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

CR189. MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa (2nd edn)

Price: £0.00

Approved: Apr 2014

Published: Oct 2014

Status: current

Number of pages: 60

Review by: 2019

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This report is only available online – there are no printed copies available to buy.

Please use the link above to view and download a PDF file of the report.

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, the Royal College of Physicians (London) and the Royal College of Pathologists.

This report updates and replaces 'CR162: MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa', from 2010.


  • MARSIPAN working group
  • Executive summary and recommendations
  • Introduction
  • Issues arising in all settings
  • Management in different sectors
  • Treatment of children and adolescents under 18
  • Areas with limited local eating disorders provision
  • Audit and review
  • References.


  1. Cases reported to the MARSIPAN group
  2. Modified Newcastle guideline for MARSIPAN cases
  3. Healthcare provision in UK eating disorders units
  4. Compulsory treatment
  5. Initial low-calorie feeding rates in anorexia nervosa
  6. Drug treatment during assisted nutrition
  7. MARSIPAN: key points for hospital staff
  8. MARSIPAN implementation in UK localities, 2010–2014
  9. MARSIPAN implementation 2010–2014: other reported activities
  10. Re-feeding in anorexia nervosa: information for ward staff
  11. Authors’ comments.


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Download MARSIPAN checklist

A checklist has been developed in order to improve outcomes in patients with severe anorexia nervosa admitted to medical and non-specialist paediatric wards where most of the re-feeding and underfeeding problems have been reported (especially adult medical wards). It may also be relevant for non-specialist psychiatric wards. However, specialist psychiatric wards (SEDUs) for eating disorders have not reported problems and should use the checklist to inform but not replace their existing practice.

This checklist is suitable for use for all ages and can be used with CR168. Junior MARSIPAN: Management of Really Sick Patients under 18 with Anorexia Nervosa.

Download PowerPoint slides

Use these slides in lectures to medical, psychology, dietetic, nursing and other relevant staff and trainees.