Status of Women Committee on Feb. 24th, 2014

[The Chair, NDP, Hélène LeBlanc]

Good afternoon, everyone, and welcome to the 13th meeting of the Standing Committee on the Status of Women. The meeting will exceptionally end at 5:15 p.m., so that the subcommittee can sit for 15 minutes. Joining us today are three groups of witnesses. By finishing at 5:15 p.m. today, we will be able to plan the rest of the study.

In addition, supplementary estimates (C) were sent to the members of the committee on February 13. The committee can study the estimates and report on them or shall be deemed to have reported on the supply for supplementary estimates (C) by March 7, at the latest.

I would now like to welcome our witnesses. Today, we are hearing from Dr. Wendy Spettigue, who is here on behalf of the Canadian Academy of Child and Adolescent Psychiatry. We are also welcoming Dr. Lisa Votta-Bleeker, Deputy Chief Executive Officer and Director of the Science Directorate, as well as Dr. Giorgio A. Tasca, Research Chair in Psychotherapy Research at the University of Ottawa and the Ottawa Hospital. Both of them are representing the Canadian Psychological Association. Also testifying, by videoconference, is Elizabeth Phoenix, Nurse Practitioner from the Canadian Federation of Mental Health Nurses. I would like to welcome her, as well.

Each group of witnesses will have 10 minutes to make a presentation.

Dr. Spettigue will take the floor first.

[Dr. Wendy Spettigue, Psychiatrist, Canadian Academy of Child and Adolescent Psychiatry]

Thank you for the honour of presenting to you on behalf of the Canadian Academy of Child and Adolescent Psychiatry, and on behalf of clinicians who treat eating disorders in youth.

As you know, eating disorders are devastating illnesses. Research suggests that it takes between two and seven years to recover from an eating disorder, and that only 50% fully recover. Eating disorders have the highest mortality rate of any psychiatric illness due to a combination of medical complications and suicide. For a variety of reasons, eating disorders and risk factors for developing eating disorders are on the rise.

I will begin with the social context.

Rates of body dissatisfaction in women are greater than 87%. Seventy percent of women are currently dieting to lose weight. In a survey of North American women, when offered any three wishes, the majority chose weight loss as their first wish. Ten million women in the U.S. suffer from an eating disorder, more than have breast cancer. I wish I had the equivalent numbers for Canada. We need a national registry for eating disorders. Canada does not know the number of eating disorder sufferers, the average wait times for treatment, or the percentage of patients who get treatment.

Here are more statistics. Forty to fifty per cent of girls aged 11 to 15 years say they need to lose weight, and 61% of Canadian grade 7 and 8 students were trying to lose weight. Researchers in Edmonton studied 700 children in grades 5 to 7. They found that more than 15% were purging or over-exercising, 16% were binge eating, and 19% were restricting to one meal per day or less.

Why is this significant? In a study of 14- to 15-year-old adolescent girls who engaged in strict dieting practices, they were 18 times more likely to develop an eating disorder within six months compared to non-dieters, and had almost a 20% chance of developing an eating disorder within one year.

Not only are eating disorders on the rise, but pediatric mental illness in general is on the rise in Canada and North America. Here are some more statistics. In any given year, one in five people in Canada experiences a mental health illness. Up to 70% of young adults living with mental health problems report that the symptoms started in childhood.

Severe, disabling mental illness has dramatically increased in the United States. In 2011, Marcia Angell reported that mental disorders in children increased by a startling 35 times between 1987 and 2007.

In 1998, Dr. Martin Seligman, then president of the American Psychological Association, presented the results of his research. He reported:

...there is now between ten and 20 times as much [depression] as there was 50 years ago. And...it has become a young person’s problem. ...thirty years ago...the average age of which the first onset of depression occurred was 29.5. Now the average age is between 14 and 15.

These statistics are valuable because, as a child and adolescent psychiatrist, it is important for me to put eating disorders into context, given that eating disorders are highly associated with other mental illnesses, especially with depression and anxiety.

