Eat Weight Disord (2014) 19:191–197 DOI 10.1007/s40519-014-0103-x
ORIGINAL ARTICLE
Mental health services use and management of eating disorders in an Italian Department of Mental Health Simona Calugi • Vera Maria Avaldi • Riccardo Dalle Grave • Paola Rucci • Maria Pia Fantini
Received: 11 September 2013 / Accepted: 21 January 2014 / Published online: 11 February 2014 Ó Springer International Publishing Switzerland 2014
Abstract Objective To investigate the clinical characteristics of patients with eating disorders referred to Community Mental Health Centers (CMHCs) in the Department of Mental Health of Bologna, Italy, and to evaluate the number and type of interventions delivered. Methods Adult patients with eating disorders who had a first contact with CMHCs between January 1, 2007 and December 31, 2012 were extracted from Bologna Local Health Authority database. Moreover, the hospital discharge records of patients were linked to the mental health information system of Bologna. Results Among the 276 patients with eating disorders identified, 59 (21.4 %) were diagnosed as anorexia nervosa, 77 (27.9 %) as bulimia nervosa and 140 (50.7 %) as eating disorders not otherwise specified. The mean age of the sample was 37.3 (SD = 13.4), with no significant differences among the three diagnostic groups. The number of CMHCs outpatients increased each year from 2007 to 2011 and decreased in 2012. The proportion of new patients by year comprised about 50 % of the total of patients. Psychotherapy accounted for about 10 % of the interventions. Day-hospital and hospital admissions concerned 6.1 and 11.6 % of the sample. Conclusions CMHCs are part of the system of care outlined by the Regional policies for eating disorders and are S. Calugi V. M. Avaldi P. Rucci M. P. Fantini (&) Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum-University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy e-mail: [email protected] R. Dalle Grave Department of Eating and Weight Disorders, Villa Garda Hospital, Via Montebaldo 89, 37016 Garda (VR), Italy
responsible for providing the first level of outpatient care to adults. To date, there is the need to extend our monitoring across the whole system of care, to assess the implementation of specific and effective strategies to decrease the age of access of patients and to improve the quality of care delivered with the inclusion of evidence-based treatments in the process of care. Keywords Mental health services Eating disorders Anorexia nervosa Bulimia nervosa Italy Patterns of care
Introduction Eating disorders have a young age of onset [1], are often associated with significant impairment of physical health [2] and psychosocial functioning [3] and bear an increased risk of death [4–6]. However, reports about the use of health services for patients with eating disorders are scanty [7]. This is an important limitation because the health services use is a potential indicator of eating disorders impairment and reveals the economic burden for the society due to direct (e.g., costs of services) and indirect (e.g., disability and early mortality) costs for the management of these disorders [8]. To date, few European and North American studies evaluated both economic costs and health services use in outpatient and inpatient settings of patients with eating disorders. A systematic review of the literature on the resource use and cost of eating disorders identified 17 studies and concluded that patients with eating disorders use frequently health services and represent a considerable cost burden to the society [9]. It has also suggested that available data probably underestimated the real economic
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treatment costs because the results are based on limited databases [10] evaluating only inpatient costs [11]. Studies using national [10] and regional [12] databases found that patients with eating disorders are mainly treated in outpatient settings. Evidence from the literature suggests also that health services use is significantly higher in eating disorder patients than matched controls and similar across the spectrum of eating disorders (anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified [NOS]) [7]. However, health services use data indicate also that this population is undertreated [7] and do not specify the type of interventions provided, except for hospitalization that, in studies based on just 1 year of observation, has been required in about 10–20 % of eating disorder patients and frequently occurred in non-specialist inpatient units [10, 12]. The paucity of data available indicates that studies with more comprehensive data on current and long-term healthcare resource use of eating disorder patients, describing also the type of interventions provided, are warranted. The aim of the study was to explore the clinical characteristics of adult patients with eating disorders referred to community mental health centers (CMHCs) of the Department of Mental Health of Bologna, Italy from 2007 to 2012, and the number and type of treatments provided.
Materials and methods Setting and data source The data source for this study was the mental health information system of the CMHCs of the Bologna Local Health Authority (LHA). The Bologna LHA is one of the largest of Italy and serves approximately 850,000 inhabitants, roughly one-fifth of the regional population. The mental health information system was implemented in 2004 and refined in 2007 for administrative and clinicalepidemiological purposes. All adult patients (age C18) who had at least one contact with CMHCs were recorded in the database since then, reflecting the total secondary mental health care in the area. Data include, in addition to patient’s ID number, demographic characteristics, the ICD9 CM diagnosis, and information on each type of intervention administered. No information is recorded about whether patients previously received treatments for eating disorders. The hospital discharge records of the patients were linked to the mental health information system of Bologna. Records of patients with eating disorders were identified using Disease Related Groups (DRGs) 428 and 432 or ICD-9 CM codes in primary or secondary diagnosis.
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Mental health services In the Italian National Health Service, mental health care is provided by Departments of Mental Health (DMH). Within the DMH, CMHCs are in charge of delivering outpatient care for adult patients and coordinating treatments provided by day-care centers and non-hospital residential facilities. In case of admission to hospital wards, continuity of care is ensured by CMHC through interactive work and close cooperation with inpatient teams [13]. Inpatient care is provided by general hospital psychiatric units [14], licensed private hospitals and residential intensive units. A network of community services for minors has also been implemented, with relevant differences according to Regional policies. In Emilia-Romagna Region, outpatient mental health care for minors is delivered by dedicated services within the DMH. Patterns of care Over the last years Emilia-Romagna has implemented a regional program of health care for patients with eating disorders, comparable to national indications recently outlined by the Ministry of Health [15]. Since 2004, the regional program was based on the multidisciplinary integration between clinical teams, across levels of progressive intensity of care [16]. At present, five levels of care are identified: the primary care access and referral, the outpatient assessment and treatment in the DMH community services for adults and minors, the specialist outpatient assessment and treatment in University or other expert multidisciplinary units, the specialist day-hospital or residential treatment and the medical or psychiatric inpatient treatment. Study sample Demographic, diagnostic and treatment information of adult patients who had their first contact with one of the 11 Community Mental Health Centers of the Local Health Authority between January 2007 and December 2012 were extracted from the database. Data on the outpatient level of care carried out by University or other expert multidisciplinary teams were not available. ICD-9 CM diagnoses were classified into three groups: anorexia nervosa (307.1), bulimia nervosa (307.51), and eating disorders NOS (307.5; 307.50; 307.52; 307.53; 307.54; and 307.59). Interventions Patients received outpatient and/or hospital treatments. Outpatient therapeutic interventions were coded into four main categories: (i) psychotherapy; (ii) socio-rehabilitative
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interventions, aimed at strengthening the social capacities, and consisting in individual rehabilitation (skills training related to activities of daily living and to social relationships), group activities (sports teams, leisure time, socialization opportunities) and vocational training activities; (iii) intensive outpatient treatment, provided by CMHC staff, consisting in daily visits along a short period of time, with pharmacological treatment and monitoring of physical conditions to avoid hospital admission in severe patients who are not in high medical risk; (iv) others, including medical visits and clinical interviews with the patients and their families. Hospital care was coded in two main categories: (i) day-hospital admissions; (ii) hospital admissions. The choice of the interventions was based on the clinical evaluation of the disorder severity and on patients’ needs. Statistical analyses Continuous variables were summarized as mean and SD and categorical variables as frequency and percentage. Analysis of variance with Bonferroni post hoc test, Kruskal–Wallis test and v2 test were carried out to compare the three eating disorder diagnostic categories on continuous and categorical variables, as appropriate.
