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The Royal College of Psychiatrists Improving the lives of people with mental illness

CR162. MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa

Price: £10.00

Approved: Jan 2010

Published: Oct 2010

Status: current

Number of pages: 58

Review by: 2013

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Download PDF of Key Points - This sheet gives key point for hospital staff, including diagrams of the Sit up–Squat–Stand test (to detect muscle weakness).

The Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN) working group arose out of concerns that a number of patients with severe anorexia nervosa were being admitted to general medical units and sometimes deteriorating and dying on those units because of psychiatric problems, such as non-adherence to nutritional treatment, and medical complications, such as re-feeding syndrome. Sometimes overzealous application of National Institute for Health and Clinical Excellence (NICE) guidelines led to death from underfeeding syndrome. It seems there are also worrying variations in practice.


This report aims to clarify the situation and provides recommendations and unambiguous guidelines on the management of this patient group in a number of settings, in order to help reduce the number of avoidable deaths of patients with severe anorexia nervosa. It provides:


  • Advice on physical assessment.
  • Advice to the primary care team and criteria for admission to both medical units and specialist eating disorder units as well as non-specialist psychiatric units, and criteria for transfer between those services.
  • Advice on the required members of the in-patient medical team.
  • Medical, nutritional and psychiatric management of patients with severe anorexia nervosa in medical units, including the appropriate use of mental health legislation.
  • Advice for commissioners on required services for this group of very ill patients.

This is a joint report from the Royal College of Psychiatrists and the Royal College of Physicians (London).


  • Organisations endorsing the report
  • MARSIPAN Working Group
  • Executive summary and recommendations
  • Introduction
  • Issues arising in all settings
  • Management in different sectors
  • Audit and review
  • References


  1. Some cases reported to the MARSIPAN group by colleagues
  2. Modified Newcastle guideline for MARSIPAN cases
  3. Survey questionnaire sent to members of the Eating Disorders Section electronic mailing list
  4. Compulsory treatment
  5. Use of initial low-calorie feeding rates in anorexia nervosa
  6. Drug treatment during assisted nutrition in patients extremely agitated and resistant to treatment
  7. MARSIPAN – Management of Really Sick Patients with Anorexia Nervosa: key points for hospital staff


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