This guidance is for eating disorder services during the COVID-19 pandemic. It covers outpatient and inpatient services as well as the effect of COVID-19 on patients. It should be read in conjunction with NHSE/I's guidance on managing capacity and demand.
For people with eating disorders, the risk of contracting COVID-19 is accompanied by additional stress and anxieties. When social distancing policies are in place, they are likely to increase isolation and result in the loss of support networks such as friends and family. Young people living at home continue to have parental support, although family relations can often already be strained. The economic consequences of lockdowns may further increase stress and high expressed emotions or even lead to abuse in some families.
It is important for specialist eating disorder services to be aware of this risk, and offer the young person a safe way of expressing their difficulties. Adults with eating disorders often live alone and the isolation is likely to get worse during periods of lockdown. Many adults may also experience significant financial difficulties, and they may worry about job and accommodation security. Young people with eating disorders who are in education may also worry excessively about the impact on their academic progress.
Furthermore, lockdowns disrupt safe routines, such as access to specific foods and options for exercise, which could worsen eating disorder psychopathology and behaviours. For example, if people with EDs have severe restriction to certain ‘safe’ foods which aren’t easily available, this could mean visiting numerous food outlets, with increased risk of COVID-19 infection. If the patient is unable to be more flexible using alternatives, it may be helpful for specialist services to consider writing a letter explaining the situation which the individual can carry with them.
Raised general anxiety due to the pandemic may translate into agitation and distress which may further interfere with eating and can trigger unhelpful coping mechanisms, such as bingeing and purging or excessive exercise. These can be reinforced by an unhelpful narrative about food/meals and fitness on social media and on the news, which encourages exercise and the prevention of weight gain during lockdowns. Increased alcohol consumption is an additional risk, and can lead to severe consequences, particularly in binge-purging anorexia subtype.
It is important to encourage patients to continue keeping in touch with their friends and family (even if it is only possible remotely) as they are an important resource for emotional and for practical support, such as helping with routines, shopping and activities.
Most psychological interventions can continue to be offered via online platforms in cases when face to face is not available or appropriate. Systematic reviews of telehealth interventions have consistently found that there is strong evidence of high acceptability, feasibility, and sustainability as well as good evidence of non-inferiority as compared to face to face contact, although there is less robust evidence of effectiveness. There is more research regarding remote psychological treatment for eating disorders than for other patient groups in psychiatry. NICE approved treatments, such as cognitive behavioural therapy, can be effectively delivered remotely. Please refer to NHSE IAPT guidance and NICE guidance on recognising and treating eating disorders.
In cases where face to face assessment is not possible, video technologies are helpful for remote assessments in a significant number of cases, where the assessment consists of a clinical interview and collection of baseline outcome measures. Many patients with eating disorders use mobile technologies and are familiar with video chats and in our experience find it helpful to discuss their difficulties with a clinician. Remote technologies can also be helpful for interviewing young people and their families and may be preferable to face to face contact where the clinician would need to wear PPE covering their face and impairing non-verbal communication. If the patient does not have a smartphone, tablet, or computer, telephone consultation may be an alternative. For further information on this, please refer to RCPsych’s guidance on remote consultations.
Physical examination and blood test
Physical examination is an important part of the assessment, particularly if the patient is malnourished. The decision about blood tests and ECG needs to be made between the consultant psychiatrist and the patient's GP depending on the level of risk and local arrangements.
This is part of CBT-E and can be arranged remotely with a cooperative patient. For those patients, who are likely to falsify their weights a specific care plan needs to be agreed upon with the GP, the eating disorder team, and carers depending on local availability and risk.
Medication may be used to manage significant comorbidities These should be done via telephone/video reviews where feasible and prescribing continued via shared care where possible. Electronic prescription is only available in some parts of the country, and therefore local solutions need to be generated to avoid delay. Please see RCPsych’s guidance on providing medication during the COVID-19 pandemic for more information.
The COVID-19 crisis meant the cessation of day patient services for patients with eating disorders in many areas. Many services have also been unable to reopen due to crowded, poorly ventilated environments.
Alternative ways of supporting patients should include more frequent remote support by staff, or if possible, the encouragement of telehealth alternatives for groups.