Results Two hundred and seventy-six eating disorder patients—out of 39,125 psychiatric patients recorded from 2007 to 2012—with a mean age of 37.3 years (SD 13.4, range 18–78) were recorded in the mental health information system. Over fifty percent (53.3 %) had an age between 18 and 35 years and 15.6 % had more than 50 years. Most patients were females (89.5 %) and of Italian nationality (97.1 %). More than half of the sample was single (56.2 %), while 33.3 % lived with the partner. One
hundred and twenty-five patients completed high school (45.3 %), 19.2 % had graduated, and more than one half (59.8 %) were employed. Among the 276 cases identified, 59 (21.4 %) received a diagnosis of anorexia nervosa, 77 (27.9 %) a diagnosis of bulimia nervosa, and 140 (50.7 %) a diagnosis of eating disorder NOS at the index visit. Mean age was 34.5 ± 13.3 years for anorexia nervosa, 37.7 ± 12.8 for bulimia nervosa, and 38.3 ± 13.6 years for eating disorder NOS, with no significant differences between the three diagnostic categories (F = 1.76, p = 0.174). No significant difference was also found on gender, marital status, educational level and occupational status (v2 = 0.39, p = 0.824; v2 = 10.57, p = 0.392; 9.38, p = 0.496, v2 = 0.35, p = 0.470, respectively). Almost 20 % of patients with eating disorders received a diagnosis of another psychiatric disorder, and the most common were mood disorders, personality disorders and anxiety disorders (Table 1). CMHCs use The number of patients accessing the CMHCs increased over time from 2007 to 2011 although in 2012 the number decreased (37 patients in 2007, 66 in 2008, 87 in 2009, 106 in 2010, 119 in 2011 and 63 in 2012). The proportion of new patients accessing mental health services by year was about 50 % of the total of patients. The annual number of mental health interventions was stable over time and ranged from 3.0 to 6.0 per patient with two peaks in 2011 and 2012 of more than 140 interventions for 2 patients. In 2011 patients with anoressia nervosa received a significant higher number of mental health interventions than those with eating disorder NOS (Kruskal–Wallis test 8.96, p = 0.011, post hoc test p \ 0.05), while in the other years no differences emerged among eating disorder diagnosis.
Table 1 Psychiatric comorbidity according to ICD-9 CM in AN, BN and eating disorder NOS patients
Mood disorders Anxiety disorders Personality disorders Psychotic disorders Mental retardation Alcohol dependence syndrome Somatization disorder Sedatives or hypnotics dependence Any psychiatric disorder
AN (n = 59)
BN (n = 77)
Eating disorder NOS (n = 140)
Total
4 0 3 1 1 0 0 0 9
5 (6.5 %) 3 (3.9 %) 4 (5.2 %) 0 0 1 (1.3 %) 1 (1.3 %) 0 15 (19.5 %)
13 (9.3 %) 9 (6.4 %) 8 (5.7 %) 0 0 0 0 1 (0.7 %) 28 (20 %)
22 (8.0 %) 12 (4.3 %) 15 (5.4 %) 1 (0.4 %) 1 (0.4 %) 1 (0.4 %) 1 (0.4 %) 1 (0.4 %) 52 (18.8 %)
(6.8 %) (5.1 %) (1.7 %) (1.7 %)
(15.2 %)
Data are presented as number (percentage) AN anorexia nervosa, BN bulimia nervosa, NOS not otherwise specified
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Table 2 Number of outpatient and hospital interventions in mental health services, by year 2007
2008
2009
2010
2011
2012
Outpatient treatments Psychotherapy
34 (3.6 %)
89 (10.5 %)
120 (9.1)
127 (11.2 %)
96 (6.1 %)
147 (15.5 %)
Socio-rehabilitative therapy
10 (1.1 %)
4 (0.5 %)
0
9 (0.8 %)
16 (1.0 %)
26 (2.7 %)
Intensive outpatient intervention
168 (18.0 %)
69 (8.1 %)
249 (18.9 %)
0
0
0
Other outpatients interventions
723 (77.3 %)
685 (80.8 %)
949 (72.0 %)
993 (87.9 %)
1,469 (92.9 %)
772 (81.7 %)
Total outpatient interventions
935
847
1,318
1,129
1,581
945
Day-hospital
3 (33.3)
1 (14.3)
6 (17.1)
9 (34.6)
11 (55.0)
5 (45.5)
Hospitalization
6 (66.7)
6 (85.7)
21 (77.8)
17 (65.4)
9 (45.0)
6 (56.5)
Total hospital interventions
9
7
27
26
20
11
Total interventions
944
854
1,345
1,155
1,601
956
Hospital treatments
Data are presented as number (percentage)
Type of intervention Table 2 shows the type of intervention according to the coding classification described above. Psychotherapy accounted for about 10 % of the interventions provided each year and during the treatment period. Among the 276 patients assessed, 23 (8.3 %) received psychotherapy, 6 (2.1 %) socio-rehabilitative interventions and 7 (2.5 %) intensive outpatient treatment. Of the 23 patients who received psychotherapy, 13 completed at least 15 therapy sessions and reached the goals set by their therapists, 3 discontinued treatment, 4 had their treatment plan changed and 2 attended fewer than 15 therapy sessions. Thirty-five day-hospital interventions occurred between 2007 and 2012 (22 [62.9 %] for anorexia nervosa, 4 [11.4 %] for bulimia nervosa and 9 [25.7 %] for eating disorder NOS). Twenty-nine (82.9 %) day-hospital occurred in specialist eating disorder units (anorexia nervosa = 18; bulimia nervosa = 2; eating disorder NOS = 9) and 6 (17.1 %) in general psychiatric or internal medicine units (anorexia nervosa = 4; bulimia nervosa = 2; eating disorder NOS = 0). The median duration of day-hospital treatment was 8.0 (range 1–78) days in specialists units (anorexia nervosa: median 4.5 [1–71] days; bulimia nervosa: median 23.5 [1–46] days; eating disorder NOS: median 34 [1–78] days) and 5.0 (range 1–35) days in general psychiatric or internal medicine units (anorexia nervosa: median 4.5 [1–35] days; bulimia nervosa: median 6 [5–7] days). The total number of hospitalizations was 65, 51 in anorexia nervosa (78.5 %), 2 in bulimia nervosa (3.1 %) and 12 (18.5 %) in eating disorder NOS patients. Twentyfive (38.5 %) hospitalizations occurred in specialist eating disorder inpatient units (anorexia nervosa = 17; bulimia nervosa = 2; eating disorder NOS = 6), 19 (29.2 %), in general hospital psychiatric units (anorexia nervosa = 16;
