Self-admission as a treatment tool in severe anorexia nervosa

Abstract

Self-admission to psychiatric inpatient treatment is an innovative collaborative approach to healthcare rationing that invites patients to play a more active role in deciding when they need a higher level of care. In self-admission, patients with a history of high utilization of inpatient treatment are offered the choice to decide for themselves when an episode of brief hospital admission — usually 3-7 days at a time — is warranted. Self-admission has been offered in mental healthcare in Scandinavian countries and the Netherlands for over a decade as a tool in the treatment of severe and enduring mental illnesses such as schizophrenia, bipolar disorder, and borderline personality disorder. In self-admission, high-utilizers of healthcare are offered “fast lane” access to earmarked beds to make use of as they see fit, without waiting time and risk of being sent home by a psychiatric emergency service. Patients eligible for self-admission typically present with a history of multiple and prolonged episodes of hospital admission. By encouraging self-monitoring of their mental health status and promoting swift help seeking, the delay between the first signs of deterioration and subsequent hospital admission can theoretically be minimized, ultimately reducing the total time spent in hospital—if patients are invited to act early in response to subjective cues that might not prompt admission if assessed through a regular emergency service, they can potentially avoid further deterioration and lengthier hospital admissions.

This thesis is an evaluation of the self-admission program targeted to patients with severe anorexia nervosa at the Stockholm Centre for Eating Disorders, employing a mixed methods approach integrating qualitative, quantitative, and health economic components. For the qualitative component of the thesis, 16 participants were interviewed about their experiences in the self-admission program. For the quantitative component, outcomes in terms of healthcare utilization, eating disorder morbidity, health-related quality of life, and sick leave for 29 participants were compared to a group of 113 non-participants matched according to age, duration of illness, and body mass index. For the health economics component, the healthcare resources reallocated within the program were analyzed relative to the reduction in days spent in inpatient treatment seen among these 29 participants, in order to identify any potential crowding out effects.

In sum, the findings show that self-admission to inpatient treatment is a viable and effective treatment tool for individuals with severe anorexia nervosa in terms of strengthening patient autonomy and reducing the total number of days spent hospitalized. The introduction of the self-admission program led to a more than 50% decrease in the total number of days that participants spent in inpatient treatment during 12 months in the program. In comparison, only small and statistically non-significant changes over time were observed in low- and moderate-utilization comparison groups. However, no significant effects were seen in terms of the number of days spent in involuntary inpatient treatment or the number of visits to the outpatient clinic. Moreover, the introduction of self-admission did not have any significant or clinically relevant effects on participants’ self-rated eating disorder morbidity or body mass index. In terms of health-related quality of life, mixed results were seen. Whereas participant interviews pointed to marked improvements in agency, motivation, and autonomy that made a real difference in patients’ everyday lives, these changes were not mirrored by improvements on health-related quality of life as measured by standard quantitative self-rating instruments. A beneficial tendency was seen for participants in terms of number of days on sick leave; this finding, however, did not reach statistical significance. Importantly, the reallocation of hospital beds earmarked for self-admission was offset by an overall reduced need for inpatient treatment among participants, resulting in a net increase in available hospital beds for non-participants.

These findings imply that self-admission in anorexia nervosa may be most useful as a tool within a recovery model framework—an approach where the primary goal is not necessarily to achieve full symptom remission and recovery in a traditional sense, but instead to improve symptom management, strengthen the overall levels of functioning and social inclusion, and maintain a community-based treatment focus. Thus, the self-admission model underscores how hospitalization can serve as a complement to community treatment rather than a substitute. For patients with longstanding illness and pervasive difficulties in maintaining community-based treatment contacts, self-admission can be used as a tool in striving for a higher level of functioning in everyday life. Not least, the self-admission approach may help promote an understanding of the hospital ward as a safe and helpful sanctuary in times of need rather than a place implicitly associated with crisis and coercion. In its proper context, the self-admission model holds the potential to transform the delivery of healthcare from crisis-driven to pre-emptive, and to strengthen autonomy for severely ill patients.