Pilot assessment of a virtual intensive outpatient program for adults with eating disorders

Eating disorder virtual intensive outpatient program: patient satisfaction according to age group

The COVID-19 pandemic has required a shift to telehealth services. However, not all patients are similarly satisfied with this shift, with some studies finding that midlife and older adults are less comfortable with telehealth. The current study examined patient satisfaction with a virtual intensive outpatient program (VIOP) for eating disorders (EDs) among 305 adults (ages 18-25, ages 26-39, and ages 40+), and compared adult satisfaction to satisfaction among children/adolescents (n = 33) receiving VIOP treatment between August 2020 and March 2022 from a large ED treatment facility. It was hypothesized that adults aged 40+ would report lower satisfaction than younger age groups. Patients completed several questions regarding satisfaction with treatment upon discharge, including a question about likelihood of recommending the program, which was used to calculate a Net Promoter Score (NPS). The NPS was 33.3 for children/adolescents, 33.3 for 18-25 year-olds, 57.7 for 26-39 year-olds, and 30.9 for the 40+ year age group. NPS of 31-50 = quality services; 51-70 = excellent customer experiences. Satisfaction was high, with no statistically significant differences between age groups after Bonferroni correction. The current study adds to the limited literature on the treatment experiences of midlife adults with EDs.

Traditional versus virtual partial hospital programme for eating disorders: Feasibility and preliminary comparison of effects

OBJECTIVE

Minimal research has examined teletherapy for group or intensive eating disorder (ED) treatment, particularly partial hospital programme (PHP). This study compared treatment outcomes for individuals treated before and after a pandemic-driven implementation of virtual PHP.

METHOD

Patients received care at ED treatment centres using the Renfrew Unified Treatment for Eating Disorders and Comorbidity. Patients treated with virtual PHP were compared to patients treated with traditional PHP. Measures of ED symptomology and behaviours, depressive symptoms, anxiety severity, anxiety sensitivity, experiential avoidance, mindfulness, and body mass index (BMI; reported for anorexia nervosa [AN] patients only) were collected at intake and discharge. Multiple regression analyses were conducted to examine the effect of treatment group on outcomes, controlling for intake score, comorbidity, discharge status, AN diagnosis, and step-down status.

RESULTS

Differences in treatment type were only found for binge eating frequency, with those in virtual PHP reporting significantly lower binge eating episodes at discharge than those in traditional PHP. Body mass index showed significantly less improvement in virtual PHP than in traditional PHP.

CONCLUSIONS

Preliminary results suggest virtual PHP is feasible and effective, potentially increasing access to evidence-based, intensive ED treatment. However, additional research is needed to establish efficacious support for weight gain among individuals with AN in virtual programs.

New understandings meet old treatments: putting a contemporary face on established protocols

In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.

Telehealth and the COVID-19 Pandemic: Making the Pivot from Offline to Online Therapeutic Interventions

While the global health crisis was not responsible for the creation of virtual environments, the COVID-19 pandemic has spawned increased interest in the use of virtual technologies in the workplace and beyond. The current review highlights some of the methods, modalities, and outcomes of the pivot from in-person (offline) therapeutic interactions to the mode of telehealth (online) strategies. Global social-distancing mandates were especially troubling for mental health clients accustomed to in-person counseling and psychotherapy. Panic, fear, and isolation only compounded the reality of health and financial concerns. Lessons about the advantages of telehealth therapies during the most recent global health crisis, will help prepare us all for the next Disease X event. The primary aim of this brief report is to inform the reader about recent research on the advantages of telehealth modalities. In particular, an examination of online technologies in the midst of a Disease X milieu (i.e., COVID-19) was explored. While the current review is far from exhaustive, research in general should leave us optimistic about the "new normal" of utilizing online communication strategies in mental health and beyond. While a Disease X event did not directly lead to the creation of virtual meetings, emerging research is beginning to enlighten the positive consequences of making the pivot from offline to online therapeutic interventions.

Experiences of a virtual day program for adolescents with eating disorders: a qualitative analysis of benefits and barriers

BACKGROUND

Throughout the COVID-19 pandemic, there was a detrimental impact to the symptoms and treatment of eating disorders, causing an increase in medical admissions and visits. Day treatment programs (DTPs), often used to bridge the gap between inpatient and outpatient treatment, were converted to online formats. This study aims to explore the impact of the transition to virtual DTPs on eating disorder treatment from the perspective of adolescents, their caregivers, and program staff.