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bulimia nervosa = 0; eating disorder NOS = 3) and 21 (32.3 %) in internal medicine units (anorexia nervosa = 18; bulimia nervosa = 0; eating disorder NOS = 3). The duration of inpatient treatment ranged from 3 to 91 (median = 56.0) days in specialist units (anorexia nervosa: median 56 [3–91] days; bulimia nervosa: median 59 [28–90] days; eating disorder NOS: median 61.5 [25–84] days), from 1 to 26 (median = 14.0) days in general hospital inpatient psychiatric units (anorexia nervosa: median 11.5 [1–23] days; eating disorder NOS: median 25 [23–26] days), and from 1 to 22 (median = 4.0) days in internal medicine units (anorexia nervosa: median 3 [1–22] days; eating disorder NOS: median 6 [2–14] days). Overall, 17 patients received day-hospital interventions (6.1 % of the overall sample; anorexia nervosa = 12, bulimia nervosa = 2, eating disorder NOS = 3) and 32 (11.6 %; anorexia nervosa = 23, bulimia nervosa = 2; eating disorder NOS = 7) were admitted to inpatient units. In these subgroups of patients, the median number of dayhospital interventions was 2 (range 1–4) (anorexia nervosa: median 1.5 [1–4]; bulimia nervosa: median 1 [1, 2]; eating disorder NOS: median 2 [2, 3]) and the median number of hospitalizations was 1 (range 1–24) (anorexia nervosa: median 1 [1–24]; bulimia nervosa: median 1; eating disorder NOS: median 1 [1–3]). Hospitalizations for medical reasons Table 3 reports the number of hospitalizations for medical reasons. Data indicated that from 2007 to 2012, hospitalizations for endocrine, nutritional and metabolic diseases were most common among anorexia nervosa patients (13.6 %). Patients with bulimia nervosa and eating disorders NOS were mainly hospitalized for complications of pregnancy, childbirth, and the puerperium (21.5 and 15.9 %, respectively).
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Table 3 Number of hospitalizations for medical reasons in the study sample, broken down by eating disorder diagnosis AN
BN
Eating disorders NOS
Patients, n
59
77
140
Patients hospitalized at least once, n (%)
49 (83.0)
51 (66.2)
86 (61.4)
Hospitalizations for medical reasons, n (%) Infectious and parasitic diseases (001–139)
1 (0.7)
2 (1.5)
0
Neoplasms (140–239)
18 (11.8)
5 (3.7)
31 (13.4)
Endocrine, nutritional and metabolic diseases, and immunity disorders (240–279)
21 (13.6)
18 (13.3)
23 (9.9)
Diseases of the blood and blood-forming organs (280–289)
8 (5.2)
0
2 (0.9)
Diseases of the nervous system and sense organs (320–389)
18 (11.8)
11 (8.1)
17 (7.3)
Diseases of the circulatory system (390–459)
4 (2.6)
11 (8.1)
19 (8.2)
Diseases of the respiratory system (460–519)
9 (5.8)
5 (3.7)
9 (3.9)
Diseases of the digestive system (520–579)
17 (11.0)
4 (3.0)
24 (10.3)
Diseases of the genitourinary system (580–629)
8 (5.2)
11 (8.1)
17 (7.3)
Complications of pregnancy, childbirth, and the puerperium (630–679)
8 (5.2)
29 (21.5)
37 (15.9)
Diseases of the skin and subcutaneous tissue (680–709)
0
2 (1.5)
4 (1.7)
Diseases of the musculoskeletal system and connective tissue (710–739)
6 (3.9)
17 (12.6)
18 (7.8)
Congenital anomalies (740–759)
5 (3.2)
1 (0.7)
2 (0.9)
Symptoms, signs, and ill-defined conditions (780–799)
7 (4.5)
4 (3.0)
7 (3.0)
Injury and poisoning (800–999) Other (electrocardiogram, blood tests)
11 (7.1) 13 (8.4)
7 (5.3) 8 (5.9)
19 (8.2) 3 (1.3)
Total number of hospitalizations
154
135
232
ICD-9 CM codes are specified AN anorexia nervosa, BN bulimia nervosa, NOS not otherwise specified
Discussion The study described mental health services use and therapeutic interventions among adult patients with eating disorders referring to Community Mental Health Centers of the Department of Mental Health of Bologna between January 2007 and December 2012. The investigation yielded five main findings. The first was that the percentage of eating disorder NOS was over 50 %, much higher than the two specified eating disorders, anorexia nervosa and bulimia nervosa. The data confirm previous observation that eating disorder NOS is the most common eating disorder diagnosis both in outpatient [17– 19] and inpatient settings [20]. This problem has been addressed by the recent DSM-5 that distinguished ‘seven’ different categories within the eating disorder NOS diagnostic category [21]. The second finding was that adult patients were referred (or self-referred) to the CMHCs at a mean age of 37.3 years. This age is much higher than that of eating disorder onset [1], and higher than that found in studies evaluating adult clinical outpatient [22] and inpatient treatments [23]. We hypothesize that patients arrive at CMHCs only after many years of illness and many
