The impacts of COVID-19 on eating disorders and disordered eating: A mixed studies systematic review and implications

Trends in the Observed Versus Expected Incidence of Eating Disorders Before, During, and After the COVID-19 Pandemic: A National Patient Registry Study

OBJECTIVE

This study investigated post-pandemic trends in the incidence of eating disorders (EDs) by comparing the annual observed incidence from January 1st, 2020, to December 31st, 2023, to the expected incidence based on pre-pandemic trends (2010-2019).

METHOD

Primary and auxiliary ICD-10 diagnoses of new-onset ED cases were retrieved from the Norwegian Patient Registry which is a national register covering all specialized healthcare services in Norway. Incidence rates (IRs) per 100,000 were stratified by age, sex, and diagnosis: anorexia nervosa (AN; F50.0 + 50.1), bulimia nervosa (BN; F50.2 + 50.3), and other EDs (F50.4-50.9). To assess the impact of the COVID-19 pandemic, linear regression models were used to estimate the annual excess incidence of EDs between 2020 and 2023.

RESULTS

IRs for EDs peaked in 2021, with the overall rate for females being 45.5% higher than expected in 2021 before declining to an excess of 19.4% in 2023. The highest IRs were observed in females aged 15-19, followed by females aged 10-14 and 20-24 years. In 2021, the IR for females aged 15-19 was 64.7% higher than expected before declining sharply to 10.9% in 2023, whereas IRs for ages 10-14 and 20-24 remained approximately 30% higher than expected. Increases were particularly pronounced for AN, while the incidence of BN remained comparatively low, tracking with observed pre-pandemic declines.

CONCLUSIONS

New-onset ED cases peaked in 2021, then declined in 2022 and 2023, despite remaining higher than expected based on 10 years of pre-pandemic data. Future research should continue to monitor trends in incidence, and community-based studies are necessary for replication.

The impact of COVID-19 fear during the later stages of the pandemic on maladaptive eating, psychological distress and body weight: a global cross-sectional study

BACKGROUND

The COVID-19 pandemic significantly impacted global mental health, leading to increased levels of fear, stress, and anxiety [1]. Previous research has suggested associations between functional fear of detrimental mental health outcomes and psychological stressors which may drive maladaptive eating behaviors. This study explored the associations between COVID-19 fear during later stages of the pandemic, psychological distress (anxiety, depression, and stress), maladaptive eating behaviors (emotional, uncontrolled, binge, and nighttime eating), and self-reported body weight.

METHODS

This was a global cross-sectional survey conducted from February 2022 to February 2024, involving 4390 adults (70% female) from 25 countries. The survey collected information on demographics, psychosocial impact, eating behaviors, and COVID-19 related behaviors. General linear models, multinomial logistic regression modes, and structural equation modeling were used to analyze the data.

RESULTS

Higher fear of COVID-19 was significantly associated with increased emotional and uncontrolled eating, even after adjusting for psychological distress and other covariates. Specifically, each unit increase in fear of COVID-19 scores was associated with a corresponding increase in emotional eating (β = 0.018) and uncontrolled eating (β = 0.029) behaviors (p-values < 0.0001). Furthermore, fear of COVID-19 was linked to higher odds of engaging in binge eating (OR = 1.05, 95% CI: 1.03, 1.07, p-value < 0.0001) and nighttime eating behaviors (OR = 1.04, 95% CI: 1.03, 1.06, p-value < 0.0001) in models adjusted for covariates; however, these associations were no longer significant when psychological distress variables were included. Fear of COVID-19 was also associated with body weight (β = 0.18) and BMI (β = 0.08) even with adjustments of covariates and psychological distress variables (p-values < 0.01). Structural equation modeling showed that fear of COVID-19 was related to current body weight through its impact on psychological distress and maladaptive eating behaviors.

CONCLUSIONS

Maladaptive eating behaviors influenced by the psychological distress experienced during the COVID-19 pandemic have persisted into the later stages of the pandemic. These results underscore an interconnectedness between functional fear and its influence on maladaptive eating behaviors and body weight. Understanding this link is crucial and has the potential to inform the development of public health policies.

TRIAL REGISTRATION

Clinical Trials.gov NCT04896060 Date of Registration: May 21, 2021.

Exploring the COVID-19 pandemic's influence on eating disorders: insights from an Italian residential center

Introduction

The COVID-19 pandemic has significantly impacted global mental health, exacerbating the prevalence and severity of Eating Disorders (EDs). This study evaluates changes in the presentation and severity of EDs before and after the pandemic at the Regional Residential Center "Mariconda" in Salerno.

Methods

This retrospective cohort study analyzed records from 162 patients admitted to the center between December 2018 and December 2023. The onset of pandemic restrictions in mid-2020 divided the subjects into pre-COVID and COVID groups. Data collected included age, gender, education level, previous hospital admissions, admission diagnoses, body mass index (BMI), and comorbidity with other psychiatric conditions.

Results

Among the 162 subjects, 115 (71%) were admitted during the pandemic period. This group was significantly younger (mean age: 18.3 vs. 20.6 years, p = 0.009), had lower educational attainment (67% vs. 49% below secondary school diploma, p = 0.025), had a higher rate of prior hospitalizations (49% vs. 26%, p = 0.007), and demonstrated a higher prevalence of severe comorbidities with other mental illnesses (94% vs. 82%, p = 0.009) compared to the pre-COVID cohort. No significant differences were observed in gender distribution, initial diagnoses upon admission, or average length of hospital stay.

