European Eating Disorders Review Eur. Eat. Disorders Rev. 16, 199–206 (2008)
Why (and When) Clinicians Compel Treatment of Anorexia Nervosa Patients Terry Carney 1*,y, David Tait 2z, Alice Richardson 3 and Stephen Touyz 1x 1
The University of Sydney, Australia Law School, University of Canberra, Australia 3 Department of Information Sciences and Engineering, University of Canberra, Australia 2
Objective: This paper addresses the question of the circumstances which lead clinicians to use legal coercion in the management of patients with severe anorexia nervosa, and explores similarities and differences between such formal coercion and other forms of ‘strong persuasion’ in patient management. Method: Logistic regression and other statistical analysis was undertaken on 75 first admissions for anorexia nervosa from a sample of 117 successive admissions to an eating disorder facility in New South Wales, Australia, where an eating disorder was the primary diagnosis. Admissions with other primary diagnoses, such as bulimia nervosa (25 episodes), and entries with a co-morbid diagnosis (e.g. depression or opiate overdose), were discarded, leaving 96 admissions by 75 individuals. Results: Resort to measures of legal coercion into treatment was found to be associated with three main indicators: the patient’s past history (number of previous admissions); the complexity of their condition (the number of other psychiatric co-morbidities); and their current health risk (measured either by Body Mass Index (BMI) or the risk of re-feeding syndrome). Conclusions: Our study is consistent with the few earlier studies about indicators for legal coercion in anorexia nervosa management, and suggests that clinicians use legal coercion very sparingly, distinguishing legal coercion from other forms of close clinical management of patients. Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Keywords:
compulsory treatment; anorexia nervosa; legal coercion; indicators for treatment
INTRODUCTION * Correspondence to: Terry Carney, 173-175 Phillip St., Sydney 2000, Australia. Fax: þ612 9351 0200. E-mail:
[email protected] y Professor of Law. z Associate Professor. x Professor of Clinical Psychology.
Severe and enduring anorexia nervosa is a condition with a very high mortality and morbidity rate. Despite this, there is no clear consensus about which treatments or interventions should be preferred
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Published online 5 December 2007 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/erv.845
T. Carney et al.
200 (Carney, Tait, Touyz, Ingvarson, Saunders, & Wakefield, 2006), although there are helpful clinical guidelines (APA, 2006) and some agreement is emerging about aspects such as the advantage of specialist units (Lindblad, Lindberg, & Hjern, 2006). This paper addresses the question of the circumstances which lead clinicians to use legal coercion in the management of patients with severe anorexia nervosa. This distinction between social influence and legal ‘coercion’ can become blurred (40 per cent of ‘voluntary’ mental patients in the MacArthur Coercion study anticipated involuntarily committal should they decline voluntary admission: Pescosolido, Boyer, & Lubell, 1999). Indeed, our own study (Carney et al., 2006) supported Monahan et al.’s (2005) characterisation of community-based coercion not so much as diluted institutionalisation but rather as part of a set of welfare and clinical tools to encourage adherence to treatment (Bonnie & Monahan, 2005). However the clinical picture is arguably more sophisticated, as discussed in this paper. Real coercion is occasionally used in the management of seriously ill anorexia nervosa patients in some jurisdictions (Carney, Tait, Saunders, Touyz, & Beumont, 2003; Tiller, Schmidt, & Treasure, 1993), but surprisingly little is known about when it is indicated. An Iowa study (Watson, Bowers, & Andersen, 2000) supported coercion for some severely ill patients, while other studies indicate that coercion in aid of treatment is employed for younger patients, with chronic illness duration and patterns of prior treatment, often associated with complicated psychiatric presentation (Griffiths, Beumont, & Russell, 1997). British research (Ramsay, Ward, Treasure, & Russell, 1999) reported that 16 per cent of anorexia nervosa patients in mental health facilities had been committed (mostly after their original entry as a ‘voluntary’ patient). The study found that both involuntary and voluntary patients succeeded in regaining weight, though more slowly on the part of involuntary patients. The involuntary patients were not more severely ill than their voluntary counterparts, unlike the Iowa study (Griffiths et al., 1997), but their condition was both more intractable and more commonly associated with personality or trauma variables. That study found that involuntary status was statistically associated with prior episodes of admission, and a strong (but not statistically significant) relationship was found with psychiatric co-morbidity (Ramsay et al., 1999). A United States study of a matched sample of voluntary and involuntary patients found little
