Clinical Science Can Address Rising Eating Disorder Psychopathology during the Covid-19 Pandemic: Comment on Gruber et al., 2020

Authors: *Kara A. Christensen1, *Kelsey E. Hagan2, & Kelsie T. Forbush1 1 Department of Psychology, University of Kansas, Lawrence, KS USA 2 Department of Psychiatry, Columbia University Medical Center/New York State Psychiatric Institute, New York City, NY USA * Shared first authorship

Corresponding author: Kara A. Christensen, Ph.D. University of Kansas, 1415 Jayhawk Blvd, Lawrence, KS 66045 USA, [email protected]

Contact information: Kelsey E. Hagan: [email protected] Kelsie T. Forbush: [email protected]

Funding information and conflicts of interest: Dr. Christensen is funded by a TL1 postdoctoral fellowship awarded by Frontiers: University of Kansas Clinical and Translational Science Institute (#TL1TR002368) through a CTSA grant from NCATS. Dr. Christensen is a former trainee of original paper author, Dr. Amelia Aldao. Dr. Hagan is funded by a T32 postdoctoral fellowship awarded by Columbia University (T32MH096679). Dr. Forbush is funded by the Department of Defense Peer-Reviewed Medical Research Grant (PR180387) and the University of Kansas Research Excellence Initiative. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the University of Kansas, Columbia University Medical Center, NYSPI, NIH, NCATS, or DoD.

©American Psychological Association, 2021. This paper is not the copy of record and may not exactly replicate the authoritative document published in the APA journal. Please do not copy or cite without author's permission. The final article will be available, upon publication, in American Psychologist.

Abstract

Eating disorders (EDs) are serious psychiatric disorders that affect 13-18% of young men and women. EDs are associated with substantial psychiatric and medical morbidity and mortality, indicating a critical need for improved identification and treatment. Despite the relatively high prevalence and severity of EDs, they are often omitted from discussions of mental health. This comment is in response to Gruber et al. (2020), who wrote an important article on the challenges and opportunities facing clinical scientists in the time of COVID-19. Our response article extends Gruber et al.’s (2020) paper by noting additional challenges facing people with an eating disorder during COVID-19 and recognizing opportunities for improved evidence-based assessment and treatment of this important population.

Keywords: COVID-19, eating disorders, commentary

Clinical Science Can Address Rising Eating Disorder Psychopathology during the COVID-

19 Pandemic: Comment on Gruber et al., 2020

In their recent article, Gruber et al. (2020) provided a clear framework for using clinical science to inform our understanding of the impacts of the COVID-19 crisis on mental health. We wish to extend the principles of their article to eating disorder (ED) psychopathology, which was not originally discussed, but is highly relevant during the COVID-19 pandemic. Lockdown procedures, social isolation, increased food insecurity, restricted access to care, limitations on physical activity, and increases in stress have created conditions that place people at higher risk for the development of ED symptoms or the exacerbation of symptoms in those with EDs.

Increases in ED risk factors due to COVID-19 are concerning because EDs affect 13-18% of young people (Allen et al., 2013; Stice et al., 2013), have among the highest mortality rate of all mental illnesses (Arcelus et al., 2011), and an economic cost of $64.7 billion per year in the

United States (Deloitte Access Economics, 2020).

Eating and physical activity patterns have changed for many people as a result of

COVID-19 restrictions, with people reporting reduced physical activity, increased binge-eating, and poorer diet quality (Ammar et al., 2020). Furthermore, early data suggest that ED symptoms have increased among people with and without eating disorders. Results from the Australian

COLLATE survey indicated that many of the 180 respondents with self-reported eating disorders endorsed an increase in binge eating (35.5%), purging (18.9%), restriction (64.5%), and compulsive exercise (47.3%) (Phillipou et al., 2020). Among people without a history of eating disorders (n = 5,289), approximately 27.6% reported increased food restriction and 34.6% reported increased binge-eating behaviors. These recent findings converge with survey data from people with EDs in Germany (Schlegl et al., 2020), and the United States/Netherlands (Termorshuizen et al., 2020), who reported increased severity of symptoms during COVID-19.

Additionally, hospital admissions for children with anorexia nervosa have increased 104% in

Australia (Haripersad et al., 2020). Overall, data suggest concerning increases in ED psychopathology, such that people with eating disorders are displaying increased severity and risks of relapse, and those without eating disorders are reporting the new development of ED symptoms.

