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.