The COVID-19 pandemic had a broad impact on the social, psychological, financial aspects of many individuals. Global crises affect people’s mental health, and those who already have a diagnosis of mental health disorders are particularly vulnerable to the changes brought about by a pandemic. The fear of contagion related to COVID-19 has left individuals with huge uncertainty and raised significant health concerns. The pandemic crisis has, however, also impacted the mental health of many people as a result of the isolation measures imposed at a global level. The emotional implications of social distancing measures include anxiety, sadness, grief, anger, and loneliness. And while these emotions are challenging even to individuals with no underlying mental health concerns, those with a mental illness diagnosis have found themselves even further affected by the global crisis (1).
Individuals with disordered eating have a dysfunctional relationship with food and this is even more affected at a time of social, financial and food insecurity. While research is yet to document the specific ways in which the current pandemic has impacted the eating disordered community from the perspective of both practitioners and patients, one can speculate about how changes in social norms and in the public healthcare system have influenced individuals with disordered eating. Besides the impact of the stress created by the pandemic, individuals receiving treatment for eating disorders undergo significant changes in the way they receive therapeutic interventions. More specifically, traditional methods of therapy delivery have been shifted towards digital approaches, which ensure safe physical distancing and prevent further contamination.
These current changes in health interventions, albeit effective in nature, can represent significant challenges for individuals with poor mental health, who need consistency and an effective rapport with the clinician. While changing the approach of the therapeutic intervention is challenging and perhaps even distressing for vulnerable individuals, resorting to telemental health can actually be a viable and efficient alternative in the long term.
More studies clearly demonstrate that using teletherapy for the treatment of eating disorders is a safe, evidence-based practice that yields results similar to face-to-face therapy. If this type of intervention is beneficial and meets its aims of alleviating symptoms associated with disordered eating, can we claim that teletherapy can be now seen as a viable alternative medium for the treatment of eating disorders? How are therapy services coping with the current changes and how are they meeting therapeutic goals with their patients? In this article, we will explore arguments based on recent research studies that show how COVID-19 has reshaped the face of eating disorders treatment.
COVID-19’s implications for eating disorders
In the context of the current pandemic, in many healthcare settings inpatient treatments for disordered eating have been restricted to urgent and severe cases (2). Healthcare systems across the globe recommend mental health practitioners to use digital and remote therapy services as much as possible. Remote and virtual treatments for eating disorders have been developed and implemented for over 20 years, and numerous studies have demonstrated the efficiency of such interventions in reducing symptoms of eating disorders (3) (4). Despite the efficiency of digital treatment alternatives, the implications of the current pandemic on the mental health of individuals diagnosed with EDs are serious: A pilot study has examined the effects of two weeks of home isolation on patients with bulimia nervosa (BN) and anorexia nervosa (AN). Self-reports of the 32 patients enrolled in the study showed increased worries related to the uncertainty of the pandemic and the possibility of infections of themselves or loved ones. Furthermore, 38% of the study participants showed worsened ED symptomatology and almost 53% reported increased anxiety and stress which negatively impacted their emotional eating (2). The COVID-19 pandemic affects individuals with eating disorders not only from a psychological standpoint: people with an anorexia nervosa diagnosis who have a low body weight can be vulnerable to COVID-19 because of their compromised physical health and low immune system (1). On the other hand, individuals suffering from bulimia nervosa can be negatively affected by social isolation, as being at home with food provisions can be a trigger for binging and purging episodes. Furthermore, shortage of food items in the supermarket have also been an issue for people who eat specific ranges of food that can become unavailable due to panic buying. The increased stress around food acquisition and availability can trigger even more stress for individuals who already have a dysfunctional relationship around food and eating. A qualitative recent study explored the impact of COVID-related measures on adults with eating disorders in the UK and identified some important findings related to patient concerns (5). Research participants reported worries related to social restrictions, functional restrictions (e.g. lack of routine or structure) and limitations to accessing mental health services. The impact of physical distancing measures was experienced as a trigger for either an increase in disordered eating behaviour or a catalyst for recovery.
Needless to say, the impact of COVID-19 on patients with disordered eating has been clearly negative. The need for therapy intervention increased even further, with more and more individuals resorting to psychology services as a result of worsened mental health. In conditions where physical contact is unsafe especially for vulnerable individuals with compromised physical health, teletherapy seems a safe option which can not only provide the adequate support needed for both eating disorders and the distress created by the pandemic but can also safeguard vulnerable individuals from the risk of contamination. Telemental health can thus become the preferred method of therapy delivery because it meets both the demands of therapy in safe conditions, but it also provides the support needed through challenging times.
