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What are the issues for young people affected by an eating disorder ?

The purpose of this briefing is to provide you with some summary information on a key mental health issue for young people.  The contents of this briefing are:

Mental Health and Young People

Eating Disorders and Young People

Untreated Eating Disorders Amongst Young People in Ireland

Recommendations

About Bodywhys – The Eating Disorders Association of Ireland

Mental Health and Young People

Children under 18 years comprise 25% of the population i.e. 1 million[1]. Overall 1 in 5 children in Ireland have a mental or behavioural disorder[2].  International evidence indicates that mental illness is young people’s number one health issue, representing over half their total burden of disease (combining both fatal and non-fatal measures)[3]. Three quarters of lifetime cases of mental illnesses emerge by the age of 24[4] and, across Europe, the overall prevalence of mental disorders in adolescence is in the region of 15 to 20%[5]. Most of these young people will get no treatment[6].

The consequences of no or delayed treatment are serious. Just as in physical health, the longer a mental illness is allowed to develop untreated, the more severe and potentially disabling it becomes[7]. Untreated mental disorder in young people is the principal threat to their vocational attainment[8] and the late identification of mental illness is a feature of a large proportion of young people who complete suicide[9].

However, treatments have never been better and if treated appropriately and early, a young person has excellent prospects for a happy and healthy life. Early identification and treatment of emerging mental disorders have been shown to be effective, reducing the need for inpatient treatment and associated with better outcomes and subsequent cost reductions for the health care system[10].

To be most effective, interventions aimed at prevention or early treatment of mental illnesses should focus on young people4. Furthermore, there are proven benefits to a separate system of youth psychiatry that provides interventions tailored to the unique needs and development phase of young people[11],[12],[13]. Investing in the mental health of children and adolescents represents the most cost-effective action to prevent the continuous increase of mental health problems in all age groups[14]. Despite this, none of the four child and adolescent services in Ireland has the appropriate range and number of staff[15].

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Eating Disorders and Young People

According to a recent Government report, A Vision For Change, up to 200,000 people have an eating disorder in Ireland.[16] Eating disorders are serious mental illnesses that can represent a major threat to normal development in young people. A 2000 European Commission working paper5 states that:

• The prevalence of anorexia nervosa among adolescents stands at about 1%, and that of bulimia nervosa at 1.5-2%
• About 20% of early cases of eating disorders become chronic and about 6% will die of their illness
• Eating disorders have become more common in adolescents during the past 20 years. Anorexia nervosa among young females increased until the late 1980s, while bulimia is still increasing.
• About 10 times more females have an eating disorders than males.

Elsewhere, Binge Eating Disorder (which often results in considerable weight gain) has been estimated at 4% of the general population[17] whilst in Ireland, obesity levels increased by 67% between 1990 and 2000[18].

The World Health Organisation stresses that eating disorders must be seen as disorders with lifelong consequences[19], citing a study of college students that found that 21.6% of females with eating disorders still met the clinical criteria 10 years later[20]

Currently, the outcome for Anorexia Nervosa is less encouraging than that for Bulimia Nervosa, which can be effectively treated[21]. Anorexia is a severe disorder which can become chronic and which is associated with a mortality rate of 15-20% after 20 years[22].

There is a clear relationship between high levels of disordered body image and development of eating disorders. By definition, body image disturbance is one criterion for the diagnosis of both bulimia and anorexia nervosa. Body image encompasses feelings of body satisfaction, self-esteem and beliefs about appearance.

Body image disturbance is more complex than just a fear of being overweight or a drive for thinness. There is overwhelmingly evidence[23],[24],[25],[26] that body image is intrinsically linked with self-esteem. The factors that affect and shape it include the beliefs and behaviors within individuals, families, peer groups and the media. Our society’s emphasis on how we look also seems to affect the way people feel about themselves[27],[28],[29].

Dieting is one of the greatest risk factors for the development of eating disorders. A study of adolescent girls found that 68% of 15 year old females are on a diet and of these, 8% are on a severe diet[30]. The study also suggested that girls who diet moderately are five times more likely to develop an eating disorder than those who do not diet, while the risk of this for the severe dieters is 18 times greater than for non-dieters.

It is becoming more apparent that body image disturbance and concerns about body shape and size are formed very early in life and are often well formed by mid childhood[31]. Body image disturbance is a fairly stable belief pattern - children who exhibit higher levels of body dissatisfaction will tend to continue to express this into adolescence and young adulthood[32],[33]. Addressing issues of body image and eating disorders will therefore include as core components awareness raising and health promotion activities aimed specifically at school age children.

