menu-iconMore mobile-close-icon
Skip Navigation
Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
Clinical practice guideline for eating disorders.
Bibliographic Source(s)
Working Group of the Clinical Practice Guideline for Eating Disorders. Clinical practice guideline for eating disorders. Madrid (Spain): Quality Plan for the National Health System of the Ministry of Health and Consumer Affairs, Catalan Agency for Health Technology Assessment and Research; 2009 Feb 1. 287 p. (Clinical practice guideline in the NHS: CAHTA; no. 2006/05-01).  [447 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Eating disorders including:

  • Anorexia nervosa (AN)
  • Bulimia nervosa (BN)
  • Eating disorder not otherwise specified including include: binge-eating disorder (BED) and non-specific, incomplete or partial forms that do not satisfy all criteria for AN, BN and BED.

Note: This clinical practice guideline (CPG) does not include the following diagnoses related with eating disorders: orthorexia (extreme focus on eating healthy), bigorexia (muscle dysmorphia), or night eating syndrome (nocturnal eaters).

Guideline Category
Diagnosis
Evaluation
Prevention
Risk Assessment
Screening
Treatment
Clinical Specialty
Endocrinology
Family Practice
Internal Medicine
Nutrition
Obstetrics and Gynecology
Pediatrics
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Nurses
Occupational Therapists
Pharmacists
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Guideline Objective(s)

Main Objective

To provide health care professionals responsible for the management of patients with eating disorders with a tool that enables them to make the best decisions to address the problems their care entails

Secondary Objectives

  • To help patients with eating disorders by providing them with useful information that will aid them in making decisions concerning their disease
  • To inform families and carer on eating disorders and provide them with counselling and advice so they become actively involved in treatment
  • To implement and develop health care quality indicators that enable the assessment of the clinical practice of recommendations presented in this clinical practice guideline
  • To establish recommendations for research on eating disorders that enable knowledge to grow
  • To address confidentiality and informed consent issues of patients, especially in the case of minors under the age of 18, and to include legal procedures in the cases of complete hospitalization (inpatient care) and involuntary treatment
Target Population

Patients aged 8 years and older with the diagnoses: anorexia nervosa (AN), bulimia nervosa (BN) and eating disorders not otherwise specified (EDNOS)

Note: This clinical practice guideline (CPG) does not include patients under the age of 8 and, thus, diagnoses relating to eating disorders most common during those ages, such as swallowing phobia, selective eating and refusal to eat are not included.

Interventions and Practices Considered

Prevention/Screening

  1. Protective messages (eating a healthy diet, one meal each day with the family, communication and improving self-esteem, avoiding jokes and disapproval regarding the body)
  2. Screening of:
    • Individuals with risk behaviours (repeated vomiting)
    • Target groups (young persons with low body mass index, weight concerns, menstrual disorders or amenorrhoea, gastrointestinal symptoms)
  3. Use of screening tools (e.g., Sick, Control, One, Fat, Food questionnaire [SCOFF], Branched Eating Disorders Test [BET], Eating Attitudes Test [EAT])
  4. Use of diagnostic criteria (e.g., Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision [DSM-IV-TR], International Classification of Diseases [ICD]-10)

Treatment

  1. Medical measures:
    • Oral nutritional support
    • Enteral oral (nasogastric tube) and nutritional support
    • Nutritional counseling
  2. Psychological therapies:
    • Cognitive-behavioural therapy (CBT)
    • Self-help (SH) and guided self-help (GSH)
    • Interpersonal therapy (IPT)
    • Family therapy (FT)
    • Psychodynamic therapy (PDT)
    • Behavioural therapy (BT)
  3. Pharmacological treatments:
    • Antidepressants
    • Antipsychotics
    • Appetite stimulants
    • Opioid antagonists
    • Other psychoactive drugs
  4. Combined interventions (psychological and pharmacological or more than one psychological intervention)
Major Outcomes Considered
  • Body mass index (BMI)
  • Menstruation
  • Pubertal development
  • Reduction/elimination of binge-eating and purging
  • Restoration of a healthy diet
  • Absence of depression
  • Psychosocial and interpersonal functioning

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Search for Scientific Evidence

The search for scientific evidence was structured in different stages:

  1. Generic databases, meta-search engines and organizations that compile guidelines (National Guideline Clearinghouse, National Electronic Library for Health, Trip database, The Cochrane Library, PubMed/Medline and British Medical Journal [BMJ] Clinical Evidence) were consulted between 2003 and March 2007.
  2. To complete the search, a manual search was performed for protocols, recommendations, narrative reviews, therapeutic orientations and guides on eating disorders elaborated by organizations pertaining to the health care administration, scientific societies, hospitals and other organizations of our setting. Some of these documents have inspired and served as a model for certain sections of this guide (see Annex 6.1 in the original guideline document.). This annex also lists documents created outside of Spain that have been excluded from the selection process due to low quality. However, some have been considered for the development of certain aspects of this clinical practice guideline (CPG).
  3. To respond to those questions unanswered by the CPGs, systematic review of scientific evidence (SRSE) and assessment reports (AR) included or to update them, a search for randomized controlled trials (RCTs) was performed in PubMed/Medline between March 2007 and October 2007.
  4. The search for CPG/SRSE/AR in Trip database and PubMed/Medline was also updated up to October 2007.
  5. Additional searches were carried out in PubMed/Medline and Scopus for primary prevention of eating disorders due to the limited information available in the documents included (until June 2008). The effect of primary prevention interventions for eating disorders has been assessed in RCT or in SRSE of RCT.
  6. A search was also performed for cohort studies and prognosis of eating disorders in the Scopus and PsycINFO databases during the period spanning from 2000 to 2008.
  7. The Ginebrina Foundation was also consulted for Medical Training and Research and the documents provided by the working group and the references of the documents included were reviewed.

Selection of Evidence

The most relevant documents were selected by applying predefined inclusion and exclusion criteria:

  • Inclusion criteria: guides, SRSE and ARs in certain languages (Spanish, Catalan, French, English and Italian) that dealt with the previously mentioned objectives. Minimum quality criteria were established for the guides, SRSE and ARs: the bibliographic bases consulted and/or the formulation process of recommendations (ad hoc defined criteria) had to be described.
  • Exclusion criteria: documents/guides that were not original, unavailable (wrong reference or electronic address), not directly related with the proposed objectives, already included in the bibliography of other documents/guides or that didn't comply with minimum quality criteria.