difference in short-term outcomes, other than that the involuntary group would mainly have been lost to treatment but for the resort to coercion (Watson et al., 2000, 2001). It found that the two groups were similar in age, gender and marital status, but the coerced group had been ill for significantly longer and had more episodes of prior hospitalisation (Watson et al., 2000). An Australian 5 year follow-up of over 200 patients (methodologically compromised by including a range of eating disorders) concluded that, for the severe cases of anorexia nervosa, treatment had at best a marginal benefit (Ben-Tovim, 2001; Ben-Tovim, Gilchrist, & Walker, 2001). Research from Germany did not find the presence of depressive co-morbidity to be predictive of formal coercion, but did find illness duration and prior hospitalisations to be predictive, along with self-mutilative behaviour (Brunner, Parzer, & Resch, 2005). Even short-term outcomes of compulsory treatment interventions have been found to be quite similar to outcomes for voluntary patients (Yager & Andersen, 2005). Guarda, Pinto, Coughlin, Hussain, Haug, and Heinberg (2007) recently studied perceived coercion in 139 patients with eating disorders both at admission and 2 weeks into inpatient treatment, finding that anorexia nervosa patients reported higher levels of perceived coercion and pressure, and a lower sense of procedural justice than did those with bulimia, while younger patients (under 18) were most likely to disagree with the need for hospitalisation irrespective of their eating disorder. While perceptions of coercion (and of outside pressure to accept treatment) remained stable in the short term, 20 of the 46 patients initially objecting to their original admission had changed their mind within 2 weeks, with more adults doing so than younger patients. The current study addresses the question of the circumstances that inevitably lead clinicians to enact legal coercion in treating their patients with severe and enduring anorexia nervosa, and describes similarities and differences between such formal coercion and other forms of ‘strong persuasion’.
METHODS Study Sample The study data analysed in this paper were extracted from records of a major Australian specialist anorexia nervosa treatment facility (in the state of New South Wales) over a period of
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Eur. Eat. Disorders Rev. 16, 199–206 (2008) DOI: 10.1002/erv
Compulsory Treatment of Anorexia Nervosa Patients nearly 5 years (Carney, Wakefield, Tait, & Touyz, 2004). The facility adopted a ‘progressive’ regime that minimised the level of coercion, within a jurisdiction where coercion might be legally imposed either under adult guardianship orders or by means of mental health committal, with guardianship reportedly mainly used to ‘initiate’ rather than coerce treatment (Newman, Russell, & Beumont, 1995). The sample size was determined pragmatically, by the size of the available data set. Due to the paucity of literature, power calculations were unable to be made, however the risk of Type II errors was low, given its size.1 The sample comprised all 117 hospital admissions to a specialist program where an eating disorder was the primary diagnosis; 25 cases diagnosed as having other conditions such as bulimia nervosa, or where entry was on a co-morbid diagnosis (e.g. depression or opiate overdose), were discarded, leaving 96 admissions by 75 individuals for anorexia nervosa as a primary diagnosis. Second and subsequent admissions were discarded from the analysis. This is because the methods of analysis used rely on independent observations, that is admissions of separate patients. It also turns out that the removal of the 21 multiple admissions does not change the parameter estimates greatly. Finally, the quantity of repeated measures is so small (9 patients with two admissions, 2 with three, 1 with four and 1 with five) that parameter estimates in repeated-measures models are likely to be unreliable. Some individuals were diagnosed as suffering only from anorexia nervosa, however nearly three-quarters had at least one other co-morbid mental illness and one third two or more such diagnoses. Formal legal coercion was defined as involuntary admission under mental health legislation, or appointment of a third party as a guardian with authority to consent to treatment, under adult guardianship (substitute consent) laws (Carney, 2002; Carney et al., 2003). Twenty-seven coercive 1
The likelihood of a Type II error is equal to one minus the power of any particular test. It can be calculated by specifying the effect size, significance level and sample size in each group. In this study the sample sizes differ (57 coerced and 18 voluntary) but by taking the smaller of these, an indication of the power of our tests can be obtained. For an effect size of 1 (i.e. a detectable difference of 1 standard deviation) at a significance level of 0.05, the power with sample sizes of 18 is 0.83 rising to 0.99 when the effect size is doubled. This suggests that even with the larger samples available in this study, the power of the tests will be high. Non-parametric tests, as are eventually employed here, will be slightly less powerful but the difference is unlikely to be crucial.