METHODS

Twelve participants (3 adolescents, 4 caregivers, 5 healthcare providers) in a virtual day treatment program were interviewed using a semi-structured interview guide. Interviews were transcribed and managed with qualitative software NVivo 11.0. Conventional analysis was used to inductively identify pertinent themes related to patient, caregiver, and healthcare staff perceptions and experiences of the virtual day treatment. Summative content analysis provided counts of the barriers and benefits of virtual day treatment as identified by participants.

RESULTS

The majority of participants (10/12) had exposure to both virtual and in person settings, most participants (11/12) felt in-person day programs would be superior to virtual programs. Common limitations of the virtual format were feelings of isolation, less support from healthcare providers, parental burnout, and increased disordered eating. Common benefits were increased accessibility, parental involvement, improved communication with healthcare staff, and the ability for participants to be in their home environment and eat home food. Suggestions for improvement included designing a hybrid model of day treatment, increased family involvement, extending the day program to include dinners with family, and screening for patient appropriateness for the virtual setting.

CONCLUSION

This qualitative study suggests that there are many barriers to effective implementation of virtual day programs. However, the virtual DTP program offers increased accessibility to patients during a period of a health pandemic and to patients in rural/remote areas with limited treatment options. Suggestions provided by participants in this study, such as increased family involvement, frequency of in person check-ins and increased number of meals supported by the program, may help to improve outcomes in virtual day treatment programs.

Outcomes for binge eating disorder in a remote weight-inclusive treatment program: a case report

BACKGROUND

There are no known published reports on outcomes for medically and psychiatrically compromised patients with binge eating disorder (BED) treated remotely in higher level of care settings. This case report presents outcomes of an intentionally remote weight-inclusive partial hospitalization and intensive outpatient program based on Health at Every Size® and intuitive eating principles.

CASE PRESENTATION

The patient presented with an extensive trauma background and long history of disturbed eating and body image. She was diagnosed with BED along with several comorbidities, most notably major depressive disorder with suicidality and non-insulin dependent diabetes mellitus. She completed a total of 186 days in the comprehensive, multidisciplinary treatment program encompassing individual and group therapy, as well as other supportive services such as meal support and in vivo exposure sessions. Upon discharge, her BED was in remission, her major depressive disorder was in partial remission, and she no longer exhibited signs of suicidality. Overall, she showed decreases in eating disorder, depressive, and anxiety symptoms as well as increases in quality of life and intuitive eating throughout treatment, which were largely maintained after one year.

CONCLUSIONS

This case highlights the potential of remote treatment as an option for individuals with BED, especially in cases where access to higher levels of care might be limited. These findings exemplify how a weight-inclusive approach can be effectively applied when working with this population.

Adolescent eating disorder treatment outcomes of an in-person partial hospital program versus a virtual intensive outpatient program

OBJECTIVE

Though virtual outpatient psychotherapy for eating disorders is likely effective, less is known about virtual higher levels of care. The current study examined the clinical outcomes of a family-based virtual intensive outpatient program (vIOP) for youth with eating disorders which was developed in response to the COVID-19 pandemic, compared to the same institution's in-person partial hospital program (PHP).

METHODS

Treatment outcomes were assessed via chart review in 102 patients between the ages of 9-23 (M = 15.2, SD = 2.5) who were predominantly cisgender female (84.3%) and primarily diagnosed with anorexia nervosa (64.7%) or atypical anorexia (23.5%). Participants were either treated in the in-person PHP before the pandemic (n = 49) or the vIOP during the pandemic (n = 53). Percent expected body weight (%EBW) was examined at baseline, end of treatment, 3-months post-treatment, and 6-months post-treatment, as well as the frequency of medical, psychiatric, and residential admissions before, during, and after vIOP or PHP participation.

RESULTS

Linear mixed models demonstrated no effect of treatment modality (in-person versus virtual) on %EBW over time. The duration of the vIOP was, on average, 12 calendar days longer, though the amount billed for the vIOP was lower. Survival analyses and Cox regression models did not suggest differences in the frequency of hospital and residential treatment admissions during treatment (vIOP: 9.4%, PHP: 10.0%) or post-treatment (vIOP: 15.0%, PHP: 10.2%).