Two independent reviewers examined the titles and/or summaries of the documents identified by the search strategy. If any of the inclusion criteria were not fulfilled, the document was excluded. If criteria were fulfilled, the complete document was requested and evaluated in order to decide whether it would be included or not. Discrepancies or doubts that arose during the process were resolved by consensus of the entire technical team.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Scientific Evidence

1++ High quality meta-analysis, systematic reviews of clinical trials or high-quality clinical trials with low risk of bias

1+ Well conducted meta-analysis, systematic reviews of clinical trials, or well conducted clinical trials with low risk of bias

1- Meta-analysis, systematic reviews of clinical trials, or clinical trials with high risk of bias

2++ High quality systematic reviews of cohort or case-control studies. Cohort or case-control studies with very low risk of bias and high probability of establishing a causal relationship.

2+ Well conducted cohort or case-control studies with low risk of bias and moderate probability of establishing a causal relationship

2- Cohort or case-control studies with high risk of bias and significant risk of non-causal relationship

3 Non-analytic studies such as case reports, case series or descriptive studies

4 Expert opinion

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Quality Assessment of the Scientific Evidence

Assessment of clinical practice guidelines (CPG) quality was performed by a trained evaluator using the Assessment of Guidelines Research and Evaluation (AGREE) instrument. Guides were considered of quality when they were classified as Recommended in the overall assessment. For systematic review of scientific evidence (SRSE)/assessment reports (AR) and randomized controlled trials (RCT), the Scottish Intercollegiate Guidelines Network's (SIGN's) methodology checklists were applied by an evaluator, following the recommendations established in the Ministry of Health and Consumer Affairs's (MSC's) CPG development manual. Classification of evidence has been carried out using the SIGN system (see Annex 1 in the original guideline document).

Synthesis and Analysis of the Scientific Evidence

Different templates were used for information retrieval. Information regarding the main characteristics of the studies was obtained and then synthesized in evidence tables for a subsequent qualitative analysis. When the SRSE or CPGs reported the results of individual studies, these results were described in the section "scientific evidence."

In Annex 6.2 of the original guideline document, results of the CPG's search, selection and assessment of quality are described. In Annex 6.3 and Annex 6.4 of the original guideline document, National Institute for Clinical Excellence's (NICE's) CPG and The Agency for Healthcare Research and Quality's (AHRQ's) SRSE are respectively described, representing the main scientific base on which this guideline is founded.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The grading of recommendations has been performed using Scottish Intercollegiate Guidelines Network's (SIGN's) system (see Annex 1 in the original guideline document). Recommendations pertaining to the National Institute for Clinical Excellence (NICE) CPG have been considered by the working group and have been classified as: adopted (and, hence, accepted; they have simply been translated into Spanish) or adapted (and, hence, modified: changes have been made with the purpose of contextualizing them to the Spanish setting). Controversial recommendations or those lacking in evidence have been resolved by the working group's consensus. The category of each recommendation appears in the chapters in the original guideline document.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendation

A: At least one meta-analysis, systematic review or clinical trial classified as 1++ and directly applicable to the guide's target population, or a body of evidence composed of studies classified as 1+ with high consistency amongst them

B: Body of evidence composed of studies classified 2++, directly applicable to the guide's target population and that have been shown to have high consistency amongst them, or evidence extrapolated from studies classified as 1++ or 1+

C: Body of evidence composed of studies classified as 2+ directly applicable to the guide's target population and that have shown to have high consistency amongst them; or evidence extrapolated from studies classified as 2++

D: Level 3 or 4 evidence or evidence extrapolated from studies classified as 2+

Good clinical practice: Recommended practice based on clinical experience and the consensus of the drafting team

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Description of Method of Guideline Validation

The external reviewers of the clinical practice guideline (CPG) are a group of experts in eating disorders (psychiatry, psychology and genetics specialists) selected for being heads of eating disorder units in Spanish hospitals and/or authors of relevant publications on the matter. Representatives from certain organizations who were unable to be a part of the CPG working group for a variety of reasons also served as external reviewers. The final version of the guide's text has been revised and approved by the group of authors.

Recommendations

Major Recommendations

Levels of evidence (1++ - 4) and grades of recommendation (A-D and good clinical practice points) are defined at the end of the "Major Recommendations" field.

Prevention of Eating Disorders

Good clinical practice: Sample, format and design characteristics of eating disorder programmes that have demonstrated the highest efficacy should be considered the model for future programmes.

Good clinical practice: In the design of universal eating disorder prevention strategies it must be taken into account that expected behaviour and attitude changes in children and adolescents without these types of problems may differ from those of higher risk populations.

Good clinical practice: Messages on measures that indirectly protect individuals from eating disorders should be passed on to the family and adolescent: following a healthy diet and eating at least one meal at home with the family, facilitating communication and improving self-esteem, avoiding family conversations from compulsively turning to eating and image and avoiding jokes and disapproval regarding the body, weight or eating manner of children and adolescents.

Detection of Eating Disorders

D - Target groups for screening should include young people with low body mass index (BMI) compared to age-based reference values, patients consulting with weight concerns without being overweight or people who are overweight, women with menstrual disorders or amenorrhoea, patients with gastrointestinal symptoms, patients with signs of starvation or repeated vomiting, and children with delayed or stunted growth, children, adolescents and young adults who perform sports that entail a risk of developing an eating disorder (athletics, dance, synchronized swimming, etc.). (Adapted from recommendation 5.2.5.3 of the National Institute for Clinical Excellence [NICE] clinical practice guideline [CPG])

D - In anorexia nervosa (AN), weight and BMI are not considered the only indicators of physical risk. (Adapted from recommendation 5.2.5.6 of the NICE CPG)

D - Early identification and intervention of individuals presenting weight loss are important to prevent the development of severe emaciation. (Adapted from recommendation 6.6.1.2 of the NICE CPG)

D - In the case of suspected AN, attention should be paid to overall clinical assessment (repeated over time), including rate of weight loss, growth curve in children, objective physical signs and appropriate laboratory tests. (Adopted from recommendation 5.2.5.7 of the NICE CPG)

Good clinical practice: It is recommended to use questionnaires adapted and validated in the Spanish population for the detection of eating disorder cases (screening). The use of the following tools is recommended: Eating disorders in general: Sick, Control, One, Fat, Food questionnaire (SCOFF) (for individuals aged 11 years and over); AN: Eating Attitudes Test (EAT)-40, EAT-26 and Child Eating Attitudes Test (ChEAT) (the latter for individuals aged between 8 and 12 years); Bulimia nervosa (BN): Bulimia Test (BULIT), Bulimia Test Revised (BULIT-R) and Bulimia Investigatory Test Edinburgh (BITE) (all for individuals aged 12-13 years and over).

