Eating disorders; The big issue - Ellern Mede (PDF)

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/300368547 Eating disorders: The big issue Article in The Lancet Psychiatry · April 2016 DOI: 10.1016/S2215-0366(16)00081-X CITATIONS 4 READS 401 21 authors, including: Some of the authors of this publication are also working on these related projects: Cognitive Remediation Therapy as a treatment enhancer in eating disorders and obsessive compulsive disorders View project Social Skills in Anorexia Nervosa View project Stefan Ehrlich Harvard Medical School 138 PUBLICATIONS 2,197 CITATIONS SEE PROFILE Beate Herpertz-Dahlmann RWTH Aachen University 420 PUBLICATIONS 8,511 CITATIONS SEE PROFILE Elena Tenconi University of Padova 39 PUBLICATIONS 713 CITATIONS SEE PROFILE A.A. van Elburg Utrecht University 91 PUBLICATIONS 1,163 CITATIONS SEE PROFILE All content following this page was uploaded by A.A. van Elburg on 17 April 2016. The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the original document and are linked to publications on ResearchGate, letting you access and read them immediately.  Comment www.thelancet.com/psychiatry Vol 3 April 2016 313 A new report7 from the King’s Fund entitled Bringing Together Physical and Mental Health: a New Frontier for Integrated Care not only reviews the case for integration, but also provides real practical examples of how it has been achieved. Importantly, the report describes both the barriers to and facilitators of its successful implementation on the basis of interviews of those involved. The barriers are many and not all will be overcome simply by colocation of services (colocation is not integration). They include deeply ingrained cultural factors in the workforce that reinforce division and the separate organisational and payment systems for physical and mental health care. Key facilitators to achievement of integration include strong leadership for change at both clinical and board level and a willingness to innovate in the relevant organisations. Policy developments in various countries, including the new models of care introduced by the National Health Service Five Year Forward View in England8 and the growth of accountable care organisations in the USA have the exciting potential to facilitate integration of physical and mental health care. However, this integration will only happen if psychiatrists and other professionals now actively engage with these developments and use them as opportunities to advocate for and lead new forms of collaborative or even integrated working. The idea of so-called parity of esteem for patients’ mental and physical health care, which has been successfully championed by the Royal College of Psychiatrists,9 has achieved considerable infl uence. Indeed, in England, the Health and Social Care Act 2012 created a new legal responsibility for the National Health Service to deliver parity of esteem between physical and mental health, something that the Government has pledged to achieve by 2020. However, interpretations of parity of esteem vary. One interpretation is simply for existing mental health services to be as well funded and provide as good care as existing physical health services. Although this interpretation is an important ambition, the report from the King’s Fund7 raises sights much higher than this ambition to a vision in which mental health care is not only as good as physical care is, but is also delivered as part of all health and care services. This challenge should be addressed and the opportunity seized if we are to repair the harm caused by 100 years of separation. *Michael Sharpe, Chris Naylor Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK (MS); and The King’s Fund, London, UK (CN) [email protected] We declare no competing interests. 1 Sharpe M. Psychological medicine and the future of psychiatry. Br J Psychiatry 2014; 204: 91–92. 2 Mayou RA. The history of general hospital psychiatry. Br J Psychiatry 1989; 155: 764–76. 3 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380: 37–43. 4 Naylor C, Parsonage M, McDaid D, Knapp M, Fossey M, Galea A. Long-term conditions and mental health. The cost of co-morbidities. London: The King’s Fund, 2012. 5 Collins C, Levis Hewson D, Munger R, Wade T. Evolving models of behavioral health integration in primary care. New York: Milbank Memorial Fund, 2010. 6 Thornicroft G. Premature death among people with mental illness. BMJ 2013; 346: f2969. 7 Naylor C, Das P, Ross S, Honeyman M, Thompson J, Gilburt H. Bringing together mental and physical health. A new frontier for integrated care. London: The Kings Fund, 2016 (in press). 8 National Health Service. Five year forward view. London: National Health Service, 2014. 9 Royal College of Psychiatrists. Whole-person care: from rhetoric to reality. Achieving parity between mental and physical health. London: Royal College of Psychiatrists, 2013. Eating disorders: the big issue The eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder, and related syndromes) are highly distinctive psychiatric disorders. The peak age of onset is 15–25 years—ie, at a developmentally sensitive time. The average illness duration is about 6 years. Young women make up the majority of people with anorexia and bulimia nervosa, with binge eating disorder nearly equally common in both sexes. The prevalence of eating disorder behaviours is rising in high-income countries, especially in combination with obesity.1 This increase is refl ected in rising numbers of these presentations to health services. Moreover, the illness is aff ecting people at an increasingly younger age.2 One in every six or seven young women have an eating