When we can’t see the forest for the trees: exploring the invisibility of eating disorders in mental health contexts.

For UK based researchers, practitioners and policy makers interested in the area of eating disorders 2017 marks an important milestone. This year the updated National Institute for Health and Care Excellence (NICE) guidelines will be published in the UK after a 14 year wait. This is a long awaited release as these guidelines provide momentous support to professionals on the frontline of services by helping to inform the best care and treatment modalities for the most vulnerable. The 15 year wait begs many questions - none more so than why so long? In the post below, Dr Una Foye looks at why eating disorders have not received sufficient attention in mental health contexts.

One answer may relate to the lack of visibility that eating disorders have had within the health and specifically mental health debate. As an illness that manifests in physical symptoms, alongside complex psychopathology, is it difficult to place these illnesses entirely in the mental health context. Much of the care given requires medical input that can be absent from more purely psychological contexts, resulting in diagnostic focus being placed almost entirely on the physical symptomology (APA, 2013). As a result, this range of illnesses uncomfortably straddled both health and mental health policy contexts.  Any ongoing debate and discussion needs to recognise the intertwined relationship between different aspects of service.

This is even more pertinent when we consider that anorexia nervosa has the highest mortality rate of any other mental health problem, with research in the USA and the UK exemplifyingmortality rates ranging between 5.0 to 12.82 times the expected rates for anorexia and 1% to 3% for bulimia as a result of associated medical complications, as well as significantly high suicide rates. Statistics suggest that an estimated 15% of women have had an eating disorder at some point in their lives. Research has also found that these illness are no longer a problem associated with young white females as there has been an increased recognition in regarding the wider range of ethnicities who are now seeking treatment for these illnesses, as well as males. Worryingly, hospitalizations for eating disorders in children under the age of 12 years old increased by 119 percent between the years of 1999 and 2006. Anecdotally I have worked with families of children as young as 8 who are seeking inpatient treatment for anorexia.

With increasing prevalence comes increased associated costs; eating disorders are the 12th leading cause of mental health hospitalisation costs within Australia, and B-eat (the leading eating disorders charity in the UK) estimate that the cost to society of eating disorders is circa £15 billion per annum.  Policy needs to develop in order to ensure both that services exist to support those at highest risk, and also to account for the need of increased prevention and early intervention work.

To know where to invest and how best to support practitioners on the frontline of services to work with these disorders, we need research in this area. The 15 year delay in the development of the NICE guidelines has in part been the result of the lack of a strong evidence base enabling policy makers and practitioners to understand what works to prevent and treat these disorders. While strides have been made in the progression of research in the area of eating disorders, and the development of more flexible diagnostic categories in the DSM-5 released in 2013; the fact it has taken 15 years to update the best practice guidelines in the UK for these illnesses highlights that research and consequent policy shifts are not gaining traction quickly enough As highlighted in the MQ Mental Health Research Funding landscape review, in the UK eating disorders receive and average £0.5 million on average, or £0.15 per adult, compared to depression research which receives £8.3 million or psychosis research receiving £5.7 million.

Without investment in understanding the complexity of these illnesses and about effective ways of working with and treating them, policy risks stagnating again. Research could facilitate debate about how best to invest the limited funds that exist for mental health as a whole and where best to target support in terms of downstream prevention and specialist resources. Eating disorder is amongst one of the most complex disorders to treat and life all mental illness, has debilitating and sometimes life changing consequences for the individuals and families involved. Eating disorders that so often go unseen until they are severe, cannot continue to go unseen in terms of policy and so this must be an area that researchers and professionals continue to advocate for and place squarely at the centre of the international mental health agenda.

We cannot, and should not, have to wait another 15 years for updates on best practice guidelines; the cost in terms of lives is too high.