Diagnosis, provision and service organization
Authors: ROBERT PALMER
Journal: World Psychiatry (2009)

K. Halmi has shared her vision of the elements that need to be included in any “comprehensive” service response to the needs of people with clinical eating disorders. And few clinicians in the field would wish to argue with her about most of what she has set out. Some card-carrying nit-pickers such as myself could find things about which to quibble. For instance, the figure of 23 which she quotes for the standardized mortality is rather an outlier on the high side 1,2. Indeed, it is probably for this reason that it gets quoted frequently when the case is being made that eating disorders need to be taken seriously. I have so used it myself. Others in critical mode might question her proposal that multidisciplinary teams should always have the psychiatrist as their “captain”. As a medic myself this seems entirely reasonable and in tune with my view of how things should be, although an irritating part of my mind insists upon coming up with examples of good services that are led — either managerially or clinically or both — by non-medically qualified clinicians. And what about the nurses? They are not on Halmi's list. Yet, where I work they are the biggest professional group, both obviously in the inpatient unit but also less obviously in the outpatient teams, where with appropriate further training and support they make assessments and deliver psychological treatments. But to spend much time on such matters would be to miss the point. So, I shall flag up and comment mainly upon two issues. Each is touched upon but arguably neither receives sufficient emphasis in Halmi's text. The first issue is that of diagnosis and its implications. Of course, this is mentioned in the text, but often the terms eating disorder and anorexia nervosa seem to be used almost interchangeably. Most of the statements about what is required sit well with a discussion of anorexia nervosa, but less so with other types of eating disorders. Thus, the emphasis on multi-disciplinary teams, including psychiatrists, psychologists, nutritionists, physicians and so on, is appropriate for the management of the most seriously ill and risky patients. These challenging cases will be in the main people with a diagnosis of anorexia nervosa, but even within that diagnostic category they will be a minority. Most eating disorders can be assessed and treated adequately by an appropriately trained clinician working within an outpatient service or in office practice. This majority — my guess is that it would be of the order of 90% or more of presenting cases — includes many people with anorexia nervosa and the great majority of those with bulimia nervosa and the various forms of eating disorders not otherwise specified, including binge eating disorder. Such a clinician would need to be aware of physical risk and should know how to seek relevant expertise when complication or uncertainty arises. But the requirement of a full multi-disciplinary team confronting all patients is neither necessary nor practical. There are ways in which the current diagnostic classification of the eating disorders is unsatisfactory and in many respects the “transdiagnostic” view has merit 3. However, no one denies the practical relevance of very low weight and the associated complications. A comprehensive service needs to include a centre or team that can cope with the most difficult and risky cases. Inpatient treatment should be among the available interventions. However, this small part of clinical services for eating disorders need not predominate and arguably has been overemphasized in the past. What is often missing is the availability of suitably supported, competent and confident therapists/case managers who are able take on the majority of people with eating disorders. The other issue that is not emphasized in Halmi's text is that of service organization. How are the various elements of a comprehensive service to relate to each other? To a degree this will vary with the economic and political framework within which services are delivered. This can be a touchy subject and clinical guidelines often avoid it 4,5. Taxation funded state provision, such as the National Health Service in the UK, tends to have problems, but so do insurance based systems. Furthermore, there is some convergence with the growth of massive comprehensive health systems in the latter and attempts to inject ideas of a “market” and “choice” in the former. Third parties of whatever kind are increasingly influential. There is a need for clinicians to consider how much provision of what kind is reasonable for a population. We need to address such issues and come up with clinically relevant answers if we are not to be buffeted or unduly constrained by those with a more distant and mainly financial perspective. Of course, for the patient what matters is the ready availability of good quality services which are coherent and manage transitions for instance between child and adult or between outpatient and inpatient provision with a minimum of fuss and disruption. Patient and carer organizations should be important allies in these matters. The exercise of defining the components of a comprehensive service for people with eating disorders is important and K. Halmi and indeed World Psychiatry are to be congratulated on confronting this issue. The question is complicated but enriched by adding the issue of how these components may best be put together in practice. Undoubtedly there are more ways than one.