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High mortality rates and poor outcomes from eating disorders, especially anorexia nervosa, are largely preventable and require urgent action. A national strategy to address this should include prevention; early detection; timely access to integrated physical and psychological treatments; safe management of emergencies; suicide prevention; and investment in training, services and research.
This national pre-pandemic survey compared demand and capacity of adult community eating disorder services (ACEDS) with NHS England (NHSE) commissioning guidance.
Thirteen services in England and Scotland responded (covering 10.7 million population). Between 2016–2017 and 2019–2020 mean referral rates increased by 18.8%, from 378 to 449/million population. Only 3.7% of referrals were from child and adolescent eating disorder services (CEDS-CYP), but 46% of patients were aged 18–25 and 54% were aged >25. Most ACEDS had waiting lists and rationed access. Many could not provide full medical monitoring, adapt treatment for comorbidities, offer assertive outreach or provide seamless transitions. For patient volume, the ACEDS workforce budget was 15%, compared with the NHSE workforce calculator recommendations for CEDS-CYP. Parity required £7 million investment/million population for the ACEDS.
This study highlights the severe pressure in ACEDS, which has increased since the COVID-19 pandemic. Substantial investment is required to ensure NHS ACEDS meet national guidance, offer evidence-based treatment, reduce risk and preventable deaths, and achieve parity with CEDS-CYP.
The focus of this chapter is on evolutionary theories and models of anorexia nervosa (AN), bulimia nervosa (BN) and obesity. Although obesity is not considered a mental health problem, its link with binge eating disorder and its massively increased prevalence in recent decades, in association with modernisation and Westernisation together with increased morbidity and mortality, have stimulated much evolutionary theorising. Disorders of eating and weight are of particular interest to evolutionary scholars for a number of reasons. These include the claim that many of these disorders are evolutionarily novel, that they have increased in prevalence in developed countries in recent decades, that they have a large female preponderance, particularly of AN and BN, and that they have an increased risk of mortality. Our poor understanding of the aetiology of eating disorders together with poor outcomes (especially for AN) has been associated with a proliferation of proximate theories/models within mainstream psychiatry but without any one theory gaining wide acceptance. This presents an opportunity for evolutionary models to propose new ways of thinking and new avenues for research on these disorders. A review of the current evolutionary literature on AN and BN shows that despite the wide range and variety of models, the sexual competition hypothesis has, so far, had the strongest empirical support from clinical and non-clinical studies. While other evolutionary theories focus on AN, the sexual competition hypothesis provides an explanation for both AN and BN, as well as for the widespread dieting seen in the population. Furthermore, it uniquely makes sense of the specific presentations of eating disorders in males. Nevertheless, it seems increasingly clear that intrasexual competition is not the whole story. More recent work that considers other areas of mismatch in the modern environment represents a necessary extension to this theoretical perspective. It is concluded that larger-scale studies on clinical populations are required to put these theoretical formulations to the test and to explore their potential clinical utility.
This is a longitudinal cohort study describing the demand, capacity and outcomes of adult specialist eating disorder in-patient services covering a population of 3.5 million in a South-East England provider collaborative before and since the COVID-19 pandemic, between July 2018 and March 2021.
There were 351 referrals for admission; 97% were female, 95% had a diagnosis of anorexia nervosa and 19% had a body mass index (BMI) <13. Referrals have increased by 21% since the start of pandemic, coinciding with reduced capacity. Waiting times have increased from 33 to 46 days. There were significant differences in outcomes between providers. A novel, integrated enhanced cognitive behaviour theapy treatment model showed a 25% reduction in length of stay and improved BMI on discharge (50% v. 16% BMI >19), compared with traditional eclectic in-patient treatment.
Integrated enhanced cognitive behaviour theapy reduced length of stay and improved outcomes, and can offer more effective use of healthcare resources.
Deliberate self-harm (DSH) is common but rarely studied among inpatients with eating disorders. We sought to investigate the frequency of DSH among inpatients in a specialist adult eating disorders unit, and the association of DSH with comorbidities and treatment outcomes. We also investigated changes in these parameters during the pandemic.
