Ulrike Schmidt is professor of eating disorders and head of the Department of Psychological Medicine at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London and a consultant psychiatrist at the South London and Maudsley NHS Foundation Trust’s eating disorders service.
She talks to Léa Legraien about the changes she would like to see in the management of eating disorders.
Q. Although we’ve seen shorter waiting times for treatments for children and young people with eating disorders, research showed that adults wait twice as long before seeking and starting treatment. Why are adults being left behind?
A. Mental health services in the country are divided into those for the under-18s and those for young people aged 18 and above. The Government gave some money – £150m over five years – to set up specific teams for early intervention for those under the age of 18. There are very clear waiting time standards for this group of people, who can self refer to services and have to be seen within a month.
If you’re aged 18 and above, there may be considerable hurdles to get to services in a timely manner [as] there are no specific waiting list targets designed to get people into treatment early.
I guess the Government thought they had to start somewhere and focused on children and young people. What they ignored is that half of the first-episode cases – where someone gets into an eating disorder – present [to services] below the age of 18 and the other half aged between 18 and 25.
These emerging adults [haven’t got] their brain fully developed yet. They’re learning to be adults and are often at a stage in life where they launch themselves into independency, leave home and cook for themselves. They are a vulnerable population and can sleep into an eating disorder much more easily.
Q. What changes have you seen in this sector over the past 10 years?
A. There has been a bit of improvement. People are more ready to recognise that eating disorders can kill and thus the message is beginning to get through.
In parallel, we’ve seen an explosion in social media and diet or fitness apps. Social media is a factor that has changed the way people present to us. We see a lot of younger people who compare themselves against other people and doctor their images to cover up perceived imperfections.
Those societal phenomena have some influence in making vulnerable people more vulnerable to develop eating disorders. There is also more emphasis now on clean eating.
People are getting into eating disorders because they want to be healthy but end up misunderstanding what healthy is. [Some] think that if they only eat green leaves they’re eating a healthy diet but that’s not the case.
Q. What measures did you put into place within your trust to reduce waiting times for adults with an eating disorder?
A. We set up an early intervention service, called first episode and rapid early intervention for eating disorders (FREED), for young adults so they could be seen as soon as possible.
We did a pilot project in 2013/14 including adults aged 18-25 who had a short illness duration – less than three years because clinical and biological studies suggest treatment outcomes are much better in the first three years.
We put a lot emphasis on tailoring treatment to the needs of these young adults, and found that the recovery rate got much better, compared to previous patients we had seen with similar illness duration and age range.
For example, after one year with the programme in place, 60% of anorexia patients were back to their healthy weight, whereas previously only 16% of similar patients had got back to their normal weight.
We had money from the Health Foundation that initially supported us in this pilot work. They then gave us more money to roll this out to three other big eating disorder services in London and Leeds. We’re now doing a bigger project with 300 participants to see if we can replicate what we found in the wider cohort of trusts. That project will come to an end later this year, with a one-year follow up sometime next year.
The uptake and satisfaction rates were very good and we seem to be able to reduce waiting times. If that service was rolled out nationally, we would be a whole lot further in terms of getting away from a postcode lottery.
Q. How can we improve these services across the country?
A. Establishing early intervention for all and focusing on people that come for help for the first time and have a short period of illness would be really helpful, which may mean more money invested in adult eating disorder services.
There are some services up and down the country that are so poorly resourced they only see people who are under a certain body mass index index, such as 17.5 or 15. The message to patients is they’re not ill enough and can only be seen when they’ve reached a certain degree of illness. It’s really unhelpful.
What’s helpful is to get in there early and not wait until people have deteriorated so much that they need more intensive or in-patient treatment.
The good point about early intervention is that many of the changes in the brain and body in eating disorders are very changeable and malleable. If you get in there early, people can make a full recovery.
Q. How can we better educate people about the risks of eating disorders?
A. It’s a really difficult task because eating disorders are quite stigmatised. Different eating disorders have different stigmas attached to them. With anorexia, people usually feel sorry for them but there’s also an element where [the illness] is seen as self inflicted.
For bulimia, the stigma is about not having enough self control or being gluttonous. If other people stigmatise someone, they end up stigmatising themself as well and stop accessing treatment because they’re ashamed [or think] they’re not worth it.
[It’s important to] get the message across that eating disorders are serious illnesses with multiple biological and psychological risk factors that can kill.
Q. What advice would you give to trust leaders to improve their services?
A. Make sure you have an appropriate eating disorder provision and look very closely at the links between children and adolescents and adults eating disorders services.
Often, these services are very separate but around 30% of young people who get seen by children and adolescents eating disorder services need to come to adults eating disorders services so you [need] really good arrangements for any transition.
It would be really helpful for patients if the borders between the two services were blurred.