Compulsory treatments in eating disorders: a systematic review and meta-analysis

Abstract

Introduction The aims of this systematic review and meta-analysis are to provide a summary of the current literature concerning compulsory treatments in patients with eating disorders (ED) and to understand whether compulsorily and involuntarily treated patients differ in terms of baseline characteristics and treatment outcomes. Methods Relevant articles were identified following the PRISMA guidelines by searching the following terms: “treatment refusal”, “forced feeding”, “compulsory/coercive/involuntary/forced treatment/admission”, “eating disorders”, “feeding and eating disorders”, “anorexia nervosa”, “bulimia nervosa”. Research was restricted to articles concerning humans and published between 1975 and 2020 in English. Results Out of 905 articles retrieved, nine were included for the analyses allowing the comparisons between 242 compulsorily and 738 voluntarily treated patients. Mean body mass index (BMI) was slightly lower in patients compelled to treatments. Mean illness duration, BMI at discharge and BMI variation showed no significant differences between the two groups. Average length of hospitalization was 3 weeks longer among compulsory-treated patients, but this did not result in a higher increase in BMI. No significant risk difference on mortality was estimated (three studies). Conclusions Compulsory treatments are usually intended for patients having worse baseline conditions than voluntary ones. Those patients are unlikely to engage in treatments without being compelled but, after the treatments, albeit with longer hospitalisations, they do achieve similar outcomes. Therefore, we can conclude that forcing patients to treatment is a conceivable option. Level of evidence Level I, systematic review and meta-analysis.

Models of care for eating disorders: findings from a rapid review

“…This finding held true controlling for important covariates (e.g., age, sex, ethnicity), and mediation analyses revealed this effect occurred due to patients presenting with a higher percent median body mass index (BMI) at intake, resulting in lower odds of admission [ 54 ]. In a systematic review by Atti et al (2021) comparing compulsorily and voluntarily treated patients, those who were compelled to inpatient treatment (i.e., under compulsory orders) had more frequent prior hospitalisations and more psychiatric comorbidities, including depression, substance abuse and self-harm [ 34 ]. However, meta-analytic evidence generated from this review indicated that despite having a lower BMI at admission and on average a 3-week longer hospital stay, compulsorily treated patients achieved similar BMI at discharge [ 34 ].…”

“…Sometimes patients are also admitted without a medical emergency, rather to improve ED symptoms (e.g., break binge/purge cycle) [ 33 ], meet weight objectives for safety, or in the case of suicidal ideation [ 32 ]. When care is not received voluntarily, patients may be compelled to inpatient care under local legislation [ 34 , 35 ]. Similar treatment modalities to inpatient care include residential care – where medical monitoring, meal support and therapy (individual and group) are offered in a residential setting [ 36 ] – and day programs, where patients receive supervised meal support, individual and group therapy during the day but continue residence in their homes [ 37 ].…”

“…Reviews of current service delivery for EDs have typically explored different models of care for particular ED subtypes, including primary care [in AN, BN, BED; 41 ], and inpatient care for AN [ 42 ] and Avoidant/Restrictive Food Intake Disorder (ARFID) [ 43 ]; as well as compulsory treatments [ 34 ], day programs [ 36 ] and the relative benefits of inpatient versus outpatient care for AN and BN [ 44 ]. Many of these reviews have relied exclusively on randomised controlled trial (RCT) data which, despite providing high quality evidence for the effectiveness of different treatments, are not without their limitations.…”

“…Food Intake Disorder (ARFID) [43]; as well as compulsory treatments [34], day programs [36] and the relative benefits of inpatient versus outpatient care for AN and BN [44]. Many of these reviews have relied exclusively on randomised controlled trial (RCT) data which, despite providing high quality evidence for the effectiveness of different treatments, are not without their limitations.…”

Understanding Treatment‐Seeking Behavior among Female Survivors of Eating Disorders

“…Although external social supports “cued” participants to act on their ED and enter treatment, more research is needed about the voluntary vs. compelled nature of treatment seeking and how this shapes long‐term recovery. Some research suggests that treatment outcomes are similar among ED survivors who entered treatment voluntarily vs. those who were compelled (Atti et al, 2020). However, compulsion into treatment is largely based on severity of symptoms and as evidenced in the current study, young women engaging in anorexic behaviors go to great lengths to conceal their ED and related pathologies, and compulsion into treatment may be needed before symptoms escalate to the point of dire health consequences.…”