We included the records of 70 patients consecutively admitted to Cotswold House in Oxford between April 2018 and November 2020. Data were analysed using Microsoft Excel using descriptive statistics. For comparisons, student T-tests were used for continuous variables and Chi-square tests used for categorical variables.
99% of patients were female; their ages ranged from 17 to 67 years (mean 30.7). 81% had a primary diagnosis of anorexia nervosa, and 67% had a history of DSH prior to admission. There was a total of 100 incidences of DSH, of which 12% required transfer to a general hospital for medical treatment.
Frequency of self-harm decreased with time throughout admission (17% self-harming on admission, vs 7% at discharge, p = 0.043).
Compared to those with no history of DSH, patients who self-harmed during admission were more likely to be detained under the Mental Health Act (45% vs 17.4%, p = 0.003), and to have psychiatric comorbidities (85% vs 35%, p = 0.001). Patients whose self-harm required transfer for general hospital treatment had a lower mean discharge BMI (18.18kg/m2 vs 20.23kg/m2, p = 0.039), longer admission (105.9 days vs 78.1 days, p = 0.037), and gained weight at a slower rate (0.26kg/m2/week vs 0.43kg/m2/week, p = 0.048) than those who did not require transfer.
During the pandemic, the frequency of DSH doubled on the ward. Overall outcomes were similar, however mean length of admission was lower during the pandemic (67.83 vs 89.94 days, p = 0.046), and patients regained weight more rapidly (0.43kg/m2/week vs 0.28kg/m2/week, p = 0.003) than prior to it.
Self-harm during admission was seen in 29% of patients and was associated with the presence of comorbid psychiatric diagnoses. The frequency of DSH much reduced between admission and discharge, suggesting a beneficial effect of treatment. Medical transfer for DSH, considered as a proxy measure for severity, predicted poorer outcomes in weight restoration. We also noted an increase in rates of DSH during the pandemic, which may have resulted from a combination of increased psychosocial stressors and a reduction in admission capacity in eating disorder units.
Trinucleotide repeats have been associated with schizophrenia, but the evidence, based on cross-sectional clinical information, is equivocal.
To examine the relationship between genomic CAG/CTG repeat size and premorbid development in schizophrenia.
Early development and premorbid functioning of 22 patients with DSM-IV diagnosis of schizophrenia were assessed by parental interviews. Repeat expansion detection (RED) technique was used to measure genomic CAG/CTG repeat size, and PCR for CAG repeat size at the ERDA-1 and CTG 18.1 loci.
There was an inverse association between CAG/CTG size and perinatal complications. Patients with speech and motor developmental delay had larger repeats. The results were not due to expansion in the ERDA-1 and CTG 18.1 genes.
CAG/CTG repeat expansion is associated with speech and motor developmental delay in schizophrenia. We propose that the developmental model may be useful for research into the genetics of schizophrenia.
Evolutionary science can serve as the high-level organising principle for understanding psychiatry. Evolutionary concepts generate new models and ideas for future psychiatric study, research, policy and therapy. The authors accordingly make the case for the inclusion of evolutionary biology in the postgraduate education of psychiatric trainees.
Las repeticiones de trinucleótidos se han asociado con la esquizofrenia, pero los datos, basados en información clínica transversal, son equívocos.
Examinar la relación entre el tamaño de la repetición de CAG/CTG genómico y el desarrollo premórbido en la esquizofrenia.
Se evaluó por entrevistas con los padres el desarrollo temprano y el funcionamiento premórbido de 22 pacientes con diagnóstico de esquizofrenia del DSM IV. Se utilizó la técnica de detección de la expansión de repeticiones (DER) para medir el tamaño de la repetición de CAG/CTG genómico, y la RCP para el tamaño de la repetición de CAG en los loci ERDA-1 y CTG 18.1.
Hubo una asociación inversa entre el tamaño de CAG/CTG y las complicaciones perinatales. Los pacientes con retraso evolutivo del habla y motor tenían repeticiones mayores. Los resultados no se debían a la expansión en los genes ERDA-1 y CTG 18.1.
La expansión de la repetición de CAG/CTG se asocia con retraso evolutivo del habla y motor en la esquizofrenia. Proponemos que el modelo evolutivo puede ser útil para la investigación en la genética de la esquizofrenia.
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