Happy youngsters don’t develop eating disorders. An eating disorder develops when a young person feels not good enough, or literally and figuratively, as though they don’t deserve to take up a normal amount of space in this world. Eating disorders arise when a young person feels scared, sad, worried, guilty, angry, stressed, or unworthy to such an extent that starving herself seems like a better alternative, a way to cope with those intolerable feelings and to help her feel good enough. An eating disorder is thus a form of self-treatment akin to drug and alcohol addictions, only in this case, the youth gets addicted to bingeing and purging or to seeing the numbers on the scale go down.

Unfortunately, one side effect of lack of nutrition is increased obsessiveness, so what might start out as a diet or weight loss plan can spiral out of control into an illness similar to obsessive-compulsive disorder, in which the obsessive thought is “I’m eating too much, I’m gaining too much weight”, and the patient then feels compelled to decrease the intensity of these obsessive worries through symptoms such as restricting, purging, and exercising.

Associated extreme hunger can then lead to bingeing, although in children, they often just continue to restrict, and lose more and more weight.

Thus, as you can imagine, eating disorders are highly associated with other mental illnesses, including anxiety, depression, obsessive-compulsive disorder, and substance abuse. As those illnesses increase in number so do eating disorders. But other factors are also associated with the rise in eating disorders, including an increase in anxiety about the food we eat and the epidemic of obesity; an increasing emphasis on appearances and celebrity culture; and the huge diet and weight loss industry, all of which lead more and more young females to feel self-conscious and not good enough about their looks.

As mental illnesses and eating disorders have increased the resources and small number of clinicians available to treat these disorders have not been able to keep up with the demand. The number of family doctors trained in the treatment of eating disorders is almost nil. Community mental health agencies lack time or funding for training in eating disorders, and are overwhelmed by mental health referrals in general. There is a terrible shortage of psychiatrists across the country, even fewer child and adolescent psychiatrists, and only a very small handful of us who have specialized training in the treatment of pediatric eating disorders.

So what can we do to improve the situation? Let’s examine the various levels of intervention, starting with prevention.

One challenge is that efforts to prevent obesity have actually increased the number of eating disorders. I am frustrated by hearing one story after another of young girls whose eating disorder was triggered by a health class, school project, teacher, coach, or family doctor. We need more research into the causes and risk factors and how to prevent eating disorders, including how to prevent obesity without causing a concomitant increase in eating disorders.

We need to find a message of balance, moderation, size acceptance, and healthy body image that applies to all. We still don’t know enough about how to prevent eating disorders. We know that teaching eating disorders in school not only does not help, it actually increases the number of eating disorders. Yet, have we been effective in changing this in the schools? No. It is part of the curriculum and thus difficult to change.

We also need to do a better job of teaching family doctors and medical students, not just about eating disorders but also about the dangers of dieting, that low weight is as unhealthy as overweight, and how to treat obesity without causing eating disorders.

We need to train family doctors to screen for eating disorders and to have the language to talk to girls about nutrition, body image, and eating disorder thoughts, urges, and symptoms.

We need to send more trained mental health nurses into the high schools to help young people who are struggling with depression, anxiety, and eating disorders.

We need more trained community health counsellors who can counsel students who suffer from depression, anxiety, self-injurious behaviour, eating disorders, and addictions.

At the secondary level of care, we find girls with severe anorexia nervosa admitted to smaller community hospitals where the doctors and nurses do not understand eating disorders and are frustrated by the adolescent’s stubborn refusal to take nutrition. They resort to behavioural approaches, which often involve sending parents away while the young person stays alone in bed all day until she earns her privileges. This doesn't make sense when you understand that the patient is being controlled by the illness, rather than the other way around.

I also hear horror stories of young girls being sent home from the emergency department at dangerously low weights because their blood work is normal. If only the doctors understood that these girls meet the definition of medically unstable by their low weight alone, despite their body’s attempts to compensate for the starvation.

