Abstract
In this issue of the Journal we publish a Clinical Practice Guideline for Eating Disorders (Hay et al., this issue), the first of a new series of Clinical Practice Guidelines (CPGs) produced by the Royal Australian and New Zealand College of Psychiatrists (RANZCP). This will be the third iteration of CPGs produced by the College. The RANZCP was one of the pioneers in developing CPGs with the Quality Assurance Project in the 1980s; an innovative project aimed at producing evidence-based treatment outlines for the major psychiatric disorders. While there was some controversy in the production of CPGs, they were, in the main, accepted as setting a benchmark for evidence-based practice. The methodology for the Quality Assurance Project included surveying practising psychiatrists and using the then new statistical tool of meta-analysis to synthesise clinical trial data (Quality Assurance Project team, 1982); meta-analyses are now the mainstay of CPGs.
An inevitable problem with CPGs is they can become dated as new evidence emerges and so there is a necessity to update them regularly. The College has embraced this and the CPGs were completely reworked at the beginning of the new millennium with a set of six CPGs (and accompanying consumer/carer guidelines) that covered the common disorders seen in clinical practice (Boyce et al., 2003a, 2003b). That was over a decade ago and now the CPGs are being updated once again to incorporate new data and changes in contemporary practice, with CPGs on eating disorders, schizophrenia, mood disorders, anxiety disorders and deliberate self-harm in development and due to be published in the ANZJP over the next year.
The eating disorder CPG is informative, reassuring and illuminating.
It is informative as it gives us a detailed overview of the assessment and management of the full range of eating disorders. It also provides an outline of the elements of using a recovery-oriented approach to the management of people with eating disorders. A more detailed description of the recovery model and its application in anorexia nervosa is provided in a paper by Dawson and colleagues (this issue). They point out the recovery model is not, in itself, an empirical treatment, but rather an overarching philosophy of treatment that uses a collaborative management approach that is quite compatible with the empirically based treatments of the medical model. The sections in the CPG on assessment should be required reading for general psychiatrists and psychiatric trainees. The section on the monitoring and management of the refeeding syndrome is particularly instructive, especially for those that don’t often see severely underweight patients with anorexia nervosa.
The eating disorders CPG is reassuring as the evidence-based treatments discussed in the guideline reflect what thoughtful clinicians are already doing. This section on severe and enduring anorexia nervosa is also reassuring as it emphasises the difficulties in managing such patients and that there are no ‘magical’ fixes for it. Managing patients with severe and enduring anorexia nervosa is a specialised area requiring a committed clinician to look after such patients; it is not something to be taken on by a generalist psychiatrist. The management of severe and enduring anorexia nervosa requires a paradigm shift; here the recovery model can be used (Dawson et al., this issue) to redefine treatment goals.
The eating disorders CPG is illuminating because they highlight the dearth of knowledge as regards real-world management and the fact that there remains much to learn about these disorders and many aspects require careful investigation and inquiry. But this is an opportunity and the CPG provides a clear indication of where our future energies need to be focused.
CPGs are important tools for clinicians as they bring together the most recent evidence about treatment of a particular disorder, but there are caveats: research evidence from clinical trials do not take into account the complexities of ‘real world’ patients that can have a profound impact on treatment outcomes. This is an area where clinical experience and common sense can play an important role in the management of patients, especially when there is research evidence demonstrating the impact of psychosocial adversity of treatment outcomes. Daglas and colleagues (this issue) examined the early traumatic experiences of a cohort of patients with a first episode of psychotic mania. Almost half of the cohort reported direct-personal trauma experiences. Those who had experienced direct trauma had a poorer outcome of their bipolar disorder, with more manic symptoms, more depressive symptoms and poorer social and functional outcomes. There are a number of reasons for this and poor outcome among this cohort of patients. Predominant among them is the effect that early trauma may have upon their attachment systems and personality development, although this was not accurately assessed in this study. This point is taken up in an accompanying commentary (Watson and Porter, this issue), which points out that treatment of such patients with bipolar disorder needs to go beyond the standard pharmacological and psychological treatment to providing psychotherapeutic interventions that address the psychological consequences of upbringing and early life experiences. This clearly is where the art of psychiatry needs to come to the fore and we need to go beyond the treatment recommendations that populate the guidelines. It also emphasises the importance of careful clinical treatment of patients with bipolar disorder when they have remitted from their symptoms. These are not patients who need to be discharged upon remission but work needs to be done beyond the standard psychosocial treatments to enable them to be able to deal with the long-term impact of early traumatic experiences.
The social environment and lifestyle also have major impacts upon the outcome of our patients, despite them being provided with the evidence-based treatments found in CPGs. Various issues such as comorbid substance misuse, particularly using stimulants and marijuana, unstable housing and accommodation and diet all have an impact on the outcome of patients with psychotic disorders, as discussed in a series of papers in this month’s ANZJP. Sara et al. (this issue) examine the impact of stimulant and substance abuse in patients with schizophrenia. Around 50% of those with schizophrenia had a comorbid substance disorder, and the majority of those with stimulant disorders also included cannabis. Comorbid substance misuse, particularly stimulant use in combination with marijuana, contributes to poorer psychosocial outcomes, especially housing instability, more frequent physical comorbidity and increased service use. Unstable housing was a major factor in health care costs, as shown in a detailed analysis of health care costs associated with patients admitted into psychiatric units (Siskind et al., this issue). An interesting observation from this study is that patients who presented regularly to emergency departments, particularly with self-harm, had lower health care costs in terms of admissions than other patients. The diet of people living with psychosis is the topic of another study from the second Australian national survey of people living with psychosis (Hahn et al., this issue). Three-quarters of the participants of the survey failed to meet the WHO dietary guidelines with regard to fruit and vegetable intake (at least five serves/day – something that many in the general population fail to achieve). Notably, those who failed to consume the appropriate fruit and vegetable intake were also more likely to smoke, drink alcohol and use cannabis and stimulants. Those who did eat sufficient fruit and vegetables had fewer negative symptoms, suggesting they are more able to make healthy lifestyle choices. There were high rates of obesity within this cohort (47%) and 50% had metabolic syndrome. This is a matter of great concern as we need to be regularly monitoring the diet and physical health (as recommended in guidelines; for example, Waterreus and Laugharne, 2009) of our patients (Curtis and Shiers, this issue) and ensuring that they are referred (and take up the referral) to primary care.
Alas, it is something that we do not do particularly well at present, as discussed in a Commentary and a Letter in this issue (Kølbaek et al., this issue; Rosenbaum et al., this issue).
Future issues of the ANZJP will be publishing further guidelines that will hopefully be viewed as essential reading for one and all.