Good clinical practice: Adequate training of primary care (PC) physicians is considered essential for early detection and diagnosis of eating disorders to ensure prompt treatment, or referral, when deemed necessary.

Good clinical practice: Due to the low frequency of consultations during childhood and adolescence, it is recommended to take advantage of any opportunity to provide comprehensive care and to detect eating disorder risk habits and cases. Eating disorder risk behaviour, such as repeated vomiting, can be detected at dental check-ups.

Good clinical practice: When interviewing a patient with a suspected eating disorder, especially if the suspected disorder is AN, it is important to take into account the patient’s lack of awareness of the disease, the tendency to deny the disorder and the scarce motivation to change, this being more pronounced in earlier stages of the disease.

Good clinical practice: It is recommended that different groups of professionals (teachers, school psychologists, chemists, nutritionists and dieticians, social workers, etc.) who may be in contact with at-risk population have adequate training and be able to act as eating disorder detection agents.

Diagnosis of Eating Disorders

Good clinical practice: It is recommended to follow the diagnostic criteria of the World Health Organization (WHO) (International Classification of Diseases [ICD]-10) and the American Psychiatric Association (APA) (the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV or DSM-IV-TR).

D - Health care professionals should acknowledge that many eating disorder patients are ambivalent regarding treatment due to the demands and challenges that it entails. (Adapted from recommendation 1.10.1.1 of the NICE CPG)

D - Patients and, when deemed necessary, carers should be provided with information and education regarding the nature, course and treatment of eating disorders. (Adapted from recommendation 2.10.1.2 of the NICE CPG)

D - Families and carers may be informed of existing eating disorder associations and support groups. (Adapted from recommendation 2.11.5.5 of the NICE CPG)

Good clinical practice: It is recommended that the diagnosis of eating disorders include anamnesis, physical and psychopathological examinations and complementary explorations.

Good clinical practice: Diagnostic confirmation and therapeutic implications should be in the hands of psychiatrists and clinical psychologists.

Interventions at the Different Levels of Care in the Management of Eating Disorders

D - Individuals with eating disorders should be treated in the appropriate care level based on clinical criteria: outpatient, day hospital (day care) and general or psychiatric hospital (inpatient care). (Adapted from recommendation 6.5.8.1 of the NICE CPG)

D - Health care professionals without specialist experience in eating disorders or who are faced with uncertain situations should seek the advice of a trained specialist when emergency inpatient care is deemed the most appropriate option for a patient with an eating disorder. (Adapted from recommendation 6.5.8.6 of the NICE CPG)

D - The majority of patients with BN can be treated on an outpatient basis. Inpatient care is indicated when there is risk of suicide, self-injuries and serious physical complications. (Adapted from recommendations 6.5.8.1 and 6.5.8.4 of the NICE CPG)

D - Health care professionals should assess patients with eating disorders and osteoporosis and advise them to refrain from performing physical activities that may significantly increase the risk of fracture. (Adopted from recommendation 6.4.5.3 of the NICE CPG)

D - The paediatrician and the family physician must be in charge of the management of eating disorders in children and adolescents. Growth and development must be closely monitored. (Adapted from recommendation 6.4.5.4 of the NICE CPG)

D - Primary care centres should offer monitoring and management of physical complications to patients with chronic AN and repeated therapeutic failures who do not wish to be treated by mental health services. (Adapted from recommendation 5.2.5.8 of the NICE CPG)

D - Family members, especially siblings, should be included in the individualized treatment plan (ITP) of children and adolescents with eating disorders. The most common interventions involve sharing of information, advice on behavioural management of eating disorders and improving communication skills. The patient's motivation to change should be promoted by means of family intervention. (Adapted from recommendation 6.2.9.13 of the NICE CPG)

D - Where inpatient care is required, it should be carried out within a reasonable distance to the patient's home to enable the involvement of relatives and carers in treatment, to enable the patient to maintain social and occupational links and to prevent difficulties between care levels. This is particularly important in the treatment of children and adolescents (Adopted from recommendation 6.5.8.4 of the NICE CPG)

D - Patients with AN whose disorder has not improved with outpatient treatment must be referred to day patient treatment or inpatient treatment. For those who present a high risk of suicide or serious self-injuries, inpatient management is indicated. (Adapted from recommendation 6.5.8.2 of the NICE CPG)

D - Inpatient management should be considered for patients with AN whose disorder is associated with high or moderate risk due to common disease or physical complications of AN. (Adapted from recommendation 6.5.8.3 of the NICE CPG)

D - Patients with AN who require inpatient treatment should be admitted to a centre that ensures adequate renutrition, avoiding the re-feeding syndrome, with close physical monitoring (especially in the first few days), along with the appropriate psychological intervention. (Adapted from recommendation 6.5.8.5 of the NICE CPG)

D - The family physician and paediatrician should take charge of the assessment and initial intervention of patients with eating disorders who attend primary care. (Adapted from recommendation 5.2.5.1 of the NICE CPG)

D - When management is shared between primary and specialized care, there should be close collaboration between health care professionals, patients and relatives and carers. (Adapted from recommendation 5.2.5.2 of the NICE CPG)

Good clinical practice: Patients with confirmed diagnosis or clear suspicion of an eating disorder will be referred to different health care resources based on clinical and age criteria.

Good clinical practice: Referral to adult and children mental health centres (MHCs) by the family physician or paediatrician should consist of integrated management with shared responsibilities.