unsuccessful treatments, thus increasing the difficulties of the interventions. The third finding was that over 50 % of patients accessing CMHCs each year were incident cases although the number of patients treated each year increased only weakly. This suggests that the number of patients discontinuing treatment was high or that patients were referred to other levels of care or to private services. To date, no studies examined incident eating disorder cases in mental health services. However, we speculate that eating disorder adult patients are treated in community mental health services for short periods of time and the slow increase of the number of patients each year is probably due to the quick turn-over and to a compensation mechanism of new cases replacing those who discontinued treatment. The high number of patients discontinuing treatment each year seems to be the consequence of the high drop-out rates that typically occurs with eating disorder patients [24] rather than the effectiveness of the treatment, because the relatively old age of patients accessing services suggests that remission after a brief intervention is unlikely [25]. The fourth finding was that only a small number of patients received a psychotherapy treatment and that, among the interventions provided, psychotherapy represented only
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about 10 %. Although it is not always suitable for patients with severe emaciation, for which nutritional rehabilitation should be a treatment priority, the psychotherapy is recommended by national [15, 26] and international [27] guidelines as the intervention of first choice. These data are in line with other studies investigating the type of intervention provided to eating disorder patients [7, 28, 29]. Moreover, among the few patients receiving a psychotherapeutic intervention, about one half (56 %, 13/23) completed at least 15 sessions and reached the therapy goals set by the therapist, while 44 % dropped out or had the treatment plan changed. Unfortunately, the database does not include information on the specific psychotherapy provided, so we are unable to establish whether the number of sessions provided was consistent with the standards set for specific evidence-based psychotherapies for adults (i.e., cognitive behavior therapy and interpersonal psychotherapy) [30]. The fifth and last finding was that inpatient treatment was provided to about 12 % of the sample. The length of inpatient treatment, as expected, was higher in specialist units than non-specialist units. However, the length of specialist inpatient treatment was significantly lower than 90 days, the mean optimal duration of treatment recently recommended by a document published by the Italian Ministry of Health [15]. Moreover, most of admitted patients received one hospitalization and 2 day-hospital interventions. These data seem to confirm that our healthcare system tends to favor relatively brief periods of hospital stay that can be inadequate to meet some long-term rehabilitative needs. The main strength of the study is the use of health services data over multiple years both for outpatient and inpatient settings, that overcomes the limits of previous studies assessing periods of 12 months or less. Moreover, to our knowledge, the study is one of the few assessing the access and use of mental health services in adult patients with eating disorders in Europe. Nevertheless, the study has three main limitations. First, data were gathered from the mental health information system of the Local Health Authority, and it was not possible to determine the completeness and the accuracy of the information recorded. However, this is a very common problem of using administrative databases not designed for research purposes [7]. Second, the absence of significant information (i.e., body weight, body mass index, and eating disorder psychopathology) did not permit to confirm the eating disorder diagnosis and to give a detailed description of patients’ clinical characteristics. Third, data concerning the level of outpatient care carried out by University or other expert multidisciplinary teams were not available, and as a consequence the number of patients assessed and treated in outpatient setting was underestimated.
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In conclusion, our data emphasize the need to prioritize the integration of information systems, to provide a full picture of the system of care for eating disorders. Moreover, we need to fully accomplish the national indications [15] and the regional program [16], so as to improve the continuity of care and the quality of treatment delivered. For this purpose, we recommend the implementation of some specific strategies. First, pediatricians and general practitioners should be trained to improve the identification of early signs and symptoms of eating disorders and help to accelerate the referral process to mental health services for minors and adults or to the upper specialist level of outpatient care. Second, the specific care pathway dedicated to patients with eating disorders should be strengthened involving, a multidisciplinary team (psychiatrists, internists, clinical nutritionists, psychologists, dieticians) and promoting training activities across services to facilitate the integration between professionals, and the adoption of evidence-based treatments. This will help deliver a coherent and coordinated treatment to the patients. Lastly, although the mainstay of eating disorders treatment is outpatient treatment, there is the need to improve both the availability and access to more intensive levels of care (i.e., residential or hospital treatments) in a coordinated network. Acknowledgments The authors thank Antonella Piazza, Mila Ferri, Angelo Fioritti and Drusilla Sangermani for providing data and information on regional policies and pathways to care for patients with eating disorders. Conflict of interest The authors have no conflict of interest to declare in relation to the present work.
