Psychiatrists

Child and Adolescent Psychiatry and Mental Health BioMed Central Research Open Access Psychiatrists' attitudes towards autonomy, best interests and compulsory treatment in anorexia nervosa: a questionnaire survey Jacinta OA Tan*1, Helen A Doll2, Raymond Fitzpatrick2, Anne Stewart3 and Tony Hope1 Address: 1The Ethox Centre, Department of Public Health, University of Oxford, Oxford, UK, 2Department of Public Health, University of Oxford, Oxford, UK and 3Oxfordshire and Buckinghamshire Mental Health Foundation NHS Trust, Oxford, UK Email: Jacinta OA Tan* - ; Helen A Doll - ; Raymond Fitzpatrick - ; Anne Stewart - ; Tony Hope - * Corresponding author Published: 17 December 2008 Child and Adolescent Psychiatry and Mental Health 2008, 2:40 doi:10.1186/1753-2000-2-40 Received: 1 August 2008 Accepted: 17 December 2008 This article is available from: http://www.capmh.com/content/2/1/40 © 2008 Tan et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: The compulsory treatment of anorexia nervosa is a contentious issue. Research suggests that psychiatrists have a range of attitudes towards patients suffering from anorexia nervosa, and towards the use of compulsory treatment for the disorder. Methods: A postal self-completed attitudinal questionnaire was sent to senior psychiatrists in the United Kingdom who were mostly general adult psychiatrists, child and adolescent psychiatrists, or psychiatrists with an interest in eating disorders. Results: Respondents generally supported a role for compulsory measures under mental health legislation in the treatment of patients with anorexia nervosa. Compared to 'mild' anorexia nervosa, respondents generally were less likely to feel that patients with 'severe' anorexia nervosa were intentionally engaging in weight loss behaviours, were able to control their behaviours, wanted to get better, or were able to reason properly. However, eating disorder specialists were less likely than other psychiatrists to think that patients with 'mild' anorexia nervosa were choosing to engage in their behaviours or able to control their behaviours. Child and adolescent psychiatrists were more likely to have a positive view of the use of parental consent and compulsory treatment for an adolescent with anorexia nervosa. Three factors emerged from factor analysis of the responses named: 'Support for the powers of the Mental Health Act to protect from harm'; 'Primacy of best interests'; and 'Autonomy viewed as being preserved in anorexia nervosa'. Different scores on these factor scales were given in terms of type of specialist and gender. Conclusion: In general, senior psychiatrists tend to support the use of compulsory treatment to protect the health of patients at risk and also to protect the welfare of patients in their best interests. In particular, eating disorder specialists tend to support the compulsory treatment of patients with anorexia nervosa independently of views about their decision-making capacity, while child and adolescent psychiatrists tend to support the treatment of patients with anorexia nervosa in their best interests where decision-making is impaired. Page 1 of 14 (page number not for citation purposes) Child and Adolescent Psychiatry and Mental Health 2008, 2:40 Background Patients suffering from anorexia nervosa may refuse treatment. One of the ethical issues pertinent to the management of treatment refusal is that of competence, or the ability of patients to make their own treatment decisions. It is generally agreed that patients who possess the competence to make treatment decisions should be allowed to make their own treatment choices, even if these choices appear to be foolish or unwise [1,2]. The legal criteria of this ability of competence in the United Kingdom, which is called capacity, generally focus on abilities to understand, retain and weigh treatment information, to come to a decision, and to express a choice (see the Mental Capacity Act 2005 and Adults with Incapacity (Scotland) Act 2000). Research suggests that there can be additional areas in which patients with mental disorder can have difficulties with making decisions, such as appreciation (applying information to oneself) [3]. Furthermore, research suggests that for anorexia nervosa in particular, patients can experience difficulties with making decisions to accept treatment because of shifts in value systems, the incorporation of the mental disorder in the patient's sense of personal identity, and battles for control with mental health professionals [4-7]. As anorexia nervosa is a relatively rare mental disorder, most general psychiatrists treat relatively few patients with anorexia nervosa and may not feel highly skilled in its management. At the same time, the paucity and uneven distribution of dedicated eating disorder services [8,9] means that it is likely that the majority of patients with anorexia nervosa in the United Kingdom would be seen and treated by general psychiatrists who do not have special expertise in treating eating disorders. There is relatively little known about the frequency of use of compulsory treatment in anorexia nervosa. Legislation relevant to compulsory treatment of anorexia nervosa in legal minors and adults varies internationally [10]. In England and Wales, the Mental Health Act 1983 (now amended by the Mental Health Act 2007) allows compulsory treatment of mental disorders across all ages, so long as there is risk to the person or others. In Scotland, the Mental Health (Care and Treatment) (Scotland) Act 2003 also allows compulsory treatment of mental disorders in the presence of risk to health or safety, so long as the mental disorder is impairing the ability of the patient to make treatment decisions. Mental health professionals in England and Wales may use the Children Act 2004 to provide care and treat legal minors (those under the age of 18 years) without consent in the interests of their welfare. Legal minors may also be treated without their consent if parental consent is given. In the United Kingdom, a survey by the Royal College of Psychiatrists in 1992 found that 9% of inpatient anorexia nervosa patients in the United Kingdom were given compulsory treatment under the http://www.capmh.com/content/2/1/40 Mental Health Act 1983 [8]. An English specialist adult eating disorder centre receiving nationwide referrals of particularly difficult cases reported a rate of use as high as 16% [11]. An American specialist eating disorder unit also reported a similar rate of 16.6% (66 out of 397 inpatient admissions) compulsory inpatient admissions over a period of 7 years [12]. With regard to the course and outcome of compulsory treatment in anorexia (...truncated)