Good clinical practice: Cases referred to adult or children MHCs still require different levels to work together and short- and mid-term monitoring of patients, to avoid complications, recurrences and the onset of emotional disorders, and to detect changes in the patient's environment that could influence the disease.

Good clinical practice: The need to prescribe oestrogen treatment to prevent osteoporosis in girls and adolescents with AN should be carefully assessed, given that this medication can hide the presence of amenorrhoea.

Good clinical practice: In childhood, specific eating disorder treatment programmes designed for these ages will be required.

Treatment of Eating Disorders

D - Physical exploration and in some cases treatment with multi-vitamin/mineral supplements in oral form, both on an outpatient and inpatient basis, is recommended for patients with AN who are at the stage of body weight restoration. (Adopted from recommendation 6.4.5.2 of the NICE CPG)

D - Total parenteral nutrition should not be used for patients with AN unless the patient refuses nasogastric feeding and/or presents gastrointestinal dysfunction. (Adopted from recommendation 6.4.11.1 of the NICE CPG)

Good clinical practice: Enteral or parenteral renutrition must be applied using strict medical criteria and its duration will depend on when the patient is able to resume oral feeding.

General Recommendations on Medical Measures for Eating Disorders

Good clinical practice: Nutritional support for patients with eating disorders will be selected based on the patient's degree of malnutrition and collaboration, and always with the psychiatrist's approval.

Good clinical practice: Before initiating artificial nutrition the patient's degree of collaboration must be assessed and an attempt must always be made to convince him/her of the benefits of natural oral feeding.

Good clinical practice: In day hospitals, nutritional support for low-weight patients, where an oral diet is insufficient, can be supplemented with artificial nutrition (oral enteral nutrition). To ensure its intake, it must be administered during the day hospital's hours, providing supplementary energy ranging from 300 to 1,000 kcal/day.

Good clinical practice: Oral nutritional support in eating disorder inpatients is deemed adequate (favourable progress) when a ponderal gain greater than 0.5 kg per week is produced, with up to 1 kg increments being the usual during that period. Sometimes, when the patient with moderate malnutrition resists resuming normal feeding, the diet can be reduced by 500-700 kcal and be supplemented by complementary oral enteral nutrition in the same amount, which must be administered after meals and not instead of meals.

Good clinical practice: In the case of severe malnutrition, extreme starvation, poor progress or lack of cooperation of the patient in terms of intake, artificial nutrition treatment is indicated. If possible, an oral diet with or without oral enteral nutrition is always the first step, followed by a 3 to 6 day period to assess the degree of collaboration and medical-nutritional evolution.

Good clinical practice: Regarding estimated energetic requirements, it is recommended that caloric needs at the beginning always be below the usual, that real weight, as opposed to ideal weight, be used to make the estimation; and that in cases of severe malnutrition energetic requirements be 25 to 30 kcal/kg real weight or total kcal not higher than 1,000/day.

Anorexia Nervosa

D - In feeding guidelines for children and adolescents with anorexia nervosa, carers should be included in any dietary information, education and meal planning. (Adopted from recommendation 6.5.8.9 of the NICE CPG)

D - Feeding against the will of the patient should be used as a last resort in the management of AN. (Adopted from recommendation 6.4.13.5 of the NICE CPG)

D - Feeding against the will of the patient is an intervention that must be performed by experts in the management of eating disorders and related clinical complications. (Adopted from recommendation 6.4.13.6 of the NICE CPG)

D - Legal requirements must be acknowledged and complied with when deciding whether to feed a patient against his/her will. (Adopted from recommendation 6.4.13.7 of the NICE CPG)

D - Health care professionals must be careful with the healthy weight restoration process in children and adolescents with AN, administering the nutrients and energy required by providing an adequate diet to promote normal growth and development. (Adopted from recommendation 6.5.8.8 of the NICE CPG)

Bulimia Nervosa (BN)

D - Patients with BN who frequently vomit and abuse laxatives can develop abnormalities in electrolyte balance. (Adopted from recommendation 7.5.3.1 of the NICE CPG)

D - When electrolyte imbalance is detected, in most cases elimination of the behaviour that caused it is sufficient to correct the problem. In a small number of cases, oral administration of electrolytes whose plasmatic levels are insufficient is necessary to restore normal levels, except in cases involving gastrointestinal absorption. (Adopted from recommendation 7.5.3.2 of the NICE CPG)

D - In the case of laxative misuse, patients with BN must be advised on how to decrease and stop abuse. This process must be carried out gradually. Patients must also be informed that the use of laxatives does not decrease nutrient absorption. (Adapted from recommendation 7.5.3.3 of the NICE CPG)

D - Patients who vomit habitually must have regular dental check-ups and be provided with dental hygiene advice. (Adapted from recommendations 7.5.3.4 and 7.5.3.5 of the NICE CPG)

Psychological Therapies

Cognitive-Behavioural Therapy (CBT)

Bulimia Nervosa

A - Cognitive-behavioural therapy in bulimia nervosa (CBT-BN) is a specifically adapted form of CBT and it is recommended that 16 to 20 sessions be performed over 4 or 5 months of treatment. (Adopted from recommendation 7.2.7.3. of the NICE CPG).

B - Patients with BN who do not respond to or refuse to receive CBT treatment may be offered alternative psychological recommendation (Adopted from recommendation 7.2.7.5. of the NICE CPG)

D - Adolescents with BN can be treated with CBT adapted to their age needs, level of development, and, if appropriate, the family's treatment. (Adopted from recommendation 7.2.7.4. of the NICE CPG)

Binge-Eating Disorder

A - Adult patients with binge eating disorder (BED) can be offered a specifically adapted form of CBT. (Adopted from recommendation 8.2.7.4. of the NICE CPG)

Self-Help (SH) and Guided Self-Help (GSH)

Bulimia Nervosa

B - A possible first step in BN treatment is encouraging patients to initiate a SH programme (guided or not). (Adapted from recommendation 7.2.7.1. of the NICE CPG).

B - SH (guided or not) is sufficient treatment for a limited number of patients with BN. (Adapted from recommendation 7.2.7.2. of the NICE CPG).