201 admissions were under mental health committal or adult guardianship orders. Seven admissions considered for coercion resulted in patients agreeing to informal admission, following a ‘strategic’ initiation and abandonment of resort to the law (Carney, Saunders, Tait, Touyz, & Ingvarson, 2004). Such abandonment of legal action, once a patient accepted treatment, was separately classified as a less coercive form of intervention (and not included as ‘legal coercion’ for the purposes of the statistical analysis). Other lesser forms of leverage adopted to obtain treatment compliance were treated as forms of ‘suasion’ (of various degrees of intensity: Rathner, 1998) and are reported separately (Carney et al., 2006). Variables such as age, number of previous admissions with a diagnosis of severe anorexia nervosa, the number of clinical diagnoses for other DSM (IV) psychological conditions, use of purging, admission to ‘locked ward’ status during treatment, Body Mass Index (BMI) at admission and discharge, weight gain during treatment, development of re-feeding syndrome during treatment and use of tube feeding—were extracted from clinical files and the data anonymised in accordance with a human ethics protocol. Extraction was conducted by a trained dietician specialising in anorexia nervosa cases, under the supervision of senior clinician, and was undertaken in accordance with internationally accepted definitions.
Statistical Analysis Two main methods of statistical analysis were employed. First, Wilcoxon rank tests (also known as Mann–Whitney U tests) were used to test whether there was a difference in the mean of each variable between the coerced and non-coerced groups. These tests correct for the lack of normality in the distribution of each variable,2 otherwise required for independent t tests. Summary statistics (means and standard deviations) for each variable within the coerced and non-coerced groups are given in Table 1. It can be seen that two variables yielded significant results: the number of prior admissions for anorexia nervosa (W ¼ 311.5, df ¼ 54,17; p ¼ 0.0368), and the number of co-morbid psychiatric conditions (W ¼ 353.5, df ¼ 57,18; p ¼ 0.0378). BMI on admission (W ¼ 518.5, df 53,18; p ¼ 0.5877) was also of interest. These data suggested that coercion is most likely indicated for 2 Of the five quantitative variables, only BMI on admission passed a Shapiro–Wilk test for normality (0.8834).
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Eur. Eat. Disorders Rev. 16, 199–206 (2008) DOI: 10.1002/erv
T. Carney et al.
202 Table 1. Use of coercion (means and odds ratios) Mean
Background Age Aged 20–29 Previous admissions Diagnosis Type of eating disorder Psychiatric co-morbidities BMI on admission Re-feeding syndrome Treatment Days in treatment Tube feeding Locked ward
Significance
Zero-order odds ratio
Voluntary
Coerced
Test statistic
df
Sig.
Ratio
Sig.
25.04 0.49 1.74
25.61 0.28 3.88
W ¼ 518.5 x2 ¼ 1.73 W ¼ 311.5
57,18 1 54,17
0.9505 0.1875 0.0368
1.009 0.398 1.262
0.792 0.118 0.032
0.37 1.05 14.13 0.16
0.28 1.94 13.66 0.33
x2 ¼ 0.18 W ¼ 353.5 W ¼ 518.5 x2 ¼ 1.65
1 57,18 53,18 1
0.6742 0.0378 0.5877 0.1991
0.659 1.804 0.864 2.667
0.483 0.013 0.346 0.112
42.89 0.16 0.02
43.78 0.33 0.33
W ¼ 539.5 x2 ¼ 1.65 x2 ¼ 12.61
57,18 1 1
0.7470 0.1991 0.0003
1.000 2.667 28
0.937 0.112 0.003
patients with more chronic histories (prior AN admissions), where they present with other psychiatric illnesses (and possibly a low BMI). Secondly, multiple logistic regression was used to estimate the effect of each variable on the probability of coercion, allowing for the effect of other variables in the model.