I hear of family doctors who, when faced with teenage girls with obsessive exercising and low heart rates who have lost their menstrual periods, reassure concerned mothers that this is just an effect of being a top athlete.

I often hear my colleagues in child psychiatry say they don’t treat eating disorders, or they don’t get eating disorders. They can't understand how an underweight teenager can refuse food because she's “too fat”. If only they could be helped to understand that this is similar to a person with obsessive-compulsive disorder, who can't stop cleaning their house or washing their hands. It has nothing to do with how clean the house is or how dirty their hands are but instead with the intensity of the obsessions and compulsions.

Many clinicians find it too frustrating to treat an illness in which a young person is extremely medically and psychologically compromised, is angry and depressed, does not want help because she's terrified it will cause weight gain, often resists treatment, and usually takes a very long time and a lot of specialized care to treat. The clinician has to be comfortable working with not just these patients but also their families. Given that most communities have a terrible shortage of child psychiatrists, few of these psychiatrists have enough time to dedicate to these patients or to their distraught, exhausted parents and families.

[The Chair, NDP, Hélène LeBlanc]

Dr. Spettigue, I thank you very much for your testimony. I know you are not finished, so I am telling the members we will have the whole testimony of Dr. Spettigue translated and distributed to members.

Hopefully, during the question period you will be able to complete your testimony with the rest of your presentation.

Thank you very much.

Now I would like to hear from the Canadian Psychological Association, for 10 minutes, please.

[Dr. Giorgio A. Tasca, Research Chair in Psychotherapy Research, University of Ottawa and the Ottawa Hospital, Canadian Psychological Association]

Thank you for inviting us today. The Canadian Psychological Association is the national association for psychology in Canada. There are approximately 18,000 psychologists in Canada, making up the largest group of regulated specialized mental health care providers in the country.

Psychologists are committed to evidence-based care—that is, care that is clinically effective and cost-effective. We accomplish this by developing, delivering, and evaluating treatments and programs across a wide range of mental and behavioural health disorders, including eating disorders.

Eating disorders are characterized by severely disturbed eating behaviour, body image, and self-esteem, which typically begin in adolescence or young adulthood. Although boys, men, girls, and women can all be affected by an eating disorder, eating disorders typically affect 10 times more females than males.

Two of the most commonly known eating disorders are anorexia nervosa and bulimia nervosa. Anorexia nervosa is characterized by a refusal to maintain a normal body weight through severe dietary restriction, while bulimia nervosa is characterized by eating an excessive amount of food and losing control during that episode, which is called a binge, followed by purging, usually by vomiting. Binge-eating disorder, which is less well known but is actually the most commonly occurring eating disorder, involves binge eating without purging.

The lifetime prevalence for anorexia nervosa is about 0.9% of the population, for bulimia nervosa it's about 1.5% to 2% of the population, and for binge-eating disorder it's 3.5%. The prevalence of eating disorders, though, is highest among teenage girls and young women.

As Dr. Spettigue mentioned, although we don't have a registry in Canada, if we extrapolate those percentages to the Canadian population we can guess that about 450,000 to 500,000 Canadian women have experienced or will experience an eating disorder during their lifetime. The prevalence rates may actually increase in the coming years, partly for social reasons but also because the diagnostic criteria we use for eating disorders have changed. We're finally recognizing that less extreme levels of disordered eating significantly affect health and functioning.

As was mentioned, eating disorders have a devastating effect on individuals and their families. These disorders often co-occur with other debilitating mental health disorders, such as depression and anxiety. Quality of life, work, education, family, and social functioning are all negatively and significantly affected by an eating disorder. As was previously mentioned, compared with all other mental health disorders, anorexia nervosa has the highest rate of death.

Psychological interventions have the best evidence base for treating eating disorders. Evidence-based psychological treatments are considered by most international treatment guidelines to be the first line of intervention for most eating disorders. Treatments can be provided on an outpatient basis for less severe cases. However, specialist care is required for more severe individuals in both day treatment and in-patient programs for those who are medically compromised.

