Self-admission: A New Treatment Approach for Patients With Severe Eating Disorders

There are approximately 100 000 individuals in Sweden who suffer from an eating disorder such as anorexia nervosa or bulimia nervosa. The course of these disorders is often prolonged and can lead to enduring disability for many years. Some patients require lengthy periods of inpatient care, and relapse after discharge is common. Unfortunately, there is still little evidence concerning the optimal model of inpatient care for patients suffering from a severe and enduring eating disorder (SE-ED) and unlike psychiatry in general, the hospitalization rate for SE-ED patients has not been markedly reduced in the past decades.

In Norway, a novel treatment concept for psychiatric patients has been in place for about ten years: self-admission. In self-admission, patients who are well-known to a service who have high previous utilization of health care are offered the possibility of self-admission to the inpatient ward for up to seven days without having their motive for admission questioned. Patients are free to admit themselves because of deteriorating mental health, acute stress, lack of structure in their everyday life, loneliness, boredom, or any other reason. The patients decide when they want to admit themselves and can discharge themselves at any time. The purpose behind the self-admission model is to increase the availability of inpatient care for severely ill patients, to avoid stressful and possibly destructive visits to the emergency service, and to decrease total inpatient care utilization. Patients offered a contract for self-admission usually have a history of repeated and prolonged hospitalizations. By encouraging them to monitor their own mental health status and allowing them to seek help swiftly when they are feeling poorly, the delay from first signs of deterioration to admission can be minimized and full-blown relapse can be avoided, ultimately reducing the total time spent in hospital.

The Norwegian results are very promising. Self-admission has led to increased patient participation and compliance, strengthened the patients' abilities to handle their symptoms and their everyday life, and clearly reduced the total time spent in inpatient care. The total time spent in non-voluntary inpatient care and the number of violent or threatening episodes at the ward was also reduced.

Until now, projects of self-admission have mainly targeted patients with long-standing psychotic disorders, such as schizophrenia, or bipolar disorder. Starting in August 2014, a three-year clinical project at the Stockholm Centre for Eating Disorders (SCÄ) began offering self-admission to patients with SE-ED (mainly anorexia nervosa, which is the most common diagnosis at the SCÄ inpatient ward). The overall goal of the self-admission project at SCÄ is to create a high-quality treatment approach that is also cost-effective. The relatively brief nature of these self-admissions will of course not allow for full-scale weight restoration or achievement of other long-term treatment goals. Instead, this admission concept is probably best used as booster opportunity or for providing a short respite from stressful life situations where the risk of relapse is elevated. In this way, offering brief inpatient treatment as a preemptory tool to be made use of rather than as a "necessary evil" when severe mental breakdown has already occurred can increase patient participation, agency, self-awareness, and autonomy. Furthermore, bypassing the traditional clinician-led decision-making in evaluating whether inpatient treatment should occur could also foster reflection on subjective motives and barriers in asking for help. Here, self-admission promotes partnership between patient and clinicians instead of distrust. The approach could enhance self-knowledge and motivation and, by extension, foster skills and strategies that can influence the course and prognosis of the disorder. It has been shown that patients suffering from anorexia nervosa do request inpatient treatment after the initial period of reinforcement inherent to the disorder has passed and that this is part of a personal process of increased awareness. As they gradually become more aware of their loss of control over eating disorder symptoms and of their ambivalence towards change, they also become less reluctant to ask for assistance in regaining control. For patients with long-standing illness this process may take several years. It is hypothesized that such a process could be solidified and hastened by offering patients a concrete tool in the form of self-admission, by which they are also required to practice self-monitoring and develop agency.

The current program is the first of its kind to offer self-admission to patients with an eating disorder. If the model proves to be successful, it can hopefully be established as a standard tool in the treatment of patients with SE-ED. However, a health economics analysis is critical to determining whether the model merits broader implementation. The potential health economic benefits are evident: lower health care costs for the specific patient group, increased availability of much sought after hospital beds for "regular" patients in the queue to the ward, improving patients' chances of maintaining everyday activities with functioning family life and work, lowered rates of sick leave, etc.