Status of Women Committee on Feb. 24th, 2014

[Dr. Wendy Spettigue]

That's an easy one, but I warn, I can talk a long time about it.

I want you to imagine a patient with severe obsessive-compulsive disorder, who has the constant thought, “There are germs on my hands,” and the only thing that makes it better is if that patient goes and washes their hands, and then the anxiety decreases. But that patient sits down and the thoughts appear again, “There are still hidden germs on your hands. You didn't get them all. They're going to get inside you. They're going to make you sick. They're going to make you die.” You can't stand the agitation, and the only thing that makes it better is washing your hands. Individual treatment would be like trying to get the person to choose not to wash their hands. Even if they're motivated to do that, they probably can't tolerate the severe urges.

Anorexia nervosa in youth is the exact same kind of illness where they can't tolerate the severe anxiety and agitation that goes with the thoughts that have taken over their minds that constantly say, “You're eating too much. You're gaining too much weight.” They feel compelled to restrict or purge, or whatever, to get rid of that. You can't just talk them into not doing it. First of all, they're not motivated because they're afraid of gaining weight. Secondly, even if they were, they can't tolerate it. So we put their renourishment into the hands of parents whose job it is to prevent the opportunity to have symptoms.

[The Chair, NDP, Hélène LeBlanc]

Thank you very much.

Mrs. Sellah, you have seven minutes.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

Thank you, Madam Chair.

I want to begin by thanking our witnesses for joining us and participating by videoconference. I am glad to hear their suggestions to improve diagnoses or treatment plans for people with eating disorders.

My first question is for the representatives of the Canadian Psychological Association.

For the sake of full disclosure, I want to say that I am a health professional and I know that the most used method is the cognitive-behavioural approach. That psychological approach is used the most often to treat those types of disorders. I saw one of your pamphlets released in 2012 that focused on that method. How successful is the approach?

My question is for Dr. Lisa Votta-Bleeker or Dr. Giorgio A. Tasca.

[Dr. Giorgio A. Tasca]

How effective is it for eating disorders? Cognitive behavioural therapy is the treatment that has the most research behind it. There are other treatments that are variously effective as well, but not as well researched. I would say my reading of the literature is that probably, in terms of bulimia nervosa, about 50% of the patients get better through cognitive behavioural therapy or other treatments that have some evidence base to them. For anorexia nervosa, it's probably around 25% to 30%.

The evidence-based treatments are good, but they're not great in that sense, so there needs to be a lot more done in terms of researching more effective means of getting better outcomes for these patients.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

Thank you for your answer. That brings me to my next question.

We have received a lot of information since we began our study on eating disorders. One of the things I have learned is that people treated for eating disorders are being discriminated against compared with people receiving general treatment. I know that your association issues guidelines on discrimination in the provision of psychological care. I would like to know whether you have guidelines specifically for the treatment of individuals with eating disorders.

[Dr. Lisa Votta-Bleeker]

Specific guidelines for...?

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

Yes.

[Dr. Lisa Votta-Bleeker]

I'm not sure I understood the question.

Our mantra at the Canadian Psychological Association is that everyone should have access to psychological services regardless of whatever mental health disorder they are suffering from. We want the right provider at the right time, regardless of what their diagnosis is.

I don't know if that's answering the question sufficiently.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

I know you have this kind of guideline.

I am talking about the psychological approach in a general sense. However, do you have any guidelines that apply specifically to potential discrimination against patients with eating disorders?

[Dr. Lisa Votta-Bleeker]

Not to my knowledge. We have practice guidelines, yes, but not specific to eating disorders.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

So that is another shortcoming in the system when it comes to treatment for those kinds of individuals.

Thank you.

[Dr. Wendy Spettigue]

Again, perhaps I can just clarify. There are practice guidelines for the treatment of child and adolescent eating disorders. There are American practice guidelines, which I helped to develop, and we're in the process of trying to make some Canadian guidelines.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

If I have understood correctly, we still don't have those guidelines in Canada.

[Dr. Wendy Spettigue]

They do not entail Canadian guidelines.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

Thank you for your comment, Dr. Spettigue.

I know that one of the books you wrote contains a chapter titled Pharmacotherapy for eating disorders in children and adolescents. In that chapter, you focused on medical treatments for eating disorders. You think that the best solution for combatting or reducing eating disorders is based on medication. Is that correct?

[Dr. Wendy Spettigue]

No, I definitely favour evidenced-based treatment for eating disorders, and we lack a lot of evidence. So at this point, for example, there is no evidence whatsoever that there is any medication to treat children and adolescents with anorexia nervosa. Having said that, as I pointed out there is a very high association between eating disorders, depression, and anxiety, and there are medications that are helpful for treating depression and anxiety although they don't work in low-weight patients. We tell them that their food is the medicine they need to start with. We renourish them and then we can treat the depression and anxiety.

Having said that, it's the kind of patient Ms. Phoenix was talking about who is very ill in hospital. I specialize in treating the youth who are so medically unstable and unwell that they require hospitalization at CHEO. For those youth we sometimes get rather desperate in terms of trying to calm them when they become severely agitated or resistant to treatment and to taking nutrition, and they may be trying to kill themselves or to run away, or whatever. We sometimes end up desperately using medications that clinically seem to be helpful in calming their agitation. I'm trying to study a medication that was studied at the Ottawa General Hospital and found to be helpful in adults, but it's taking a long time and it's hard to get enough funding to study these adults and youth with eating disorders.

[The Chair, NDP, Hélène LeBlanc]

Thank you very much.

Mr. Young, go ahead. You have seven minutes.

[Terence Young, Conservative, Oakville, ON]

Thank you, Chair.

Thank you, everyone, for giving us your time today. It's been extremely interesting and valuable to us.

Dr. Spettigue, what is the minimal level of treatment that girls and women with eating disorders should receive in Canada?

[Dr. Wendy Spettigue]

It depends on the severity of their illness because I wouldn't want to hospitalize a patient with a mild eating disorder, nor would I want to keep a patient out of hospital who was very severely ill and medically unstable. So it does depend on the level of intervention, and it's important that we match the level of intervention to the severity of the illness.

One of the problems that's happened in Ottawa is that the specialized eating disorder program at CHEO became so overwhelmed by the number of referrals that we had to close and only treat those acutely medically ill patients who required hospitalization. This meant that patients with mild, moderate, or even moderately severe eating disorders in the Ottawa region for the last 20 months have had no specialized eating disorder care, which is atrocious.

[Terence Young, Conservative, Oakville, ON]

Perhaps you could comment on the components of care at the various levels, depending on severity. That would be helpful. Thanks.

[Dr. Wendy Spettigue]

The components of care are that you need psychological treatment, medical treatment, and nutritional treatment, and they all need to be combined. For most patients, the recommended treatment is outpatient treatment, where they're followed for their medical issues by a medical doctor and they have nutritional input if that's available, although it's not absolutely necessary. Most important is the outpatient family therapy. A huge issue is that there are very, very few people in Canada who are trained to provide that specialized family therapy for adolescent eating disorders.

[Terence Young, Conservative, Oakville, ON]

So what percentage of adolescents with eating disorders, when that range of therapy is needed, actually gets it?

[Dr. Wendy Spettigue]

It would be less than 1%, I would guess, if we looked at the whole country.

[Terence Young, Conservative, Oakville, ON]

Thank you.

Dr. Votta-Bleeker, do you have anything to add to the components of treatment?

[Dr. Lisa Votta-Bleeker]

No. She highlighted them.