Issue 65 | COVID-19 and Eating Disorders
About this resource
The arrival of the COVID-19 pandemic marked the beginning of a series of significant and evolving changes that show few signs of ending soon. In Australia strict lockdowns are beginning to ease and infection rates are relatively low. There are both challenges and opportunities ahead.
In this issue we will look at the impact so far of the global pandemic on the eating disorder community.
We’ll discuss the effects on people with eating disorders, including innovations in treatment, coping with the potential consequences of enforced isolation and increased anxiety on mental health and dealing with the difficulties caused by food shortages and panic buying.
We will consider the practical issues faced by people supporting and caring for those with an eating disorder, dealing with potential mental health complications caused by enforced inactivity and coping with quarantine.
We’ll also examine the new demands faced by health professionals, from the wide-scale transfer to telehealth, working with restrictions affecting face-to-face sessions and day programs and improving online treatment.
There is an interview with NEDC chair Professor Phillipa Hay and Steering Committee member Professor Stephen Touyz that expands on topics touched on in their recent article in the Journal of Eating Disorders, which includes a call for research on Eating Disorders in the time of COVID-19.
We will also look at ramifications for research, with conferences cancelled or going online and trials stopped, but there are hopes for new studies.
Since the beginning of the pandemic we have been collating and updating COVID-19 information on our website from evidence-based organisations and other trusted sources. Please check our COVID-19 Latest information page here for a list of regularly updated curated links.
As a community we are still finding our way in the “new normal” but a crisis can hold opportunities in producing innovations and creating new pathways in evidence-based eating disorder treatment.
Australia has been relatively successful at keeping the virus at bay in the general community. Government-mandated travel bans, strict lockdowns and physical distancing requirements have kept infection numbers down.
Telehealth expansion ensures patients can continue to receive care for their eating disorder, with new telehealth item numbers available to support providers to deliver this.
For people with eating disorders, there have been several innovations in treatment, particularly in regard to telehealth. Many practices have switched to providing care by telephone and online, through Zoom, Skype and other video-linked counselling session formats. EDQ has created an online guide for people undergoing telehealth treatment with tips about creating a safe space and dealing with technical issues,
Eating disorders thrive in isolation. To combat this, eating disorder organisations have shared information on coping with social isolation, quarantine and increased anxiety about mental health, with solutions offered for keeping up with treatment, staying connected despite the need for social distancing, keeping physically active and avoiding unhealthy media habits. The Butterfly Foundation, EDV, EDQ, and the InsideOut Institute have all published tip sheets, with practical advice for parents and caregivers available from EDFA and F.E.A.S.T. and mental health advice from the Department of Health.
Food shortages and panic buying were thankfully a short-lived feature of the pandemic but allowances were made for people with eating disorders by some grocery stores.
The sudden wide-scale transfer to telehealth after the Health Minister Greg Hunt’s announcement on the expansion of telehealth services on March 23 was a challenge for health professions who have embraced the necessary change. Telehealth could be instrumental in future efforts in building the system of care in Australia, particularly for providing access to services for people in rural and remote locations.
The NEDC created a helpful guide to MBS item numbers aimed at health professionals. Other useful resources include Mental Health Online’s guide to setting up a practice for telehealth services and the Department of Health’s online training modules for health care workers.
There are guide sheets for primary care practitioners and mental health clinicians and services with development led by CEED in collaboration with EDV, NEDC, EDFA and Austin Health, Monash Children’s Hospital and Royal Children’s Hospital. Related resources for people experiencing eating disorders and their carers have been developed by the same collaboration, led by EDV.
ANZAED has also published useful advice for eating disorder clinicians, including Australian and New Zealand government information, Australian Psychological Society guidelines on using telehealth, and video support for therapists.
In the article 'Eating disorders in the time of COVID-19', the co-editors of the Journal of Eating Disorders have put out a call to the sector to “rapidly develop a repository of comments, protocols, case histories, pertinent literature reviews as well as empirical papers” on the topic.
The journal’s co-editors, NEDC chair Professor Phillipa Hay and Steering Committee member Professor Stephen Touyz, co-authored the article, which was published on 20 April, with Professor Hubert Lacey of the Nightingale Hospital.
The NEDC interviewed Prof. Hay and Prof. Touyz and asked them to expand on their thoughts about what COVID-19 means for the eating disorder community.
“We will need to study what happened because it may not be the last pandemic in the modern world,” Prof. Hay said. “We have to study it to find out what happened with hospital admissions, what happened with treatment services, and what we can learn.”
Prof. Touyz added that in some ways, “this is a wonderful opportunity … we’ve been locked in with standard treatments for so long and ... it’s been too hard to innovate. Now (we have) an opportunity to test things out”.
