Weighing the options: Compulsory treatment, mental capacity and decision making in anorexia nervosa

Abstract

Anorexia nervosa (AN) is a severe mental illness impacting on all life domains and one of the leading causes of burden of disease in young females. Lifetime prevalence is 1 to 4 % in Europe indicating that AN is not uncommon. Central features are an intense fear of weight gain, body image disturbance and altered cognitive and emotional functioning. In extreme cases patients can die of AN.Mortality rates are amongst the highest in psychiatric disorders. Not only are mortality rates high, prognosis is also unfavourable with only 50% of adults recovering completely, 30% reaching partial recovery and 20% remaining severely ill. Surprisingly, given this unfavourable outcome and the severe consequences, many patients resist treatment. This calls into question whether or not patients are able to decide adequately regarding treatment, or in other words, have adequate mental capacity. Clinicians assess mental capacity by checking understanding, reasoning, appreciation and the ability to choose in a patient. However, this assessment is notably unreliable. A semi-structured interview has been designed to aid the clinician in this assessment (the MacCAT-T) and has good interrater reliability. In AN there is a lack of studies regarding mental capacity. The present thesis describes the results of the first large longitudinal study into mental capacity in adults with severe AN. As in the scientific literature doubts are voiced regarding the use of the MacCAT-T, in the thesis this instrument is compared to clinical judgment and suggestions regarding use in clinical practice are provided. Next to questions regarding mental capacity, discussion surrounds the use of compulsory treatment in AN. In this thesis a literature review of the published studies comparing compulsory and voluntary treatment is presented. Decision making on a neuropsychological level is also assesses longitudinally in relation to depressive symptoms. Results show that mental capacity problems occur in about a third of the population in the study. This is associated with a lower weight, more previous treatment for AN and lesser appreciation of the illness. Decision making, as assessed neuropsychologically, is less advantageous in patients with diminished mental capacity and does not improve in the course of two years. Patients with diminished mental capacity at baseline do less well in treatment; their weight does rise, but a larger proportion of patients remains severely ill after two years. They are admitted more often than patients with adequate mental capacity. Compulsory treatment is understudied, only 5 publications have been identified in the review. Compulsorily treated patients do equally well at discharge, but their stay was longer. The therapeutic alliance was not hindered by the invocation of compulsory treatment, which is reassuring. This suggests that there is no need to shy away from compulsory treatment in severe cases. Further research should focus on emotion regulation in relation to mental capacity, as it is hypothesized that inadequate emotion regulation has a detrimental effect on decision making and hence on mental capacity. Concerning compulsory treatment, qualitative studies are suggested to unravel underlying themes in patients and clinicians regarding the invocation of legal measures.