appointed guardian) able to provide alternative community-based management or to bring informal persuasion/support to bear to encourage compliance with treatment, clinicians have few remaining options other than coercing treatment. Persuading patients of the severity of their illness is often a forlorn prospect, according to Dr. Carney. While they certainly do not wish to die, many patients lack the “insight” to understand how seriously ill they are.

Deciding when coercion should be used

Who should be coerced for treatment and how is this best achieved? According to the authors, the answer is never easy. By the very nature of severe AN, most patients will react badly to any attempts at refeeding. Since their reasoning is often impaired by the overlay of comorbid conditions and the possibility of brain atrophy, their capacity of reasoned judgment may be further hindered. Finding a way to balance the urgency to intervene and the therapeutic relationship is a true challenge, and while adult guardianship might cause less anger and resentment, it is often ineffective for these patients.