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Managing Eating Disorders in Primary Care

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

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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

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