Interpersonal Therapy (IPT)

Bulimia Nervosa

B - IPT should be considered as an alternative to CBT even though patients should be informed it takes 8 to 12 months to obtain results comparable with CBT (Adopted from recommendation 7.2.7.6. of the NICE CPG)

Binge-Eating Disorder

B - Interpersonal therapy for binge-eating disorder (IPT-BED) can be offered to patients with persistent BED (Adapted from recommendation 8.2.7.5. of the NICE CPG)

Family Therapy (FT) (Systemic or Unspecified)

Anorexia Nervosa

B - FT is indicated in children and adolescents with AN. (Adopted from recommendation 6.2.9.14. of the NICE guide)

D - Family members of children with AN and siblings and family members of adolescents with AN can be included in treatment, taking part in improving communication, supporting behavioural treatment and sharing therapeutic information. (Adopted from recommendation 6.2.9.13. of the NICE guide)

D - Children and adolescents with AN can be offered individual appointments with health care professionals, separate from those in which the family is involved. (Adopted from recommendation 6.2.9.15. of the NICE guide)

D - The effects of AN on siblings and other family members justifies their involvement in treatment. (Adopted from recommendation 6.2.9.16. of the NICE guide)

General Recommendations for Psychological Therapy in Eating Disorders

Anorexia Nervosa

D - The psychological therapies to be assessed for AN are: CBT, systemic family therapy (SFT), IPT, psychodynamic therapy (PDT) and behavioural therapy (BT). (Adapted from recommendation 6.2.9.1. of the NICE guide)

D - In the case of patients who require special care, the selection of the psychological treatment model that will be offered is even more important. (Adopted from recommendation 6.2.9.2. of the NICE guide)

D - The objective of psychological treatment is to reduce risk, to encourage weight gain by means of a healthy diet, to reduce other symptoms related with eating disorders and to facilitate physical and psychological recovery. (Adopted from recommendation 6.2.9.3. of the NICE guide)

D - Most psychological treatments for patients with AN can be performed on an outpatient basis (with physical monitoring) by professionals specialized in eating disorders. (Adopted from recommendation 6.2.9.4. of the NICE guide)

D - The duration of psychological treatment should be of at least 6 months when performed on an outpatient basis (with physical monitoring) and 12 months for inpatients (Adopted from recommendation 6.2.9.5. of the NICE guide)

D - For patients with AN who have undergone outpatient psychological therapy but have not improved or have deteriorated, the indication of more intensive treatments (combined individual and family therapy, day or inpatient care) must be considered. (Adapted from recommendation 6.2.9.6. of the NICE guide)

D - For inpatients with AN, a treatment programme aimed at suppressing symptoms and achieving normal weight should be established. Adequate physical monitoring is important during renutrition. (Adopted from recommendation 6.2.9.8. of the NICE guide.)

D - Psychological treatments must be aimed at modifying behavioural attitudes, attitudes related to weight and body shape and the fear of gaining weight. (Adopted from recommendation 6.2.9.9. of the NICE guide)

D - The use of excessively rigid behaviour modification programmes is not recommended for inpatients with AN. (Adopted from recommendation 6.2.9.10. of the NICE guide)

D - Following hospital discharge, patients with AN should be offered outpatient care that includes monitoring of normal weight restoration and psychological intervention that focuses on eating behaviour, attitudes to weight and shape and the fear of social response regarding weight gain, along with regular physical and psychological follow-up. Follow-up duration must be of at least 12 months. (Adopted from recommendations 6.2.9.11. and 6.2.9.12. of the NICE guide)

D - In children and adolescents with AN who require inpatient treatment and urgent weight restoration, age-related educational and social needs should be taken into account. (Adopted from recommendation 6.2.9.17. of the NICE guide)

Binge-Eating Disorder

A - Patients must be informed that all psychological treatments have a limited effect on body weight. (Adopted from recommendation 8.2.7.6. of the NICE guide)

B - A possible first step in the treatment of patients with BED is to encourage them to follow a SH programme (guided or not). (Adapted from recommendation 8.2.7.2. of the NICE guide)

B - Health care professionals can consider providing BED patients with SH programmes (guided or not) that may yield positive results. However, this treatment is only effective in a limited number of patients with BED. (Adapted from recommendation 8.2.7.3. of the NICE guide)

D - If there is a lack of evidence to guide the care of patients with eating disorder not otherwise specified (EDNOS) or BED, health care professionals are recommended to follow the eating disorder treatment that most resembles the eating disorder the patient presents. (Adopted from recommendation 8.2.7.1. of the NICE guide)

D - When psychological treatments are performed on patients with BED, it may be necessary in some cases to treat comorbid obesity. (Adopted from recommendation 8.2.7.7. of the NICE guide)

D - Adolescents with BED must be provided with psychological treatments adapted to their developmental stage. (Adopted from recommendation 8.2.7.8. of the NICE guide)

Pharmacological Treatment

Antidepressants

Bulimia Nervosa

B - Patients should be informed that antidepressant treatment can reduce the frequency of binge-eating and purging episodes but effects are not immediate. (Adopted from recommendation 7.3.6.2. of the NICE guide)

B - In the treatment of BN pharmacological treatments other than antidepressants are not recommended. (Adopted from recommendation 7.3.6.4. of the NICE guide)

D - The dose of fluoxetine used in patients with BN is greater than the dose used for treating depression (60 mg/day). (Adopted from recommendation 7.7.6.5. of the NICE guide)

D - Amongst selective serotonin reuptake inhibitors (SSRI) antidepressants, fluoxetine is the first-choice drug for treatment of BN, in terms of acceptability, tolerability and symptom reduction. (Adopted from recommendation 7.3.6.3. of the NICE guide)

Binge Eating Disorder

B - SSRI antidepressant treatment can be offered to a patient with BED, regardless of whether he/she follows a guided SH programme or not. (Adopted from recommendation 8.3.5.1. of the NICE guide)

B - Patients must be informed that SSRI antidepressant treatment can reduce the frequency of binge-eating, but the duration of long-term effects is unknown. Antidepressant treatment may be beneficial for a small number of patients. (Adopted from recommendation 8.3.5.2. of the NICE guide)

