Treatments for anorexia and bulimia may have little or no effect, suggests a new report. But where does that leave millions of sufferers? Sophie Petit-Zeman weighs the arguments

A report in the medical journal The Lancet last month has sparked debate among those treating eating disorders such as anorexia and bulimia. It claims that there is no evidence that proves the benefits of current treatments: patients fare equally well, or indeed badly, with or without them.

A report in the medical journal The Lancet last month has sparked debate among those treating eating disorders such as anorexia and bulimia. It claims that there is no evidence that proves the benefits of current treatments: patients fare equally well, or indeed badly, with or without them.

An estimated 1.1 million people in Britain have an eating disorder, most commonly anorexia or bulimia. Characterised by a desperation to be thin, people with anorexia restrict food intake while their bodies waste away. Those with bulimia may maintain normal weight, but have distressing cycles of starving, bingeing and purging. In both conditions, problems often begin in adolescence or early adulthood and the underlying emotional turmoil is usually immense.

Anorexia and bulimia have the highest mortality rate of any psychiatric condition. About one in five sufferers die, because they become too thin to live, develop serious physical complications including kidney or heart failure, or commit suicide.

The Lancet paper, from a team of psychiatrists and epidemiologists led by David Ben-Tovim, charted the progress of 220 people with eating disorders in Adelaide, Australia. The patients were divided into those who had and had not received specialist treatment, and further classified by whether this was in- or outpatient, and how long it went on. Five years after their initial contact with services, according to the report, "our results indicate that many patients make a good recovery without accessing specialised treatments of any kind. Furthermore, there was no indication that resource-intensive and widely used treatments, such as lengthy admissions for weight gain, or long-term outpatient care, necessarily affected long-term patient outcome".

The report comes at a time of intense pressure on health professionals to practice evidence-based medicine ­ offering treatments that are demonstrably beneficial. But, in common with many medical specialties, ascertaining what "works" for those with eating disorders is complex.

Paul Flower is a child and adolescent psychiatrist at Ellern Mede, a major new centre for the treatment of young people with eating disorders that opens in London in July. He says that: "Eating disorders involve both severe physical problems, and complex emotional and psychological needs. It's not enough to say treatment has worked if the patient is simply heavier or happier. Recovery needs to be clear in both these areas, and sustained. Also, eating disorders often occur in a family context. Families are not to blame, but they are involved. We must measure the impact of treatments on family functioning as well as on individuals."

One of the big questions simmering in the melting pot of differing clinical opinion, with a generous sprinkling of professional rivalry, is whether it is better to treat those with eating disorders as in- or outpatients. Whether therapy, medication, or both are offered, the arguments in favour of hospital admission are compelling: it may be life-saving, allows the chance for comprehensive assessment and intensive treatment, including that for other psychological problems that may occur alongside eating disorders, and helps patients develop autonomy in a new setting.

Stephanie Grace's daughters, Jill, 21, and Sara, 23, are both recovering from eating disorders. She fought long and hard to find the right treatment for them and is excited to hear about the facilities on offer at Ellern Mede. She believes strongly that her daughters' hospital treatment has helped them towards recovery. "Recovering from eating disorders needs a kick-start, which is only effective as an in-patient," she says. Sara, who developed bulimia when she was 10, but was not diagnosed until 17, is still two stone underweight and has spent more than a year in hospital, spread over five admissions. Yet Grace says: "Sara's cracked it, she's getting better. If she hadn't had those periods in hospital, we'd still be at square one."

But arguments in favour of in-patient care are counterbalanced by those against. It can be maintained that it creates an artificial environment, allows family problems to persist unconfronted, takes people away from supportive people and routines, exposes patients to "new tricks", and creates difficulties when they leave.

Steve Bloomfield, spokesman for the Eating Disorders Association (EDA), says that debate on this issue is vital, but academic to most people with eating disorders, or their carers. "We don't have an official line on in- versus outpatient care for two reasons. Firstly, the 'right' treatment differs from patient to patient, and secondly, choosing between the two is simply not an option for the vast majority of people."

There is a dearth of specialist eating-disorder services. Cornwall, Devon and Dorset have none, Wales has no in-patient beds. As Bloomfield explains, many people have no access to specialist care, let alone the luxury of choice. "If you're offered any treatment, you're lucky, if it's the appropriate treatment, you're luckier. If it's not, there's usually nothing else available."

Lack of specialist services and financial constraints leave many patients at the mercy of what is available locally, or with the offer of in-patient care far from home, after long waits, and for limited periods of time. Bloomfield says: "If doctors refer out of the area or to private centres, then the referring health authority or patients' insurance has to pay. They will often fund only 12 weeks in-patient treatment, which is absurd for illnesses from which recovery takes months or years."

Arnon Bentovim, honorary child and adolescent psychiatrist at Great Ormond Street Hospital, director of the London Child and Family Consultation Service and chair of the advisory board at Ellern Mede, is involved in assessing what helps people with eating disorders. He stresses that "we must constantly examine what we do to ensure that we're helping patients as best we can, and that we're spending hard-stretched healthcare resources most effectively". He admits, wryly, that the Lancet report "sets a challenge to doctors to see how they can do better" ­ the study's principal researcher is his younger brother.

The EDA publishes widely used guidelines for treating eating disorders, but Steve Bloomfield agrees that a lack of evidence creates problems. "We're pushing for treatments to be better assessed, but the Department of Health and NHS currently do not amass data about outcomes nationally. It's impossible to find out which treatments are working."

Sir Iain Chalmers, Director of the UK Cochrane Centre, an organisation that collects evidence on treatments, is adamant that medical practice should be grounded on approaches of proven worth. Referring to "the catalogue of disasters" associated with doctors basing treatment on hunches, he illustrates how lack of evidence highlights research gaps: "Survey professionals treating eating disorders and you won't get uniform opinions about how it should be done. As long as such debate exists, there is obviously room for comparative studies."

But he concedes that "good doctors modify treatments to suit individuals", an open-mindedness reflected in Paul Flower's approach. Flower trained in medicine at 32, after working as a corporate planner at London Transport, and he says that: "Treatment decisions often need to be based on feelings as well as 'hard science'." While his centre, the Ellern Mede, will research different treatments, he stresses: "You can't discount experience. As long as you are rigorously reflective and sceptical about your own practice, it makes sense to trust your feelings, and those of your patients and their families."

Set against Flower's goal ­ providing optimum in-patient care ­ Mark Berelowitz, child and adolescent psychiatrist at London's Royal Free Hospital, believes that it is better to keep people out of hospital. "We want treatment success in young people's own environments, helping them to regain control at home, rather than worrying about when they'll be discharged, and giving families a sense that they have been involved in aiding recovery." Berelowitz's approach of "assertive outreach nursing" is based on methods developed to ensure that people with illnesses such as schizophrenia receive care even if reluctant to seek it. He says that his pioneering method has succeeded with 50 patients over the last three years, preventing costly hospital admissions.

The Adelaide researchers have brought some important questions to the fore, which professionals in the field are keenly debating. Until they have found their answers, they would do well to heed Sir Iain Chalmers, who urges: "The key starting point for doctors has to be humility, the awareness that they can do harm, and the self-discipline to work towards finding out the best ways to ensure that they do good."

Eating Disorders Association (01603 621 414; www.edauk.com); Ellern Mede Centre for Eating Disorders (020-8959 7774; www.ellernmede.org)

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