Conclusion

The findings indicate that the COVID-19 pandemic intensified the presentation and severity of EDs, particularly among younger individuals with lower educational backgrounds. This underscores the urgent need for targeted, integrated treatment approaches for EDs in the context of global crises, including the development of strategies to address the increased severity of comorbid conditions and higher frequency of hospital readmissions observed in this study. These results highlight the necessity of reinforcing multidisciplinary care models that integrate medical, psychological, and social support to address the heightened complexity of post-pandemic ED cases and ensure more effective, long-term treatment outcomes. Future research is essential to explore the long-term effects of the pandemic on EDs, as well as to refine treatment strategies that better support those affected.

Co-design of a single session intervention chatbot for people on waitlists for eating disorder treatment: a qualitative interview and workshop study

BACKGROUND

Early treatment is critical to improve eating disorder prognosis. Single session interventions have been proposed as a strategy to provide short term support to people on waitlists for eating disorder treatment, however, it is not always possible to access this early intervention. Conversational artificial intelligence agents or "chatbots" reflect a unique opportunity to attempt to fill this gap in service provision. The aim of this research was to co-design a novel chatbot capable of delivering a single session intervention for adults on the waitlist for eating disorder treatment across the diagnostic spectrum and ascertain its preliminary acceptability and feasibility.

METHODS

A Double Diamond co-design approach was employed which included four phases: discover, define, develop, and deliver. There were 17 participants in total in Australia; ten adults with a lived experience of an eating disorder and seven registered psychologists working in the field of eating disorders, who participated in online interviews and workshops. Thematic and content analyses were undertaken with interview/workshop transcriptions with findings from the previous phase informing the ideas and development of the next phase. A final prototype of a single session intervention chatbot was presented to the participants in the deliver phase.

RESULTS

Thematic and content analyses identified four main themes that were present across the four phases of interviews/workshops: conversational tone, safety and risk management, user journey and session structure, and content.

CONCLUSIONS

Overall, the feedback on the single session intervention chatbot was positive throughout the Double Diamond process from both people with a lived experience of an eating disorder and psychologists. Incorporating the feedback across the four themes and four co-design phases allowed for refinement of the chatbot. Further research is required to evaluate the chatbot's efficacy in early treatment settings.

Eating disorders: clinical update

Variation exists in our attitude and behaviour towards food and exercise, resulting in different degrees of health and ill health. Cultural and economic factors contribute to this, alongside personal choices, leading to a spectrum from normative eating, through disordered eating to the extremes of eating disorders (EDs). Understanding the intricate interplay between biological, psychological, and sociocultural factors to eating, exercise and body image is paramount to understand the current state regarding EDs and to deliver/develop multifaceted and individualised treatments. Significant service developments have occurred following the launch of the Irish Health Service Executive Model of Care for EDs in 2018. However, incomplete roll out and surge in EDs referrals post Covid-19 require generic child and adolescent mental health services (CAMHS) to be competent in assessment of EDs, and to keep abreast of clinical updates in order to offer effective treatment.This review provides an evidenced based update on eating related difficulties, outlines a useful assessment framework, offers information on appropriate clinical management, and highlights exciting clinically relevant research developments.

Staying isolated indoors means that nobody sees me": ontological (in)security and living with significant appearance concerns before, during, and 'since' COVID-19

PURPOSE

Though a worldwide period of uncertainty (COVID-19) has 'ended', there exists a legacy of maladaptive experiences among people with significant appearance concerns (SAC) that requires care and attention.

METHODS

Using Giddens' concept of ontological security, we explored how people experienced their SAC before, during and "since" COVID-19. Qualitative surveys allowed us to capture diverse perspectives from individuals transnationally, analysed with deductive reflexive thematic analysis using ontological security as our theoretical foundation.

RESULTS

Themes named "More Mirror(ed) Time" and "Locked Out, Shut Down, and Shut Out" gave a contextual grounding for the embodied experiences of this group through times of social restrictions, and the theme "Redefining Relevance" explored the continued legacy of COVID-19 - and continued global uncertainties such as economic hardship and warfare - that impact the wellbeing of people with SAC.

CONCLUSIONS

People with SAC are still 'locked out' from essential healthcare support as those providing healthcare are overworked, under-resourced and rely on efficient interactive methods such as tele-health that may be triggers for people with SAC. Care providers may consider expanding appearance concerns verbiage, look to involve trusted others in the care-seeking process, and utilize modalities beyond digital health to support people with SAC.

Sexual orientation discrimination and eating disorder symptoms in early adolescence: a prospective cohort study

BACKGROUND

Sexual orientation discrimination increases the risks of negative health outcomes for sexual minorities. Previous studies have found increased rates of eating disorder symptoms in sexual minority individuals, which is attributable to minority stress and discrimination that they experience. Emerging research suggests relationships between sexual orientation discrimination and eating disorder symptoms. However, there is a lack of studies focusing on early adolescents. The objective of this study was to determine prospective associations between discrimination based on sexual orientation and eating disorder symptoms in a national sample of 10-13-year-old early adolescents in the U.S.