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197 22. Fairburn CG, Cooper Z, Doll HA, O’Connor ME, Palmer RL, Dalle Grave R (2013) Enhanced cognitive behaviour therapy for adults with anorexia nervosa: a UK-Italy study. Behav Res Ther 51(1):R2–R8 23. Dalle Grave R, Calugi S, Conti M, Doll H, Fairburn CG (2013) Inpatient cognitive behavioral therapy for anorexia nervosa: a randomized controlled trial. Psychother Psychosom 82(6): 390–398 24. Fassino S, Piero A, Tomba E, Abbate-Daga G (2009) Factors associated with dropout from treatment for eating disorders: a comprehensive literature review. BMC Psychiatry 9:67 25. Wonderlich S, Mitchell JE, Crosby RD, Myers TC, Kadlec K, Lahaise K, Swan-Kremeier L, Dokken J, Lange M, Dinkel J, Jorgensen M, Schander L (2012) Minimizing and treating chronicity in the eating disorders: a clinical overview. Int J Eat Disord 45(4):467–475 26. Donini LM, Cuzzolaro M, Spera G, Badiali M, Basso N, Bollea MR, Bosello O, Brunani A, Busetto L, Cairella G, Cannella C, Capodaglio P, Carbonelli MG, Castellaneta E, Castra R, Clini E, Contaldo F, Dalla Ragione L, Dalle Grave R, D’Andrea F, Del Balzo V, De Cristofaro P, Di Flaviano E, Fassino S, Ferro AM, Forestieri P, Franzoni E, Gentile MG, Giustini A, Jacoangeli F, Lubrano C, Lucchin L, Manara F, Marangi G, Marcelli M, Marchesini G, Marri G, Marrocco W, Melchionda N, Mezzani B, Migliaccio P, Muratori F, Nizzoli U, Ostuzzi R, Panzolato G, Pasanisi F, Persichetti P, Petroni ML, Pontieri V, Prosperi E, Renna C, Rovera G, Santini F, Saraceni V, Savina C, Scuderi N, Silecchia G, Strollo F, Todisco P, Tubili C, Ugolini G, Zamboni M (2010) Obesity and eating disorders. indications for the different levels of care. An Italian Expert Consensus Document. Eat Weight Disord 15(1–2 Suppl):1–31 27. National Institute of Clinical Excellence (2004) Eating disorders. Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Clinical Guideline 9. National Collaborating Centre for Mental Health 28. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC (2005) Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):629–640 29. Alonso J, Codony M, Kovess V, Angermeyer MC, Katz SJ, Haro JM, De Girolamo G, De Graaf R, Demyttenaere K, Vilagut G, Almansa J, Lepine JP, Brugha TS (2007) Population level of unmet need for mental healthcare in Europe. Br J Psychiatry 190:299–306 30. Wilson GT, Fairburn CG (2007) Treatments for eating disorders. In: Nathan PE, Gorman JM (eds) A guide to treatments that work, 3rd edn. Oxford University Press, New York, pp 581–583
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ORIGINAL ARTICLE
Mental health services use and management of eating disorders in an Italian Department of Mental Health Simona Calugi • Vera Maria Avaldi • Riccardo Dalle Grave • Paola Rucci • Maria Pia Fantini
Received: 11 September 2013 / Accepted: 21 January 2014 / Published online: 11 February 2014 Ó Springer International Publishing Switzerland 2014
Abstract Objective To investigate the clinical characteristics of patients with eating disorders referred to Community Mental Health Centers (CMHCs) in the Department of Mental Health of Bologna, Italy, and to evaluate the number and type of interventions delivered. Methods Adult patients with eating disorders who had a first contact with CMHCs between January 1, 2007 and December 31, 2012 were extracted from Bologna Local Health Authority database. Moreover, the hospital discharge records of patients were linked to the mental health information system of Bologna. Results Among the 276 patients with eating disorders identified, 59 (21.4 %) were diagnosed as anorexia nervosa, 77 (27.9 %) as bulimia nervosa and 140 (50.7 %) as eating disorders not otherwise specified. The mean age of the sample was 37.3 (SD = 13.4), with no significant differences among the three diagnostic groups. The number of CMHCs outpatients increased each year from 2007 to 2011 and decreased in 2012. The proportion of new patients by year comprised about 50 % of the total of patients. Psychotherapy accounted for about 10 % of the interventions. Day-hospital and hospital admissions concerned 6.1 and 11.6 % of the sample. Conclusions CMHCs are part of the system of care outlined by the Regional policies for eating disorders and are S. Calugi V. M. Avaldi P. Rucci M. P. Fantini (&) Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum-University of Bologna, Via San Giacomo 12, 40126 Bologna, Italy e-mail: [email protected] R. Dalle Grave Department of Eating and Weight Disorders, Villa Garda Hospital, Via Montebaldo 89, 37016 Garda (VR), Italy
responsible for providing the first level of outpatient care to adults. To date, there is the need to extend our monitoring across the whole system of care, to assess the implementation of specific and effective strategies to decrease the age of access of patients and to improve the quality of care delivered with the inclusion of evidence-based treatments in the process of care. Keywords Mental health services Eating disorders Anorexia nervosa Bulimia nervosa Italy Patterns of care
Introduction Eating disorders have a young age of onset [1], are often associated with significant impairment of physical health [2] and psychosocial functioning [3] and bear an increased risk of death [4–6]. However, reports about the use of health services for patients with eating disorders are scanty [7]. This is an important limitation because the health services use is a potential indicator of eating disorders impairment and reveals the economic burden for the society due to direct (e.g., costs of services) and indirect (e.g., disability and early mortality) costs for the management of these disorders [8]. To date, few European and North American studies evaluated both economic costs and health services use in outpatient and inpatient settings of patients with eating disorders. A systematic review of the literature on the resource use and cost of eating disorders identified 17 studies and concluded that patients with eating disorders use frequently health services and represent a considerable cost burden to the society [9]. It has also suggested that available data probably underestimated the real economic
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treatment costs because the results are based on limited databases [10] evaluating only inpatient costs [11]. Studies using national [10] and regional [12] databases found that patients with eating disorders are mainly treated in outpatient settings. Evidence from the literature suggests also that health services use is significantly higher in eating disorder patients than matched controls and similar across the spectrum of eating disorders (anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified [NOS]) [7]. However, health services use data indicate also that this population is undertreated [7] and do not specify the type of interventions provided, except for hospitalization that, in studies based on just 1 year of observation, has been required in about 10–20 % of eating disorder patients and frequently occurred in non-specialist inpatient units [10, 12]. The paucity of data available indicates that studies with more comprehensive data on current and long-term healthcare resource use of eating disorder patients, describing also the type of interventions provided, are warranted. The aim of the study was to explore the clinical characteristics of adult patients with eating disorders referred to community mental health centers (CMHCs) of the Department of Mental Health of Bologna, Italy from 2007 to 2012, and the number and type of treatments provided.
Materials and methods Setting and data source The data source for this study was the mental health information system of the CMHCs of the Bologna Local Health Authority (LHA). The Bologna LHA is one of the largest of Italy and serves approximately 850,000 inhabitants, roughly one-fifth of the regional population. The mental health information system was implemented in 2004 and refined in 2007 for administrative and clinicalepidemiological purposes. All adult patients (age C18) who had at least one contact with CMHCs were recorded in the database since then, reflecting the total secondary mental health care in the area. Data include, in addition to patient’s ID number, demographic characteristics, the ICD9 CM diagnosis, and information on each type of intervention administered. No information is recorded about whether patients previously received treatments for eating disorders. The hospital discharge records of the patients were linked to the mental health information system of Bologna. Records of patients with eating disorders were identified using Disease Related Groups (DRGs) 428 and 432 or ICD-9 CM codes in primary or secondary diagnosis.