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Untreated Eating Disorders Amongst Young People in Ireland

Only a tiny proportion (between 5% and 10% percent) of young people with mental health disorders are in contact with helping agencies. Most mental health disorders in adolescents are unrecognised and untreated[34]. As indicated previously, this means that treatment is only offered once the illness has progressed to its most severe stages. In Ireland, this is true of eating disorders and other mental illnesses.

To give an indication of the unmet demand for services, Bodywhys receives 500 calls to its helpline and 4,500 visitors to its website every month. About half of these contacts are made directly by people with eating disorders (most of the remainder are contacts by family / friends of people with eating disorders). Half of the people with eating disorders who contact Bodywhys are between the ages of 10-24.

Applying the prevalence data cited previously to Irish census figures indicates that in Ireland about 3,500 12-17 year olds will be affected by Anorexia Nervosa, up to 7,000 of the same age group will have Bulimia Nervosa and perhaps 14,000 will have Binge Eating Disorder.

In 2003 there were 188 admissions to adult psychiatric units and hospitals with eating disorder diagnoses. Most of these admissions are to public units or hospitals. As there are currently only three specialist beds for eating disorders (all based in Dublin) only about 1/5th of those admitted to adult psychiatric units and hospitals with eating disorder diagnoses receive specialist care.[35] Previous Irish research indicates that 15-24 year old women make up the majority of eating disorder admissions.[36]

From its extensive experience with people with eating disorders, Bodywhys can identify the following critical service gaps:

• The primary care sector often lacks necessary knowledge about eating disorders, resulting in delayed identification of illnesses and inappropriate treatment
• Publicly funded, out-patient and day care programmes are scarce and often lack a comprehensive, long term strategy for each individual patient.
• The three specialist beds for eating disorders (all in Dublin) are manifestly inadequate to meet demand.

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Recommendations

There are a number of key challenges to be addressed in the area of body image and mental health in young people:

Recommendation 1: Provide education for medical practitioners and the community.

Better knowledge of both the illnesses and how they present will be an important means of increasing referrals and early detection. The primary care sector needs to be resourced to better detect and manage mental health problems in young people. This includes education programs for GPs to help increase early detection of eating disorders and enhance the confidence of GPs in the treatment of sub-clinical eating issues as a whole. Positive body image could be promoted through health promotion campaigns and community education programs. Research27, 31 indicates that the level of body image disturbance in young children is increasing. Therefore the population for intervention strategies promoting healthy body image should primarily be school age children. Bodywhys has developed i-figure: A mind and body model CD Rom resource aimed at 14-16 year olds.

Recommendation 2: Identify and promptly treat young people with emerging eating disorders.

Early treatment gives young people the best chance of recovery. A network of services providing referral, assessment and care is required to provide such early treatment. A more streamlined referral pathway would enable GPs to have access to an easy route to specialist care for those in need of more intensive input for treatment. Additional specialist mental health services are required to ensure there is the capacity to adequately treat young people before their illnesses become more severe and disability becomes irreversible. Out-patient services in particular are needed.

Recommendation 3: Provide accessible, youth oriented services.

Innovative, youth appropriate methods of delivery of treatment or health promotion should be investigated. For example, computer based education or treatment programs using e-mail have been used successfully for mental health problems such as bulimia or depression. Use of these types of innovative treatments would make them accessible outside traditional mental health services and available in schools, youth centres, etc. This may increase the likelihood of help seeking and accessing of treatment by a group of patients which is difficult to engage with because of the nature of the illness and the age group.

Recommendation 4: Research new treatments

The relationship between body image disturbance and eating disorder pathology should be researched in order to better identify risk factors and understand how these influence the development of eating disorders at a later date. Research into innovative interventions for eating disorders would enable care to be provided at the earliest possible opportunity, and reduce the likelihood of ongoing chronic illness and poorer outcomes in a group of patients where mortality and morbidity are already high.

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About Bodywhys – The Eating Disorders Association of Ireland

This briefing has been prepared for you by Bodywhys. Bodywhys is the Irish national charity which offers support, information and understanding for people affected by eating disorders. For more information visit www.bodywhys.ie.

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References & Acknowledgements

This E-Brief has been prepared with the assistance of our colleagues in ORYGEN Research Centre in Melbourne – one of the world’s leading sources of expertise on youth mental health. More information is available at www.orygen.org.au