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In the eating disorder unit (lrb.co.uk)
85 points by fern12 11 months ago | hide | past | web | favorite | 37 comments

> "Some of the help and therapy I eventually received was excellent, but as much as my recovery was supported by the NHS, it was also fuelled by my determination never to have to rely on it again."

When I read this line, it hit home. I've been in and out of NHS treatment for years for other (not anorexia) issues. I never ever want to rely on the NHS again. They failed me so much I now avoid having to interact with anyone in the medical field. I deliberately avoid going to my GP for anything. Mental health care in the UK is so bad that you really wouldn't believe without first-hand experience. It needs to be scrapped and started again. I don't want to rant here on Hacker News too much (almost never comment) but this hit a nerve and I'm angry just thinking about the mental health care the NHS pretends to provide.

People love comparing countries for their non-mental healthcare (physiological care?), but I never seem to hear about countries that actually have good, functioning mental healthcare systems.

New Zealand has what could be described as a well-functioning (most of the time) healthcare system, if you break your arm, it's not a worry at all. But the mental healthcare system is a complete shitshow.

It's an absolute disgrace, especially considering that NZ has the highest youth suicide rate in the world.

Perhaps it has more to do with us (i.e. humans) not having a deep understanding of mental health treatment? I mean, we really don't understand the mind very well at all.

It's not just a clinical understanding either. We culturally approach mental health differently than other health. Get cancer and everybody rushes to your aid. Have anorexia and people ask questions about why we should pay for "self-inflicted" injuries (devil's advocacy couched, but still the question is posed).

Thankfully the cultural stance is changing. It wasn't long ago that the question about "self-inflicted" injuries wouldn't have even had to be couched in devil's advocacy.

I'm a clinical psychologist in the US, and it is a complete total shitshow, a combination of stigma and bigotry from outside the system, and self-inflicted nonsense from within.

People misunderstand and have trouble thinking of mental health to begin with, so you end up with general attitudes of "people just have to pull themselves up by their bootstraps" or "just get over it," not understanding that the problem is often that people lack that ability. Other times it's just sheer lack of empathy for people who have had to deal with more difficult circumstances (or even just different circumstances). And then there's the recurring idea that behavioral sciences should just be like all the other sciences, or that it's not worth paying attention to because we don't have it all figured out like basic Newtonian physics.

On the other side, within the field it's a mess too. There should be many more professional models, for example, and a lot more to offer, but territorial battles screw it over for everyone. Psychologists, for example, shoot themselves in the foot with bullshit licensing requirements for reasons I don't understand (maybe to appear more rigorous? to keep competition from entering the field?), requirements that are even more stringent than for MDs in certain ways. There's also no reason psychologists shouldn't be able to learn to prescribe--many people enter clinical doctoral programs with as much natural sciences as premeds, and leave having all sorts of neuro-genetic-chemical-physiology coursework and research experience, often more than MDs in the area of neurobehavioral sciences per se. But psychiatrists bristle at the competition, and certain segments of psychologists want to control the field with their romanticized idea of what psychology "should be," again, for reasons I don't understand.

On top of that, there's various trends in treatment that have led to screwing clients over, to put it bluntly. I can't tell you the number of times I hear colleagues (not all, but a sold number) argue that treatment should be limited for its own sake, to prevent dependency or to encourage change. Sometimes that's true, but you wouldn't say that a cancer patient in need of treatment should have their treatment stopped just to teach them a lesson. And drugs are great for some people, but not for others, and in general, the administration of those drugs has become divorced from any kind of real monitoring of peoples' situations. Add to that the fact that many people's problems derive from the collapse of societal safety nets, which also means lack of funding for mental health services, and, well, you get the point.

To play a bit of devil's advocate here:

At what point does a socialised health service with limited resources, stop providing care for "self-inflicted" injuries?

In a busy hospital, the doctors have to triage and make priority decisions over where to apply resources and who to treat first.

Much like an alcoholic would never be at the top of a liver transplant list, at what point would an anorexic - who in this case had already been through over 30 mental health sessions - start to be denied care? At what point is it more ethical to spend those resources treating someone else, who might actually respond to treatment?

