Abstract
Since the beginning of the COVID-19 pandemic, our daily lives have changed drastically. The United States has gone through multiple iterations of lockdowns, mandates, and re-openings that have varied throughout the country. The impact of the pandemic on our social, economic, physical, and mental health is still being determined. One area that we are starting to recognize is the impact of the pandemic on eating disorders (ED) in children and adolescents. The treatment of ED has had a long history of treatment barriers that has worsened with the pandemic, making finding care for patients in need significantly more difficult.
To the Editor:
Since the beginning of the COVID-19 pandemic, our daily lives have changed drastically. The United States has gone through multiple iterations of lockdowns, mandates, and re-openings that have varied throughout the country. The impact of the pandemic on our social, economic, physical, and mental health is still being determined. One area that we are starting to recognize is the impact of the pandemic on eating disorders (ED) in children and adolescents. The treatment of ED has had a long history of treatment barriers that has worsened with the pandemic, making finding care for patients in need significantly more difficult.
The health and economic effects of ED are substantial and thus any increase in presentations to the health system should be taken seriously. With the peak age of onset of anorexia nervosa (AN) and bulimia nervosa (BN) being 13 to 18 years and 16 to 17 years, respectively, AN has the highest mortality rate of any psychiatric illness, 5% to 6%.1 In the Global Burden of Disease Study of 2013, AN and BN “combined were the 12th leading cause of DALYs [disability-adjusted life year] in females aged 15–19 years in HICs [high income countries], responsible for 2.2% of all DALYs.” 2 As of 2106, an article on the treatment barriers of ED in women reported “only ten states…require private insurers to cover treatment for anorexia and bulimia…[additionally,] according to the National Eating Disorders Association (2014), several insurers routinely deny adequate coverage of eating disorders on the grounds that there is not enough evidence on how best to treat them.” 3 This just factors in patients with insurance and does not take into account the many more that are uninsured and lack access to appropriate care.
At our hospital, the child and adolescent psychiatry consultation liaison service saw a 3-fold increase (from 5 to 15) in the number of consults for restrictive ED in a 6-month comparison, with 3 to 14 unique patients in these same periods. We compared September 1, 2019, to March 31, 2020, and compared September 1, 2020, to March 31, 2021, from NYU Langone Hassenfeld Children’s Hospital and Bellevue Hospital in New York City. Patients included in these data were 5 to 18 years of age, with a diagnosis of AN (2 unique patients prior to the pandemic and 11 unique patients following the start of the pandemic) being the most common. Other diagnoses included in these data were avoidant restrictive food intake disorder and eating disorder unspecified.
Similar increases in the number of ED presentations have been reported from Pennsylvania and Australia. In Lehigh Valley Health Network in Pennsylvania, the health system reported a doubling of unique patients in outpatient clinics.4 Similarly, in Western Australia at Perth Children’s Hospital, a 104% increase in admissions of adolescents with AN was reported.5 The data suggest a trend in ED throughout the world, not only in the inpatient setting but also among outpatient and emergency room visits.
The current causes of an increase in ED are speculative in nature; some hypothesized factors include disruption in daily activities including mealtime, physical activity, and disturbance in sleep, media effects, social isolation, emotional distress, and contagion fear.6 Additional factors that may be playing a part in this increase are closure of community programs because of COVID-19, an increase in parental knowledge of mental health disorders, and increased awareness from parents because of increased supervision of children at home. Thus it is not surprising to see a large increase in cases, with New York City being the epicenter of the pandemic in the United States during 2020.
In addition to the increase in patients presenting to health care systems with ED, many programs changed program delivery to telehealth and contracted in size and scope, which made finding treatment burdensome. This is compounded by the financial component of these specialized programs, which often require top-tier insurance or private pay only. This renders significant inequities in who is able to receive appropriate treatment. One patient treated after the start of the pandemic was hospitalized for 29 days because of inability to find an inpatient treatment facility due to financial barriers, even with a full team of medical professionals and social workers.
As we continue to learn about the impact of the pandemic on the physical and mental health of human beings, we should continue to explore the role that the pandemic has on ED in the pediatric population. Given the large impact that ED has on mental health, societal costs, and quality of life, this is an issue that requires additional discussion. Furthermore, it is necessary to increase the supply and access to specialized programs and services to help bridge the gap between increased demand, low supply, and accessibility, which often leaves those in the most need with substandard care.
Footnotes
The authors have reported no funding for this work.
Author Contributions Writing – original draft: Reed, Ort Writing – review and editing: Reed, Ort
Disclosure: Drs. Reed and Ort have reported no biomedical financial interests or potential conflicts of interest.
All statements expressed in this column are those of the authors and do not reflect the opinions of the Journal of the American Academy of Child and Adolescent Psychiatry. See the Guide for Authors for information about the preparation and submission of Letters to the Editor.
References
- 1.Sacco B., Kelley U. Diagnosis and evaluation of eating disorders in the pediatric patient. Pediatr Ann. 2018;47:e244–e249. doi: 10.3928/19382359-20180523-02. [DOI] [PubMed] [Google Scholar]
- 2.Erskine H.E., Whiteford H.A., Pike K.M. The global burden of eating disorders. Curr Opin Psychiatry. 2016;29(6):346–353. doi: 10.1097/YCO.0000000000000276. [DOI] [PubMed] [Google Scholar]
- 3.Thompson C., Park S. Barriers to access and utilization of eating disorder treatment among women. Arch Womens Ment Health. 2016;19(5):753–760. doi: 10.1007/s00737-016-0618-4. [DOI] [PubMed] [Google Scholar]
- 4.Schwartz M.D., Costello K.L. Eating disorder in teens during the COVID-19 pandemic. J Adolesc Health. 2021;68(5):1022. doi: 10.1016/j.jadohealth.2021.02.014. [DOI] [PubMed] [Google Scholar]
- 5.Haripersad Y.V., Kannegiesser-Bailey M., Morton K., et al. Outbreak of anorexia nervosa admissions during the COVID-19 pandemic. Arch Dis Child. 2021;106(3):e15. doi: 10.1136/archdischild-2020-319868. [DOI] [PubMed] [Google Scholar]
- 6.Touyz S., Lacey H., Hay P. Eating disorders in the time of COVID-19. J Eat Disord. 2020;8:19. doi: 10.1186/s40337-020-00295-3. [DOI] [PMC free article] [PubMed] [Google Scholar]