More on COVID-19

As of mid-June, the number of coronavirus cases reported worldwide was 7,997,084, with 435,662 deaths. Better news: to date, more than 4 million persons have recovered.

All aspects of life have been impacted by COVID-19.  This includes providing treatment for those who have eating disorders. Current modeling predicts continuing or recurring impacts from this pandemic over the next couple years (for example, see Kissler et al, Science. 10.1126/science.abb5793 (2020).  For that reason, it makes sense to learn from how the pandemic has impacted some of the regions hit earliest, in order to plan evolving treatment approaches.

Perhaps the earliest report comes from a preliminary paper by Davis and colleagues regarding the experience in Singapore (J Adolesc Health.  This paper describes the experience of an eating disorder service providing care, both inpatient and outpatient, to those 16 and under.

Adaptations have included “modular” staffing with dedicated inpatient providers, rather than crossing over levels of care; retraining of staff to new roles; and more use of telehealth.   High levels of stress for staff members have been noted, including among those not caring directly for people with COVID-19.

Singapore was affected by the pandemic earlier than many parts of the world, so this report provides a useful look forward.

EDs can worsen or relapse during a quarantine

Riccardo Dalle Grave, MD, director of the Department of Eating and Weight Disorders at Villa Garda Hospital in Italy, recently noted that people with eating disorders are at high risk of relapse or the severity of their disorders can worsen because of infection, or the effects of the quarantine, and the shortage of adequate psychological and psychiatric treatments.  His home country, Italy, has had a particularly high fatality rate: thus far, 34,405 deaths and 237,500 cases of the coronavirus.

According to Dr. Dalle Grave, patients’ fears of infection tend to increase their efforts to not lose control by using dietary restriction or other extreme weight control measures or by turning to binge-eating episodes.  Some specific elements of a quarantine, such as separation from others and restriction of movement, can contribute to maintenance of eating disorder psychopathology. For example, the limited possibility of normal walking and exercising can increase a patient’s fear of weight gain, which can accentuate dietary restriction. Access to greater-than-normal food supplies can trigger binge-eating episodes.

With some adaptations, online technology can maintain the delivery of outpatient psychological treatment, says Dr. Dalla Grave. He noted that in coming days the training group of enhanced cognitive behavior therapy  (CBT-E) [see article elsewhere in this issue] is scheduled to release specific suggestions for delivering treatment online and for helping patients with eating disorders cope with the anxiety associated with infection fears and the effects of being under quarantine.

Adverse effects on the ED population

In an editorial in the Journal of Eating Disorders (2020.8:19), Drs. Stephen Touyz, Hubert Lacey, and Phillipa Hay raised questions about the adverse impact that COVID-19 may have on the eating disorder population. For example, in the short term, should people who are undernourished and who have compromised cardiovascular function be admitted for inpatient care?  And, will the number of admissions decrease during the pandemic? Or, because of fears of transmission in the community, would there be a greater sense of safety with admission to an eating disorders program, increasing admissions and placing an increased demand on these facilities? And what about day hospital programs for ED patients during the pandemic?  While group programs directed through videoconferencing are efficacious, the effects of adapting these to half-day and full-day programs have yet to be investigated. Online and alternate ways of delivering care, from brief guided CBT to more comprehensive care, are urgently needed, according to the authors.

Dr. Touyz and colleagues also single out people with bulimia nervosa and binge-eating disorder, who are now at home for 24 hours a day, seven days a week, with no escape from food, and only limited ways to leave home to buy food.  Bingeing on the household’s food when restocking is problematic, can lead to further family conflicts, emotional arousal, depression and anxiety, and even the risk of increased self-harm.

“Both the long-term and short-term consequences of having an eating disorder and COVID-19 simultaneously are still unknown and in time will become more apparent,” the authors write.  The situation calls for rapid development of a repository of comments, protocols, case histories, pertinent literature reviews, as well as empirical papers on this topic.

Telehealth and insurance coverage

Finally, another issue, raised by Lauren Muhlheim, PsyD, CEDS, is the question of health insurance coverage for telehealth services. Although many states and companies have announced telehealth coverage for behavioral health services, the overall question remains unanswered.

According to the website,, Medicare telehealth covers services including office visits, psychotherapy, consultations, and certain other medical or health services that are provided by an eligible provider using an interactive two-way telecommunications system (like real-time audio and video). Starting in 2020, Medicare Advantage Plans may offer more telehealth benefits than did original Medicare. These benefits can be available in a variety of places, and patients can use them at home instead of going to a health care facility.

Medicare made these changes to telehealth in 2019:

  • Medicare telehealth services are available at renal dialysis facilities and at home.
  • Patients can get Medicare telehealth services for faster diagnosis, evaluation, or treatment of symptoms of an acute stroke, no matter where they live.
  • If a patient is being treated for a substance use disorder or a co-occurring mental health disorder, he or she can get Medicare telehealth services from home.
  • Medicare also covers virtual check-ins and E-visits.

Scott Crow, MD, Medical Editor

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