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Compulsory treatment in anorexia nervosa

Department of Psychological Medicine, Faculty of Medicine, The University of Sydney, NSW 2006, Australia

EDITED BY LOUISE HOWARD

I read with interest the paper by Ramsay et al (1999).

The matter of compulsory treatment in anorexia nervosa is clinically important. The lifetime risk of women developing this disease is 0.5%, that is half the lifetime risk of schizophrenia. The mortality rate is unacceptably high, reaching nearly 20% at 20-year follow-up. This would suggest the need for compulsory treatment in certain circumstances. However, there is disagreement between authorities about the issue, and in relation to the right of anorexic patients to receive life-saving treatment if they are unable to consent to it by reason of their mental disturbance. Various viewpoints have been presented in a recent multi-authored book (Vandereycken & Beaumont, 1999). As Ramsay et al point out, the only other empirical study attempted in this area was by Griffiths et al (1997) in New South Wales. The situation in New South Wales at the time of the latter publication was rather different from that in the UK inasmuch as anorexia nervosa is not considered a mental illness as defined in the Mental Health Act of this State. On that ground, Mr Justice Powell of the Supreme Court of New South Wales ordered the discharge of a severely ill patient with anorexia nervosa in 1986, setting a precedent that persisted until 1999. Incidentally, the patient in question died some time after her discharge.

In the absence of suitable mental health legislation in this area, the management of severely ill patients with anorexia nervosa who refused treatment became an issue for the Guardianship Board. Unfortunately, no new provisions were inserted into the Guardianship Act to deal precisely with this responsibility. Consequently, the treatment of patients has often been severely impeded, the public guardian demanding formal requests at each stage of treatment, and hence causing a considerable delay, and sometimes refusing treatment on grounds which appear ridiculous, for example refusing a cognitive-behavioural programme because it was not ‘medical’ treatment.

As recently as 1999, the situation in New South Wales has again changed. At a hearing concerning a 19-year-old severely ill patient with anorexia nervosa, Mrs Brennan, senior member of the Mental Health Tribunal, decided that she was a mentally ill person, and hence did fall under the Act even though anorexia nervosa as such was not considered a mental illness (mine not to comment on the niceties of the use of words in law, merely to report). This brings our State in line with legislation in the UK, and other states of Australia.

REFERENCES

Griffiths, R. A., Beumont, P. J. V., Russell, J., et al (1997) The use of guardianship legislation for anorexia nervosa: a report of 15 cases. Australian and New Zealand Journal of Psychiatry, 31, 524-531.

Ramsay, R., Ward, A., Treasure, J., et al (1999) Compulsory treatment in anorexia nervosa. Short-term benefits and long-term mortality. British Journal of Psychiatry, 175, 147-153.[Abstract/Free Full Text]

Vandereycken, W. & Beaumont, P. J. V. (eds) (1999) Treating Eating Disorders: Ethical, Legal and Personal Issues. London: Athlone Press.

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