A challenge for clinical science will be to identify those with increased ED psychopathology and to meet the rising need for treatment. Medical settings, such as primary care and obstetrics/gynecology, could be more efficiently leveraged as the frontlines for detection. Similarly, university medical and psychological providers may wish to expand their screening to encompass EDs. Given that many people with EDs do not seek treatment for their symptoms, these points of contact are prime opportunities for people to be screened for eating psychopathology and avoid falling through the cracks. Existing measures such as the SCOFF

(Morgan et al., 2000) or the Screen for Disordered Eating (SDE; Maguen et al., 2018) are brief measures (four and five items, respectively), with empirically-supported cutoff values indicating the probable presence of an eating disorder. ED screening measures could be integrated into assessment batteries, with referrals made to specialists when patients report elevated symptoms.

For people with ED symptoms, guided self-help treatments have shown positive effects on symptoms of binge eating disorder and bulimia nervosa (Traviss‐Turner et al., 2017) and may be particularly useful as first-line treatments, due to their ability to be disseminated easily by non- expert providers.

Delivery of specialized treatments for eating disorders rapidly shifted from face-to-face interventions to distance-based videoconferencing methods (telehealth) due to COVID-19. Although telehealth comes with practical (e.g., internet connectivity issues), therapeutic (e.g., privacy, alliance building) and regulatory/legal issues, there are benefits to telehealth. For instance, a barrier for access to evidence-based specialty ED treatment is limited patient access to qualified providers. Another barrier is limited resources to attend in-person psychotherapy, such as transportation resources and inability to take off from work to commute to and from appointments. Thus, during the COVID-19 pandemic, some patients may have better access to specialty care compared to pre-COVID-19, when sessions were primarily delivered face-to-face.

Research suggests comparable outcomes for telehealth and face-to-face ED treatment in adults

(Mitchell et al., 2008). Recent publications by Mattheson et al. (2020) and Waller et al. (2020) are excellent resources for delivering telehealth family-based treatment and cognitive-behavioral therapy for EDs, respectively.

Caregivers of persons with ED also require clinical attention and support. Caregiver burden for those with EDs is high in typical times, with high levels of caregiver stress linked to negative outcomes for both the patient and the caregiver (Anastasiadou et al., 2014). Now, caregivers may be faced with greater burden, due to increased care need, fewer opportunities for social support, and limited respite. As such, it is important for providers to intentionally check-in with caregivers, provide referrals, and familiarize themselves with online support groups and resources for caregivers to reduce stress.

With increased discussion and concern about weight gain during the pandemic, it will be important to use our knowledge of clinical science to discourage the implementation of weight- loss interventions that may have iatrogenic effects on ED symptoms. Care must be taken when considering the implementation of health programs to ensure that they do not increase weight stigma or encourage unhealthy dieting behaviors. Overall, the preliminary data on COVID-19 and ED symptoms suggest an increase in symptom severity for people with EDs, as well as an increase in ED symptoms among the general population. As a result, it is critical that we apply a clinical science framework to address the growing need for identification and treatment of people with ED psychopathology, particularly given the significant physical and psychological consequences of these illnesses.

Early treatment and diagnosis is critical and interventions delivered through telehealth offer unique opportunities to reach individuals who may not have otherwise received treatment. At the same time, it will be important for clinical scientists to inform policy on interventions that have the potential to cause harm. Although these challenges are great, we believe that clinical science will prevail in helping people to receive the care they need in these difficult times.

References

Allen, K. L., Byrne, S. M., Oddy, W. H., & Crosby, R. D. (2013). DSM–IV–TR and DSM-5

eating disorders in adolescents: Prevalence, stability, and psychosocial correlates in a

population-based sample of male and female adolescents. Journal of Abnormal

Psychology, 122(3), 720.