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Mental health services In the Italian National Health Service, mental health care is provided by Departments of Mental Health (DMH). Within the DMH, CMHCs are in charge of delivering outpatient care for adult patients and coordinating treatments provided by day-care centers and non-hospital residential facilities. In case of admission to hospital wards, continuity of care is ensured by CMHC through interactive work and close cooperation with inpatient teams [13]. Inpatient care is provided by general hospital psychiatric units [14], licensed private hospitals and residential intensive units. A network of community services for minors has also been implemented, with relevant differences according to Regional policies. In Emilia-Romagna Region, outpatient mental health care for minors is delivered by dedicated services within the DMH. Patterns of care Over the last years Emilia-Romagna has implemented a regional program of health care for patients with eating disorders, comparable to national indications recently outlined by the Ministry of Health [15]. Since 2004, the regional program was based on the multidisciplinary integration between clinical teams, across levels of progressive intensity of care [16]. At present, five levels of care are identified: the primary care access and referral, the outpatient assessment and treatment in the DMH community services for adults and minors, the specialist outpatient assessment and treatment in University or other expert multidisciplinary units, the specialist day-hospital or residential treatment and the medical or psychiatric inpatient treatment. Study sample Demographic, diagnostic and treatment information of adult patients who had their first contact with one of the 11 Community Mental Health Centers of the Local Health Authority between January 2007 and December 2012 were extracted from the database. Data on the outpatient level of care carried out by University or other expert multidisciplinary teams were not available. ICD-9 CM diagnoses were classified into three groups: anorexia nervosa (307.1), bulimia nervosa (307.51), and eating disorders NOS (307.5; 307.50; 307.52; 307.53; 307.54; and 307.59). Interventions Patients received outpatient and/or hospital treatments. Outpatient therapeutic interventions were coded into four main categories: (i) psychotherapy; (ii) socio-rehabilitative
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interventions, aimed at strengthening the social capacities, and consisting in individual rehabilitation (skills training related to activities of daily living and to social relationships), group activities (sports teams, leisure time, socialization opportunities) and vocational training activities; (iii) intensive outpatient treatment, provided by CMHC staff, consisting in daily visits along a short period of time, with pharmacological treatment and monitoring of physical conditions to avoid hospital admission in severe patients who are not in high medical risk; (iv) others, including medical visits and clinical interviews with the patients and their families. Hospital care was coded in two main categories: (i) day-hospital admissions; (ii) hospital admissions. The choice of the interventions was based on the clinical evaluation of the disorder severity and on patients’ needs. Statistical analyses Continuous variables were summarized as mean and SD and categorical variables as frequency and percentage. Analysis of variance with Bonferroni post hoc test, Kruskal–Wallis test and v2 test were carried out to compare the three eating disorder diagnostic categories on continuous and categorical variables, as appropriate.
Results Two hundred and seventy-six eating disorder patients—out of 39,125 psychiatric patients recorded from 2007 to 2012—with a mean age of 37.3 years (SD 13.4, range 18–78) were recorded in the mental health information system. Over fifty percent (53.3 %) had an age between 18 and 35 years and 15.6 % had more than 50 years. Most patients were females (89.5 %) and of Italian nationality (97.1 %). More than half of the sample was single (56.2 %), while 33.3 % lived with the partner. One
hundred and twenty-five patients completed high school (45.3 %), 19.2 % had graduated, and more than one half (59.8 %) were employed. Among the 276 cases identified, 59 (21.4 %) received a diagnosis of anorexia nervosa, 77 (27.9 %) a diagnosis of bulimia nervosa, and 140 (50.7 %) a diagnosis of eating disorder NOS at the index visit. Mean age was 34.5 ± 13.3 years for anorexia nervosa, 37.7 ± 12.8 for bulimia nervosa, and 38.3 ± 13.6 years for eating disorder NOS, with no significant differences between the three diagnostic categories (F = 1.76, p = 0.174). No significant difference was also found on gender, marital status, educational level and occupational status (v2 = 0.39, p = 0.824; v2 = 10.57, p = 0.392; 9.38, p = 0.496, v2 = 0.35, p = 0.470, respectively). Almost 20 % of patients with eating disorders received a diagnosis of another psychiatric disorder, and the most common were mood disorders, personality disorders and anxiety disorders (Table 1). CMHCs use The number of patients accessing the CMHCs increased over time from 2007 to 2011 although in 2012 the number decreased (37 patients in 2007, 66 in 2008, 87 in 2009, 106 in 2010, 119 in 2011 and 63 in 2012). The proportion of new patients accessing mental health services by year was about 50 % of the total of patients. The annual number of mental health interventions was stable over time and ranged from 3.0 to 6.0 per patient with two peaks in 2011 and 2012 of more than 140 interventions for 2 patients. In 2011 patients with anoressia nervosa received a significant higher number of mental health interventions than those with eating disorder NOS (Kruskal–Wallis test 8.96, p = 0.011, post hoc test p \ 0.05), while in the other years no differences emerged among eating disorder diagnosis.
