This study examined the association between markers of care and ED thoughts and behaviors in youth, five months after Massachusetts enacted stay-at-home orders due to the COVID-19 pandemic. Our participants reported marked increases in both intrusive ED thoughts and behaviors, which they attributed to the COVID-19 pandemic. Reassuringly, the majority of our cohort was able to maintain access to at least one member of their care team via telehealth and some were able to continue to see their providers in person. However, half had to stop some aspect of their treatment because of the pandemic. Despite these changes, patient-reported quality of care did not suffer, and most patients did not perceive a disruption to their care. Those who perceived a treatment disruption to care were more likely to rate their care lower than those who did not perceive a disruption. None of the markers of care described was statistically associated with increased ED thoughts and behaviors, though our results may indicate that patients who perceive their quality of care as worse than usual are more likely to have intrusive ED thoughts.
Like many institutions across the globe,11,18−20 our clinicians transitioned their practices to videoconferencing platforms shortly after stay-at-home advisories were issued in March 2020.23 Despite providers’ concerns about patients’ perceptions of adapting evidence-based ED treatment to telehealth,12–14, 21 the majority of our patients who accessed their care via telehealth felt their quality of care was as good as, or better, than usual. Previous research has shown telehealth to be effective for use in psychotherapy,22,23 as well as effective in adolescent/young adult populations,24–26 however little research exists examining the use of this technology for multi-disciplinary ED treatment.27,28 Although more research is necessary to determine efficacy,4,29 our findings suggest providing ED care via telehealth is well accepted and provides good quality of care for ED patients. Moreover, the expansion and continued use of telehealth for multi-disciplinary ED treatment could mitigate barriers to care and increase access for patients who are less connected or away for college or employment, even after the restrictions of the pandemic are lifted.30
Similar to other studies, our patients with EDs reported increases in ED thoughts and behaviors related to the COVID-19 pandemic. 3,5,31,32 One study attributed an increase in ED thoughts during the COVID-19 pandemic to the lack of in-person care and absence of distractions.33 Our findings suggest that continued access to care may be associated with more intrusive ED thoughts, but also could have a protective effect on actual ED behaviors. Although our multivariate analyses were not statistically significant, the trends noted could have clinical implications. Treatment may serve as a protective factor, preventing an increase in ED behaviors. This finding is comparable to another study by Schlegl and colleagues, who found an increase in ED cognitions, but not an increase in behaviors during the initial months of the COVID-19 pandemic.5 It is critical to understand how to support our patients so that they may remain resilient against their ED behaviors, particularly during these times of stress and isolation, which are known risk factors for patients with EDs.33–37 Based on our results, future research should continue to explore how access to care may mitigate ED symptomatology.
One limitation of the present study was the total number of respondents, which decreased the power to address our primary question.
Post-hoc power calculations coupled with wide confidence intervals suggest that we were underpowered to detect statistically significant associations between our markers of care and ED symptomatology, due to the high prevalence of the symptomatology and moderately small sample size.
Given the effect size we observed for the association between access to care and intrusive ED thoughts, we had 66% power to detect a statistically significant difference. We observed significant associations between our quality of care measure and intrusive ED thoughts in bivariate analysis, though this effect was attenuated after adjustment for other factors. It is likely our findings may be a conservative estimate of the true association: those who perceive quality of care as worse than usual are more likely to have intrusive ED thoughts. An additional limitation is the response rate; only half of participants in the RECOVERY study responded to the COVID-19 survey. There is a possibility that those who did not respond were affected by COVID-19 differently than those who did respond, which could affect the results of this study. Notably, this survey was sent out of sequence and remuneration was not available for completion of this survey, which may explain some loss of respondents. Overall, there were no differences between survey respondents and non-respondents in age, race/ethnicity, sex, but those with restrictive EDs were more likely to respond to the survey.
An additional limitation is the generalizability of our findings. The majority of our study participants identified as white and were diagnosed with restrictive EDs. Future research should examine the differences in markers of care by ED diagnosis and demographic groups, particularly with respect to race/ethnicity and socioeconomic status. Additionally, our participants may be more representative of individuals who were already engaged in care and connected to their health care team, as most participants were in treatment and the majority had been in treatment for more than two years. All the participants in this cohort had providers with ED expertise at some point, making it an easier transition to COVID-19 modified treatment. Published literature has reported increased ED incidence as a result of the pandemic,38 which is consistent with our clinical experience during this time. Anecdotally, we have noted that it is especially difficult for these new patients to find providers. Thus, our findings may not be generalizable to patients with new onset EDs and therefore it is critical that we examine the effect of COVID-19 on the incidence of EDs and access to care for new patients.