Ammar, A., Brach, M., Trabelsi, K., Chtourou, H., Boukhris, O., Masmoudi, L., Bouaziz, B.,

Bentlage, E., How, D., Ahmed, M., Müller, P., Müller, N., Aloui, A., Hammouda, O.,

Paineiras-Domingos, L. L., Braakman-Jansen, A., Wrede, C., Bastoni, S., Pernambuco,

C. S., … On Behalf of the ECLB-COVID19 Consortium. (2020). Effects of COVID-19

Home Confinement on Eating Behaviour and Physical Activity: Results of the ECLB-

COVID19 International Online Survey. Nutrients, 12(6), 1583.

https://doi.org/10.3390/nu12061583

Anastasiadou, D., Medina-Pradas, C., Sepulveda, A. R., & Treasure, J. (2014). A systematic

review of family caregiving in eating disorders. Eating Behaviors, 15(3), 464–477.

https://doi.org/10.1016/j.eatbeh.2014.06.001

Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality Rates in Patients With

Anorexia Nervosa and Other Eating Disorders: A Meta-analysis of 36 Studies. Archives

of General Psychiatry, 68(7), 724–731.

https://doi.org/10.1001/archgenpsychiatry.2011.74

Deloitte Access Economics. (2020). The Social and Economic Cost of Eating Disorders in the

United States of America: A Report for the Strategic Training Initiative for the

Prevention of Eating Disorders and the Academy for Eating Disorders. 92. Haripersad, Y. V., Kannegiesser-Bailey, M., Morton, K., Skeldon, S., Shipton, N., Edwards, K.,

Newton, R., Newell, A., Stevenson, P. G., & Martin, A. C. (2020). Outbreak of anorexia

nervosa admissions during the COVID-19 pandemic. Archives of Disease in Childhood.

https://doi.org/10.1136/archdischild-2020-319868

Maguen, S., Hebenstreit, C., Li, Y., Dinh, J. V., Donalson, R., Dalton, S., Rubin, E., & Masheb,

R. (2018). Screen for Disordered Eating: Improving the accuracy of eating disorder

screening in primary care. General Hospital Psychiatry, 50, 20–25.

https://doi.org/10.1016/j.genhosppsych.2017.09.004

Matheson, B. E., Bohon, C., & Lock, J. (2020). Family-based treatment via videoconference:

Clinical recommendations for treatment providers during COVID-19 and beyond.

International Journal of Eating Disorders.

Mitchell, J. E., Crosby, R. D., Wonderlich, S. A., Crow, S., Lancaster, K., Simonich, H., Swan-

Kremeier, L., Lysne, C., & Myers, T. C. (2008). A randomized trial comparing the

efficacy of cognitive–behavioral therapy for bulimia nervosa delivered via telemedicine

versus face-to-face. Behaviour Research and Therapy, 46(5), 581–592.

Morgan, J. F., Reid, F., & Lacey, J. H. (2000). The SCOFF questionnaire. Western Journal of

Medicine, 172(3), 164–165.

Phillipou, A., Meyer, D., Neill, E., Tan, E. J., Toh, W. L., Rheenen, T. E. V., & Rossell, S. L.

(2020). Eating and exercise behaviors in eating disorders and the general population

during the COVID-19 pandemic in Australia: Initial results from the COLLATE project.

International Journal of Eating Disorders, 53(7), 1158–1165.

https://doi.org/10.1002/eat.23317 Schlegl, S., Meule, A., Favreau, M., & Voderholzer, U. (2020). Bulimia nervosa in times of the

COVID-19 pandemic—Results from an online survey of former inpatients. European

Eating Disorders Review, n/a(n/a). https://doi.org/10.1002/erv.2773

Stice, E., Marti, C. N., & Rohde, P. (2013). Prevalence, incidence, impairment, and course of the

proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of

young women. Journal of Abnormal Psychology, 122(2), 445.

Termorshuizen, J. D., Watson, H. J., Thornton, L. M., Borg, S., Flatt, R. E., MacDermod, C. M.,

Harper, L. E., Furth, E. F. van, Peat, C. M., & Bulik, C. M. (2020). Early Impact of

COVID-19 on Individuals with Eating Disorders: A survey of ~1000 Individuals in the

United States and the Netherlands. MedRxiv, 2020.05.28.20116301.

https://doi.org/10.1101/2020.05.28.20116301

Traviss‐Turner, G. D., West, R. M., & Hill, A. J. (2017). Guided Self-help for Eating Disorders:

A Systematic Review and Metaregression. European Eating Disorders Review, 25(3),

148–164. https://doi.org/10.1002/erv.2507

Waller, G., Pugh, M., Mulkens, S., Moore, E., Mountford, V. A., Carter, J., Wicksteed, A.,

Maharaj, A., Wade, T. D., & Wisniewski, L. (2020). 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.