Table 1 Psychiatric comorbidity according to ICD-9 CM in AN, BN and eating disorder NOS patients
Mood disorders Anxiety disorders Personality disorders Psychotic disorders Mental retardation Alcohol dependence syndrome Somatization disorder Sedatives or hypnotics dependence Any psychiatric disorder
AN (n = 59)
BN (n = 77)
Eating disorder NOS (n = 140)
Total
4 0 3 1 1 0 0 0 9
5 (6.5 %) 3 (3.9 %) 4 (5.2 %) 0 0 1 (1.3 %) 1 (1.3 %) 0 15 (19.5 %)
13 (9.3 %) 9 (6.4 %) 8 (5.7 %) 0 0 0 0 1 (0.7 %) 28 (20 %)
22 (8.0 %) 12 (4.3 %) 15 (5.4 %) 1 (0.4 %) 1 (0.4 %) 1 (0.4 %) 1 (0.4 %) 1 (0.4 %) 52 (18.8 %)
(6.8 %) (5.1 %) (1.7 %) (1.7 %)
(15.2 %)
Data are presented as number (percentage) AN anorexia nervosa, BN bulimia nervosa, NOS not otherwise specified
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Table 2 Number of outpatient and hospital interventions in mental health services, by year 2007
2008
2009
2010
2011
2012
Outpatient treatments Psychotherapy
34 (3.6 %)
89 (10.5 %)
120 (9.1)
127 (11.2 %)
96 (6.1 %)
147 (15.5 %)
Socio-rehabilitative therapy
10 (1.1 %)
4 (0.5 %)
0
9 (0.8 %)
16 (1.0 %)
26 (2.7 %)
Intensive outpatient intervention
168 (18.0 %)
69 (8.1 %)
249 (18.9 %)
0
0
0
Other outpatients interventions
723 (77.3 %)
685 (80.8 %)
949 (72.0 %)
993 (87.9 %)
1,469 (92.9 %)
772 (81.7 %)
Total outpatient interventions
935
847
1,318
1,129
1,581
945
Day-hospital
3 (33.3)
1 (14.3)
6 (17.1)
9 (34.6)
11 (55.0)
5 (45.5)
Hospitalization
6 (66.7)
6 (85.7)
21 (77.8)
17 (65.4)
9 (45.0)
6 (56.5)
Total hospital interventions
9
7
27
26
20
11
Total interventions
944
854
1,345
1,155
1,601
956
Hospital treatments
Data are presented as number (percentage)
Type of intervention Table 2 shows the type of intervention according to the coding classification described above. Psychotherapy accounted for about 10 % of the interventions provided each year and during the treatment period. Among the 276 patients assessed, 23 (8.3 %) received psychotherapy, 6 (2.1 %) socio-rehabilitative interventions and 7 (2.5 %) intensive outpatient treatment. Of the 23 patients who received psychotherapy, 13 completed at least 15 therapy sessions and reached the goals set by their therapists, 3 discontinued treatment, 4 had their treatment plan changed and 2 attended fewer than 15 therapy sessions. Thirty-five day-hospital interventions occurred between 2007 and 2012 (22 [62.9 %] for anorexia nervosa, 4 [11.4 %] for bulimia nervosa and 9 [25.7 %] for eating disorder NOS). Twenty-nine (82.9 %) day-hospital occurred in specialist eating disorder units (anorexia nervosa = 18; bulimia nervosa = 2; eating disorder NOS = 9) and 6 (17.1 %) in general psychiatric or internal medicine units (anorexia nervosa = 4; bulimia nervosa = 2; eating disorder NOS = 0). The median duration of day-hospital treatment was 8.0 (range 1–78) days in specialists units (anorexia nervosa: median 4.5 [1–71] days; bulimia nervosa: median 23.5 [1–46] days; eating disorder NOS: median 34 [1–78] days) and 5.0 (range 1–35) days in general psychiatric or internal medicine units (anorexia nervosa: median 4.5 [1–35] days; bulimia nervosa: median 6 [5–7] days). The total number of hospitalizations was 65, 51 in anorexia nervosa (78.5 %), 2 in bulimia nervosa (3.1 %) and 12 (18.5 %) in eating disorder NOS patients. Twentyfive (38.5 %) hospitalizations occurred in specialist eating disorder inpatient units (anorexia nervosa = 17; bulimia nervosa = 2; eating disorder NOS = 6), 19 (29.2 %), in general hospital psychiatric units (anorexia nervosa = 16;
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bulimia nervosa = 0; eating disorder NOS = 3) and 21 (32.3 %) in internal medicine units (anorexia nervosa = 18; bulimia nervosa = 0; eating disorder NOS = 3). The duration of inpatient treatment ranged from 3 to 91 (median = 56.0) days in specialist units (anorexia nervosa: median 56 [3–91] days; bulimia nervosa: median 59 [28–90] days; eating disorder NOS: median 61.5 [25–84] days), from 1 to 26 (median = 14.0) days in general hospital inpatient psychiatric units (anorexia nervosa: median 11.5 [1–23] days; eating disorder NOS: median 25 [23–26] days), and from 1 to 22 (median = 4.0) days in internal medicine units (anorexia nervosa: median 3 [1–22] days; eating disorder NOS: median 6 [2–14] days). Overall, 17 patients received day-hospital interventions (6.1 % of the overall sample; anorexia nervosa = 12, bulimia nervosa = 2, eating disorder NOS = 3) and 32 (11.6 %; anorexia nervosa = 23, bulimia nervosa = 2; eating disorder NOS = 7) were admitted to inpatient units. In these subgroups of patients, the median number of dayhospital interventions was 2 (range 1–4) (anorexia nervosa: median 1.5 [1–4]; bulimia nervosa: median 1 [1, 2]; eating disorder NOS: median 2 [2, 3]) and the median number of hospitalizations was 1 (range 1–24) (anorexia nervosa: median 1 [1–24]; bulimia nervosa: median 1; eating disorder NOS: median 1 [1–3]). Hospitalizations for medical reasons Table 3 reports the number of hospitalizations for medical reasons. Data indicated that from 2007 to 2012, hospitalizations for endocrine, nutritional and metabolic diseases were most common among anorexia nervosa patients (13.6 %). Patients with bulimia nervosa and eating disorders NOS were mainly hospitalized for complications of pregnancy, childbirth, and the puerperium (21.5 and 15.9 %, respectively).