RESULTS Findings from Statistical Analysis of the Data In this part of the paper we use multivariate analysis to further explore which characteristics were most closely associated with the use of coercion (Table 1). To do this, we grouped variables into those related to the patient’s background (age and previous admissions), those related to diagnosis (the type of eating disorder, number of other psychiatric co-morbidities identified, BMI on admission to the eating disorders unit) and those specifying aspects of the treatment which might retrospectively offer a measure of the ‘gravity’ of the illness (number of days the treatment took, whether tube feeding was attempted or given and whether the patient was placed in a locked ward). We also paid regard to the development of re-feeding syndrome (below), which also arguably reflects earlier measures of the severity of illness. This allows us to put these in a rough temporal order, distinguishing prior experiences that led the
medical team to consider coercion was required, from aspects of the patient’s current condition, and also from coercive features of the treatment itself that were, in some cases, made possible by the legal order. Some of the variables used above were dropped to simplify the interpretation, due to their weak link with the use of coercion—the number of medical co-morbidities, weight gain and the use of ‘purging’, while the number of prior admissions to the study site unit was dropped because the total number of admissions for eating disorders is a more powerful alternative. One way of interpreting the relationship between variables is in terms of changes in the odds of an event occurring, in this case coercion being used. These are presented as the ‘zero-order’ odds ratios, in that they are the estimates from a logistic model in which the only other term is an intercept. The zero-order odds ratio refers to the odds ratio for coercion calculated from a logistic regression model involving one variable at a time. For example if a patient develops re-feeding syndrome—a potentially fatal disturbance of electrolyte, vitamin, mineral, bone and muscle homeostasis, to which anorexia nervosa patients are especially prone (Beumont & Large, 1991; Birmingham, Alothman, & Goldner, 1996), when re-feeding patients who have experienced severe weight loss (Brooks & Melnik, 1995; Solomon & Kirby, 1990)—then they are three times as likely to be treated with the assistance of a legal order than if they do not have this syndrome, because this is also synonymous
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Eur. Eat. Disorders Rev. 16, 199–206 (2008) DOI: 10.1002/erv
Compulsory Treatment of Anorexia Nervosa Patients with the severity of the illness at the point of admission. If they are given tube feeding, they are almost five times as likely to be on a legal order than if they are fed some other way. For legal reasons under the New South Wales Mental Health Act, being in a locked ward is virtually synonymous with being legally coerced (those in a locked ward are 50 times more likely to be coerced than others), but precisely because there is a close match between the two conditions, the parameter estimates can become a little unstable. For two of the variables the sign is reversed to make interpretation simpler. Thus patients who are not in the 20–29 age group are 2.2 times more likely to be treated with the assistance of legal coercion than those who are within this age group, perhaps because younger patients are still under the moral influence of their parents. These variables are all binary, the patient is either in the group or not. The other variables are continuous and are interpreted in the following manner. For every unit increase in the number of previous admissions, the odds of being under a coercive order increase by 1.3. These estimates are multiplicative, so a two unit increase in admissions would result in an estimated 1.3 1.3 (1.7) increase in the odds, reflecting clinical experience of a group of patients who drop out of regular follow-up or postpone appointments because they know they will be hospitalised and have to gain weight. Similarly, for every extra psychiatric co-morbidity recorded, the odds of being treated under a coercive order double. Meanwhile, for every unit decrease in BMI, the odds of coercion being used increase by 1.3. All these estimates are ‘zero order’, they do not take into account the relative contribution of other variables. Logistic regression allows us to sort out which variables make a net contribution to the likelihood of coercion being used once the impact of other variables is taken into account, and also gives an estimate of the size of that contribution, using the odds ratio interpretations presented above. If all the variables are considered for inclusion in the model, then only the number of previous admissions for eating disorders and the number of other psychiatric co-morbidities make a difference to the likelihood of getting a legal order to compel treatment. Having a number of prior admissions shows that the patient is clearly not responding to treatments. Mortality increases with the length of treatments, accounting for the fact that there are fewer teenage deaths from this condition but more when patients are in their 30s, 40s or 50s. In the case of co-morbidities, patients often become
