MARSIPAN: management of really sick patients with anorexia nervosa


Report from the MARSIPAN group (2nd edition), published October 2014 

Joint Working party report by the Royal College of Psychiatrists and the Royal College of Physicians

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, which is available to download as a pdf, updates and replaces CR162 MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa, published in 2010.

  • MARSIPAN working group
  • Executive summary
  • 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, 2010-14
  9. MARSIPAN implementation 2010-14: other reported activities
  10. Re-feeding in anorexia nervosa: information for ward staff
  11. Author's comments

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