DISCUSSION

Findings support virtual family-based programs as suitable alternatives to in-person treatment and underscore the potential cost-effectiveness of a family-based IOP versus PHP.

PUBLIC SIGNIFICANCE

This study demonstrates that a virtual, family-based, intensive outpatient program for youth with eating disorders had similar treatment outcomes to an in-person partial hospitalization program. Specifically, the virtual and in-person programs had similar weight restoration outcomes and rates of medical, psychiatric, or residential treatment admissions during or after treatment initiation. Findings support the use of virtual treatment, even for youth requiring a high level of intervention.

Effectiveness of delivering evidence-based eating disorder treatment via telemedicine for children, adolescents, and youth

Barriers limit access to eating disorder treatment. Evidence-based treatment delivered using telemedicine could expand access. This study determined the effectiveness of enhanced Family-Based Treatment (FBT+) delivered using telemedicine for children and adolescents with eating disorders. Participants had a confirmed eating disorder diagnosis, lived in states where treatment was available, and lived with a family member willing to participate. Virtual FBT+ was administered by a five-person team including a therapist, dietitian, medical provider, peer mentor, and family mentor for up to 12 months. Measures were recorded at baseline and varying frequencies throughout treatment. Weight was self-reported. Eating disorder symptoms were assessed with the Eating Disorder Examination-Questionnaire Short Form (EDE-QS) and depression and anxiety were measured using the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7). Caregiver burden and self-efficacy were measured using the Burden Assessment Scale, and Parent Versus Eating Disorder scale. The majority of patients (N = 210; 6 to 24 years old [mean 16 · 1 years]) were cisgender female (83%) White, (71%), required weight restoration (78%), and had anorexia nervosa, restricting type (63%). After 16 weeks, patients on weight restoration gained on average 11 · 3 [9 · 86, 12 · 8] pounds and the average change in EDE-QS score was -6 · 31 [-8 · 67, -4 · 10] points. Similar reductions were seen for depression (-2 · 62 [-4 · 24, -1 · 04]), anxiety (-1 · 44 [-1 · 12, 0 · 78]), and caregiver burden (-4 · 41 [2 · 45, 6 · 31]). Caregiver self-efficacy increased by 4 · 56 [3 · 53, 5 · 61] points. Patients and caregivers reported satisfaction with treatment. Virtual FBT+ for eating disorders can transcend geographical and psychosocial treatment barriers, expanding access to evidence-based eating disorder treatment.

Acceptability of Telehealth for Multidiagnostic Suicidal Patients in a Real-World Dialectical Behavior Therapy Clinic During the COVID-19 Pandemic

Objective: This study aimed to evaluate the acceptability of Dialectical Behavior Therapy (DBT) delivered through telehealth to complex, suicidal patients during the COVID-19 pandemic. Methods: We surveyed 163 adult participants enrolled in outpatient services at a private, free-standing DBT clinic certified by the DBT-Linehan Board of Certification for its fidelity to the treatment. Treatment satisfaction was assessed, as well as ease of telehealth over time, differences in satisfaction between patients who had previously experienced face-to-face treatment and those who had only experienced telehealth, patients' beliefs regarding the impact of telehealth on their progress, and preference for face-to-face versus telehealth services. Additionally, participants' reasons for liking and disliking telehealth were reported. Results: The average overall satisfaction rating was 82.26 (±18.71) on a 100-point scale. Factors identified as being relevant to satisfaction included increased access to care, saving time and money, and increased comfort participating in therapy from home. Factors identified as relevant to dissatisfaction included feeling less connected to therapists and other patients. The majority of participants reported that telehealth positively impacted or did not impact treatment progress. Satisfaction was significantly related to participants' perception of telehealth's impact on progress in treatment. Demographic variables were also included in the analyses, but were unrelated to satisfaction. Conclusions: Findings indicate that, from the point of view of consumer satisfaction, telehealth appears satisfactory for delivery of DBT and may play an increased role in behavioral health care postpandemic.