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Table 3 Number of hospitalizations for medical reasons in the study sample, broken down by eating disorder diagnosis AN
BN
Eating disorders NOS
Patients, n
59
77
140
Patients hospitalized at least once, n (%)
49 (83.0)
51 (66.2)
86 (61.4)
Hospitalizations for medical reasons, n (%) Infectious and parasitic diseases (001–139)
1 (0.7)
2 (1.5)
0
Neoplasms (140–239)
18 (11.8)
5 (3.7)
31 (13.4)
Endocrine, nutritional and metabolic diseases, and immunity disorders (240–279)
21 (13.6)
18 (13.3)
23 (9.9)
Diseases of the blood and blood-forming organs (280–289)
8 (5.2)
0
2 (0.9)
Diseases of the nervous system and sense organs (320–389)
18 (11.8)
11 (8.1)
17 (7.3)
Diseases of the circulatory system (390–459)
4 (2.6)
11 (8.1)
19 (8.2)
Diseases of the respiratory system (460–519)
9 (5.8)
5 (3.7)
9 (3.9)
Diseases of the digestive system (520–579)
17 (11.0)
4 (3.0)
24 (10.3)
Diseases of the genitourinary system (580–629)
8 (5.2)
11 (8.1)
17 (7.3)
Complications of pregnancy, childbirth, and the puerperium (630–679)
8 (5.2)
29 (21.5)
37 (15.9)
Diseases of the skin and subcutaneous tissue (680–709)
0
2 (1.5)
4 (1.7)
Diseases of the musculoskeletal system and connective tissue (710–739)
6 (3.9)
17 (12.6)
18 (7.8)
Congenital anomalies (740–759)
5 (3.2)
1 (0.7)
2 (0.9)
Symptoms, signs, and ill-defined conditions (780–799)
7 (4.5)
4 (3.0)
7 (3.0)
Injury and poisoning (800–999) Other (electrocardiogram, blood tests)
11 (7.1) 13 (8.4)
7 (5.3) 8 (5.9)
19 (8.2) 3 (1.3)
Total number of hospitalizations
154
135
232
ICD-9 CM codes are specified AN anorexia nervosa, BN bulimia nervosa, NOS not otherwise specified
Discussion The study described mental health services use and therapeutic interventions among adult patients with eating disorders referring to Community Mental Health Centers of the Department of Mental Health of Bologna between January 2007 and December 2012. The investigation yielded five main findings. The first was that the percentage of eating disorder NOS was over 50 %, much higher than the two specified eating disorders, anorexia nervosa and bulimia nervosa. The data confirm previous observation that eating disorder NOS is the most common eating disorder diagnosis both in outpatient [17– 19] and inpatient settings [20]. This problem has been addressed by the recent DSM-5 that distinguished ‘seven’ different categories within the eating disorder NOS diagnostic category [21]. The second finding was that adult patients were referred (or self-referred) to the CMHCs at a mean age of 37.3 years. This age is much higher than that of eating disorder onset [1], and higher than that found in studies evaluating adult clinical outpatient [22] and inpatient treatments [23]. We hypothesize that patients arrive at CMHCs only after many years of illness and many
unsuccessful treatments, thus increasing the difficulties of the interventions. The third finding was that over 50 % of patients accessing CMHCs each year were incident cases although the number of patients treated each year increased only weakly. This suggests that the number of patients discontinuing treatment was high or that patients were referred to other levels of care or to private services. To date, no studies examined incident eating disorder cases in mental health services. However, we speculate that eating disorder adult patients are treated in community mental health services for short periods of time and the slow increase of the number of patients each year is probably due to the quick turn-over and to a compensation mechanism of new cases replacing those who discontinued treatment. The high number of patients discontinuing treatment each year seems to be the consequence of the high drop-out rates that typically occurs with eating disorder patients [24] rather than the effectiveness of the treatment, because the relatively old age of patients accessing services suggests that remission after a brief intervention is unlikely [25]. The fourth finding was that only a small number of patients received a psychotherapy treatment and that, among the interventions provided, psychotherapy represented only
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about 10 %. Although it is not always suitable for patients with severe emaciation, for which nutritional rehabilitation should be a treatment priority, the psychotherapy is recommended by national [15, 26] and international [27] guidelines as the intervention of first choice. These data are in line with other studies investigating the type of intervention provided to eating disorder patients [7, 28, 29]. Moreover, among the few patients receiving a psychotherapeutic intervention, about one half (56 %, 13/23) completed at least 15 sessions and reached the therapy goals set by the therapist, while 44 % dropped out or had the treatment plan changed. Unfortunately, the database does not include information on the specific psychotherapy provided, so we are unable to establish whether the number of sessions provided was consistent with the standards set for specific evidence-based psychotherapies for adults (i.e., cognitive behavior therapy and interpersonal psychotherapy) [30]. The fifth and last finding was that inpatient treatment was provided to about 12 % of the sample. The length of inpatient treatment, as expected, was higher in specialist units than non-specialist units. However, the length of specialist inpatient treatment was significantly lower than 90 days, the mean optimal duration of treatment recently recommended by a document published by the Italian Ministry of Health [15]. Moreover, most of admitted patients received one hospitalization and 2 day-hospital interventions. These data seem to confirm that our healthcare system tends to favor relatively brief periods of hospital stay that can be inadequate to meet some long-term rehabilitative needs. The main strength of the study is the use of health services data over multiple years both for outpatient and inpatient settings, that overcomes the limits of previous studies assessing periods of 12 months or less. Moreover, to our knowledge, the study is one of the few assessing the access and use of mental health services in adult patients with eating disorders in Europe. Nevertheless, the study has three main limitations. First, data were gathered from the mental health information system of the Local Health Authority, and it was not possible to determine the completeness and the accuracy of the information recorded. However, this is a very common problem of using administrative databases not designed for research purposes [7]. Second, the absence of significant information (i.e., body weight, body mass index, and eating disorder psychopathology) did not permit to confirm the eating disorder diagnosis and to give a detailed description of patients’ clinical characteristics. Third, data concerning the level of outpatient care carried out by University or other expert multidisciplinary teams were not available, and as a consequence the number of patients assessed and treated in outpatient setting was underestimated.
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In conclusion, our data emphasize the need to prioritize the integration of information systems, to provide a full picture of the system of care for eating disorders. Moreover, we need to fully accomplish the national indications [15] and the regional program [16], so as to improve the continuity of care and the quality of treatment delivered. For this purpose, we recommend the implementation of some specific strategies. First, pediatricians and general practitioners should be trained to improve the identification of early signs and symptoms of eating disorders and help to accelerate the referral process to mental health services for minors and adults or to the upper specialist level of outpatient care. Second, the specific care pathway dedicated to patients with eating disorders should be strengthened involving, a multidisciplinary team (psychiatrists, internists, clinical nutritionists, psychologists, dieticians) and promoting training activities across services to facilitate the integration between professionals, and the adoption of evidence-based treatments. This will help deliver a coherent and coordinated treatment to the patients. Lastly, although the mainstay of eating disorders treatment is outpatient treatment, there is the need to improve both the availability and access to more intensive levels of care (i.e., residential or hospital treatments) in a coordinated network. Acknowledgments The authors thank Antonella Piazza, Mila Ferri, Angelo Fioritti and Drusilla Sangermani for providing data and information on regional policies and pathways to care for patients with eating disorders. Conflict of interest The authors have no conflict of interest to declare in relation to the present work.
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