General Recommendations for Pharmacological Treatment of Eating Disorders

Anorexia Nervosa

D - Pharmacological treatment is not recommended as the only primary treatment in patients with AN. (Adopted from recommendation 6.3.6.1. of the NICE guide)

D - Caution should be exercised when prescribing pharmacological treatment for patients with AN who have associated comorbidities such as obsessive-compulsive disorder (OCD) or depression. (Adopted from recommendation 6.3.6.2. of the NICE guide)

D - Given the risk of heart complications presented by patients with AN, prescription of drugs whose side effects may affect cardiac function must be avoided. (Adopted from recommendation 6.3.6.4. of the NICE guide)

D - If drugs with adverse cardiovascular effects are administered, ECG monitoring of patients should be carried out. (Adopted from recommendation 6.3.6.3. of the NICE guide)

D - All patients with AN must be warned of the side effects of pharmacological treatments. (Adopted from recommendation 6.3.6.5. of the NICE guide)

Binge-Eating Disorder

D - In the absence of evidence to guide the management of BED, it is recommended that the clinician treat the patient based on the eating problem that most closely resembles the patient's eating disorder according to BN or AN guides. (Adopted from recommendation 8.2.7.1. of the NICE guide)

Treatment of Eating Disorders that Occur with Comorbidities

D - Treatment in clinical and subclinical cases of eating disorders in patients with diabetes mellitus (DM) is essential due to the increased risk presented by this group. (Adopted from recommendation 7.5.8.1. of the NICE guide)

D - Patients with type 1 DM and an eating disorder must be monitored due to the high risk of developing retinopathy and other complications. (Adopted from recommendation 7.5.8.2. of the NICE guide)

D - Young people with type 1 DM and poor adherence to antidiabetic treatment should be assessed for the probable presence of an eating disorder. (Adopted from recommendation 5.2.5.5. of the NICE guide)

Treatment of Chronic Eating Disorders

Good clinical practice: The health care professional in charge of the management of chronic eating disorder cases should inform the patient on the possibility of recovery and advise him/her to see the specialist regularly regardless of the number of years elapsed and previous therapeutic failures.

Good clinical practice: It is necessary to have access to health care resources that are able to provide long-term treatments and follow-up on the evolution of chronic eating disorder cases, as well as to have social support to decrease future disability.

Treatment of Eating Disorders in Special Cases

D - Pregnant patients with AN, whether it is the first episode or a relapse, require intensive prenatal care with adequate nutrition and follow-up of foetal development. (Adopted from recommendation 6.4.8.1. of the NICE guide)

D - Pregnant women with eating disorders require careful follow-up throughout pregnancy and the postpartum period. (Adopted from recommendation 7.5.10.1. of the NICE guide)

Assessment of Eating Disorders

D - Assessment of patients with eating disorders should be comprehensive and include physical, psychological and social aspects, as well as a complete assessment of risk to self. (Adopted from recommendation 2.8.1.1. of the NICE guide)

D - The therapeutic process modifies the level of risk for the mental and physical health of patients with eating disorders, and thus should be monitored throughout treatment. (Adopted from recommendation 2.8.1.2. of the NICE guide)

D - Throughout treatment, health care professionals who evaluate children and adolescents with eating disorders should be alert to possible indicators of abuse (emotional, physical and sexual) to ensure an early response to this problem. (Adapted from recommendation 2.8.1.3. of the NICE guide)

D - Health care professionals who work with children and adolescents with eating disorders should familiarize themselves with national CPGs and current legislation regarding confidentiality. (Adapted from recommendation 2.8.1.5. of the NICE guide)

Good clinical practice: The use of questionnaires adapted and validated in the Spanish population is recommended for assessment of eating disorders. At present, the following specific instruments for eating disorders are recommended: Eating Attitudes Test (EAT), Eating Disorder Inventory (EDI), Bulimia Test (BULIT), Bulimia Investigatory Test Edinburgh (BITE), Sick, Control, One, Fat, Food questionnaire (SCOFF), Attitude Towards Change in Eating Disorders (acronym in Spanish) (ACTA) and Anorectic Behaviour Observation Scale for parents/spouse (ABOS) (version selection based on the patient's age and other application criteria). To assess aspects related with eating disorders, the following questionnaires are recommended: Body Shape Questionnaire (BSQ), Body Image Assessment (BIA), Body Attitude Test (BAT), Body-Esteem Scale (BES) and Questionnaire on Influences of the Aesthetic Body Model (acronym in Spanish) (CIMEC) (the selection of the version should be based on age and other application criteria).

Good clinical practice: It is recommended to use questionnaires that have been adapted and validated in the Spanish population for the psychopathological assessment of eating disorders. At present, the following instruments are recommended to carry out the psychopathological assessment of eating disorders (version selection based on age and other application conditions):

  • Impulsiveness: Barratt Impulsiveness Scale (BIS-11)
  • Anxiety: State-Trait Anxiety Inventory (STAI), Hamilton Anxiety Rating Scale (HARS), Assessment of Anxiety Disorders in Children and Adolescents (CETA)
  • Depression: Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HAM-D), Children Depression Inventory (CDI)
  • Personality: Millon Multiaxial Clinical Inventory-III (MCMI-III), Millon Adolescent Clinical Inventory (MACI), Temperament and Character Inventory, revised (TCI-R), International Personality Disorder Examination (IPDE)
  • Obsessiveness: Yale-Brown Obsessive-Compulsive Scale for OCD (Y-BOCS).

Legal Aspects Concerning Patients with Eating Disorders in Spain

According to current legislation: The use of legal (judicial) channels is recommended in cases where the health professional deems it appropriate to safeguard the health of the patient, observing in all circumstances the patient's right to be heard and to be conveniently informed of the process and the medical and legal measures that will be applied. The well-informed procedure not only respects the right to information but also encourages the patient’s cooperation and motivation and that of his or her closer relatives in the total hospitalization procedure.

According to current legislation: One characteristic symptom of EDs and specifically of AN is the absence of awareness of the disease among sufferers. The disease itself often causes a lack of sufficient judgement to issue a valid and unbiased consent concerning the acceptance and choice of treatment. Hence, in the assumptions of severe risk to the health of a minor afflicted with AN who refuses treatment, established legal and judicial channels must specially be followed.

