Management of eating disorders: optimal vs. minimum treatment
Authors: MANFRED M. FICHTER
Journal: World Psychiatry (2009)

As K. Halmi points out, anorexia nervosa is the mental disorder of young people with the highest mortality rate. While Harris and Barrow-clough's mortality rates for anorexia nervosa, reported in 1997 1, are still correct, the data they presented for bulimia nervosa and binge eating disorder were based on too few cases. According to more recent larger case series, the mortality rate (raw percentages) in treated cases of bulimia nervosa is 2.04%, and that in binge eating disorder is 2.94%, whereas the mortality rate of anorexia nervosa is 7.7% over 12 years 2–4. Factors contributing to these high mortality rates, especially in anorexia nervosa, are denial of illness, secrecy of symptoms, and resistance to treatment, which still represent a challenge to successfully design and implement comprehensive services for eating disorders. K. Halmi correctly emphasizes that there is a poverty of evidence-based randomized controlled trials on the basis of which we can recommend the salient components of a comprehensive service for eating disorders. A stepped care approach has been advocated, which would mean that each patient gets the minimum treatment needed. From the point of view of a close relative or friend, however, one would instead advocate for optimal treatment conditions. In the advocacy of stepped care approaches, it has at times been forgotten that the more intense a treatment is at the start, the less likely the course of illness will be chronic. Follow-up studies conducted by child and adolescent psychiatrists who treated anorexic patients at a younger age show that early and intensively treated cases have a much better prognosis than cases treated by psychiatrists in adult eating disorders services 5. Psychiatrists in adult services frequently treat cases which have become chronic, having not received or having refused appropriate treatment in time. In the various countries of the world, there are significant differences in medical and psychotherapeutic services for eating disorders. Some countries highly restrict inpatient services. In many countries a large proportion of the population has no (adequate) health insurance. Frequently the amount of money which insurance companies or governments spend on health services for eating disorders is insufficient, especially as compared with disorders for which advocacy is more active, such as diabetes, cancer and hypertension. In many countries, eating disorders are considered tangential to the field of psychiatry and are not in its mainstream. Nevertheless, over the past decades, the number and quality of services for eating disorders have improved in industrialized countries, and the relevance and importance of these disorders and their treatment has been more and more accepted by lay people and professionals. Specialized comprehensive services for eating disordered patients have been built up, which usually offer treatments focusing on the eating disorder itself (maturity fears, body image distortions, anxiety related to eating and gain weight), nutritional counseling, social skills training. Frequently they also offer specialized treatments focusing on comorbid conditions such as borderline personality disorder (dialectic behavior therapy), depression, social anxiety and phobias. Networking with general practitioners and self-help groups is often well developed. The possible use of specialized computer programs is currently being evaluated as part of a comprehensive service for eating disorders.