Involuntary Treatment of Patients with Eating Disorders

Involuntary legal commitment for the treatment of eating disorders is a controversial issue. Although most patients with eating disorders are not globally incompetent, some have such impaired thoughts, perceptions, judgment and behavior, along with reduced capacity to care for themselves, that they are good candidates for commitment.1 (See “Requirements for Legal Commitment, page 3.)

Some have suggested that coerced treatment is counterproductive and adversely affects the therapeutic relationship. Hiday found that two hypotheses guide outcome studies of involuntary commitment.2 The first is that patients who are hospitalized involuntarily will be angry and negative about their hospitalization and treatment. As a result, they will be less likely to cooperate with inpatient and outpatient treatment and will have to be rehospitalized. The second hypothesis predicts that involuntary patients will become positive toward hospitalization and treatment after their initial anger and negativism subside and after they are treated. Their symptoms will become minimized and functioning maximized, which will help them avoid rehospitalizations.

Some researchers have reported that involuntary patients tend to hold more negative views of hospitalization than voluntary patients and when discharged report that little or no benefit has occurred.3,4,5 In contrast, others have found that most involuntary patients who initially objected to their commitment later reported they would want to be hospitalized in the future if they became dangerously ill again.6,7 These contradictory results could be due to patients expressing negative attitudes toward certain parts of their hospitalization, even while appreciating the help they received.2

Few Empirical Studies Exist

Given the controversy about involuntary treatment in psychiatry and in law, it is surprising that so few empirical studies have addressed involuntary commitment of persons with eating disorders. Ramsay, Ward, Treasure, and Russell have reported that involuntary commitment of patients with anorexia nervosa leads to satisfactory short-term results, but found increased morbidity when they followed patients for a mean of 5.7 years after the first admission for treatment.8 The mortality rate at follow-up for detained patients was 12.7%, compared to 2.6% for voluntary patients. In Sullivan’s review of 42 studies, the aggregate annual mortality rate from AN averaged 0.56% per year—more than twice that of female psychiatric patients with other diagnoses.9

A Study of Voluntary and Involuntary Patients

We designed a study to compare 66 involuntary and 331 voluntary eating disorder patients who were consecutively referred for treatment at the University of Iowa Hospital and Clinics Eating Disorders Program from July 1991 to June 1998. Pertinent information was taken from the patients’ clinical charts retrospectively and recorded on a coding sheet. For those who were admitted more than once, only information from the first admission was recorded.

Body weights were calculated by body mass index (BMI), kg/m2, and as a percentage of mean matched population weight (MMPW).12 BMI has the advantage of being reference-free and standardized by height and weight. MMPW has a reference population standardized by weight, height, and gender.

All diagnoses were made by reference to the DSM-IV. Chart reviewers then independently confirmed the diagnoses. The code sheet information was double entered into an ACCESS database. Statistical analysis was performed using SAS software.

Of the 397 patients admitted, 16.6% (66 of 397) had been referred by involuntary legal commitment. Involuntary patients were not different from voluntary patients in age, gender, marital status, diagnostic distribution, or psychiatric comorbidity. Within the involuntary population, 28.8% had a history of substance abuse (alcohol and drug abuse were combined), compared to 23.6% of the voluntary population. The proportion of patients who had a history of substance abuse was similar for commitment status, diagnosis, gender, and depression. Both of the populations also had a similar proportion of depression: involuntary, 47% (31/66) and voluntary, 42% (138/331).

Both groups had begun dieting at weights above their MMPW. On admission, involuntary patients were 81.8% of their MMPW, while voluntary patients were 86.2% of their MMPW. Involuntary patients’ mean BMI was 17.4 on admission, compared to 18.4 among voluntary patients. The involuntary group had also been ill longer than the voluntary group (a mean of 96.8 months vs. 83.7 months, respectively) and had more prior hospitalizations than the voluntary group. The number of past hospitalizations was skewed. Most of the study population, 52%, had no previous hospitalizations. About 2% had more than 10 past hospitalizations. Among the study population, 95% had 5 or fewer past hospitalizations; involuntary patients had a mean of 3 prior hospitalizations compared to 1.4 among the voluntary group.

