Objective

Primary care practitioners are well placed to support diagnosis and appropriate treatment of eating disorders as they are often the first point of contact with the health care system. However, little is known about management of eating disorders in primary care. We aimed to estimate the prevalence of management of eating disorders in primary care and identify how these disorders are managed.

Methods

This study used data from the Bettering the Evaluation of Care of Health programme, which annually surveys 1000 randomly sampled general practitioners in Australia who each record details of 100 successive patient encounters. In total, data were utilised from 1,568,100 primary care encounters between 2000/2001 and 2015/2016.

Results

Eating disorders were managed in less than 1% of primary care encounters between 2000/2001 and 2015/2016. When extrapolated to the Australian population, up to 0.32% of the population were managed in primary care for a primary or probable eating disorder. In the majority of encounters where an eating disorder was managed (58.5%), the encounter was initiated for reasons other than the eating disorder itself. Of a group of patients identified with a clinically significant low body mass index (N = 5917), a small number (n = 118) had either no other diagnosis or a related condition that may be indicative of an eating disorder. In encounters where an eating disorder was managed, referrals to a mental health specialist/service, medical specialist and nutritionist/dietician were provided in 20%, 8% and 6% of encounters, respectively. Mental health treatment plans, which provide subsidised access to mental health services, were ascribed in approximately 7.7% of encounters where an eating disorder was managed.

Conclusion

Primary care provides an opportunity to improve detection and management of eating disorders, particularly when patients present for ‘other’ issues or with unexplained low body mass index and one or more symptoms related to an eating disorder.

Eating disorders are estimated to affect up to 15% of the Australian population (Hay et al., 2015, 2017). Onset of these disorders typically occurs between 12 and 21 years of age (Hudson et al., 2007; Swanson et al., 2011; Volpe et al., 2016), and females are estimated to be 4.2 times more likely to develop an eating disorder than males (Qian et al., 2013). Eating disorders are related to a wide range of medical complications in the gastrointestinal, cardiovascular, neurological and skeletal system (Mitchell and Crow, 2006; Westmoreland et al., 2016). In addition, they have high mortality and suicide rates (Chesney et al., 2014; Smink et al., 2012) with anorexia nervosa having one of the highest mortality rates of any psychiatric illness (Arcelus et al., 2011; Chesney et al., 2014). The psychological impact of eating disorders is also considerable with approximately 70% of those affected having at least one additional mental health diagnosis (Keski-Rahkonen and Mustelin, 2016; Ulfvebrand et al., 2015) often co-occurring anxiety and mood disorders (Hach et al., 2005; Keski-Rahkonen and Mustelin, 2016; Ulfvebrand et al., 2015).

Despite the associated morbidity and mortality experienced by people with an eating disorder, a systematic review of 14 studies found only one in four people (23.2%) accessed treatment for the disorder, where treatment included access to any medical or mental health professional who was qualified to provide treatment for an eating disorder (Hart et al., 2011). Importantly, while many individuals do not seek treatment for the eating disorder per se, studies show that they may have relatively higher rates of health service utilisation than their healthy counterparts (Ogg et al., 1997; Striegel-Moore et al., 2008; Swanson et al., 2011). In particular, higher access rates have been found in primary care, both before and after diagnosis (Mond et al., 2008; Ogg et al., 1997; Striegel-Moore et al., 2008). These findings suggest that primary care may provide an opportunity to identify and manage people with eating disorders; however, there is little contemporary data on rates and reasons for presentation, and course of care.

Primary care practitioners are well placed to support the diagnosis of eating disorders and facilitate access to appropriate treatment as they often are the first point of contact with the health care system and first to diagnose and treat eating disorders (Walsh et al., 2000). There is limited data on the number and incidence of people presenting to primary care and how they are managed. Previous, older studies that assessed rates between the 1990s and early 2000s found relatively stable rates of anorexia nervosa and declines in rates of bulimia nervosa (Currin et al., 2005; Smink et al., 2012; van Son et al., 2006). In a more recent UK study, eating disorders identified by general practitioners (GPs) were estimated to almost double in incidence from 17 to 30 per 100,000 persons between 1993/1994 and 2003/2004 and then levelled off at 22 per 100,000 persons in 2016/2017 (Demmler et al., 2020). More contemporary data exploring current rates and reasons of people with eating disorders presenting to primary care and subsequent referral and management of these patients are required to assess whether this entry point into the healthcare system is being effectively utilised.

The role of the primary care practitioner in managing eating disorders is even more crucial in Australia as they are one of the main gatekeepers for patients to access subsidised mental health care. Since 2006, primary care practitioners in Australia, along with paediatricians and psychiatrists, have been able to complete a Mental Health Treatment Plan (MHTP) that allows patients with a mental health diagnosis to access 6–10 subsidised sessions with a mental health clinician each year (Australian Government Department of Health, 2012). In late 2019, this programme was extended to enable individuals with an eating disorder to access up to 60 rebated sessions (40 psychological, 20 dietetic) (Australian Government Department of Health, 2019). Despite the key role primary care practitioners play in identifying eating disorders and managing and facilitating access to multidisciplinary care for patients with an eating disorder, there is limited data on the uptake and use of MHTPs for this group.

Given the limited contemporary data on rates and management of people with eating disorders presenting to primary care, the aims of this study were to estimate the prevalence and management of people with eating disorders in primary care; to identify their demographic characteristics, examine reasons for attendance, nature of management, referral and/or intervention; and to assess the extent to which MHTPs are utilised in the management of eating disorders.