Successful treatment of eating disorders depends on a comprehensive plan that includes ongoing monitoring of symptoms and stabilizing nutritional status; psychological interventions that include cognitive behavioural therapy, personal psychotherapy, and family counselling; education and nutrition counselling; and in some cases medications.

Often primary care is the first place those suffering with an eating disorder go to for help, so it's critical that family physicians are educated as to the seriousness of eating disorder symptoms, to be able to recognize when there's an eating disorder present and to recognize when the patient requires specialist care.

[Dr. Lisa Votta-Bleeker, Deputy Chief Executive Officer and Director, Science Directorate, Canadian Psychological Association]

Madam Chair, one of the greatest challenges when it comes to caring for the mental health of Canadians is the significant barriers to accessing mental health services. Only one-third of those in need of mental health services will actually receive the help they need. We have psychological treatments that work and experts who are trained to deliver them. Because these services are not funded by provincial health insurance plans, and because private insurance offered by most plans is frequently too little to allow for meaningful service, Canadians cannot often access the services they need.

The cost of mental illness in Canada is estimated at $51 billion annually. In response to Canada's national mental health strategy, which called for increased access to evidence-based psychotherapies by service providers that are qualified to deliver them, the Canadian Psychological Association commissioned a report to look at how this can be achieved. It is our association's position that psychological assessments and treatments for all mental health problems, including eating disorders, are a necessary basic health service. As concerns eating disorders in particular, several of the models that were recommended in the report we commissioned are especially relevant.

First, Canada needs to integrate psychologists on primary care teams. Various estimates are that 30% to 60% of visits to family physicians and primary care are for, or related to, a mental health problem or disorder. With psychologists working or consulting with primary care, a youth or young adult who presents with an eating disorder will have access to the right care in the right place at the right time.

Patients with eating disorders are often ambivalent about seeking help, so their symptoms can be easily missed in a busy family practice. Having a mental health specialist like a psychologist in primary care settings can reduce these missed patients. Further, girls and women with mild eating disorder symptoms can be cared for by a specialist in a private office. This would reduce the burden on tertiary care centres and provide family physicians with specialists to whom they can refer a patient with an eating disorder.

Second would be to include or maintain psychologists on specialist care teams and secondary and tertiary care facilities for health and mental health conditions. Budget cuts to secondary and tertiary care centres in recent years have reduced the availability of psychological and other services to patients with eating disorders. Given the incidence and prevalence of mental disorders, particularly eating disorders, we need to maintain and augment our mental health resource within publicly funded health care institutions.

Third would be to provide sustained funding for community-based resource and support centres to help those who are recovering from an eating disorder. These centres currently receive little or no public funding and depend on a range of health care providers and services for their success.

Finally, Canada needs to expand private insurance coverage and promote employer support for psychological services. The best mental health return on investment is when services and supports are provided for children and youth. Most mental health disorders begin before young adulthood, and this, as we've heard, is especially true of eating disorders. Children, youth, and families need better access to needed psychological care, whether in a health facility, a primary care setting, or a community-based centre.

It is CPA's mandate and commitment since the commission of our 2013 report to speak with funders of care, and the organizations and agencies that deliver it, to create parity in how Canada takes care of the mental and physical health of its citizens.

Thank you.

[The Chair, NDP, Hélène LeBlanc]

Thank you very much.

Now, Ms. Phoenix for 10 minutes.

[Elizabeth Phoenix, Nurse Practitioner, Canadian Federation of Mental Health Nurses]

Thank you.

As a tertiary care nurse practitioner, I bring 22 years of mental health experience to this consultation session. During my career I have been a part of system and program development in geriatric mental health, adult mood and anxiety. I spent nine years as a pediatric mental health nurse practitioner, and two years as an adult eating disorders nurse practitioner. Along this journey I have been a witness and influencer of implementing evidenced-based mental health treatment. This is a value I hold very strongly as a right for all our mental health patients and families to receive the best of care and the most appropriate level of care. This has lead me to believe that quality research and evidenced-based treatment should inform and guide practice. This evolves from effective training and knowledge dissemination. This body of research should guide policy-makers and decision-makers in the development of programs.

