While many of us focus on healthy diets and exercise regimes, for others an unhealthy obsession with weight and diet is a year round concern.
With an estimated almost 725,000 individuals in the UK suffering from some form of eating disorder and the numbers of reported cases having risen from 32 per 100,000 population to 37 between 2000 and 2009, GPs are more likely than ever to be faced with a patient with an eating disorder.
Over the last five years the MDU has advised more than 70 members relating to the management of patients with eating disorders. Commonly, this was because of a complaint from the patient or their relative. Tragically, nearly a third of these (30%) were in relation to preparing a report for a coroner’s inquest. Patients with eating disorders have the highest mortality rate of any mental illness, and a significant risk of suicide, according to the charity beat.
So how can GPs assess and treat these vulnerable patients?
1. Keep an open mind about which patients could be affected
Typically eating disorders emerge in adolescence with females more commonly affected, but it is important to bear in mind that men, ethnic minorities and children can also be affected.
Sufferers may be ambivalent to diagnosis, remain in denial and may also be secretive or ashamed. This means that for many individuals with an eating disorder, there is significant delay in seeking help, which may in turn impact their prognosis.
There may also be a delay between a patient being seen in primary care and receiving specialist input due to difficulties in accessing the appropriate services. This is often the case with children.
2. Be alert to signs
Early diagnosis of eating disorders is important, with GPs, parents, schools, colleges and community organisations encouraged to be proactive in recognising the symptoms.
NICE guidance suggests that GPs should consider the possibility of an eating disorder in high risk groups and those presenting with certain clinical symptoms, for example, adolescent girls with concerns about weight or delayed puberty and women consulting with menstrual disturbances, gastrointestinal or psychological symptoms.
Be aware of the NICE guidance on diagnosis and management of eating disorders and mindful that patients can be slow to present. An opportunistic approach to screening high risk patients and those with ‘red flag’ symptoms, might allow early recognition.
3. Clearly communicate to avoid complaints
The complex and prolonged nature of these illnesses, can mean that patients and those who care for them, present with difficult management dilemmas and complex ethical questions. Complaints can arise if patients and relatives feel these issues haven’t been dealt with to their satisfaction.
A common theme in the complaints relating to eating disorders that the MDU has dealt with was a delay in diagnosis or delayed referral to a specialist centre, but complaints about the clinician’s attitude also featured prominently.
There can be breakdowns in communication, particularly when patients’ care is being shared between primary and secondary care. When care is shared, there should be a clear agreement, preferably written, on how the patient should be monitored and who is responsible for each aspect of the care.
4. Keep consent and confidentiality under review
Concerns about confidentiality can occur such as whether to disclose the patient’s information to third parties, for example other clinicians, employers or insurers, when the patient did not want their diagnosis divulged.
Patients may also refuse treatment, and this can be a difficult dilemma for GPs to deal with. When assessing a patient’s capacity to reach a decision regarding treatment, remember that the patient’s capacity is time and decision specific. Keep these matters under review, and consider whether the patient should be assessed under the Mental Health Act.
5. Get expert advice
Although GPs will only occasionally see a patient who is newly presenting with an eating disorder, you do have a significant part to play in the early detection of these debilitating and life-threatening disorders.
Patients with eating disorders commonly have co-morbidities and other mental and physical conditions.
Treatment can be complex and the incidence of relapse amongst sufferers is high.
As a result, management of patients can be complex and challenging not only from the clinical aspect, but also with ethical and medico-legal dilemmas. When complex confidentiality or capacity questions arise, get specific advice from your medical defence organisation.