A Clinician’s Perspective on the Ontario Health Eating Disorders Quality Standard

Prior to the COVID-19 pandemic, eating disorders were common, with a lifetime prevalence of about 15 percent. 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%.

Treatment Challenges

There are well-researched effective psychological interventions to treat eating disorders, including specific cognitive behavioural 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 long. 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. 

An Urgent Need

In response to these challenges, Ontario Health recently 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; psychotherapy; monitoring and medical stabilization; support for family and caregivers; physical, mental health and addiction comorbidities; promoting equity; and 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. 

Accompanying the Eating Disorders quality standard are useful resources for providers, including a patient guide and caregiver guide that providers can share with people with eating disorders and their families, a two-page placemat for use at the point of care, and a performance measurement guide with technical specifications for the indicators within the quality standard.

Evidence-Based Psychotherapy

As the Mental Health and Addictions Centre of Excellence works to build a comprehensive and connected system of care for eating disorder, an initial area of focus will be to improve timely access to evidence-based psychotherapy that considers the needs and preferences of the individual with an eating disorder and, when appropriate, family and caregivers (Quality Statement 4). When people receive timely access to effective evidence-based psychotherapies, they have the opportunity to recover sooner and may be less likely to relapse, which is best for the individual, their loved ones, and the healthcare system. 

Ideally, psychotherapy should begin within four to eight weeks following comprehensive assessment. 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.

First-Line Treatments

For children and young people under age 18, family-based treatment (FBT) is the first-line recommended treatment for anorexia nervosa or bulimia nervosa.  If FBT isn’t effective or suitable, 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 the first-line recommended 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 a recommended treatment. 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.

Learn More

With the apparent increased incidence of eating disorders and long wait times for treatment in many areas of Ontario, this is an urgent issue with many opportunities to improve care. 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.

Please share this quality standard with your networks. Also, note that 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.

Author Biography

Dr. Kathryn Trottier is a clinical psychologist and Clinical Program Lead for the Eating Disorders Program at University Health Network, and Provincial Clinical Lead for Eating Disorders at the Mental Health and Addictions Centre of Excellence. She was also the co-chair of the Eating Disorders quality standard advisory committee.