How can this happen? It commences with the collection of research and expert input, such as what we are engaged in today, and it continues with the commitment to excellence in treatment that is the right of all our patients and families.

My additional comments are going to be structured based on the three asks that have been brought forward by previous members consulted before.

Family physicians and nurse practitioners are well positioned as primary care providers to screen and diagnose eating disorders. It is imperative the current and new diagnostic criteria from DSM-5, which was published in May 2013, be taught in education programs and also to practitioners currently in practice. In particular, an existing barrier to timely referral of individuals with eating disorders is the preoccupation by primary care providers with weight and seemingly normal blood work. When weight and blood are within normal limits practitioners, patients, and families can easily think that the individual is still well. Current DSM-5 criteria remove the stringent weight criterion and the amenorrhea, or loss of menstrual cycle, diagnostic measure that previously we had to work with.

Physicians and nurse practitioners need to better understand and communicate to patients that although their blood work can seem normal, their body stores of these elements are significantly depleted and a reflection of their malnutrition. So they may appear to be a healthy and normal weight, but indeed they are not. More telling of their clinical impairment are their thoughts and feelings about their body shape and weight, and their impaired relationship with food. Clinically I have seen this time and again with our patients who are normal weight and have normal blood values.

An 18-year-old I co-treated this past year with our in-patient medical team met this description—

[The Chair, NDP, Hélène LeBlanc]

Ms. Phoenix, just slow down your delivery a little bit so the translation can keep up. Okay?

[Elizabeth Phoenix]

Sure. I'm just mindful of the time.

[The Chair, NDP, Hélène LeBlanc]

Thank you very much for your collaboration.

[Elizabeth Phoenix]

Okay.

Clinically I have seen this time and again with our patients who are normal weight and have normal blood values. An 18-year-old I co-treated with an in-patient medical team last year met this description. However, she had been extremely symptomatic two months prior to hospitalization with bingeing and purging up to eight times per day. She was extremely malnourished as a result; however, her weight was stable and blood work was normal.

While she was in hospital she contracted pertussis, which is whooping cough; she developed Stevens-Johnson syndrome, which is a systemic potentially life-threatening rash; and two pre-arrests were required as result of adult respiratory distress syndrome. It gradually made sense to her treating medical team that she was immunosuppressed and at risk due to her eating disorder symptoms, despite the fact that on paper her weight and blood work appeared quite normal.

I want to draw you a mental picture of what she looked like two weeks into her hospital stay. She was swelling, edematous, from head to toe; she had a rash from head to toe; she was on full isolation—gown, gloves, goggles, masks—and was really unrecognizable by visitors who were coming to see her in hospital. That's how unwell she was.

Integrating 30 nurse practitioners in eating disorders programs in the province of Ontario as an integral part of team structure has been a bold and appropriate step for the province. Nurse practitioners, because of their training and expanded scope of practice, are well positioned to provide efficacious, thorough assessments and treatment of both the mental health and complex physical health needs of individuals with eating disorders.

However, as with physicians, there appears to be inadequate time given in training programs to accurately support screening and identification of individuals who need to be referred on to more specialized services. Further advanced training for nurse practitioners to work with this complex population needs to continue and should serve as a model for other provinces to follow.

Training opportunities could occur through advanced clinical fellowships already offered through the Registered Nurses' Association of Ontario. This process matches experts with novice nurse practitioners to share knowledge through praxis and mentorship. All provinces have professional nurses' associations already to facilitate this framework or model.

Curricula could be developed and followed so that consistency of evidence-based practice is disseminated. In addition to increasing training in medical program curricula and opportunities for clinical training, this would be extremely beneficial.

In addition to increasing training opportunities for eating disorders, it's an important first step to establish Canadian practice guidelines for physicians, nurses, and nurse practitioners in primary care. Practice guidelines have been a reliable method for primary care providers to provide evidenced-based, consistent medical care to their patients over the last several decades. They have become an essential component of evidence-based practice in primary care and could facilitate more consistent screening, early identification, and appropriate referral for specialized treatment of eating disorders in the future.

