prominence

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What exactly is the role of an outpatient psychiatrist working with eating disorder pts? I work part time in an Intensive Outpatient Program setting and I have been asked to consider seeing these pts. I have been seeing pts with mood disorders and substance use disorders exclusively in this setting so far. The ED pts would have an individual therapist, work with dietician/nutritionist, and attend group psychotherapy. Besides treating co-morder psychiatric disorders and/or sx, ordering lab work in cases of purging and recommend ED pts to a higher level of care, is there anything else a psychiatrist in this setting would be expected to do? Any insight would be welcome since ED pts are not my area of expertise. Thanks in advance.
 
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whopper

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It's an odd situation to be in. Psychotherapy is really what gets the patient better in the long run. I am part of the group that believes psychiatrists should not shrug our psychotherapeutic duties to the patient but in this particular group, a specialized therapist is often times (at least IMHO) better. A run of the mill psychotherapist is better than nothing but EDs are rare and it's not easy figuring these things. It's hard to be experienced in it unless you've already had several with this problem.

Point being that most psychiatrists aren't going to get the expertise to the degree where I'd trust their abilities more than an already experienced psychotherapist in EDs and the time spent on doing it for a psychiatrist will not be cost effective to anyone given there's a shortage of (edit) psychopharmacologists to prescribe.

As for psychopharmacology, we all know that meds don't do much if at all. The only real strong data is that SSRIs help with the purging behavior. Everything else has weak data.

IMHO a psychiatrist can best act as the center lynchpin making sense of all the work the others are doing, such as the medical work-up, the psychotherapy, and possibly adding an psychotropic.

I've worked with Russell Marx
https://www.nationaleatingdisorders.org/national-eating-disorders-association-names-russell-marx-md-chief-science-officer
I've also worked with a few other top people in the field in this area.

I too had the same questions because I felt like a poseur and wanted to be able to do more. What I'm telling you is pretty much what they told me.

Dr. Marx did add that while child psychiatry is not required to treat EDs, they are useful because the origins of EDs tend to be with problems started in childhood and that there's some relationship with it and personality disorders.
 
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I have been through a ED PHP program and my psych mostly works with patients in the Eating disorder and self injury units. Mostly the role of the psychiatrist was to do a psychiatric evaluation to see if other disorders are occurring and to see if medication would be beneficial for them. You then talk to the patient and ask why there ed started and what behavior they do etc. Then you will check up on them weekly ask the therapist in the program how they are doing , then you will ask the patient how they are doing and see if they are engaging in ed behavior. That's pretty much all you are going to be doing. If your stance is meds are more important than talk therapy you won't make a good psych in the ed unit.
 

TexasPhysician

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On the other hand, there are other countries that put ED patients on 2nd gen neuroleptics and claim it cures them.

I'm not saying I do this, but there are centers specializing in this tx.
 

splik

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I think this varies highly and you will have to ask them what you will be expected to do, but it sounds like you have the right idea. You will be expected to consider the diagnostic aspects of the patients, including comorbidities, prescribing pharmacological treatment not just for comorbid conditions but also for the eating disorders themselves, monitoring the patients medical condition, and documenting risk assessments where necessary and like you said higher level of care. Considering differential diagnosis is important of course as the patient may have another primary diagnosis (e.g. delusional disorder, major depressive disorder, a severe anxiety disorder, a medical illness, OCD which is presenting like an eating disorder). Even though re-feeding (in AN) and psychotherapy is really the focus of treatment, these patients are often so difficult to treat they will likely be on SSRIs or other drugs. If not, reviewing the limited evidence for efficacy w/ patients and seeing whether they would want to give something a try anyway is not unreasonable. For many pts its not as if therapy is actually that much more helpful, let's get real. There is some weak evidence for using olanzapine in AN again with limited success but people do use it and you will see it. In addition to that people do play with other drugs (e.g. topiramate in bulimia, naltrexone in bulimia and binge-eating disorder) and patients are likely to ask you about these so it may be worthwhile familiarizing yourself with some of this literature. It is also worth bearing in mind the pharmacodynamics in the ED population - they are more sensitive to drugs, more liable to lower seizure threshold, prolong QT and so on..
 
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prominence

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Thank you for all the helpful replies.