203 depressed and suicidal. This would be a clear clinical indicator for involuntary treatment if they give no assurance that they actively want suicide. In other words, medical teams tend to take into account both the medical history of the patient and the complexity of the current situation in deciding whether to seek a mental health order; or putting it another way, they pay regard to proxies for immediate and longer-term severity of illness. They will of course consider other matters, but these do not make any measurable difference to the overall likelihood of legal coercion being used. The most robust of the background variables combines with the most robust of the diagnosis variables to provide the best guess for whether coercion will be used. To interpret the parameters: every additional psychiatric co-morbidity increases the odds of coercion being used by about 1.8, while every additional previous admission increases the odds of coercion by about 1.2. When these are compared with the ‘zero-order’ odds ratios, the estimates are only marginally lower when the two are combined, suggesting that the two variables are largely independent of each other (they are not noticeably ‘collinear’). It is useful to consider each group of variables in turn. Of the background variables, only the total number of previous admissions relating to eating disorders makes a difference. So the impact of previous admissions is the same as that reported above for the ‘zero-order’ condition—for every extra prior admission the odds of coercion go up by an estimated 1.3. Turning to the diagnostic variables the best model included two variables—lower levels of BMI on admission (odds of coercion increasing by 1.3 for every point decrease in BMI), as well as the number of psychiatric co-morbidities (1.9). For this model, the intercept term is not significant, so it is dropped. Consistent with clinical experience that people who fail to meet all the diagnostic criteria for anorexia nervosa may be just as seriously ill (or more so), no difference was observed between this diagnosis and that of ‘Eating Disorders Not Otherwise Specified’. Nor, for the reason previously anticipated, does the presence of re-feeding syndrome, perhaps because this is closely related to BMI. However if we exclude the variable with the strongest effect (number of psychiatric co-morbidities) an alternative model is also supported by the data. This simply includes one term—the development of re-feeding syndrome. The possibility of several possible models underlines the variety of interpretations possible of the
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Eur. Eat. Disorders Rev. 16, 199–206 (2008) DOI: 10.1002/erv
T. Carney et al.
204 Table 2. Coercion and treatment
Constant
Best overall
Best background
Diagnosis
Diagnosis— psychn
Treatment
Treatment— locked
1.57 0.6375 0.21
1.66 0.1006 0.19
0.98 0.7023 0.38
0.68 0.782 0.51
1.45 0.0011 0.23
1.31 0.0014 0.27
Background Age Aged 20–29 Previous admissions
0.26 0.0225 1.29
Diagnosis Type of eating disorder Psychiatric co-morbidities BMI on admission Re-feeding syndrome Treatment Days in treatment Tube feeding Locked ward
0.56 0.0315 1.75
3.15 0.0235 23.45
3.24 0.0055 25.47
Each cell contains B, sig. and OR. Values for constant are always given. For the other variables, values are given if p-value < 0.05.
chain of circumstances that lead practitioners to seek the help of the law in providing treatment. Is risk assessed in terms of the number of other complicating psychiatric conditions identified, or based on the physical condition of the person measured by their BMI or their reaching a critical stage of risk of developing re-feeding syndrome? The models tested here suggest that either the first two of these, or the last, both plausibly account for a significant part of the variation in the use of coercion. Of the treatment variables (Table 2), being in a locked ward is virtually coextensive with being treated with the sanction of a legal order (only one patient in the study was not under an order), so the other variables drop out of the picture. When ‘locked ward’ is excluded, the use of tube feeding is strongly associated with the use of coercion. In both cases, these are likely to be the result of the legal order rather than a reason for seeking one, so it is perhaps misleading to put them in the same model as background or diagnosis variables.
