Risks and pitfalls for the management of refeeding syndrome in psychiatric patients

Refeeding syndrome can be defined as severe electrolyte and fluid shift associated with metabolic abnormalities in patients with malnutrition undergoing realimentation, whether orally, enterally, or parenterally (Crook et al, 2001). Historically, refeeding syndrome was first described in starving wartime prisoners and victims of famines (Schnitker et al, 1951). More recently this syndrome has been well documented in surgical and oncology patients undergoing parenteral nutrition (Crook et al, 2001; Hearing, 2004). In psychiatry, refeeding syndrome occurs in people with eating disorders and alcoholism (Cumming et al, 1987), but it is often missed in other psychiatric patients where malnutrition is relatively common. Up to 50% of patients admitted to acute psychiatric wards are at risk of malnutrition (Abayomi & Hackett, 2004). This can be extreme in the context of self-neglect, alcohol and drug dependency, depression, schizophrenia and dementia (Gray & Gray, 1989). The consequences of missing a diagnosis of refeeding syndrome in these patients may be serious, as complications range from neurological disability (for example Wernicke-Korsakov syndrome) to metabolic complications (for example hypophosphataemia) and death (Crook et al, 2001). We describe refeeding syndrome in two patients routinely admitted to a general psychiatric ward and illustrate the potential pitfalls in the prevention, diagnosis and management of severe malnutrition and refeeding complications in patients with mental illness.