How COVID‐19 Affected Anorexia Nervosa Treatment

The coronavirus pandemic (COVID-19) is the global health crisis of our time. Most governments adopted several measures to counter its spread and limit its impact. These included periods of "lockdown," travel restrictions, the closure of schools, shops, restaurants, bars, and gyms, and other practices such as social distancing, mask-wearing, quarantine periods, and "shielding."

The social and physical distancing measures have exposed people to several stressors, and, as I predicted in an earlier post here, some of these (e.g., social isolation, life disruption and restrictions on movement and daily activities, compromised relationships with family and friends and greater exposure to weight-related social media messaging) have now been proposed as potential factors explaining the dramatically increased incidence of eating disorders recorded during the pandemic, particularly in female adolescents. Since the outbreak began, clinical records reported a significant increase in acute and routine referrals and inpatient admissions for eating disorders.

Due to the same social restrictions, eating disorder clinical services have also been under pressure, often providing treatment remotely. Furthermore, even when in-person delivery was possible, the quality of the treatment could have been negatively influenced by several factors, such as the fear of infection, the use of personal protection equipment, and mandatory social distancing and disinfection procedures.

Although these modifications to treatment implementation are likely to have negatively influenced treatment outcomes, few studies have investigated this issue to date.

A study published in the International Journal of Eating Disorders on June 25, 2022 assessed the impact of the pandemic on the effectiveness of an intensive treatment based on enhanced cognitive behavioural therapy (CBT-E) at Villa Garda Hospital in Italy for patients with anorexia nervosa. The treatment was an intensive stepped-care CBT-E program that involved 13 weeks of treatment in a residential setting followed by 7 weeks in a day hospital.

The study compared the outcome of 57 patients with anorexia nervosa (with age equal to or greater than 16 years) treated during the COVID-19 pandemic and admitted from March 9, 2020 to April 2021 with a control group of 57 gender, age, and body mass index (BMI) matched patients with anorexia nervosa admitted in the same unit between January 2016 and April 2019.

This study yielded three main findings. At admission, patients exposed to the COVID-19 pandemic and controls had comparable BMI, eating-disorder severity and clinical impairment. However, baseline general psychopathology scores were lower (i.e., better) in patients exposed to the COVID- 19 pandemic.

The second finding concerns the drop-out rate. More than 75% of patients during the pandemic versus 87.7% of controls completed the treatment, a difference that was not significant.

The third finding is that treatment was largely successful in both groups, despite significant differences between outcomes. On the one hand, it is encouraging to note that the rate of "full response"—that is, achieving a normal BMI threshold with minimal eating disorder psychopathology—was not significantly different between those exposed to the pandemic (50.9%) and controls (64.9%) at 20-week follow-up, in the intention-to-treat analysis. However, on the other hand, the improvement of BMI, eating disorder, general psychopathology, and clinical impairment was significantly lower in patients who underwent treatment during the COVID-19 pandemic.

Considering the similarity in admission characteristics between the two groups, it is likely that such differences in outcome may be partially due to the dramatic changes imposed by the pandemic restrictions on some treatment procedures. First, the traditionally "open" residential unit was forced to become "closed," with patients unable to leave the ward or see other people, likely increasing their stress levels and sense of isolation. Secondly, several essential CBT-E procedures involving real-world exposure to increase dietary flexibility (i.e., social eating) and improve body image (i.e., body exposition), for example, could not be implemented during the pandemic, limiting the effectiveness of treatment. Thirdly, all CBT-E procedures had to be administered remotely during the day-hospital phase in the national lockdown period, which could also have interfered with the treatment's efficacy in a subgroup of patients. However, it is also possible that the lesser improvement observed in patients treated during lockdown may result from the general psychological distress associated with the COVID-19 pandemic.

The longer-term impact of the COVID-19 pandemic should be accurately evaluated by future studies not only in patients with anorexia nervosa but also those with other eating disorders. It will also be essential to collect patients' reports of treatment under COVID-19 conditions to better understand the factors contributing to different outcomes.