Good data should inform decisions regarding practice. How do we get good data? As previous presenters have explained, a national registry as requested by previous clinicians would be a process to better understand the scope of eating disorders in our communities in each province. This data should be collected to track the incidence and prevalence of eating disorders, the wait times for assessments and treatment, and the outcomes from the branches of services provided. It should also track dropouts from treatment and the state of wellness achieved by those who receive treatment. Are they relapsing? Are they moving on to develop a quality of life that ensures they are contributing members of society?

Allowing treatment outcomes to be monitored on a federal level would allow us to truly know how well we are doing in the treatment of eating disorders. Further, such tracking would allow us to better assess the impact of training initiatives and efforts to improve access to quality care.

I would like everyone to imagine the following scenario. Two medications exist for a terrible illness. One of the medications has been around for a while and works for 15% of the population. One of the medications is newer and requires training to be able to administer and when properly administered, it works for about 45% of the population.

Would you, the members of this panel, be okay with the following arguments about why we should keep using the first medication? I would love to learn how to administer the new medication, but I don't have time to learn the new technique; or I don't live in a major centre and I can't find someone to train me in using the technique; or the philosophy associated with the new medication does not match my own philosophy. Which of these arguments would alleviate the duty to ensure best practice and best care is delivered? Which of these arguments would work to quell the outrage of the 30% who would have improved had they received the new treatment?

I would suggest that none of these arguments are acceptable and that they're often used in the treatment of eating disorders to rationalize the lack of use of evidence-based practice. Evidence-based practice, as my colleagues have explained, exists for eating disorders and it is important to note that not all treatments for eating disorders are equally effective.

For example, Poulsen and colleagues conducted a randomized control trial comparing cognitive behavioural therapy, CBT, and psychoanalytic psychotherapy for individuals with bulimia nervosa. The psychoanalytic psychotherapy lasted approximately three times longer. At the end of treatment, only 15% of individuals in this group were no longer binge eating compared to 44% of individuals who received CBT.

Clinicians in Calgary were surveyed to explain regular treatment for eating disorders. They found that out of the 52 clinicians who participated, 32.7% used CBT and 1.9% used interpersonal psychotherapy, IPT, as their primary approaches to treatment. Note that 86.5% and 53.8% of clinicians also stated that they used CBT and IPT respectively often or always, although it was unclear whether the treatment carried out by these clinicians was consistent with the manualized treatment approaches that have been studied.

A more recent study surveyed individuals who belonged to one of international eating disorders organizations for whom it might be expected that the use of evidence-based treatments would be higher. Out of the 402 participants surveyed, between 35% and 44% of clinicians exclusively used an evidence-based treatment for individuals with various eating disorders.

These findings further suggest that many therapists do not carry out evidence-based treatments in the manner consistent with treatment manuals. All of this evidence suggests that the treatment we deliver to sufferers does matter and that currently, evidence-based practice is not consistently used. Further, many treatment programs are not asked to prioritize longitudinal program evaluation, which would allow us to examine how effective our treatment programs really are.

I believe that in order to ensure we are most effectively using our health care dollars, there needs to be a national strategy to support the use of evidence-based care in the treatment of eating disorders, as our current efforts are not ensuring that we are giving people the most effective treatment. A significant step towards this goal would be the creation of a national research chair on empirically supported treatment for eating disorders. An important next step would be the creation of a centre of excellence for the treatment of eating disorders where programs that use evidence-based best practices in outpatient, day treatment, and in-patient settings of care would serve as a model and training ground for other programs throughout Canada.

Thank you very much.

[The Chair, NDP, Hélène LeBlanc]

Thank you very much.

Now for seven minutes, we have Mrs. Truppe.