the power one uses when one does not have power’ (p 13, emphasis added). This study of anorexia nervosa patients in New South Wales Australia found that clinicians endorsed this sentiment, using legal coercion very sparingly. The study found that the past history of the patient (measured by their number of previous admissions) was a relevant factor in deciding whether the current admission required the support of legal powers of coercion. Also highly relevant was the complexity of the patient’s condition (specifically the number of other psychiatric co-morbidities). Current health risk (measured either by BMI or the risk of re-feeding syndrome) may also make a difference, but the co-linearity of the variables and the small size of the sample made it difficult to measure these together.3 While the study cannot shed light on whether the use of coercion was unduly liberal or conservative, the data suggest that clinicians at the study site were prepared to act reasonably to impose legal coercion in response to factors which are indices of severity
DISCUSSION
3
Turner (2005) correctly observes that formal legal coercion is a last resort in management, since it ‘is
Two forms of coercion (insertion of a tube to feed the patient and placing them in a locked ward) were also closely associated with the use of legal coercion, but this probably just meant that coercive measures require coercive authority.
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Eur. Eat. Disorders Rev. 16, 199–206 (2008) DOI: 10.1002/erv
Compulsory Treatment of Anorexia Nervosa Patients of illness and risk to life. Because the multidisciplinary bodies to which such applications were made provide opportunities to canvass both the necessity for resort to coercion and possible impacts on the therapeutic balance sheet, this brings honesty and transparency to the exercise of such power in aid of treatment. In summary, it does appear that legal coercion has its place in the management of severe and enduring anorexia nervosa, especially in situations of extremely low Body Mass Indices (weight [kg]/height [m]2, even though this risks ‘distancing’ clinicians from these patients (Carney, Tait, & Touyz, 2007). This could potentially stall or reverse the effects of treatment for a time at least—the process of building therapeutic alliances or the building of the therapeutically significant wider ‘shared understandings’ with family or community members. However, notwithstanding this, in the absence of more effective treatment regimens, there is much to be said in favour of using coercion in an honest, transparent and open manner.
REFERENCES APA. (2006). Treatment of patients with eating disorders (3rd ed.). American Journal of Psychiatry, 163, 4–54. Ben-Tovim, D. (2001). Outcomes in patients with eating disorders: A 5 year study. The Lancet, 357, 1254–1257. Ben-Tovim, D., Gilchrist, P., & Walker, K. (2001). Evolving evidence and continuing uncertainties for eating disorders. Medical Journal of Australia, 175, 238– 239. Beumont, P., & Large, M. (1991). Hypophosphateamia, delirium and cardiac arrhythmia in anorexia nervosa. Medical Journal of Australia, 155, 519–522. Birmingham, C., Alothman, A., & Goldner, E. (1996). Anorexia nervosa: Refeeding and hypophosphataemia. International Journal of Eating Disorders, 20, 211–213. Bonnie, R., & Monahan, J. (2005). From coercion to contract: Reframing the debate on mandated community treatment for people with mental disorders. Law and Human Behavior, 29, 485–503. Brooks, M., & Melnik, G. (1995). The refeeding syndrome: An approach to understanding its complications and preventing its occurrence. Pharmacotherapy, 15, 713–726. Brunner, R., Parzer, P., & Resch, F. (2005). Involuntary hospitalization of patients with anorexia nervosa: Clinical issues and empirical findings. Fortschritte der Neurologie Psychiatrie, 73, 9–15. Carney, T. (2002). Regulation of treatment of severe anorexia nervosa: Assessing the options? Australian Health Law Bulletin, 11, 25–32.