disorder3 and anorexia nervosa is one of the most common chronic disorders in adolescence—at least as common as type 1 diabetes. Mortality rates are almost twice as high for people with eating disorders as in the general population, and nearly six times higher for people with anorexia nervosa. In people aged 15–24 years, the mortality risk from anorexia nervosa is higher than Detlev Van Ravenswaay/SPL  Comment 314 www.thelancet.com/psychiatry Vol 3 April 2016 For more on mental health research funding in the UK see http://www.joinmq.org/pages/ mental-health-research- funding-landscape-report for other serious diseases in adolescence, such as asthma or type 1 diabetes.4 One in every two to three people with bulimia nervosa or binge eating disorder are obese or will become obese, making them susceptible to obesity- related complications.3,5 Early intervention is key in achieving full recovery, yet many eating disorder cases are undetected and untreated. Talking therapies, including nutritional management, are the treatment of choice. In anorexia nervosa, family-based interventions for adolescents with a short illness are highly eff ective, but treatments for adults are only moderately eff ective.4,6 For bulimia nervosa and binge eating disorder, a solid body of evidence supports cognitive-behavioural interventions (including self-care and online versions). Medication has a limited role, and hence there is little involvement of so-called Big Pharma in eating disorders. Overall, fewer than half of patients with anorexia and bulimia nervosa fully recover.5,6 Many people with anorexia nervosa have long-term impairments in social functioning and employment. One in four has no paid employment.6 In binge eating disorder and bulimia nervosa, roughly half have substantial role impairment (eg, work, close relationships).7 Women with any eating disorder are more likely to stay childless, have fewer children, and need fertility treatment to conceive than those without an eating disorder. They have more diffi culties feeding their children and interacting with them. These diffi culties might contribute to the intergenerational perpetuation of eating disorders. Quality of life in eating disorders is as low as that in symptomatic coronary heart disease or major depression and worsens with illness duration.6 The burden on caregivers of people with eating disorders is substantially higher than that of caring for a relative with depression or schizophrenia. Compared with people caring for adults with serious physical or mental disorders (eg, cancer, psychosis, dementia), time spent caregiving in severe anorexia nervosa is nearly twice as high (24 h per week vs 14 h per week).8,9 Previous attempts to estimate size and cost of eating disorders in Europe10 have severely underestimated the problem because the most common eating disorders (binge eating disorder and eating disorder not otherwise specifi ed) were not counted, and key resource items, cost of lost productivity of families, and indirect costs due to reduced length of life and health were not included. Recent comprehensive estimates suggest that 20 million people in the European Union (EU) have an eating disorder, with a cost of about €1 trillion per year (fi nancial costs of about €249 billion plus burden of disease costs of about €763 billion). The fi nancial costs of eating disorders are similar and the burden of disease costs higher than those of anxiety and depression. Given the size and cost of the problem, research funding for eating disorders is inadequate—eg, in the UK, only 0·4% of mental health research expenditure is for eating disorders, compared with 7·2% for depression and 4·9% for psychosis. This funding disparity is refl ected in relatively low research activity in eating disorders. In the past decade, only 15 615 articles were published worldwide on eating disorders, compared with about 200 000 papers on depression (Web of Science, Nov 16, 2015). Most papers were about the psychology of eating disorders (42%) with only 10·5% about neurobiology. Within Horizon 2020—the biggest- ever EU research and innovation programme—no specifi c eating disorders funding is currently planned. Broad priorities for European mental health research have recently been outlined11 and are to be welcomed. A strategic plan for eating disorder research that builds on and expands this plan is now needed. Such a plan should establish a pan-European transdisciplinary framework that addresses stakeholder (eg, patients, carers, clinicians) research priorities. Further, no formal training structures are in place for young researchers in Europe that refl ect the transdisciplinary needs of the eating disorders specialty. EU-funded research and research-training initiatives in eating disorders have focused mainly on sociocultural risk and e-health. However, substantial advances will only arise if young researchers are trained and are familiar with state-of-the-art and emerging neurotechnology. Any such research training in eating disorders should be integrated across the weight spectrum, although eating disorder researchers have traditionally worked separately from those in obesity. It will also need to be a bench-to-bedside programme and span a range of neurobiological approaches used to assess cause, prevention, and treatment, and combine animal and human studies. It is unlikely that the required doctoral or post-doctoral research training programme needed to address this gap can be set up in individual countries, thus highlighting the need for an EU-wide initiative on capacity building. For more on the financial cost of eating disorders see