METHODS

We examined prospective data from Year 2 (2018-2020) and Year 3 (2019-2021) of the Adolescent Brain Cognitive Development (ABCD) Study (N = 8976). Multiple logistic regression analyses were used to estimate associations between self-reported experiences of sexual orientation discrimination in Year 2 and eating disorder symptoms in Year 3, adjusting for potential confounders, including eating disorder symptoms in Year 2. Sexual orientation discrimination was assessed based on the Perceived Discrimination Scale, which measures adolescents' perception of being treated unfairly based on various sociodemographic characteristics. Eating disorder symptoms were based on the parent-reported Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-5).

RESULTS

In this demographically diverse sample of early adolescents (N = 8976, age range 10-13 years at Year 2), 5.5% of adolescents reported sexual orientation discrimination in Year 2. The prevalence of parent-reported eating disorder symptoms in Year 3 varied from 1.0 to 8.3%. In the adjusted models, sexual orientation discrimination was prospectively associated with worry about weight gain (adjusted odds ratio [aOR] 2.33, 95% confidence interval [CI] 1.15-4.69) and self-worth tied to weight (aOR 1.60, 95% CI 1.01-2.53) one year later.

CONCLUSIONS

Early adolescents who have experienced sexual orientation discrimination have higher odds of experiencing eating disorder symptoms, particularly worrying about weight gain and tying self-worth to weight. Clinicians may consider screening for sexual orientation discrimination and providing affirmative, trauma-informed care when evaluating and treating even younger sexual minority adolescents for eating disorder symptoms.

Online dialectical behavior therapy for binge eating disorder: an open trial

The purpose of the present study was to examine the efficacy of online Dialectical Behavior Therapy for Binge Eating Disorder (DBT-BED) in reducing eating psychopathology and investigate the factors that influence the severity and frequency of binge eating. Seventy-three individuals seeking treatment for BED participated in 20 two-hour group sessions. Participants completed the Emotional Eating Scale (EES), Binge Eating Scale (BES), and Eating Disorder Examination Questionnaire (EDE-Q) before and after the treatment and at three- and six-month follow-ups. Results from 58 participants were analyzed. The study results indicated a significant decrease in objective binge eating (OBE) days, as well as in all EES, BES, and EDE-Q subscales (except the Restraint subscale), and global EDE-Q score at the end of treatment and follow-ups. Moreover, the Body Mass Index (BMI) reduced at the end of treatment and during the follow-up period. Except for the Restraint subscale, more OBE days were linked with higher EES, BES, and EDE-Q scores. Overall, the study suggests that online DBT-BED is an effective approach to treating Binge Eating Disorder (BED) for individuals who cannot receive in-person therapy. Further research is necessary to compare the efficacy of online DBT-BED with other interventions.

Perceived clinician stigma and its impact on eating disorder treatment experiences: a systematic review of the lived experience literature

OBJECTIVE

This systematic review examines the literature regarding perceived clinician stigma and treatment experiences of adult patients with eating disorders, emphasising lived experience perspectives.

METHOD

A systematic search was conducted across MEDLINE, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trials [CENTRAL] to identify studies published from 1 January 2000 until 24 March 2024 that explored patient experiences of clinician attitudes and behaviours in eating disorder treatment. Eligible studies included those reporting on perceived clinician stigma and impacts on treatment outcomes.

RESULTS

There were 11 studies that met the eligibility criteria. The studies encompassed various diagnoses, locations, and healthcare settings, reflecting a broad spectrum of experiences and contexts within treatment of eating disorders. Four key themes emerged across the studies: treatment engagement, where perceived clinician stigma led to reduced patient involvement; therapeutic alliances, with stigma compromising relationships between patients and healthcare providers; barriers to treatment and care, where stigma heightened obstacles to accessing support; and weight stigma.

DISCUSSION

Despite the overall scarcity of evidence, these qualitative studies provide evidence of impacts of perceived clinician stigma on patient experiences in eating disorder treatment. These findings provide an initial understanding of negative effects of clinician attitudes such as dismissiveness and invalidation, which may hinder treatment adherence and therapeutic outcomes. Beyond addressing stigma, future research should explore how clinician behaviours can foster positive treatment experiences, such as patients feeling heard, respected, and understood. Clinicians' reflective practices should focus on improving therapeutic alliances and fostering more inclusive, patient-centred care. Future studies should prioritise mixed-methods approaches to investigate how clinician stigma and positive care experiences influence treatment engagement, recovery trajectories, and long-term outcomes.

Social media delivered mental health campaigns and public service announcements: A systematic literature review of public engagement and help-seeking behaviours

Social media (SM) is increasingly utilised to disseminate mental health (MH) public service announcements (PSAs) and campaigns, connecting the public with support or resources. However, the effectiveness of MH campaigns/PSAs is often overlooked, and actions following exposure are rarely measured. We aimed to i) systematically review research on MH campaigns/PSAs disseminated via SM to determine their efficacy in eliciting engagement, help-seeking/behavioural change and ii) identify components that may facilitate engagement, help-seeking/behavioural change. The review followed PRISMA guidelines. Fourteen studies were eligible. The campaigns/PSAs targeted various MH concerns and country dissemination was diverse. Twitter/X was the most prevalent SM platform (n = 11), followed by Facebook (n = 8). All campaigns/PSAs generated engagement although engagement level benchmarks were inconsistent or absent, a proportion measured formal help-seeking behaviours (n = 1) or behavioural/language/knowledge change (n = 8). Components influencing engagement included videos/live streams, relatable content, the organisation/account disseminating the content, how information was conveyed, and external events. We highlight the heterogeneity of research in SM MH campaign/PSA evaluation and identify commonalities across studies potentially responsible for eliciting engagement, behavioural change and/or help-seeking in future campaigns/PSAs.

