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Managing Eating Disorders in Primary Care

Managing Eating Disorders in Primary Care

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Managing Eating Disorders in Primary Care

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  1. Managing Eating Disorders in Primary Care The Sheffield Experience By Dr Alison James June 2006

  2. Whydid 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 Sheffield’s 2 Universities – long waiting time for assessment – needs not met

  3. 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

  4. Stepped Model of Care Step 6 & 7 Specialist Day or Inpatient Care (E.D. Unit or Medical Bed) Robinson, P 1988 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 GP’s to assess severity of ED/ management of less complex cases Focused training for Practice Counsellors

  5. 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

  6. 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

  7. 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.D’s should be assessed and receive treatment at the earliest opportunity • Bulimia nervosa –possible first step – evidence based self help programme

  8. Disclosure and Identification • Eating disorders are usually hidden Why ?

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

  10. 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

  11. 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)

  12. 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

  13. 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

  14. Investigations • FBC - low wcc in anorexia, normocytic, normochromic anaemia • ESR - normal • U & E’s – low K + in severe bulimia • TFTs - normal • Sex hormone profile – anorexia –hypothalamic suppression • Bone mineral density scan

  15. 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

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

  17. 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