“Maybe post-COVID-19 we won’t go back to the world as it was pre COVID-19. (The thought) that we’re all going to flick back on 30 September – everything goes back to the way it was before - may not actually happen. We don’t know. Now would be the time to do the research,” he said.
THE IMPACT OF ANXIETY, STRESS AND CONFLICT CAUSED BY COVID-19
“Most patients with ED love to have certainty and we’re living in probably the most uncertain times we’ve lived in for 100 years,” Prof. Touyz said. “I would think this would raise anxiety among eating disorder patients.”
Prof. Hay agreed, adding that difficulties for those with eating disorders included a “sense of not being in control of their lives or their destiny”. Circumstances altering rapidly around them, and questions about regular appointment times, clinic opening hours, and changes in funding could cause “a general increase in anxiety in the population, and people who are vulnerable to that are people with other mental health problems, but also people with eating disorders”.
Prof. Touyz said that this atmosphere of uncertainty could also cause problems in families. “Many eating disorder patients, especially those with Anorexia Nervosa or Binge Eating Disorder or Bulimia, are already in conflict with parents around food,” he said. “In a family, if there are arguments about things this is going to escalate. ED patients often are already stressed, are already in conflict and this is likely to lead to further conflict.”
FOOD INSECURTY AND PANIC BUYING
Food insecurity or scarcity and panic buying, which may be particularly problematic for people with eating disorders, are also features of the COVID-19 era, mentioned in in Professors Touyz, Lacey and Hay’s article.
Prof. Hay said panic buying and lack of food in the supermarket was “very triggering for someone who has difficulty with food and buying”.
Prof. Touyz pointed out additional problems, such as difficulties purchasing perceived safe brands and eating alternatives or even takeaway could cause further conflict with families.
“Everyone’s at home, not all parents are wanting to cook all the time, so they’re getting takeaway foods brought in. Again, that would have problems for our patients in terms of the family sitting down and having takeaway chicken. The patient would (say), ‘I don’t know how that was prepared, how that was made, I’m not going to eat it’, so that leads to conflict at home as well,“ he said.
CHANGES IN EATING DISORDER TREATMENT
Standard treatment approaches – hospitalisation, day programs, face-to-face therapy – may not be as accessible in this time of lockdown and diminished hospital services and have already begun changing. What has this meant for people with eating disorders and their clinicians?
“People may delay seeking treatment or may choose not to go to hospital,” Prof. Hay said. ”Their therapist may delay sending them in because of that anxiety. (But) services do still exist.”
“Patients can continue to get treatment during the pandemic. They can get group Zoom programs, they can get individual sessions, you can even supervise someone, watching them on Zoom eating their meal,” Prof. Touyz said. ”You can provide aspects.”
People have accepted online treatment as a viable alternative to traditional treatment.
“We’re living in a pandemic so we’ve got to do what we can,” Prof. Hay said. “We are planning some studies, qualitative-type studies, to work out what people’s experiences were, and what worked and what didn’t work for them during the time of COVID-19. I think that would be most useful.”
THE FUTURE OF TELEHEALTH AND THE ROLE OF ONLINE THERAPIES
The large-scale transfer to telehealth is also having an impact on treatment methods.
“Those who like telehealth might decide they want their treatment to be done solely by telehealth. Some therapists might prefer to work from home now, and just do telehealth consultations,” Prof. Touyz said.
Both agree that online therapy can work, but with some distinctions. “There’s a lot of research around CBT for eating disorders and other disorders, as well as guided self-help and CBT online, so it is efficacious. It does work,” Prof. Hay said.
Prof. Touyz noted that CBT can be done online, but the specifics of COVID-19 restrictions on socialisation and eating out may make the behavioural aspects more challenging to put into practice.
Prof. Hay added that there are physical assessment requirements for people at risk that need to carry on even during restrictions: “You need to see people, there’s that physical aspect of medical monitoring and care. It makes a huge difference, not being able to see someone. They need to be seeing someone.”
FURTHER STUDIES IN TIME OF NATURAL EXPERIMENT
There is a great need for a range of studies in COVID-19 and eating disorders.
“There must be some adults who have an eating disorder and have developed COVID-19 and those are the cases that I’m particularly interested in,” Prof. Touyz said. “We are all sharing our knowledge about how best to treat these patients under COVID-19.”
“It’s like a natural experiment,” Prof. Hay said. “We are studying what unfolds, what’s happening with people.
“That’s why we wanted the call [for papers] to be very broad in terms of research. Some things we will only have case reports and case studies on, and we definitely want those. Fortunately we are one of the few remaining journals who will publish case studies and single case reports.”
