The management of patients reluctant to accept essential therapeutic goals requires that they should be gradually engaged in a genuine alliance. (,!,3.4) However, there remains a minority of patients with whom this strategy fails and whose health becomes endangered. For them, compulsory treatment should be considered. A compulsory admission to hospital is indicated not only when patients threaten suicide or suffer from a life-threatening malnutrition, but also when they fail to respond to simpler measures such as outpatient treatment or day care, or in the event of avoiding treatment altogether. Ill health persisting over the course of several months or the development of serious physical complications (e.g. water and electrolyte imbalance, hypoglycaemia, and myopathy) should also elicit compulsory admission if the patient cannot be persuaded to accept inpatient treatment.
In the United Kingdom the Mental Health Act Commission^.35.) has recently (1997) clarified many of the doubts in the minds of clinicians and social workers called upon to consider a compulsory admission under the Mental Health Act 1983. It recognized that anorexia nervosa is a mental disorder within the meaning of the Act and that in some patients their ability to consent may be compromised by fears of obesity or denial of the consequences of their actions. The Mental Health Act Commission concluded that when the patient's health is seriously threatened by food refusal she may be detained in hospital so as to treat the self-imposed starvation. The Commission went as far as to state that nasogastric feeding can be a medical process forming an integral part of the treatment for anorexia nervosa, notwithstanding that nasogastric feeding is seldom required even in patients who are compulsorily admitted.
In a study of the use of compulsory treatment in patients admitted to the Eating Disorders Unit of the Bethlem Royal and Maudsley Hospital, as many as 81 patients (16 per cent) were detained. Section 3 of the Mental Health Act, valid for up to 6 months, was the most frequently applied section. (!.36) The compulsorily admitted patients were compared with a population of voluntary patients. The need for a compulsory admission was found to have two dimensions—the presence of a severe illness and a rejection of treatment, the latter in part due to abnormal personality traits. The compulsory patients gained at least as much weight as the voluntary patients but required a longer admission for them to return to a near-normal weight. It was thought likely that the compulsory patients presented a selected group by virtue of a more entrenched reluctance to accept treatment. Accordingly it was predicted that in the long term they would fare less well than voluntary patients. It was possible to determine the mortality rate of these patients through the National Register which provided the data at a mean of 5.7 years after the index admission. Ten out of 79 detained patients had died in comparison with two out of 78 voluntary patients, a statistically significant difference. The deaths among the compulsory patients were all due to anorexia nervosa or one of its nutritional complications. Thus the mortality rate among compulsory patients was extremely high at 2.17 per cent per annum. It was concluded that this high mortality was due to the selection factors.
Therefore the evidence points to the usefulness of a compulsory admission in appropriate circumstances in so far as the patients responded well in the short term. Nevertheless, a patient who has required a compulsory admission carries a higher risk, so that it is essential to safeguard her through a long period of observation.
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