Patients with eating disorders are being discharged from mental health units even though they are still very thin and have “dangerously low” body mass index levels.
Some hospitals are sending home people whose BMIs are as low as 12.5, despite usual clinical practice in the NHS seeking to wait until a BMI of 18 or 19 has been achieved.
The early discharges were revealed through freedom of information requests to NHS mental health trusts in England submitted by Hope Virgo, a prominent eating disorders campaigner.
Experts said the revelation was “horrifying” and was probably linked to NHS services struggling to cope with a rise in demand.
Nine trusts discharged a total of 119 patients with conditions such as anorexia nervosa and avoidant restrictive food intake disorder (Arfid) between January and November last year, even though their BMI was less than 15. Some were discharged from inpatient units, others by community services.
These figures are an underestimate given that only nine of the health service’s 54 specialist mental health trusts shared the requested figures with Virgo.
“A BMI of 15 represents severe malnutrition, according to the World Health Organization. Discharge at this level may occur, but it means that the person remains seriously unwell and requires ongoing monitoring by the GP,” said Dr Agnes Ayton, an NHS consultant psychiatrist and vice-chair of the eating disorders faculty of the Royal College of Psychiatrists.
She said: “Mortality in anorexia nervosa increases very substantially at very low BMI due to both physical complications or suicide. Discharge at this stage carries a high risk of rapid relapse, progression to a chronic course or further physical and psychological deterioration.”
NHS eating disorder services view a BMI of 18.5 or 19 as the usual minimum level to show that a patient’s weight is healthy enough to be safely discharged, doctors said.
Dr Ashish Kumar, the chair of the eating disorders faculty of the Royal College of Psychiatrists, said discharges were based on a range of clinical, psychiatric, medical and social “risk factors, rather than a specific number by itself”.
He noted that no single BMI threshold determined when someone could be safely discharged, but agreed 19 was generally considered to be healthy.
A spokesperson for NHS England said existing discharge practices were safe. “These figures in isolation are not unusual and clinical guidance including from NICE is clear that BMI should never be used as a sole marker of readiness for discharge,” they said. “Patients are only discharged by expert clinicians when they have achieved sufficient progress in their weight, eating patterns and a range of other factors, and with support plans for recovery.”
South London and the Maudsley trust discharged nine people whose BMI was less than 15. One had a BMI of only 12.5 – the lowest of the 119 identified – and the others were between 14 and 15.
Bethany Francois, a dietitian specialising in eating disorders, said: “In my experience, no individual I’ve ever worked with has been well enough to be discharged from eating disorder treatment at a BMI of 15.”
Francois said: “Generally a BMI of 15 would raise concerns regarding cardiovascular stability, hormonal disruption, compromised immune function, [and] bone density loss if weight remains suppressed.”
Discharge from inpatient care at such a low BMI should never happen to people being treated by community mental health teams, she added.
Dr David Viljoen, a consultant clinical psychologist at the private eating disorders provider Ellern Mede, said he was “concerned” about those with a BMI below 15 being discharged “because this is against all the research evidence”, which warns of the risk of relapse, developing a chronic or longstanding eating disorder, or premature death.
Central and North West London trust discharged 38 patients with a BMI below 15 last year and Cumbria, Northumberland, Tyne and Wear trust 14 times.
A BMI below 15 was “dangerously low” for anyone to be discharged, said Virgo.
“These figures expose a deeply troubling pattern. Discharging people at BMIs associated with extreme severity and high mortality risk is not a neutral clinical decision, it is a failure of care. Patients are being blamed for ‘not wanting to recover’, while being sent home at weights known to be medically dangerous.”
In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org