[Susan Truppe, Conservative, London North Centre, ON]

Madam Chair, I'd like to thank our guests who are here in person and by video conference for sharing their expertise with us. We really appreciate that. We always look forward to hearing from the witnesses and learning more about eating disorders.

I'll start with Ms. Phoenix, and maybe, if time permits, I'll have a couple of questions for all of you.

Are nurse practitioners and mental health nurses taught about eating disorders or given training as part of their curriculum? I know you said that 30 were integrated. What about the rest? What about the other practitioners? Do they receive any training on eating disorders?

[Elizabeth Phoenix]

You're talking about registered nurses, first of all.

[Susan Truppe, Conservative, London North Centre, ON]

That's right.

[Elizabeth Phoenix]

In undergraduate programs in Ontario there is a mental health component that is part of the curriculum. Eating disorders might get one or two lectures out of that mental health curriculum. It's very minimal.

[Susan Truppe, Conservative, London North Centre, ON]

Is anyone taught to look for warning signs of eating disorders?

[Elizabeth Phoenix]

You're talking about screening? Yes. That would be part of those lectures, but again, it's very brief, and how that gets picked up into clinical practice is really tough to evaluate. I mentioned best practice guidelines used by the RNAO, which in particular in Ontario have been a really efficacious way to disseminate screening and early identification practices in the treatment of other chronic illnesses like asthma and diabetes. That would also be a really good model to follow in the treatment of eating disorders, and it would be good for primary care physicians.

[Susan Truppe, Conservative, London North Centre, ON]

Do you have any other best practices you would like to mention while I have you here? Is there anything else you think is really great that should be shared with other people or other provinces?

[Elizabeth Phoenix]

Do you mean specific to eating disorders? Because there have been many best practice guidelines launched and disseminated across Ontario. I think probably the big red-letter one at the moment is the smoking cessation program, which has been a really great program. The model and framework have been well formatted and developed over the last 15 years through RNAO, so it's a proven model that works.

[Susan Truppe, Conservative, London North Centre, ON]

Very briefly, can you describe the smoking cessation model you're talking about?

[Elizabeth Phoenix]

I haven't been part of that program myself; it's just been implemented in the last decade in Ontario. I think what I'm highlighting is that best practice guidelines through the nursing organization have been effective. For primary care physicians, practice guidelines have been another very effective strategy for screening and early identification, which are essential. Eating disorders are really being missed in lots of folks, and they're not being picked up on by primary care providers.

[Susan Truppe, Conservative, London North Centre, ON]

Thank you. I've heard that from several witnesses, that they're being misdiagnosed or missed altogether, and therefore bigger problems occur.

Thank you.

My next question is for Dr. Spettigue.

You mentioned at the beginning that it takes two to seven years to recover and that not everybody does recover. What are some of the treatments that help recovery in the two to seven years?

[Dr. Wendy Spettigue]

I should point out that those are older statistics and that they are for young adults or a study in adults. We think things are starting to get better for young people and for pediatric eating disorders because of the recognition of the need to involve families.

An exciting development you will have probably have heard of is the fact that family-based therapy, also known as Maudsley family therapy, has been studied enough for us to recognize that it is effective in young people and that it is the recommended treatment for restrictive adolescent eating disorders. The exciting thing about it is that it's effective and it's not particularly expensive, compared to in-patient hospitalization. It's an outpatient treatment.

Our problem at CHEO was that we were funded for an in-patient program and a day treatment program, but we never received funding for an outpatient program. The recommended treatment is outpatient family therapy. We've struggled with the fact that we don't have outpatient therapists, but if we just treated patients in hospital who were medically unstable and we discharged them, they wouldn't get better. There are no community resources to do this. Our team ended up doing it and following them. The program evaluation and outcomes are very positive and effective, but as a result we got very backed up with a one-year waiting list and had to close our program and try to figure out what to do about all of this.

[Susan Truppe, Conservative, London North Centre, ON]

Thank you.

In your opinion, why do you think it works so well with groups and families versus working with the individual directly, getting the families involved? Obviously, it sounds like it's working well, but why is it working well?