205 Carney, T., Saunders, D., Tait, D., Touyz, S., & Ingvarson, M. (2004). Therapeutic pathways in treatment of severe anorexia nervosa. Contemporary Issues in Law, 7, 100–118. Carney, T., Tait, D., Saunders, D., Touyz, S., & Beumont, P. (2003). Institutional options in management of coercion in anorexia treatment: The antipodean experiment. International Journal Law and Psychiatry, 26, 647–675. Carney, T., Tait, D., & Touyz, S. (2007). Coercion is coercion? Reflections on clinical trends in use of compulsion in treatment of anorexia nervosa patients. Australasian Psychiatry, 15, 390–395. Carney, T., Tait, D., Touyz, S., Ingvarson, M., Saunders, D., & Wakefield, A. (2006). Managing anorexia nervosa: Clinical, legal and social perspectives on involuntary treatment. New York: Nova Science. Carney, T., Wakefield, A., Tait, D., & Touyz, S. (2004). Clinical and demographic dimensions of coercion in the treatment of severe anorexia nervosa. Paper Presented at the 39th RANZP Congress, Christchurch New Zealand, 10–13 May 2004. Griffiths, R., Beumont, P., & Russell, J. (1997). The use of guardianship legislation for anorexia nervosa: A report of 15 cases. Australian and New Zealand Journal of Psychiatry, 31, 525–531. Guarda, A., Pinto, A., Coughlin, J., Hussain, S., Haug, N., & Heinberg, L. (2007). Perceived coercion and change in perceived need for admission in patients hospitalized for eating disorders. American Journal of Psychiatry, 164, 108–114. Lindblad, F., Lindberg, L., & Hjern, A. (2006). Improved survival in adolescent patients with anorexia nervosa: A comparison of two Swedish national cohorts of female inpatients. American Journal of Psychiatry, 163, 1433–1435. Monahan, J., Redlich, A. D., Swanson, J., Robbins, P. C., Appelbaum, P. S., Petrila, J., et al. (2005). Use of leverage to improve adherence to psychiatric treatment in the community. Psychiatric Services, 56, 37–44. Newman, L., Russell, J., & Beumont, P. (1995). Issues in the treatment of very low weight anorexics. In D. Kenny, & R. S. Job (Eds.), Australia’s adolescents: A health psychology perspective (pp. 53–58). Armidale: University of New England Press. Pescosolido, B., Boyer, C., & Lubell, K. (1999). The social dynamics of responding to mental health problems. In C. Aneshensel, & J. Phelan (Eds.), Handbook of the sociology of mental health (pp. 441–460). NY: Kluwer Academic/Plenum. Ramsay, R., Ward, A., Treasure, J., & Russell, G. (1999). Compulsory treatment in anorexia nervosa. British Journal of Psychiatry, 175, 147–153. Rathner, G. (1998). A plea against compulsory treatment of anorexia nervosa patients. In W. Vandereycken, & P. Beumont (Eds.), Treating eating disorders: Ethical, legal and personal issues (Vol. 1, pp. 179–215). London: The Athlone Press. Solomon, S., & Kirby, D. (1990). The refeeding syndrome: A review. Journal of Parenteral and Enteral Nutrition, 14, 90–97.
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Eur. Eat. Disorders Rev. 16, 199–206 (2008) DOI: 10.1002/erv
T. Carney et al.
206 Tiller, J., Schmidt, U., & Treasure, J. (1993). Compulsory treatment for anorexia nervosa: Compassion or coercion? British Journal of Psychiatry, 162, 679– 680. Turner, J. (2005). Explaining the nature of power: A three-process theory. European Journal of Social Psychology, 35, 1–22.
Watson, T., Bowers, W., & Andersen, A. (2000). Involuntary treatment of eating disorders. American Journal of Psychiatry, 157, 1806–1810. Watson, T., Bowers, W., & Andersen, A. (2001). Involuntary treatment of patients with eating disorders. Eating Disorders Review, 12, 1–7. Yager, J., & Andersen, A. (2005). Anorexia nervosa. New England Journal of Medicine, 353, 1481–1488.
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Eur. Eat. Disorders Rev. 16, 199–206 (2008) DOI: 10.1002/erv