Again, just playing devil's advocate here. My personal opinion is that the NHS is critically underfunded at the moment and that should be fixed first. But I thought it worth pointing out the ethical debate over treating self-inflicted injuries in a socialised healthcare system is quite tricky. Especially considering that almost all mental health issues can fall under "self-inflicted" if you want to be callous.

I think the analogy is a bit flawed.

The whole reason they are there is the mental health issue, so denying them because it's not fixed is more like denying a person with cancer any more treatments because they haven't responded well to the first 30 treatments.

A mental health problem is no more "self inflicted" than cancer is.

It doesn't really change your ultimate question though.

Is smoking an addiction? Is it a mental health issue?

How about overeating (thus obsesity)?

I ask because right now the UK's NHS severely limits access to healthcare for smokers and the obese.

I think the more realistic distinction between anorexia/bulimia on the one hand, and smoking/obesity on the other -if there is a distinction in NHS's "mind"- it's that the former are more sympathetic. But I dunno, I'm just guessing. I have no idea what the mandarins at NHS and similar are thinking, or, rather, will think when their resources become even more constrained than they are now. That is, I suspect they (NHS) make choices about whose healthcare to restrict... entirely on the basis of a) scarcity / need to ration, b) how sympathetic a particular target group is. How else would they (NHS) make such choices anyways? how else could they make them even remotely palatable to the polity?

We seem to be making distinctions based on some concept of free will. What happens if we view ill people as having no free will? Is it really any more wrong to deny the alcoholic high priority on the liver transplant list than to deny someone who isn't taking well to established treatments and keeps relapsing further access to treatments?

I feel like bringing up the notion of choice and free will is opening a can of black holes, but when dealing with mental illness you have to.

Yeah, I think that the mental health part confounds the issue. When it's a chronic physical illness, it's a lot easier to give someone pills to take for the rest of their life. Whereas mental health is vaguer and potentially much more expensive.

There are plenty of cancer drugs that the NHS will refuse to prescribe due to their expense. If you want them, you'll be told to go private. If mental health is so expensive, do we say the same thing?

It’s worth looking at patterns of homelessness and mass violence in the US before you take the leap. Mental illness can’t really be ignored, and untreated mental illness is dangerous for the sufferer, and the commmunity.

Anorexia is a serious mental illness, and there is nothing that's self inflicted about it.

---Edit--- So, I think you're not saying it's self inflicted, but you're wondering if that's the perception that some health staff have, and if that's why they provide poor quality treatment. If so, yes, I agree with you.

People with mental illness often find themselves at A&E. This is usualy because of their physical health - they are appropriately using A&E. (MH medication and illness can have horrible impact on physical health). But also people are often told to go to A&E if they're in crisis and not already under a MH team. That's not a great use of A&E and it's something we try to prevent, by providing better access to "crisis teams".

---end edit---

In the UK a considerable amount of money is spent on inpatient treatment for people with anorexia, and some of that is NHS funding of private for profit provision - for example Priory Group provide a lot of in-patient eating disorder treatment.

The reason it's paid for is because people who are ill deserve treatment, and a death is usually more expensive to the state than the treatment.

The reason so much private for profit provision is funded by NHS is because the NHS has underfunded mental health treatment for many years.

Yes, it's the perception that is concerning me a lot. To the physical doctor in A&E the prescription for anorexia is "1 cheeseburger daily" to which the patient says "no". To the doctor, this is then self-inflicted and less deserving of sympathy.

I agree completely that the NHS is critically underfunded and preventative mental health treatment is the ideal course of action. I didn't mean to imply that completely refusing to treat is an option, more wondering if there's a point at which a doctor can turn around and say "You say no, therefore I say no".

I recognize the devil's advocacy and will refrain from judgement on your position. In response, there are a few options (probably more that aren't occurring right now; it has been many years since I was researching this in university):

- A "need-blindness" system a la financial aid at US universities, as well as those in a few other countries. This gives deniability as its primary benefit, when people ask "why was the person with a 'self-inflicted' (replace those single quotes with very sarcastic finger wags, please) need above me?" That deniability is imperfect, and causes political problems.