Symptoms of Depression, Eating Disorders, and Binge Eating in Adolescents With Obesity: The Fast Track to Health Randomized Clinical Trial

Importance

Depression and eating disorders are heightened for adolescents with obesity. Clinical reviews alongside self-report questionnaires are important to ensure appropriate intervention.

Objective

To evaluate changes in self-report symptoms of depression, eating disorders, and binge eating in adolescents with obesity during the Fast Track to Health trial.

Design, Setting, and Participants

This was a randomized clinical trial conducted from 2018 to 2023. It was a multisite trial conducted at children's hospitals in Sydney, New South Wales, and Melbourne, Victoria, Australia, and included adolescents (13-17 years) with obesity (defined as adult equivalent body mass index ≥30; calculated as weight in kilograms divided by height in meters squared) and 1 or more related complications.

Interventions

Duration was 52 weeks including a very low energy diet for 4 weeks followed by intermittent energy restriction (IER) or continuous energy restriction (CER).

Main Outcomes and Measures

Self-report symptoms of depression (Center for Epidemiologic Studies Depression Scale-Revised 10-Item Version for Adolescents [CESDR-10]; scores 0-30), eating disorders (Eating Disorder Examination Questionnaire [EDE-Q]; scores 0-6), and binge eating (Binge Eating Scale [BES]; scores 0-46) were assessed. Adolescents were screened for depression and eating disorders (weeks 0, 4, 16, and 52) and monitored for the onset of new symptoms of disordered eating during dietetic consults.

Results

Of 141 adolescents (median [IQR] age, 14.8 [12.9-17.9] years; 71 male [50.4%]) enrolled, median baseline EDE-Q score was 2.28 (IQR, 1.43-3.14), median baseline CESDR-10 score was 9.00 (IQR, 4.00-14.50), and median baseline BES score was 11.00 (IQR, 5.00-17.00). There were no differences between groups for change in CESDR-10 (mean difference at week 52, 0.75; 95% CI, -1.86 to 3.37), EDE-Q (mean difference at week 52, 0.02; 95% CI, -0.41 to 0.45), or BES (mean difference at week 52, -2.91; 95% CI, -5.87 to 0.05). The within-group reductions at week 4 were maintained at week 52, for CESDR-10 and EDE-Q, indicating reduced symptoms of depression and eating disorders. Within-group reductions on the BES were maintained in the IER group only. Seventeen adolescents (12.1%) required support or referral for depression and/or disordered eating, including 7 (5%; 5 IER, 2 CER) adolescents who experienced the onset or reemergence of symptoms during the intervention.

Conclusions and Relevance

Results suggest that many treatment-seeking adolescents with obesity self-reported symptoms of depression and eating disorders. Although symptoms reduced for most, some required additional support. Obesity treatment is an opportune time to screen and monitor for depression and disordered eating.

Trial Registration

Australian New Zealand Clinical Trials Registry: ACTRN12617001630303.

Pilot implementation of an evidence-based online cognitive behavioural therapy for perfectionism in university students: Lessons learnt

Higher Education Institutes (HEIs) have been met with an unprecedented demand on their student counselling and wellbeing services in recent years with the impacts of COVID-19 and high rates of mental health concerns amongst student populations. Online mental health programs offer one solution by providing students with quick and easy access to effective therapeutic content. The Focused Minds Program is an evidence-based eight-module online self-guided cognitive behavioural intervention that targets the transdiagnostic risk factor of perfectionism and has been shown to decrease depression, anxiety, and disordered eating. The program was implemented at a UK university between 2021 and 2023. Recruitment occurred via departmental emails, academic staff, and the university's counselling staff and website. Participants were provided with access to the intervention for 6-weeks and completed weekly surveys of psychosocial measures. The trial's implementation was assessed using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework: reach (uptake via the recruitment channels), effectiveness (outcomes on psychometric measures of mental wellbeing), adoption (staff and organisational support), implementation (intervention engagement and attrition), and maintenance (continued implementation across the trial period). Key barriers to successful implementation, as well as proposed solutions, are discussed to guide future online mental health interventions provided in HEIs.

Harnessing Immersive Virtual Reality: A Comprehensive Scoping Review of its Applications in Assessing, Understanding, and Treating Eating Disorders

BACKGROUND

Immersive Virtual Reality (IVR) has shown promise in the assessment, understanding, and treatment of eating disorders (EDs), providing a dynamic platform for clinical innovation. This scoping review aims to synthesize the recent advancements and applications of IVR in addressing these complex psychological disorders.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols, focusing on studies published in the past five years. It included peer-reviewed papers that used IVR for ED assessment, examination, or treatment. A comprehensive database search provided a selection of relevant articles, which were then methodically screened and analyzed.

RESULTS

Twenty studies met the inclusion criteria, with a primary focus on Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED). The application of IVR was categorized into three areas: assessment, understanding, and treatment. IVR was found to be an effective tool in assessing body image distortions and emotional responses to food, providing insights that are less accessible through traditional methods. Furthermore, IVR offers innovative treatment approaches by facilitating exposure therapy, modifying body-related biases, and enabling emotional regulation through embodied experiences. The studies demonstrate IVR's potential to improve body image accuracy, reduce food-related anxieties, and support behavioral changes in ED patients.