http://thebutterflyfoundation. org.au/wp-content/ uploads/2012/12/Butterfly_ Report.pdf  Comment www.thelancet.com/psychiatry Vol 3 April 2016 315 In summary, eating disorders are serious disorders that have a major impact on individuals, families, and wider society. Data indicate funding for eating disorders research is inadequate given the size of the problem. Notably, eating disorders are highly stigmatised, more so by men than by women.12 This stigmatisation could possibly play a part in funding decisions, because many policy makers and research funders are male. Although diff erent EU countries have strengths in specifi c aspects of eating disorders research, no EU strategic plan exists for setting research priorities. No formal training structures exist for young researchers to provide the interdisciplinary skills required to advance in the fi eld. To tackle the large and rising problem of eating disorders, and improve patients’ and families’ lives, the EU needs to recognise this big issue as a priority area to facilitate adequate funding for large-scale research endeavours and capacity building. For further references see the appendix. *Ulrike Schmidt, Roger Adan, Ilka Böhm, Iain C Campbell, Alexandra Dingemans, Stefan Ehrlich, Isis Elzakkers, Angela Favaro, Katrin Giel, Amy Harrison, Hubertus Himmerich, Hans W Hoek, Beate Herpertz-Dahlmann, Martien J Kas, Jochen Seitz, Paul Smeets, Lot Sternheim, Elena Tenconi, Annemarie van Elburg, Eric van Furth, Stephan Zipfel Department of Psychological Medicine, King’s College London, London SE5 8AF, UK (US, ICC, HH); Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands (RA, MK, PS); Rintveld Hospital, Zeist, Netherlands (RA, IE); Department of Child and Adolescent Psychiatry, Technische Published Online February 8, 2016 http://dx.doi.org/10.1016/ S2215-0366(16)00014-6 Mental health in Europe’s Syrian refugee crisis Since 2011, the war in Syria has resulted in mass displacement of its population both inside and outside the country.1 Although neighbouring countries have hosted most of the refugees, since the summer of 2015 a surge of Syrian citizens have crossed through Turkey into Greece, with the ultimate aim of reaching western Europe. Thousands of Syrians are being subjected to harsh natural and manmade obstacles on their journey, while receiving poor medical care along the way.2 Although the prevalence of mental illness among these refugees is not available at present, it is expected to be greater than that of the general population, which is consistent with estimates from refugees in the countries neighbouring Syria.3,4 Longitudinal studies on the change in manifestation of psychological distress in Syrians have not been done. However, in other war-surviving populations, the prevalence of traumatic reactions and post-traumatic stress disorder (PTSD) declines over time, except in those with severe prolonged and complicated traumatic reactions.5 Hence, in the European refugee crisis, especially in the early stages of resettlement, individuals who face language barriers, unemployment, and acculturation issues might have a pervasive sense of demoralisation and hopelessness.6 In view of all these factors, care providers See Online for appendix Universität Dresden, Dresden, Germany (IB, SE); Rivierduinen Eating Disorders Ursula, Leiden, Netherlands (AD, EvF); Leiden University Medical Center, Leiden, Netherlands (EvF); University of Padova, Padova, Italy (AF, ET); Eberhard-Karls Universität, Tübingen, Germany (KG, SZ); Regent’s University London, London, UK (AH); Groningen University, Groningen, Netherlands (HWH); Technische Universität Aachen, Aachen, Germany (BH-D, JS); and University Clinics, Utrecht University, Utrecht, Netherlands (LS, AvE) [email protected] We declare no competing interests. 1 Darby A, Hay P, Mond J, Quirk F, Buttner P, Kennedy L. The rising prevalence of comorbid obesity and eating disorder behaviors from 1995 to 2005. Int J Eat Disord 2009; 42: 104–08. 2 Smink FR, van Hoeken D, Hoek HW. Epidemiology, course, and outcome of eating disorders. Curr Opin Psychiatry 2013; 26: 543–48. 3 Hay P, Girosi F, Mond J. Prevalence and sociodemographic correlates of DSM-5 eating disorders in the Australian population. J Eat Disord 2015; 3: 19. 4 Zipfel S, Giel KE, Bulik CM, Hay P, Schmidt U. Anorexia nervosa: aetiology, assessment and treatment. Lancet Psychiatry 2015; 2: 1099-111. 5 Kessler RC, Berglund PA, Chiu WT, et al. The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biol Psychiatry 2013; 73: 904–14. 6 Treasure J, Zipfel S, Micali N, et al. Anorexia nervosa. Nat Rev Dis Primers 2015; 1: 15074. 7 Kessler RC, Shahly V, Hudson JI, et al. A comparative analysis of role attainment and impairment in binge-eating disorder and bulimia nervosa: results from the WHO World Mental Health Surveys. Epidemiol Psychiatr Sci 2014; 23: 27–41. 8 Viana MC, Gruber MJ, Shahly V, et al. Family burden related to mental and physical disorders in the world: results from the WHO World Mental Health (WMH) surveys. Rev Bras Psiquiatr 2013; 35: 115–25. 9 Raenker S, Hibbs R, Goddard E, et al. Caregiving and coping in carers of people with anorexia nervosa admitted for intensive hospital care. Int J Eat Disord 2013; 46: 346–54. 10 Gustavsson A, Svensson M, Jacobi F, et al. Cost of disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 2011; 21: 718–79. 11 Wykes T, Haro JM, Belli SR, et al. Mental health research priorities for Europe. Lancet Psychiatry 2015; 2: 1036–42. 12 Mond JM, Arrighi A. Gender diff erences in perceptions of the severity and prevalence of eating disorders. Early Interv Psychiatry 2011; 5: 41–49. 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