Can CBT-E be delivered in an online group format? A pilot study of the Body Image module in a child and adolescent eating disorder service

The increased prevalence of eating disorders during the COVID-19 pandemic has led to long waiting lists in child and adolescent services. A pilot study was conducted to evaluate the feasibility and acceptability of providing the Body Image module, from the enhanced cognitive behavioral therapy for eating disorders (CBT-E), in a virtual group setting. Primary outcomes were acceptance rates, completion rates, qualitative feedback and quantitative data from routine questionnaires. From 22 eligible referrals, 12 participants accepted and enrolled in therapy. Eight completed all six sessions. Qualitative feedback was positive, with both the content and group nature of the intervention being described as helpful. There was an reduction in scores in the Clinical Impairment Assessment and all subscales of the Eating Disorder Examination for Adolescents, suggesting this was a feasible method of providing psychological therapy within the service. A larger trial is recommended to robustly test the effectiveness of the intervention compared to one-to-one in-person CBT-E, and whether the full CBT-E protocol can be effectively delivered in the same format.

Pilot outcomes from a multidisciplinary telehealth versus in-person intensive outpatient program for eating disorders during versus before the Covid-19 pandemic

INTRODUCTION

Eating disorders (EDs) are serious mental illnesses with high rates of mortality, morbidity, and personal and societal costs. Onset of the Covid-19 pandemic led to increased ED diagnoses in the general public, as well as worsening of ED symptoms in those with an existing ED diagnosis. Heightened prevalence and severity of EDs during the pandemic is complicated by the fact that traditional modes of ED care (specialty intensive treatment provided by a multidisciplinary team) have been difficult to access during the pandemic.

METHODS

The current between-groups study (N = 93 ED) tested a multidisciplinary intensive outpatient program (IOP) delivered via in-person (pre-pandemic; n = 60) and virtually via telehealth (during the pandemic; n = 33).

RESULTS

We found no differences in outcomes via delivery mode, such that regardless of in-person versus telehealth programming, ED symptoms, depression, and perfectionism significantly decreased and body mass index significantly increased.

CONCLUSIONS

Our findings suggest that a multi-disciplinary telehealth ED IOP program is feasible and has comparable outcomes to in-person IOP treatment. These findings have implications for treatment beyond the pandemic, suggesting that adoption of telehealth IOPs is warranted. Such delivery modes of intensive treatments for EDs could be expanded to reach underserved populations, especially in rural areas where treatment is often difficult to access.

Moving online: young people and parents' experiences of adolescent eating disorder day programme treatment during the COVID-19 pandemic

BACKGROUND

This study examined the experiences of young people and their parents who attended an intensive day treatment programme for eating disorders online during the global COVID-19 pandemic.

METHODS

Online questionnaires were completed by 14 adolescents (12-18 years) and their parents (n = 19). The questionnaires included a mixture of rating questions (Likert scale) and free text responses. Free text responses were analysed using reflexive thematic analysis.

RESULTS

Three main themes were identified: 1) New discoveries, 2) Lost in translation and 3) The best of a bad situation. This study provides insight into the benefits and pitfalls of online treatment delivery in the adolescent day programme context, which has rapidly had to become part of the everyday therapeutic practice. Results indicate that there are advantages and disadvantages to this, and that parents and young people's views differed.

CONCLUSIONS

This study suggests that the increased accessibility provided by online working does not necessarily translate to increased connection. Given the importance of therapeutic alliance in treatment outcomes, this will be an important consideration for future developments of online intensive treatments.

Continuation of an eating disorders day programme during the COVID-19 pandemic

The current paper describes an adaptation of a daypatient programme for adults with anorexia nervosa in the UK in response to the COVID-19 pandemic and consequent government guidelines. The paper details how the programme, which is normally delivered face-to-face, became a 'virtual' clinic, providing support to a group of patients via the Internet and conducting its core activities almost exclusively via videoconferencing. Anxiety around the pandemic influenced patients' feelings about recovery, and there were concerns about the programme moving online, which necessitated careful management. It has been possible to continue an intensive level of care given wider organisational backing and the support of the patients involved. Some of the patients' reflections on the experience are included in the article. As well as the adaptations, the article also discusses some of the challenges and opportunities encountered, in the hope of guiding similar services.