CONCLUSION

IVR stands out as a transformative technology in the field of EDs, offering comprehensive benefits across diagnostic, therapeutic, and experiential domains. The IVR's ability to simulate the brain's predictive coding mechanisms provides a powerful avenue for delivering embodied, experiential interventions that can help recalibrate distorted body representations and dysfunctional affective predictive models implicated in EDs. Future research should continue to refine these applications, ensuring consistent methodologies and wider clinical trials to fully harness IVR's potential in clinical settings.

Eating Disorder and Other Psychiatric Hospitalizations in New Zealand During the COVID-19 Pandemic

OBJECTIVE

An unprecedented rise in eating disorder presentations has been documented in several countries during the COVID-19 pandemic. We explored this phenomenon by analyzing nationwide psychiatric admissions over 5 years, controlling for demographic variables.

METHODS

We retrospectively analyzed all hospitalizations in New Zealand with a primary psychiatric diagnosis from 2017 to 2021, using Poisson regression to calculate admission rates by diagnosis, before and during the pandemic. Using Fisher's exact test and Poisson modeling, national data were validated against a manually collected sample of eating disorder admissions.

RESULTS

Eating disorder admissions rose significantly during the pandemic (RR 1.48, p < 0.0001), while other diagnoses remained unchanged or decreased slightly. Anorexia nervosa in 10 to 19-year-old females drove increases, with persistent elevations noted in the 10-14 age group. Pandemic-associated increases were more striking for Māori (RR 2.55), the indigenous Polynesian population, compared with non-Māori (RR 1.43).

CONCLUSIONS

Eating disorder hospital presentations increased during the COVID-19 pandemic, while other psychiatric presentations to hospital remained relatively unchanged. Possible drivers include disrupted routines, barriers to healthcare access, altered social networks, and increased social media use. Clinical services require additional resources to manage the increased disease burden, especially in vulnerable pediatric and indigenous populations. Ongoing monitoring will be required to establish the time-course of pandemic-related clinical demand.

Disordered eating instruments in the pregnancy cohort: a systematic review update

Pregnancy represents a crucial timepoint to screen for disordered eating due to the significant adverse impact on the woman and her infant. There has been an increased interest in disordered eating in pregnancy since the COVID-19 pandemic, which has disproportionately affected the mental health of pregnant women compared to the general population. This systematic review is an update to a previous review aiming to explore current psychometric evidence for any new pregnancy-specific instruments and other measures of disordered eating developed for non-pregnant populations. Systematic searches were conducted in PubMed, ProQuest, PsycInfo, CINAHL, Scopus, MEDLINE, and Embase from April 2019 to February 2024. A total of 20 citations met criteria for inclusion, with most studies of reasonable quality. Fourteen psychometric instruments were identified, including two new pregnancy-specific screening instruments. Overall, preliminary psychometric evidence for the PEBS, DEAPS, and EDE-PV was promising. There is an ongoing need for validation in different samples, study designs, settings, and administration methods are required. Similar to the original review on this topic, we did not find evidence to support a gold standard recommendation.

Impact of COVID-19 restrictive measures during lockdown period on eating disorders: An umbrella review

The COVID-19 pandemic has sparked or amplified many mental health problems. The aim of this study was to compile evidence from existing systematic reviews to provide an overall assessment of the impact of social restrictions during the COVID-19 pandemic on people affected by eating disorders (EDs). PubMed and Scopus were searched up to August 16, 2023. Systematic reviews and meta-analyses were selected using the PRISMA 2020 statement. The quality assessment of the included studies was conducted using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Eleven studies were included in this umbrella review. Six main categories emerged from the studies described in the review: dietary changes and psychopathological effects showed an overall worsening of symptomatology; in studies concerning the impact of isolation and restrictive measures, it was found that social distancing was associated with feelings of loneliness, anxiety, and depression; limited access to direct care was found and therapeutic changes were made; the influence of mass media negatively impacted people with ED; several studies reported positive findings regarding symptomatology; finally, studies regarding 'impact on vulnerable populations showed that vulnerable people are more at risk of reporting body image distortion and eating disorders. The COVID-19 pandemic has negatively impacted most of the population with ED leading to a worsening of specific symptomatology. In addition, this worsening of the condition may be caused by limited access to care and treatment, changes in routine, or to the negative influence of the media.

"Some distance between us": a UK mixed methods study exploring experiences of remote care for eating disorders during COVID-19

Introduction

COVID-19 necessitated a rapid move from face-to-face services to remote care for eating disorders/eating distress (EDs). This study explores the advantages and challenges of remote care, identifying future implications for service provision. Remote care has been considered in the broadest of terms, including therapeutic care (e.g., Cognitive Behavioural Therapy, peer support, forums, one-to-one and group care options).

Methods

Using a mixed methods approach, data were collected from 211 people with lived experience of EDs (PWLE), with and without formal diagnosis. 27 participants took part in semi-structured interviews/workshops and a further 184 participants took part via an online survey. Participants reported on their ED status, the impact of the pandemic on symptoms, the benefits, and challenges of remote care (and type of support accessed), and any reasons for not accessing support. Participants were invited to make future care recommendations.