Teletherapy, an emerging solution for the treatment of eating disorders
The implementation of telemedicine in healthcare services has increased from zero to 97% patient visits per month (6). Mental health providers quickly identified solutions that replaced traditional in-person therapy with digital interventions. Psychotherapists have adapted their interventions for the treatment of disordered eating in order to fit the virtual format of their interaction with the patient. Although eating disordered care through internet-based platforms, imposes a number of challenges, clinicians can still provide successful outcomes by resorting a number of alterations in their approaches. Typical sessions for disordered eating treatment often necessitate the collection of anthropomorphic data, such as vital signs and body weight. In circumstances where physical presence is impossible, mental health practitioners can implement additional measures that facilitate their interventions. For example, in cases where therapist need to collect the body weight of the patient, family members can be trained to weight the patient and then report the data to the therapist (6). Furthermore, practitioners can also use hospital satellite clinics to collect vital signs of the patient. Another important aspect that practitioners have in sight when administered online treatment for EDs is the assurance of privacy of confidential discussions. Patients are advised to access their therapy sessions from separate devices from the ones used by other family members in order to facilitate safe communication of private and confidential information (6). Even though the treatment of disordered eating through teletherapy can impose some challenges due to the additional data of vital signs that is required to monitor the progress of the patient, there are measures that clinicians can set up in place with the patient, their family members, and other professionals involved in the treatment process that can make online therapy highly efficient.
In cases where the patient displays concerning behaviours and a significant decrease in their mental health and physical symptoms (such as frequent episodes of binging/ purging, weight loss) the provider of the intervention can arrange for the patient to be examined in person in the clinic. Conducting online therapy for EDs can imply more collaborative care and more disciplinary work than the traditional approach to therapy, meaning that the therapist will need to coordinate the work with more individuals in order to collect the required data and to ensure that care protocols are adequate followed.
Digital interventions for eating disorders are convenient and efficient
When the treatment of eating disordered can be managed via online platforms, patients can benefit from particular conveniences from this type of therapy. Patients and their families are spared from the burdens of time and financial costs associated with travelling to care units or clinics. Moreover, they are also minimising the risk of virus transmission, which can pose significant challenges for ED patients who have a weak immune system or low body mass index. Telemental health is not only a more convenient and efficient option during challenging times, but it can also act as a preventive measure against the infection of vulnerable individuals or of those with comorbid diagnoses. Given the increasing measures for physical distancing, online therapy is likely to replace traditional means of in-person therapy, at least for a while.
Research is highly promising in this direction: Teletherapy has been found as an efficient approach for various eating disorders, and other related benefits have been also found, such as:
Increased cost-effectiveness:
A study published in 2009 examined the cost effectiveness of teletherapy versus in-person therapy as alternatives to interventions for the treatment of bulimia nervosa (7). One hundred twenty-eight women took part in the randomised controlled trial who also took part in 20 sessions of therapy spread over the course of 20 weeks. Both groups of participants (teletherapy and face-to-face therapy showed similar improvement in the reduction of their binging and purging symptoms. However, the cost of a recovered participant who was given online therapy was comparatively reduced ($7300.40) to the cost of those who took part in face-to-face therapy ($9324.68 per subject).
Feasibility of treatment for anorexia nervosa(AN):
Teletherapy was also proven as an adequate intervention method for anorexia nervosa (8). A study conducted in 2017 measured the feasibility of the intervention in terms of the effect size on the weight gained by participants during the study. The therapy sessions were delivered in a HIPAA compliant videoconferencing format. The findings of the study provided preliminary evidence for the fact that treatments for anorexia nervosa delivered via a telehealth platform achieved satisfactory clinical outcomes. Therefore, clinicians can use this therapy intervention method for patients diagnosed with symptoms of anorexia nervosa.
Effectiveness of CBT digital interventions for patients with bulimia nervosa:
CBT interventions delivered via videoconferencing can reduce symptoms associated with bulimia nervosa (9). The participants involved in this study used techniques like self-monitoring diaries to measure the effect of the intervention on their bulimic symptoms. Self-reports collected the end of the study revealed clinically significant reduction in binging and purging: three of six patients reported less frequent episodes of binging, and one of five patients reported less purging. Furthermore, participants also showed a reduction on both the Beck Depression Inventory scale and the Borderline Syndrome Index. Finally, the study provides reliable evidence that interventions for patients with bulimia are effective even when they are conducting via online platforms.
Telemedicine is comparable to face-to-face:
Interventions for bulimia nervosa. Further evidence was found for the effectiveness of teletherapy in improving symptoms of BN. In an attempt to make CBT interventions more widely accessible for patients from remote areas, the study included patients who received this type of therapy through telemedicine (10). 118 women took part in this study who measured the efficiency of face-to-face and CBT interventions at weeks two, four, six, and eight of the treatment. The study found that using the measures collected at these intervals are useful for predicting treatment outcomes at the end of the study, and at a three-month and one year follow up after the study. With regards to the comparison of teletherapy versus face-to-face interventions, both approaches provided clinically significant evident for the improvement of symptoms associated with the diagnostic of bulimia nervosa.