- A formalized ranking of factors that influence priority for care, performed by formulae as public and precise as possible. This could potentially include 'self-inflicted' conditions as something exerting downward pressure. Much like sentencing guidelines, there will always be some subjective/human leeway in the application of those formulae that draws accusations, founded or not, of bias. Also, in libertarian political climates, this will draw accusations of governmental meddling in personal decisions.

- Pricing care at a level likely to ensure that only a number of patients proportional to available care-giving resources are admitted. This would require massive changes (mostly removals) to subsidies that exist for healthcare. This is unlikely to succeed politically, and from a humanitarian/ethical point of view is likely to be viewed extremely negatively (a view I share). It would have the advantage of making the "real" problem (lack of caregiving resources, including skills and general awareness) directly apparent, but only as a form of shock therapy.

Those are ways to address your question directly and narrowly. Secondary solutions/those with knock-on effects (preventative care etc.) are out of scope of this answer.

EDIT and as to the "when is it ethical" portion of your question (the above answers are logistical, not ethical), it's a crapshoot. It boils down to the ethical questions of the trolley problem plus the determinism problem, neither of which are generally considered to be tractable alone, much less together.

Thank you for the reply, I was a little worried that people would think the question too unpleasant and just downvote to oblivion!

I was trying to think of explanations for the apparent callous nature of the emergency doctor who tried to discharge him from A&E and the nurses who gave equally brusk treatment. The first thing that came to mind was that they treated him effectively as a self-inflicted "slow" suicide case and it must be some ethical resource allocation issue. ie. hypothetically "Why am I treating this self-inflicted injury when there's a kid in the next ward who's been hit by a car and needs 24/7 monitoring"

Those clinicians did that because they are unlawfully discriminating against someone with mental illness.

And because UK funding for mental illness is so piss-poor there's not much service for those doctors to refer into.

The lack of funding is a political choice, it's got nothing to do with the socialised nature of funding.

stop providing care for "self-inflicted" injuries?

It’s a question that won’t go away. In the UK the NHS spends £11Bn of its £125Bn annual budget on Type 2 diabetes. Diabetes UK reckon that 80% of cases of this condition are caused by or could be resolved by lifestyle choices. NHS underfunding could be fixed in, not overnight, but in a few months surely if those choices were made... and everyone knows it.

Indeed, that's a dangerous path to start down. Something like 60% of the UK population is overweight: do we stop treating Type 2 diabetes because it's self-inflicted? It would save billions of pounds, after all.

Personally I think people should take some personal responsibility for the NHS's under funding. We eat too much, drink too much, don't do enough exercise and drive dangerously - it's hardly surprising the health service is struggling.

Edit: not that I'm suggesting Anorexia isn't a serious mental illness.

The biggest risk factor for most illness is getting old, you can't avoid that with a change in lifestyle.

Billions of pounds, are they really THAT overweight? (ba dum tsss)

This is hardly an original thought.

In the UK right now you cannot get surgeries from the NHS if you're a smoker or overweight. They've already made the leap you wonder about.

And there's been talk of the same thing in the U.S. for Medicare.

When you have access to private healthcare, you can decide where you draw the line (based on many many factors, including what resources you have, what resources you want to pass on to your children, etc.). When you don't, you're at the mercy of the state.

>In the UK right now you cannot get surgeries from the NHS if you're a smoker or overweight

This seems like such a broad statement that it can't be accurate. I'm assuming you're referring to some non-emergent and elective procedures, right?


> But the new rules, drawn up by clinical commissioning groups (CCGs) in Hertfordshire, say that obese patients “will not get non-urgent surgery until they reduce their weight” at all, unless the circumstances are exceptional.

And what is "non-urgent surgery"? Who knows. If you need knee surgery, it's probably not urgent, but you may not be able to work without it, thus having very high social costs (unemployment, disability benefits, lost labor, ...) as well as very high personal costs. But NHS almost certainly doesn't have the resources even to consider the negative externalities of this policy -- they are acting out of desperation.