Results

ED symptoms were reported as worsening during the pandemic with contributing factors including isolation, lack of routine, negative emotions, and feeling like the external situation was outside of one's control. Remote care was positively attributed to increased flexibility and facilitation of social connection. Identified barriers to access included lack of awareness about support availability, digital access/literacy, and competing commitments. Further challenges included approaches being perceived as too clinical (e.g., ED information and support presented using clinical language and/or limited to support within medical care settings, without acknowledging the broader context of disordered eating), uncertainty around remote care quality, and concerns that remote platforms may facilitate masking of symptoms. Participants reported distress caused by online platforms where self-view is the default during video calls. They expressed a need for more holistic approaches to remote care, including: "real stories" of recovery, and hybrid (online and offline) options for greater flexibility and widening of access and choice. Participants also expressed a need for appropriate digital literacy training.

Discussion

Future recommendations emphasise user-centred holistic and hybrid approaches to ED remote support, with training to address digital literacy barriers and facilitate user control of platform functionalities (e.g., self-view). This study underscores the need for continued remote care with a focus on inclusivity and user empowerment.

Caregiver and Child Mental Health During 3 Years of the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

Coronavirus disease 2019 (COVID-19) lockdowns (stay-at-home orders) had significant mental health consequences in 2020 to 2021 for caregivers and children. Little is known about "postlockdown" periods in 2022 to 2023. We investigated the mental health experiences of Australian families throughout the 3 years of the COVID-19 pandemic (2020-2023), by demographic characteristics and lockdown length.

METHODS

A total N = 12 408 caregivers (N = 20 339 children, aged 0-17 years) completed Australia's only representative, repeated, cross-sectional, National Child Health Poll across 6 waves (June 2020-April 2023). Caregivers reported mental health for themselves (Kessler-6, poor versus not) and each child (self-rated mental health, poor/fair versus good/very good/excellent), and perceived impacts of the pandemic on own/child mental health (negative versus none/positive). Binary logistic models were fitted to predict marginal probabilities of each mental health measure by state/territory group (proxy for lockdown length), over time, adjusted for potential demographic confounders.

RESULTS

Poor caregiver Kessler-6 was similar between genders but more common for sole caregivers, and those with a home language other than English and lower education. Poor/fair child self-rated mental health was similar between genders and increased with child age. Perceived negative impacts were more common for females and socially advantaged caregivers. Overall, negative mental health experiences increased with lockdown length, peaking with the height of lockdown in July 2021, before declining.

CONCLUSIONS

Negative mental health experiences of Australian caregivers and children decreased during postlockdown periods of 2022-2023; however, social gradients persisted. These data can inform more precise mental health policies that enable better use of limited mental health infrastructure.

When time worsens framing: a longitudinal analysis of the psychological effects of the COVID-19 pandemic in women with an eating disorder and their healthy sisters

The COVID-19 pandemic has profoundly affected individuals with eating disorders (ED), leading to an exacerbation of symptoms worldwide in 2020. However, there is a lack of longitudinal analyses of the psychological burdens experienced by this population. This study aims to longitudinally assess the psychological effects of the COVID-19 pandemic in people with ED and their healthy sisters (HS) 1 and 2 years after the onset of the crisis. A sample of 148 individuals, consisting of 73 with ED and 45 HS, was evaluated in spring 2021 and spring 2022 regarding their current psychological and behavioral states. Participants were also asked to reflect on their feelings and behaviors during the 2020 lockdown. General psychopathology, eating disorders, and trauma-related symptoms were evaluated using validated questionnaires. Both groups showed an overall improvement in psychopathological symptoms with time. Individuals with ED exhibited greater improvement compared to their HS, which may be attributed to their initially higher burden. Individuals with ED reported a negative reframe, characterized by internalizing negative emotions and behaviors related to the 2020 lockdown. This longitudinal evaluation revealed two distinct and contrasting effects. Both ED patients and their HS demonstrated psychological improvement over time. However, people with ED experienced a negative reframe that affected their memory of specific life events, subsequently affecting their psychological well-being. These findings shed light on the clinical severity observed in people with ED during these pandemic years.

Cognitive restraint, uncontrolled eating, and emotional eating. The Italian version of the Three Factor Eating Questionnaire-Revised 18 (TFEQ-R-18): a three-step validation study

BACKGROUND

The Three Factor Eating Questionnaire-Revised 18 (TFEQ-R-18) is an extensively used questionnaire to measure three transdiagnostic features of eating behavior: cognitive restraint, uncontrolled eating, and emotional eating.

OBJECTIVE

This research aims to investigate the psychometric properties of the Italian version of the TFEQ-R-18 in three large community samples.

METHOD

Cross-sectional research designs were employed. In Study 1 (N = 537), an exploratory graph analysis (EGA) was used to examine item clustering within the TFEQ-R-18. In Study 2 (N = 645), a confirmatory factor analysis (CFA) was conducted to test its structural validity. In Study 3 (N = 346), a MANOVA was employed assessing mean differences across eating disorders (e.g., anorexia nervosa, bulimia nervosa, binge eating disorder).

RESULTS

In Study 1, the EGA accurately identified the three original dimensions of the TFEQ-R-18. Study 2 showed that the Italian TFEQ-R-18 has good fit indexes (CFI = 0.989, RMSEA = 0.064; 90% CI [0.058, 0.070], SRMR = 0.062), and possesses robust psychometric properties. Study 3 reveals distinct, statistically significant differences among eating disorders.

