Care Is it working? Professor Janet Treasure

Transcription

1 Traditional Inpatient Care Is it working? Professor Janet Treasure

2 Talk Map What are goals and ethos? What does inpatient care post NICE look like? How is meal support organised? What do we know about other aspects of the content of treatments?

3 Service History start of the transfer of care from internal medicine i to psychiatric i wards in UK. Ethos: Restoration of normal weight with inpatient care was considered to be sufficient treatment.

4 The place of inpatient treatment questioned. No advantage over outpatient treatments (Crisp et al, 1991). No advantage over outpatient treatment (adolescents) at slightly increased cost (Gowers et al 2009, 2010).

5 Service Change A fundamental change in the NICE guidelines outpatient ti t management recommended as the initial approach. Inpatient care is now limited to those with high medical/psychosocial risk and failure to improve.

6 What patients are admitted and what is the process and outcome of inpatient units post NICE?

7 15 Collaborating sites Ascertained with condition carer involvement Barberry Unit, Birmingham Darwin Centre, North Staffordshire Kinver Centre, South Staffordshire Coventry STEPS, Bristol Cotswald House, Marlborough Haldon Unit, Exeter Cotswold House, Oxford Highfield Unit Seacroft Hospital, LPFT Cheadle Royal Hospital, Manchester Brandon Unit, Leicester St Vincent s Square, London St George s, London Bethlem Royal, London

8 Patient Characteristics Age 25.9 (9) Duration77(8) % Medication (77% antidepressants) 51% Admission in previous year 40% Binge 30% Vomit 29% Laxatives 56% Exercise. Importance of change 8/10 Confidence in change 5/10

9 Is health & risk improved?

10 Admission discharge BMI Length of stay 27 (SD16) (Range 11-36) weeks BMI Hospital (Inpatient) Admission Discharge AN Threshold 85% FU

11 Summary of medical condition at discharge Medical risk is reduced (huge effect 1.5). Few patients (31% (N = 40)) normal weight. Residual AN (BMI 17.5) 55% (N = 71).

12 What about other symptoms? Eating psychopathology Mood Social adjustment

13 EDEQ Admission i and Discharge d =.5 d =.6 d =.7 d =.4 d=.6 Admission Discharge Score 0 TOT OTAL RESTRAI AINT EAT CONCE ERN SHAPE CONCER ERN WEIGHT C CONCER ERN All effects statistically significant

14 MOOD (DASS) Admission and Discharge d = 0.4 d = 0.4 d = 0.3 Admission Discharge 0 DEP ANX STRESS All effects statistically significant

15 Social Quality of Life (0-100) Admission 30 Discharge Patient Carer

16 Summary of condition at discharge Moderate /large improvement in ED symptoms. Small/moderate improvement in mood. No change social situation.

17 Problems with meal support in UK inpatient units (Long et al.,) Wide variation in practice within and dbetween services. Nurses do not regard themselves as having sufficient skills. Patients report disengaging or in battle ground.

18 What other treatments have been tested in the inpatient setting? A systematic review (Suarez et al 2011). Antidepressants: Various Antipsychotics: py Various. (Olanzepine n=4). Nutrition: Tube feeding n=1. Zinc n=1 Other medications: Cisapride n=1, Cycloserine n=1 Psychotherapy: Motivational interviewing n=2, Family work n=3, Self help n=1.

19 Forest Plot of Olanzepine vs Placebo BMI discharge inpatients Kafantaris et al 2011 A trend of increasing fasting glucose and insulin levels in the olanzapine group

20 Conclusions Difficulty in restoring weight to normal levels. Only moderate gains in eating symptoms and depression, and no improvement in social functioning. Meal support is difficult for nursing staff and patients. t Olanzepine is associated with higher Olanzepine is associated with higher weight gain at discharge.

21 Time for a new ethos Policy Supporting Recovery

22 Acknowledgements Nina Jackson (RIED), NIHR, BRC

23 Thankyou

24 First do no harm: Iatrogenic Maintaining Factors in Anorexia Nervosa Janet Treasure, Anna Crane, Rebecca McKnight, Emmakate Buchanan & Melissa Wolfe Eur Eat Disord Rev 2011

25 Eating Interventions entions Mandometer which provides computerised feedback on the rate of eating and the perception of fullness (Bergh et al 2002) Individualised exposure therapy (Steinglass et al 2007, 2010). Relaxation techniques (progressive relaxation, guided imagery and SMR) (Shapiro et al, 2008).

26 Carers Mood Admission and discharge Adm iss ion Discharge 0 Depression Anxiety Stress

27 Expressed Emotion: Admission and Discharge Critical Comments Emotional Over involvement Admission Discharge

28 Accommodating and Enabling Admis sion Discharge AESED total