Clinical, legal and ethical implications of coercion and compulsory treatment in eating disorders: do rapid review findings identify clear answers or more muddy waters?

Abstract

Introduction: This Rapid Review (RR) aimed to assess the current literature over the past decade to determine the prevailing evidence regarding compulsory treatment* in eating disorders (ED). It is hoped that the review will help inform a consensus opinion as to whether this course of action confers significant clinical benefit, and importantly, to whom it should apply. The review also explores alternative options to involuntary care.

Methods: Four indexing databases (OVID; ProQuest; Web of Science; PubMed/MedLine) were searched using variations of the following keywords: "coercive/detained/involuntary/least restrictive care" "treatment refusal" "incarcerated/forced/compulsory admission" "moral/ethic/legal/mental health act" "eating disorder". Research was restricted to articles published between 2013 and 2023 and included grey literature.

Results: Of 9911 articles retrieved, 34 were included for final analyses, exploring ethical, legal, and physical and mental health outcomes of compulsory treatment. Studies comprised review papers, cohort studies, cross sectional research, case series reports, ethnography, commentary papers and grey literature. The majority of studies focused on individuals with anorexia nervosa (AN). Only two papers considered compulsory treatment in individuals with other eating disorders (EDs) Findings largely align with previous reviews suggesting compulsory treatment saves lives but comes at a therapeutic and personal cost. It remains unknown as to who may benefit from compulsory treatment. The decision to invoke compulsory treatment remains with the clinician and is a responsibility that is likely to be faced by most in their care of individuals with EDs.

Conclusions: Significant gaps remain in the published literature and a clear road map for a clinician-informed decision on the submission of a compulsory treatment for a person with ED does not yet exist. Further, there is little evidence as to who is most likely to benefit from compulsory treatment. There is consensus that efforts should be concentrated on reducing instances of compulsory treatment and minimising coercion through the development of open, transparent and trusting relationships between individuals and their treating clinician. Co-produced research and the development of clinical guidelines guided by the voices of individuals with lived experience are needed to ensure minimisation of potential harm.