American Psychiatric Association new guidelines on eating disorders

Eating disorders are a complex constellation of medical and psychiatric conditions, and a one-size approach doesn’t fit all, according to the newly updated guidelines on eating disorders from the American Psychiatric Association. The guidelines emphasize individualized patient-centered care, taking cultural backgrounds into account, dealing with comorbid conditions, and include a variety of treatment modalities from medications to different types of therapy. They provide excellent information, and, along with the DSM-5 section on eating disorders, are a good source for doctors in Canada to turn to, said Dr. Robbie Campbell, professor emeritus of medicine at Western University and president of the Eating Disorders Foundation of Canada (EDFC). He was not involved the writing of the guidelines. The Canadian Psychiatric Association has no official guidelines on the topic. Dr. Campbell noted the guidelines emphasize identifying and dealing with comorbid conditions. There are numerous conditions that trigger, make worse, or result from eating disorders such as anxiety, depression, substance abuse, appetite dysregulation, PTSD and other types of trauma, history of abuse and others which can be intricately woven with an eating disorder. Ignoring other psychiatric or medical issues can lead to lower success in treating an eating disorder. “You have to look at the whole person,” he told the Medical Post in an interview. At the same time, it takes a team to help patients. “Treating an eating disorder isn’t a one-person effort.” Indeed, the guidelines recommend “that patients with an eating disorder have a documented, comprehensive, culturally appropriate, and person-centered treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team.” And that the “initial psychiatric evaluation of a patient with a possible eating disorder identify co-occurring health conditions, including co-occurring psychiatric disorders.” A multidisciplinary team can include psychologists, occupational therapists, recreation therapists (to encourage healthy forms of exercise), case managers, social workers as well as medical specialists if there are associated cardiovascular, endocrine, gastrointestinal or other conditions that need attention. Patients with a possible eating disorder should have assessments done of their “vital signs, including temperature, resting heart rate, blood pressure, orthostatic pulse and orthostatic blood pressure; height, weight and BMI (or percent median BMI, BMI percentile or BMI Z-score for children and adolescents); and physical appearance, including signs of malnutrition or purging behaviors,” the guidelines said. As well, lab assessments should be done of blood samples and a metabolic panel including electrolytes, liver enzymes and renal function tests. Electrocardiograms may also be appropriate in some patients. The 122-page guidelines also come with a five-page executive summary published in the American Journal of Psychiatry. “The summary really captures the salient points that can help doctors diagnose and start treatment plans,” Dr. Campbell said. But even the presence of good guidelines doesn’t help some of the real problems doctors and patients face—dealing with systemic problems that limit how much care patients can actually get. For example, a referral from an FP can take several months to a year. Then, getting an appointment and referrals to other specialists and services takes more time on top that. It can be years before a patient starts getting the level of care they need, Dr. Campbell said. Plus, there are out-of-pocket costs most patients can’t afford—with costs from psychological counselling, occupational (and other) therapists, and other services not covered by provincial plans to the tune of $20,000 each month, he said. It takes time to treat these patients, he stressed. While people who get to a severe state end up as in-patients in hospital, there is a lack of help once they are discharged. They shouldn’t be just sent back home or they can quickly relapse. “They need transitional care” to help support them practicing healthier eating habits and to continue addressing underlying causes, he said. In his own efforts, Dr. Campbell is part of a team developing a model for transitioning care for students with eating disorders through Western University. He hopes a preliminary version of the program will be launched in the fall of this year. Canadian doctors can also get guidance from the Canadian Eating Disorders Strategy 2019-2029, developed by the Eating Disorders Association of Canada, the EDFC, National Eating Disorder Information Centre, and National Initiative for Eating Disorders. It outlines approaches to public education, prevention, caregiver support, addresses types of treatment options available across the country (some more than others depending on the province), therapeutic approaches and more. It also highlights suggestions for improving treatment access and healthcare provider training. It also shows the problem with eating disorders is not trivial, with about a million people in Canada meeting the diagnostic criteria for having an eating disorder. Eating disorders are “serious but treatable mental illnesses that can affect anyone regardless of gender, age, racial and ethnic identity, sexual orientation or socio-economic background,” the document said. Unfortunately, most patients either don’t seek out treatment, can’t get it, or face big delays that can sometimes be fatal. It also stated “The social and economic costs of untreated EDs are similar to those of depression and anxiety, with debilitating physical and mental health effects comparable to psychosis and schizophrenia.” Eating disorders also have the highest overall mortality rate of any mental illness, with estimates between 10%-to-15%. Suicide and cardiac disease are the leading causes. But deaths may be underestimated, as cause of death if often attributed to something such as a heart attack without noting that the cardiac problems were the consequence of an eating disorder, Dr. Campbell said. Or a death from a diabetic complication resulting from a binge-eating disorder. When dealing with younger patients, doctors can also turn to “The Canadian practice guidelines for the treatment of children and adolescents with eating disorders” published in the Journal of Eating Disorders in 2020 and developed by a group of researchers.

American Psychiatric Association new guidelines on eating disorders

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