> My personal opinion is that the NHS is critically underfunded at the moment and that should be fixed first.

Sounds wrong to me, but I know nothing about mental health in the UK. It's really hard to fix corrupted institutions without just restarting them from scratch. Throwing money at such institutions (in my opinion) tends to do more harm than good.

Should we deny treatment to, say, skydivers or skateboarders? Race drivers?

No I don't think we should deny treatment to anyone; I wasn't advocating for that.

The question is more, is there a theoretical end to care when the patient has failed to respond to treatment? Is there a point at which we prioritise those resources for someone else who is also in need?

Why do you consider anorexia to be self-inflicted?

Personally I don't. I was trying to imagine the thoughts going through the doctors and nurses heads when he reported their apparent callous behaviour (turning him away from A&E, poor treatment on ward etc.)

I agree. There are some types of illness you can't treat yourself: those should be prioritized. This may sound a little callous: but all she had to do was listen to her body and eat more. And, unlike many illnesses, she knew what the problem was and she knew what the solution was.

Spoken like someone who doesn't have a mental illness.

Anorexics can fix themselves! All they need to do is eat!

Depressed people can fix themselves! They just need to be happy!

ADD sufferers can fix themselves! They just need to focus!

Do you honestly think these things would be called mental DISORDERS if the solutions were this easy!?

It's desperately under-funded:

"The hospital itself was old and seemed to be in the process of being shut down around us. Half the wards were empty, including the one opposite – a strange sight to those of us who had nearly died waiting for a bed. In winter, when it was too cold to be taken to ‘the bench’, we would instead be taken down another, deserted corridor, to sit for 15 minutes in a disused waiting room. When the five-bed rehabilitation house for patients leaving the inpatient unit was threatened with closure, doctors started to send patients there at a lower weight than advised, to secure its funding. Funding applications had to be made for each patient every two weeks, and I remember at least one patient being discharged suddenly and prematurely, because she had reached a weight beyond which her Primary Care Trust wouldn’t pay for treatment. Others, including me, had to prove that we weren’t ‘chronic’ cases and therefore worth funding. "

> (...) the overstretched staff didn’t have much time to support me, and I was often left crying on my own. Sometimes my tears were taken as evidence of ‘non-compliance’.

This, on its own, is already outrageous. What could lead to forming this kind of attitude?

Eating disorder is often comorbid with what's called "personality disorder" (usually what's called borderline PD).

People with that label experience significant levels of stigma and discrimination from health workers, including mental health workers.

That said, it should not be underestimated what an immense strain those people are on mental health workers. I wonder how much time those institutions dedicate to debriefing their own staff, I think that would make a big difference in how the patients are treated as well.

Quote: "The advice was not encouraging."

What would be encouraging to hear?

> The advice was not encouraging. Since I’d already been given the treatment available in my borough, and my weight was only just within the ‘anorexic range’ (below a body mass index of 17), I was told I’d be better off registering with a university GP with access to better mental health services.

Anorexia is not about a person's weight, but about their disordered thoughts of food and eating.

When someone is doing the right thing and seeking early intervention for those disordered thoughts we should be providing them with a package of care to treat them. We know early intervention is life saving, and is more effective and cheaper than later intervention.

By forcing someone to wait until their BMI drops we're saying "come back when you're thinner" -- and that's a lethal thing to say to someone with an eating disorder.

Anorexia is one of the most fatal mental illnesses.

"There's another 30 hours of counseling and therapy available"

(which at ~£50/hr is presumably a lot cheaper than a stay in ICU)

This is what drives me mad.

Professional therapy that actually works and can help patients solve the underlying self-esteem issues from childhood isn't easily available to people suffering from anorexia.

More generally, I would argue that if we increased tax and gave everyone as much therapy as they need, the money would be saved by reducing sick days for businesses, reducing other healthcare costs, and increasing productivity of mental well people.

I think we should do it even if it wouldn't save that money, but intuitively it feels like it would, so it makes not doing it even crazier...

Does any country already do this? It would seem a humane and powerful way to beat other countries / lead the world (pick whatever motivates you).

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