According to current legislation: The balance among the different rights in conflict makes it mandatory for the physician to observe and to interpret the best solution to each case. Nonetheless, it is always of utmost importance to inform and to listen attentively to both sides so that they understand the relationship between safeguarding health and the decision taken by the physician.

Definitions:

Levels of Scientific Evidence

1++ High quality meta-analysis, systematic reviews of clinical trials or high-quality clinical trials with low risk of bias

1+ Well conducted meta-analysis, systematic reviews of clinical trials, or well conducted clinical trials with low risk of bias

1- Meta-analysis, systematic reviews of clinical trials, or clinical trials with high risk of bias

2++ High quality systematic reviews of cohort or case-control studies. Cohort or case-control studies with very low risk of bias and high probability of establishing a causal relationship.

2+ Well conducted cohort or case-control studies with low risk of bias and moderate probability of establishing a causal relationship

2- Cohort or case-control studies with high risk of bias and significant risk of non-causal relationship

3 Non-analytic studies such as case reports, case series or descriptive studies

4 Expert opinion

Grades of Recommendation

A At least one meta-analysis, systematic review or clinical trial classified as 1++ and directly applicable to the guide's target population, or a body of evidence composed of studies classified as 1+ with high consistency amongst them

B Body of evidence composed of studies classified 2++, directly applicable to the guide's target population and that have been shown to have high consistency amongst them, or evidence extrapolated from studies classified as 1++ or 1+

C Body of evidence composed of studies classified as 2+ directly applicable to the guide's target population and that have shown to have high consistency amongst them; or evidence extrapolated from studies classified as 2++

D Level 3 or 4 evidence or evidence extrapolated from studies classified as 2+

Good clinical practice: Recommended practice based on clinical experience and the consensus of the drafting team

Clinical Algorithm(s)

Algorithms are provided in the original guideline document for:

  • Detection of potential cases of eating disorders
  • Intervention if there is suspicion of an eating disorder
  • Treatment of anorexia nervosa
  • Treatment of bulimia nervosa and binge-eating disorder

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnosis and treatment of patients with eating disorders

Potential Harms

Adverse effects of medications

Contraindications

Contraindications

Weight restoration requires a normocaloric, healthy diet, except in cases in which it is contraindicated due to the patient's condition.

Qualifying Statements

Qualifying Statements

This clinical practice guideline (CPG) is an aid for decision-making in health care. It is not in any way an obliged requirement to adhere to every aspect of this CPG and it does not replace the clinical judgement of health care professionals.

Implementation of the Guideline

Description of Implementation Strategy

Dissemination and Implementation

In order for this clinical practice guideline (CPG) to reach health care professionals in the NHS, its dissemination will be carried out by means of the GuíaSalud Catalogue (www.guiasalud.es External Web Site Policy) and Catalan Agency for Health Technology Assessment and Research's (CAHTA's) website (www.aatrm.net External Web Site Policy).

Once the national dissemination Plan within the general framework of GuíaSalud has been completed, the guide's working group and CAHTA will perform further dissemination activities that are deemed appropriate.

The CPG consists of three versions for health care professionals: the full version, the summary and the quick version. The first two include information for patients (Annex 3). The CPG is edited electronically and is available on the GuíaSalud and CAHTA websites. The summarized and quick versions are also in book and leaflet form, respectively. The book contains the CD-ROM of all versions.

The measure of adherence or implementation of the CPG's recommendations by means of monitoring and/or auditing can improve its use. The manual of the Assessment of Guidelines Research and Evaluation (AGREE) instrument addresses the importance of elaborating indicators, item 21 of the "applicability" dimension tackling this issue. Hence, a CPG must offer a list of clear quantifiable criteria or quality indicators that derive from the key recommendations in the guide. The most well known and widely used indicator classification system in this guide is the one pertaining to Donabedian, which classifies indicators into: structure, process and outcome. In order to determine and assess the performance of the most important recommendations, the assessment of certain intervening process variables and the most relevant clinical outcomes is suggested.

In the clinical assessment of eating disorders it is recommended to measure key aspects related with quality for which certain indicators are initially proposed due to their validity, reliability and feasibility at different levels of care (primary care and specialized care).

Table 1 in the original guideline document describes the 11 proposed indicators according to clinical area, type of indicator, the dimension of quality they address and the care level where they may be applied. It is important to bear in mind that, in practice, available indicators are not perfect and constitute an approximation of a real situation. Their objective is to provide useful information to facilitate decision-making. They are quantitative measures, which, if obtained periodically, enable analysis of their evolution over time (monitoring).

Some of the indicators included in the Mental Health Strategy of the National Health Service (NHS) (Quality Plan) are common to eating disorders. Therefore, some of the indicators proposed are common to those included in the above-mentioned plan. Others have been adopted from the Contract Programme of the Regional Ministry of Andalusia/Andalusian Health Service and the National Institute for Clinical Excellence (NICE) CPG. Additionally, the working group has proposed others.

Implementation Tools
Audit Criteria/Indicators
Chart Documentation/Checklists/Forms
Clinical Algorithm
Foreign Language Translations
Mobile Device Resources
Patient Resources
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Working Group of the Clinical Practice Guideline for Eating Disorders. Clinical practice guideline for eating disorders. Madrid (Spain): Quality Plan for the National Health System of the Ministry of Health and Consumer Affairs, Catalan Agency for Health Technology Assessment and Research; 2009 Feb 1. 287 p. (Clinical practice guideline in the NHS: CAHTA; no. 2006/05-01).  [447 references]
Adaptation

The guideline recommendations are adopted or adapted from: National Collaborating Centre for Mental Health. Eating disorders. Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Leicester/London: The British Psychological Society. The Royal College of Psychiatrists; 2004.

Date Released
2009 Feb 1
Guideline Developer(s)
Agency for Health Quality and Assessment of Catalonia (AQuAS) - State/Local Government Agency [Non-U.S.]
GuiaSalud - National Government Agency [Non-U.S.]
Ministry of Health (Spain) - National Government Agency [Non-U.S.]
Source(s) of Funding

This clinical practice guideline (CPG) has been funded by means of the agreement between the Carlos III Institute of Health, an autonomous organism of the Ministry of Health and Consumer Affairs, and the Catalan Agency for Health Technology Assessment and Research, within the framework of collaboration established in the Quality Plan for the National Health System.