Results

Both involuntary and voluntary patients responded well to the refeeding program. Involuntary patients gained a mean of 18.8 lb during hospitalization, whereas voluntary patients gained a mean of 13.9 lb. Involuntary patients gained 2.6 lb per week, while voluntary patients gained 2.2 lb per week. Although the rate of weight restoration was not significantly different between the two groups, it took involuntary patients longer to restore their weight, which was related to the fact that they were thinner to begin with. Involuntary patients stayed in the hospital for a mean of 58 days, compared to 41 days for voluntary patients. Even though the involuntary group remained in the hospital 17 days longer than the voluntary patients, the proportion of patients in the involuntary group above 85% MMPW (or a BMI greater than 18) at discharge was 78.8% (52/66). This was not significantly different from the 80.6% (267/331) reported in the voluntary group.

Upon discharge, involuntary patients had a slightly lower MMPW than the voluntary group (96.6% vs. 97.2%). Discharge BMI was also similar in the involuntary and the voluntary groups—20.5 and 20.7, respectively.

Psychological Test Results

At admission, involuntary and voluntary patients were similar on most standardized psychological tests. There was no difference in the EAT-26, EDI, and MMPI-II admission scores for patients in either group above 15 years of age. On the Wechsler Adult Intelligence Scale (Revised) involuntary patients’ verbal IQ (VIQ), full-scale IQ (FSIQ), and performance IQ (PIQ) were significantly lower than those of the voluntary patients.

We found that involuntary patients were similar to voluntary patients in virtually all aspects, except for their lack of willingness to seek treatment for their life-threatening form of eating disorder. The frequent past hospitalizations of the involuntary patients indicated that they were more resistant to treatment than the voluntary group.

Despite the significantly longer length of hospitalization for the involuntary patients, this group responded well to treatment over the short term. About 80% were discharged at weights above 85% of MMPW. Seventy-five percent of involuntary patients were discharged at weights greater than 85% MMPW, compared to 73% MMPW among voluntary patients. This suggests that legal detainment for treatment does not necessarily prevent the development of clinical improvement.

After discharge from inpatient care, often the involuntary patients’ legal commitment was transferred to outpatient follow-up to maintain their weight and prevent future hospitalizations. The longer hospitalization of involuntary patients (54 vs. 41 days) is proportional to their lower BMIs on admission. The impact of comorbid diabetes on involuntary treatment outcome could not be determined due to the low prevalence in our study population.

Anecdotally, many of the involuntary patients reported to the treatment team at the time of discharge that they now recognized and endorsed the need for treatment. Not a single patient entered a legal complaint or complained to a medical society after discharge about the inappropriateness of the involuntary commitment or even informally complained that the treatment was unnecessary. This change in attitude suggests that the initial negative attitude might have resulted from the patient’s illness or unrealistic appraisal of the usefulness of treatment.7 It also supports the need to treat some seriously ill patients against their will.

The VIQ, PIQ, and FSIQ scores on the WAIS-R were lower for detained patients than voluntary patients. This suggests that detained patients may have slightly less capacity to recognize the severity of their condition and to seek treatment.

Legal, Moral, and Philosophical Issues Remain

Our study did not address or resolve important philosophical, legal, or moral issues about whether any person should be involuntarily committed for treatment of a psychiatric disorder. Nevertheless, there appear to be selected cases of eating disorders that are life-threatening and associated with core features of denial of illness or thinness to a degree that the use of involuntary may be appropriate.

At times the comorbid depressive illness or personality disorder or both that often accompany ancontinued from page 3

eating disorder may have added to the denial of illness and unwillingness to seek treatment. A relatively small proportion of the eating disorders population—16.6% in our study, for example—are ill enough to be detained for treatment.

It could be argued that all eating-disordered patients could be treated effectively as outpatients. Several well-designed and controlled studies comparing the effects of hospitalization and outpatient treatment of the mentally ill show that the outpatient treatment was as good or better than inpatient care and usually less costly.11 However, studies on the outpatient treatment of life-threatening forms of eating disorders are limited.

Our study suggests that these severely ill eating-disordered patients who do not recognize their need for treatment do reasonably well in short-term treatment. However, a longer-term follow-up study is needed to determine the lasting effects of involuntary admission. Ramsay and colleagues confirmed that short-term treatment of involuntary and voluntary commitment is comparatively effective, but is more problematic for the involuntary patients.8