Most patients hold positive attitudes towards telehealth for eating disorders:
as featured in a survey study of these attitudes (11). The expressed feedback about the benefits included less stigma, improved access to care, scalability and cost-effectiveness.
Limitations and challenges of delivering online interventions for ED
Despite the conclusive, yet limited evidence that exists on the safety and efficacy on teletherapy, there are situations in which using digital approaches for patients with disordered eating is not a possible alternative. For instance, severe forms of disordered eating require in-person treatment or hospitalisation in adequate clinics. Some patients with EDs can be severely malnourished or underweight, or they might present abnormal vital signs that can endanger their life. In these cases, patients need to be supported in recovering a healthy weight or adequate body weight before being considered for online sessions. Once enough progress has been made and the patients can be discharged from the hospital, therapists can attempt online therapy interventions wherein they work with the patients to change their attitudes, beliefs and view towards food issues. Clinicians are responsible for providing adequate level of care throughout the intervention and for collaborating with other medical professionals to ensure the safety and the health of the patient.
Moreover, one can also argue that more research is to determine the applicability of teletherapy on complex forms of eating disorders. Even though some research has been carried out on the most common ED forms, anorexia and bulimia nervosa, more evidence needs to be provided for other particular forms of EDs, such as “Other specified feeding and eating disorders” (OSFED). More in-depth research on the particularities of various forms of disordered eating would allow clinicians and practitioners to handle complex and novel manifestations of eating disorders symptoms.
Teletherapy shapes the face of future eating disorders interventions
Remote therapy is a novel method that can yield numerous benefits both for the therapist and for the client. In contexts where physical mental health services are challenging or inaccessible, teletherapy is an effective solution that ensures that patients have regular access to mental health support. Besides providing a solution to a highly serious matter, online therapy can also come with a host of advantages that make clients more likely to access and stay in therapy. These benefits can lead to a general improvement of mental health across a population, which eases the burden on the public healthcare system and leads to less adversities associated with poor mental health. Teletherapy is highly likely to shape the future of eating disorders interventions andencourage increased access to psychological treatment services.
References:
1. Touyz, S., Lacey, H., Hay, P. (2020) “Eating disorders in the time of COVID-19”. Journal of eating disorders, 8 (19)
2. Wiley, 2020. “COVID-19 and implications for eating disorders.” European Eating Disorders Review, 28, 239-245
3. Anderson, K., Crosby, R. (2017) “Utilising telehealth to deliver family-based treatment for adolescent anorexia nervosa.” International Journal of eating disorders 50, 1235-1238
4. Mitchel, J., Crosby, R., Wonderlich, S., Crow, S., Lancaster, K., Simonich, H., Lysne, C. (2008). “A randomised trial comparing the efficiency of cognitive-behavioural therapy for bulimia nervosa delivered via telemedicine versus face-to-face”. Behaviour Research Therapy, 46 (5), 581-592
5. Brown, S., Opitz, M., Peebles, I., Sharpe, H., Duffy, F., Newman, E. (2020). “A qualitative exploration of the impact of Covid-19 on individuals with eating disorders in the UK.” Appetite
6. Barney, A., Bucklew, S., Masheriakova, V., Flesch, M. (2020) “The COVID-19 pandemic and rapid implementation of adolescent and young adult telemedicine: Challenges and Opportunities for Innovation” Journal of adolescent health, 67, 164-171
7. Crow, S., Mitchell, j., Crosby, R., Swason, A., Wonderlich, S., Lancaster, K. (2009) “The cost effectiveness of cognitive behavioural therapy for bulimia nervosa delivered via telemedicine versus face-to-face”. Behaviour Research and Therapy 47, 451-453
8. Anderson, K., Bryne, C., Crosby, R., LeGrange, D. (2017) “Utilising telehealth to deliver family-based treatment for adolescent anorexia nervosa.” International Journal of eating Disorders, 50, 1235-1238
9. Simpson, S., Bell, L., Britton, P., Mitchell, D., Bebner, J. (2006). “Does video therapy work? A single case study series of bulimic disorders”. European Eating Disorders Review, 14, 226-241
10. Marrone, S., Mitchell, J., Crosby, R., Wonderlich, D., Jollie-Trottier, T. (2009) “Predictors of response to cognitive behavioural treatment for bulimia nervosa delivered via telemedicine versus face-to-face”. International Journal of Eating Disorders, 42 (3), 222-227
11. Linardon, J., Shatte, A., Tepper, H., & Fuller-Tyszkiewicz, M. (2020). A survey study of attitudes toward, and preferences for, e-therapy interventions for eating disorder psychopathology. International Journal of Eating Disorders. doi:10.1002/eat.23268