CONCLUSION

The TFEQ-R-18 proves to be a concise and precise tool for measuring transdiagnostic eating behaviors. Its applicability in the Italian context, supported by robust psychometric properties, suggests its utility for both research and clinical purposes. The findings affirm its potential to inform interventions aimed at enhancing psychological health.

LEVEL OF EVIDENCE

Level V, descriptive study.

The implications of the COVID-19 pandemic on eating disorder features and comorbid psychopathology among adolescents with anorexia nervosa and matched controls: a comparative cohort design study

PURPOSE

To examine implications of the COVID-19 pandemic on eating disorder (ED) features and psychopathology in female adolescents with anorexia nervosa (AN).

METHOD

In total 79 females with first-onset AN (aged 12-22 years) were included and were followed up across a period of 1 year. We assessed AN participants recruited pre-pandemic (n = 49) to those recruited peri-pandemic (n = 30). Pre- (n = 37) and peri-pandemic (n = 38) age-, and education-matched typically developing (TD) girls (n = 75) were used as a reference cohort. ED features and psychopathology were assessed at baseline. After 1 year of follow-up the association between pandemic timing and clinical course was assessed. Analyses of covariance were used to examine differences in ED features and psychopathology.

RESULTS

Peri-pandemic AN participants experienced less ED symptoms at baseline compared to pre-pandemic AN participants. In particular, they were less dissatisfied with their body shape, and experienced less interpersonal insecurity. In addition, the peri-pandemic AN group met fewer DSM-IV criteria for comorbid disorders, especially anxiety disorders. In contrast, peri-pandemic AN participants had a smaller BMI increase over time. In TD girls, there were no differences at baseline in ED features and psychopathology between the pre- and peri-pandemic group.

CONCLUSION

Overall, peri-pandemic AN participants were less severely ill, compared to pre-pandemic AN participants, which may be explained by less social pressure and peer contact, and a more protective parenting style during the pandemic. Conversely, peri-pandemic AN participants had a less favorable clinical course, which may be explained by reduced access to health care facilities during the pandemic.

LEVEL OF EVIDENCE

Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

Preparing for the next pandemic by understanding the impact of COVID-19 mitigation measures on patients with eating Disorders: observations from an inpatient setting

OBJECTIVE

The COVID-19 pandemic overwhelmed eating disorder (ED) services worldwide. Data suggests a worsening of psychopathology and an increased request for specialised treatments. Still, the studies are mostly based on experimental protocols with underpowered short-term opportunistic experimental designs. Thus, this study aims to assess the clinical and psychological differences between patients admitted to a specialised ED Unit before and after the COVID-19 breakout.

METHODS

Consecutive patients admitted from June 2014 to February 2022 in a specialised EDs Unit were enrolled. A total sample of 498 individuals was enrolled in this retrospective study, collecting demographic and psychopathological data at admission.

RESULTS

An increase in the admission of patients with anorexia nervosa has been reported, with lower age and higher levels of specific and general psychopathology, especially linked to body uneasiness.

CONCLUSIONS

Results are put into the context of the preparation for the next pandemic that may require similar mitigation measures as COVID-19 to ensure the impact on existing and new patients. Covering an extended period with validated tools, our results might help psychiatric services to reassess their treatment pathways after the pandemic, helping clinicians to delineate future treatment interventions.KEYPOINTSAfter the COVID-19 breakdown, there was an increase in the admission of patients with anorexia nervosa to specialised services.More severe psychopathology was not accompanied by lower body mass index.Specialised eating disorders services should face sudden changes in patients' requests for treatment.Understanding the impact of the Covid-19 pandemic and the resulting mitigation measures taken can lead to better preparations for the next pandemic.

Incidence rates of treated mental disorders before and during the COVID-19 pandemic-a nationwide study comparing trends in the period 2015 to 2021

BACKGROUND

There is a concern that exposure to psychosocial stressors during the COVID-19 pandemic may have led to a higher incidence of mental disorders. Thus, this study aimed to compare trends in incidence rates of depressive disorder, anxiety disorders, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and eating disorders in primary- and specialist health care before (2015-2019) and during the COVID-19 pandemic (2020-2021).

METHODS

We used aggregated population registry data to calculate incidence rates of mental disorders from primary- (The Norwegian Control and Payment of Health Reimbursements Registry (KUHR)) and specialist (The Norwegian Patient Registry (NPR)) health care. The analyses included all Norwegian residents aged 18-65 during the study period. Incident cases were defined as having no previous registration with the same mental disorder in KUHR (from 2006) or NPR (from 2008). We used linear prediction models and mean models to compare incidence rates and test trends before and during the pandemic.

RESULTS

During the pandemic, the incidence rates among women were higher or as predicted for OCD in specialist health care and for eating disorders in both primary- and specialist health care. These findings were strongest among women aged 18-24 years. Incidence rates for depression and phobia/OCD among both genders in primary health care and phobic anxiety disorders among both genders in specialist health care were lower or as predicted.

CONCLUSION

The COVID-19 pandemic may have led to more women needing treatment for OCD and eating disorders in the Norwegian population. The decreased incidence rates for some disorders might indicate that some individuals either avoided seeking help or had improved mental health during the pandemic.