“We have to wait and see. We’ve got to learn from this experience too so we can do things better,” Prof. Touyz said. “Sadly, I thought we’d never live through a pandemic but we’ve had SARS and MERS and now this in a short period of time, so who knows when the next one hits. I think we will be a lot better prepared.”
A global pandemic needs a global response. New studies, papers and research from the national and international eating disorder sector can only add to the evidence base that could inform responses to and treatment approaches for people with eating disorders in any future pandemics.
Professor Phillipa Hay
Professor Phillipa Hay is the Foundation Chair of Mental Health, Translational Health Research Institute School of Medicine, Western Sydney University, and Senior Consultant Psychiatrist for Camden and Campbelltown Hospitals. She is also the Director of the Wesley Hospital Eating Disorder Day Program, Fellow of the Academy for Eating Disorders and Editor-in-Chief Journal of Eating Disorders.
Professor Stephen Touyz
Stephen Touyz is a Professor Emeritus in the School of Psychology and Inside Out institute at the University of Sydney. He is a Member of the NEDC Steering Committee and the Federal Government TAG for Eating Disorders. He is the co-editor of the Journal of Eating Disorders.
Current Australian research on COVID-19 with relevance to eating disorders includes The Centre for Mental Health at Swinburne University’s survey ‘COVID-19 and You: Mental Health in Australia Now.’ Open for the first four days of every month, it will run until March 2025.
Another study, ‘Impact of COVID-19 on the sector: Survey to inform the National Suicide Prevention Adviser,’ which closed in mid-April, gathered information about program and service delivery, with the data used to inform the national response and build capacity.
Among the earliest published research is ‘Clinical observations on Caring for Children and Adolescents with Eating Disorders in the Current Coronavirus 19 Pandemic: A Singapore Perspective,’ published in the Journal of Adolescent Health on 7 April.
A Singapore public paediatric tertiary hospital found that practical modifications were required to operate in the post-COVID-19 era. In an inpatient setting, multidisciplinary meetings have been significantly reduced, psychology support reduced as it has been prioritized for outpatient settings, and group meals shifted to individual meal supervision. In outpatient services, FBT appointments have been maintained, as has the referral of new patients. There were also financial impacts on patient families, and training was affected, with residents unable to join outpatient clinics. Increased stress for all health professionals meant that self-care was increasingly important. The study concludes: “More research is urgently needed to understand the psychosocial fallout and evidence-based approaches to manage these issues.”
Research is still continuing in the general eating disorder field as part of the ongoing work of building on the evidence base, although some outcomes will be delayed. Non-pandemic-related studies taking place include a longitudinal study on social networks and eating behaviours and a study into the development of a body image questionnaire.
Due to COVID-19, many upcoming events have been postponed, cancelled or reconfigured into new or experimental formats. Our Upcoming Events page has regularly updated information.
The Eating Disorders Families Australia (EDFA) Pass The Baton Ball has been postponed until 2021, but will take place with the same venue, speakers and entertainment. For more information, click here.
ANZAED and AED are holding the Virtual ICED 2020 conference online from June 11-30. Conference co-chair Dr Anthea Fursland has provided this statement:
“For three years, the Australia and New Zealand Academy for Eating Disorders (ANZAED) has been collaborating with the Academy for Eating Disorders (AED) to hold the International Conference on Eating Disorders (ICED 2020) in Sydney, in June of this year. Although we are extremely disappointed that, due to COVID-19, we are not to be able to hold it in Sydney, we are excited to announce that we are in the process of converting our original face-to-face conference into the Virtual ICED 2020!
We are taking the program online, retaining much of the original scientific sessions, some of which will be presented live. In addition we will be offering social networking events, opportunities to interact with international experts, and Special Interest Group meetings, some of which will be held jointly with AED and ANZAED SIGs.
The scientific program includes the original keynote speaker, Janet Treasure, who will be presenting live (4pm Sydney time) on the original opening date of the conference: Thursday, June 11. Over the following two weeks we will be having four live plenary sessions, each with four International experts, held in the morning. The plenary topics are:
- the status of evidence-based treatments
- transdiagnostic neurobiological approaches and translating these into clinical practice
- food, food choices and eating behaviours.
Further live sessions include three Special Interest Group Panels and seven workshops. Unfortunately, not all will be live in Australia daylight hours, but people can tune in and view these presentations at their leisure. This also goes for over 100 oral presentations and a further twenty workshops, which will be pre-recorded for viewing at a convenient time. Posters will be online too, and there will be opportunities to interact with presenters.
If you are interested, please visit the ANZAED website for more information and to register.
Cognitive-behavioral therapy in the time of Coronavirus: Clinician tips for working with eating disorders via telehealth when face-to-face meetings are not possible. International Journal of Eating Disorders.
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