Managing Eating Disorders in Primary Care

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Managing Eating Disorders in Primary Care

• The Sheffield Experience
• By Dr Alison James
• June 2006

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Why did we do it?

• Sheffield population 500,000
• Student population of 2 Universities 50,000
• 1996 Specialist Eating Disorders Service set up
  by Community Mental Health Services for the city
• 1998-99 academic year 35 students were referred
  from Sheffields 2 Universities long waiting
  time for assessment needs not met
  

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NSF for Mental Health Eating Disorders 1999

• Most mild eating disorders can be managed within
  Primary Care
• Severe disorders should be referred for
  specialist assessment including a full medical
  and psychiatric assessment
• NSF was consistent with the Stepped Model of Care
  for Eating Disorders

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Stepped Model of Care

Step 6 7 Specialist Day or Inpatient
Care (E.D. Unit or Medical Bed)
Step 5 Outpatient Care Specialist Centre
Step 4 Outpatient Care (Local Psychiatrist)
Step 3 Treatment In Primary Care
Step 1 2 Self-help Manual/ Group
Develop role of Practice Nurse to include
supervision of guided self-help programme
Training of GPs to assess severity of ED/
management of less complex cases
Focused training for Practice Counsellors
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Getting Started

• Steering Group GP, Practice Nurse,
• Specialist Service,University Counselling
  Service, Sabbatical Officers,
• Voluntary sector S.Y.E.D.A.
• Personal Notebook A Self Help guide
• Training and supervision
• Funding

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Aims

• To improve recognition and identification of E.D.
  patients in Primary Care
• To improve access to services for E.D. patients
• To train Primary Care staff in assessment skills
  and provision of early intervention
• To develop referral pathways to ensure more
  appropriate referral to specialist services

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What is the Role of the GP ?

• N.I.C.E. guideline 9 Eating Disorders (Jan 2004
  responsibility for initial assessment and
  co-ordination of care)
• People with E.Ds should be assessed and receive
  treatment at the earliest opportunity
• Bulimia nervosa possible first step evidence
  based self help programme

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Disclosure and Identification

• Eating disorders are usually hidden
• Why ?

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Because !

• Shame
• Low self-esteem
• Fear
• Coping strategy
• Not ready
• Unaware that help is available
• Unsure who to trust

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Facilitating Disclosure

• Health questionnaire to new students
• Practice leaflet
• Posters in waiting and consulting rooms
• Website and links www.shef.ac.uk/health
• Information leaflets on display
• Links with counselling service, Student Services,
  Student Union, Sports Services

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Identification

• Target group young women (mostly) presenting
  with gastrointestinal, gynaecological or
  psychological difficulties
• Screening questions eating problem or worry
  excessively about your weight ?
• S.C.O.F.F. questionnaire
• (sensitivity of 100 and specificity of 90 for
  anorexia 2 or more questions answered
• positively should prompt more detailed
  assessment)

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History

• Consider the whole picture assess mood, self
  harm and risk factors
• A double appointment is useful
• A written account from the patient helps and lets
  you know their understanding of the problem

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Examination

• Height, weight and BMI
• Anorexia baggy clothes, cold hands, lanugo hair,
  low pulse rate, low B.P.
• Bulimia dental erosions, caries, parotitis,
  pharyngitis, abrasions of mouth,
• lips, fingers or knuckles

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Investigations

• FBC - low wcc in anorexia, normocytic,
  normochromic anaemia
• ESR - normal
• U Es low K in severe bulimia
• TFTs - normal
• Sex hormone profile anorexia hypothalamic
  suppression
• Bone mineral density scan

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Prescribing

• The Minority
• Supplements eg Fortisip/Fortijuice 300kcals
• SSRI eg Fluoxetine 60 mg may help in
  moderate/severe bulimia
• Anti-emetic eg Domperidone short term in early
  stages of treatment
• Calcium supplements if known Osteopenia/
  Osteoporosis

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Referral

• Primary Care eating disorders clinic
• Secondary Care specialist service if severe
• Community Mental Health Team if significant
  psychiatric co-morbidity

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Support ,Liaison and Service Development

• Ongoing support for patient
• Liaison with Primary Care Clinic Nurse or shared
  care if patient goes to specialist service
• Regular meetings with clinic nurse (in an ideal
  world !) to evaluate and develop the service