The Impact of the First and Second Wave of the COVID-19 Pandemic on Eating Symptoms and Dysfunctional Eating Behaviours in the General Population: A Systematic Review and Meta-Analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to examine the prevalence of feeding and eating disorder (FED) symptoms or dysfunctional eating behaviours (DEB) in the general population during the COVID-19 outbreak.

METHOD

We searched eligible articles in biomedical databases from 1 January 2020 to 31 March 2022. Prevalence rates of FED or DEB changes between pre-pandemic and pandemic time and correlation with psychological distress were pooled with a meta-analysis using a random-effects model. Heterogeneity was tested using I-squared (I2) statistics. A total of 186 studies with 406,076 participants met the inclusion criteria.

RESULTS

The more prevalent FED or DEB during the COVID-19 outbreak were: body image concerns (52%, 95% CI 0.38, 0.66), binge eating (40%, 95% CI 0.25, 0.55), and overeating (40%, 95% CI = 0.32-0.48). Pooled data of longitudinal studies (k = 8) only showed a significant difference in the prevalence of weight gain from pre-pandemic to the pandemic time. Finally, increased levels of psychological distress (k = 35) positively correlated with some ED symptoms.

CONCLUSION

This meta-analysis evidenced a negative impact of the pandemic on eating symptoms and DEB in the general population.

Psychological distress and caregiving experience during the first two years of the COVID-19 pandemic among parents of an offspring with anorexia nervosa

OBJECTIVE

To compare different aspects of caregiving distress and experience in parents of patients with anorexia nervosa (AN) before and during the COVID-19 pandemic.

METHODS

Three cohorts of parents of AN patients (cohort 1-pre-pandemic: N = 78, cohort 2-first pandemic year: N = 51, cohort 3-second pandemic year: N = 119) were recruited from child and adolescent psychiatry wards and cross-sectionally assessed as part of the clinical routine. Quantitative measures of psychological distress, psychopathology, eating disorder (ED)-related burden, expressed emotion and caregiver skills were obtained at the beginning of the child's inpatient or outpatient treatment.

RESULTS

Cohort 2 showed lower levels of anxiety and a tendency of lower emotional overinvolvement and higher caregiving skills compared to the pre-pandemic cohort. In contrast, the levels of general psychological distress, depression, ED-related burden and criticism observed in cohort 3 significantly exceeded pre-pandemic levels. The prevalence of clinically relevant depression was higher in cohort 3 (41.5%) compared to cohorts 1 (24.4%) and 2 (21.6%).

DISCUSSION

The pandemic effects on parents seem to be time-specific. Lower distress in the early phase of the pandemic may be associated with improvements in parent-child-relationships reported in previous studies. However, the pandemic may has negative consequences in the long-term emphasising the need of ongoing parental support.

COVID-19-related changes in eating disorder pathology, emotional and binge eating and need for care: a systematic review with frequentist and Bayesian meta-analyses

PURPOSE

The COVID-19 pandemic has been a leading cause of stress and feelings of loss of control, both of which have been related to eating disorder (ED) pathology onset and deterioration. We aim to estimate the magnitude of changes in the prevalence rates of, and indicators for, ED psychopathology in the face of the COVID-19 pandemic.

METHOD

Pre-registered systematic review with frequentist and Bayesian meta-analyses. Searches for eligible studies were performed in PubMed, Web of Science and pre-print servers until January 15 2023.

RESULTS

Our searches yielded 46 eligible studies reporting on a total of 4,688,559 subjects. These data provide strong evidence indicating increased rates of diagnosed and self-reported ED's and a concordant increased need for care in the face of the pandemic. ED symptom severity scores in patients were not elevated during the pandemic, except for those related to anorexia nervosa. On average, people in the general population report relatively high levels of emotional and binge eating during the pandemic, although the evidential strength for these associations is only anecdotal to moderate. Moderators of between-study heterogeneity were not detected.

CONCLUSIONS

Altogether, our results suggest that the COVID-19 pandemic is associated with a wide spread negative effect on ED pathology in patient samples and the general population. The development of online prevention and intervention programs for EDs during stressful times like a pandemic is encouraged. A limitation is that the results reported here may be prone to biases, amongst others, self-report bias.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis.

PREREGISTRATION

Prospero [ https://www.crd.york.ac.uk/prospero ] ID: CRD42022316105.

Psychosocial risk factors associated with social anxiety, depressive and disordered eating symptoms during COVID-19

The coronavirus (COVID-19) pandemic has disrupted society and negatively impacted mental health. Various psychosocial risk factors have been exacerbated during the pandemic, leading to the worsening of psychological distress. Specifically, a need for structure, loneliness, concerns about body image and social media use are risk factors previously implicated in poor mental health. The current study examines how these risk factors are associated with mental health outcomes (i.e., social anxiety, depressive and disordered eating symptoms) during the COVID-19 pandemic (January-March 2021). A total of 239 participants were recruited (average age = 24.74, 79% female, 68% White). The results revealed that a need for structure, loneliness and social media use were positively associated with social anxiety. In addition, loneliness, negative concerns about body image and social media use were significantly related to disordered eating and depressive symptoms. Lastly, when examined all together, the overall model for risk factors predicting mental health outcomes was significant: Wilks' Λ = 0.464, F(12, 608.814) = 17.081, p < 0.001. Loneliness and social media use were consistently associated with all psychological symptoms. These results emphasize the need for interventions for social anxiety, depressive and disordered eating symptoms that encourage structured daily activities, social connection, positive perception of oneself and mindful social media use.