Guideline Committee

Working Group of the Clinical Practice Guideline for Eating Disorders

Composition of Group That Authored the Guideline

Eating Disorders Clinical Practice Guideline Working Group: Francisco J. Arrufat, psychiatrist, Consorci Hospitalari de Vic Hospital (Barcelona); Georgina Badia, psychologist, Hospital de Santa Maria (Lérida); Dolors Benítez, research support technician, CAHTA (Barcelona); Lidia Cuesta, psychiatrist, Hospital Mútua de Terrassa (Barcelona); Lourdes Duño, psychiatrist, Hospital del Mar (Barcelona); Maria-Dolors Estrada, preventive physician and Public Health, CAHTA (Barcelona), CIBER of Epidemiology and Public Health (CIBERESP); Fernando Fernández, clinical psychologist, Hospital of Bellvitge, Hospitalet de Llobregat (Barcelona); Joan Franch, psychiatrist, Institut Pere Mata, Reus (Tarragona); Cristina Lombardia, psychiatrist, Parc Hospitalari Martí Julià, Health Care Institute, Salt (Gerona); Santiago Peruzzi, psychiatrist, Sant Joan de Déu Hospital, Esplugues de Llobregat (Barcelona); Josefa Puig, nurse, Hospital Clínic i Provincial de Barcelona (Barcelona); Maria Graciela Rodríguez, clinical and biochemical analyst, CAHTA (Barcelona); Jaume Serra, physician, nutritionist and dietician, Department of Health of Catalonia (Barcelona); José Antonio Soriano, psychiatrist, Hospital de la Santa Creu i Sant Pau (Barcelona); Gloria Trafach, clinical psychologist, Inastitut d'Assistència Sanitària, Salt (Gerona); Vicente Turón, psychiatrist, Department of Health of Catalonia (Barcelona); Marta Voltas, attorney, Fundación Imagen y Autoestima (Barcelona)

Technical Coordinator: Maria-Dolors Estrada, preventive physician and Public Health, CAHTA (Barcelona) CIBER of Epidemiology and Public Health (CIBERESP)

Clinical Coordinator: Vicente Turón, psychiatrist, Department of Health of Catalonia (Barcelona)

CAHTA Members: Silvina Berra, nutritionist and dietician, Public Health, CIBER of Epidemiology and Public Health (CIBERESP); Mònica Cortés, clinical psychologist, Public Health; Mireia Espallargues, preventive physician and Public Health, CIBER of Epidemiology and Public Health (CIBERESP); Anna Kotzeva, physician, Public Health; Nadine Kubesch, Health Sciences, Public Health; Marta Millaret, documentation support technician; Antoni Parada, documentalist, CIBER of Epidemiology and Public Health (CIBERESP)

Spanish Experts on Eating Disorders: Josefina Castro, psychiatrist, Hospital Clínic i Provincial de Barcelona (Barcelona); Marina Díaz-Marsá, psychiatrist, Hospital Clínico San Carlos Clinical (Madrid); José A. Gómez del Barrio, psychiatrist, Hospital Marqués de Valdecilla (Santander); Gonzalo Morandé, psychiatrist, Hospital Infantil Niño Jesús (Madrid); Jesús Ángel Padierna, psychiatrist, Hospital de Galdakao (Vizcaya); Luis Rojo, psychiatrist, Hospital La Fe (Valencia); Carmina Saldaña, clinical psychologist, School of Psychology, University of Barcelona (Barcelona); Luis Sánchez-Planell, psychiatrist, Hospital Germans Trias i Pujol, Badalona (Barcelona); Josep Toro, psychiatrist, School of Medicine, University of Barcelona (Barcelona); Francisco Vaz, psychiatrist, University of Badajoz (Badajoz); Mariano Velilla, psychiatrist, Hospital Clínico Lozano Blesa Clinical (Zaragoza)

External Review of the Guide: Felipe Casanueva, Hospital de Conxo Hospital, Santiago de Compostela (La Coruña); Salvador Cervera, University of Navarra (Navarra); Mercè Mercader, Department of Health of Catalonia (Barcelona); Jorge Pla, Clínica Universitaria de Navarra (Navarra); Francisco Traver, Hospital Provincial de Castellón de la Plana (Castellón)

External Review of Patient Information: Association in Defense of Anorexia Nervosa and Bulimia Management (ADANER), Spanish Federation of Support Associations for Anorexia y Bulimia (FEACAB)

Financial Disclosures/Conflicts of Interest

All members of the working group, as well as the individuals who have collaborated in the development of this guide (experts on eating disorders, representatives from different associations, scientific societies, federations and external reviewers), have carried out the declaration of conflict of interests by completing a form designed to this end.

None of the participants have declared having a conflict of interest related with eating disorders.

This guide is editorially independent from the funding organization.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in English External Web Site Policy and Spanish External Web Site Policy from the GuíaSalud Web site and from the Agency for Health Quality and Assessment of Catalonia [AQuAS] Web site.

Availability of Companion Documents

The following are available:

  • Quick reference guides and summary versions are available in Spanish from the GuíaSalud Web site External Web Site Policy.
  • The Spanish version of the guideline is also available via a mobile application from the GuíaSalud Web site External Web Site Policy.
  • Updating clinical practice guidelines in the Spanish National Healthcare System: methodology handbook. Available from the GuíaSalud Web site External Web Site Policy.

In addition, Table 1, Chapter 14, of the original guideline document External Web Site Policy provides proposed quality indicators.

Various assessment and screening questionnaires are available in the annexes to the original guideline document External Web Site Policy.

Patient Resources

Patient information is available in Annex 3 of the original guideline document External Web Site Policy. A Spanish version is available in Portable Document Format (PDF) from the Agency for Health Quality and Assessment of Catalonia (AQuAS) Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on November 2, 2011. The information was verified by the guideline developer on December 5, 2011. This summary was updated by ECRI Institute on April 16, 2012 following the updated U.S. Food and Drug Administration advisory on Celexa (citalopram hydrobromide).

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...