This article was written by: Dr. Kathryn Trottier, Provincial Clinical Lead, Eating Disorders, Ontario Health (Mental Health and Addictions Centre of Excellence).
Prior to the COVID-19 pandemic, eating disorders were common, with a lifetime prevalence of about 15% (the proportion of the population who will experience an eating disorder at some point in their life). But, as with other mental health conditions – including depression and anxiety – the incidence of eating disorders appears to have increased through the pandemic. From March to December 2021, emergency department visits related to eating disorders increased by over 60% in Ontario and eating disorder-related hospital admissions for children and adolescents increased by 37%.
There are well-researched effective psychological interventions to treat eating disorders, including specialized cognitive behavioral therapy for adults and family-based therapy for children and adolescents. However, the current system of care for people with eating disorders lacks coordination and standardization.
Evidence-based treatments are not consistently available across the province and wait times for existing treatment programs are typically many months to well over a year. Too often, eating disorders go undiagnosed and/or untreated until the individual is severely ill and requires a higher level of care, including hospitalization.
In the search for care, people may be referred to multiple programs simultaneously or to programs that don't meet their needs. This places additional stress on the individuals seeking care, as well as on the system, resulting in further delays in treatment.
Ontario Health has released the Eating Disorders quality standard which addresses care for people of all ages with anorexia nervosa, bulimia nervosa and binge eating disorder. Working with an advisory committee of clinical experts and people with lived experience, Ontario Health developed the quality standard by drawing on clinical practice guidelines, expert consensus and Ontario data.
The standard describes nine key opportunities to improve care for people with eating disorders:
- Comprehensive assessment
- Level of care
- Transition from youth to adult health care services
- Monitoring and medical stabilization
- Support for family and caregivers
- Physical, mental health and addiction comorbidities
- Promoting equity
- Care for people who are not receiving active treatment
As part of Ontario Health, the Mental Health and Addictions Centre of Excellence is using the quality standard as a guide in building a comprehensive and connected system of care for eating disorders in Ontario.
As the Mental Health and Addictions Centre of Excellence works to implement the Eating Disorders quality standard, an initial area of focus will be to improve timely access to evidence-based psychotherapy that considers the needs and preferences of the individual. When people receive timely access to the most effective evidence-based therapies, they are likely to recover sooner and with a lower likelihood of relapse. This helps reduce the need for more intensive treatment and overall wait times for care.
Ideally, psychotherapy should begin within four to eight weeks after a comprehensive assessment and treatment plan is made. Treatment length varies but is typically around 20 sessions, although more sessions may be provided to individuals who are significantly underweight to support the weight restoration process.
For children and young people under age 18, family-based treatment (FBT) is considered firstline treatment for anorexia nervosa or bulimia nervosa. If FBT is ineffective or unsuitable, other therapeutic approaches can be considered, such as cognitive behavioural therapy for eating disorders (CBT-ED) or adolescent-focused psychotherapy.
For adults aged 18 years and older with anorexia nervosa, bulimia nervosa or binge-eating disorder, CBT-ED is considered first-line treatment. This therapy targets binge eating, compensatory behaviours, dietary restriction, low weight, and excessive concern with body shape and weight. It includes psychoeducation, self-monitoring of eating and related behaviours, exposure to avoided foods, strategies to reduce concerns about shape and weight, along with strategies to prevent relapse.
For people with binge-eating disorder, interpersonal psychotherapy (IPT) is also recommended. This therapy involves identifying and working on specific interpersonal problem areas currently affecting the individual, including role disputes, role transitions, interpersonal deficits and unresolved grief.
The development of the quality standard represents an important step forward toward a future in which all Ontarians can access high-quality and effective treatments for eating disorders.
Primary care physicians can earn 2.25 Mainpro+® credits for reading the standard through the Understanding Quality Standards in Primary Care Program.
For more information, please contact QualityStandards@OntarioHealth.ca.