This review of referrals over a 3 year period to a specialist community ED treatment service confirms what is already known about eating disorders, in terms of the occurrence typically having a female predominance, occurring in an adolescent age and presenting with low ideal body weight %. However, the review signals an increase in presentation during Covid-19, and a suggestion that clinical presentations are somewhat different. Monthly referral rates were significantly higher, almost double the rate of the pre- pandemic period (3.9 compared to 2.3), referrals made from CAMHS were following a shorter duration of illness (4.9 months compared to 7.6). Referrals did not differ in terms of pre-morbid (104% versus 100%) or IBW% at assessment (87% versus 83%), but there was a significantly greater speed of IBW% loss (4.8% compared to 2.6%). Significantly fewer youth during-Covid-19 onset were on any psychotropic medications (23% post during the pandemic compared to 41% before). Although there were slightly more youth during Covid-19 who were diagnosed with an eating disorder other than Anorexia Nervosa, had an additional comorbid mental illness, and a diagnosis of ASD, these did not reach statistical.
A similar study, a retrospective case note review of referrals to a pediatric tertiary ED treatment program in Canada (N=48) covering a 7 month period (April-October 2020) examined the impact of Covid-19 on clinical profile[8]. 40% of their sample were considered to have their ED triggered by the pandemic. They found a higher rate of medical instability in Covid-19 triggered cases (79% versus 55%) and when IBW% was compared with 2019, youth presenting during the pandemic had lower IBW%s, higher self-reported impairment and were medically more unstable[6] Although Spettigue and colleagues did not report on the monthly rates of presentation, other studies have reported an increase in ED referrals. Admissions to a pediatric hospital in the Republic of Ireland (ROI) increased by 66% during the early period of the pandemic, with a suggestion by the authors of lower IBW% and increased medical instability. [6] The National Psychiatric In-Patient Reporting System (NPIRS) in ROI showed a 32% overall increase in hospital admissions for adults with an ED and an increase of 51% for youth when comparing 2019 and 2020[9]. Pediatric presentations in other countries have also increased, leading concerned clinicians to refer to a ‘tsunami’ or ‘an outbreak of AN admissions’ following a 104% increase in referrals. [10, 11]
It has also been found that as the pandemic has continued, the relative risk of eating disorders has increased. Reviewing electronic health records of 5.2 million cases, mainly from USA, Taquet and colleagues found a small but significant increased incidence of 15.3% new onset Anorexia Nervosa in those aged 10-30[12]. These were predominantly female (78.1%) and adolescent age (mean age 16.2yrs). [12] Moreover, new onset AN cases during Covid-19 had an increased risk of having made a suicide attempt or having suicidal ideation compared to cases diagnosed in the previous 3 years. This offers some support to this study, and that of others, suggesting atypicality in clinical presentation. [7]
Fear was expressed early on about the impact of ‘stay at home’ orders and lockdowns on help-seeking hesitancy and lack of access to services. Although there was a successful compensatory move to tele-psychiatry, limited access of face to face services for youth where medical reviews constitute an important part of treatment monitoring was a concern, [13] and might have contributed to delayed help seeking, lower IBW% and account in part for the increased emergency department attendances [6] The increased number of referrals, and shorter time to refer to the FBT team might reflect a true increase of more clinically sinister eating pathology, during Covid-19, or might reflect an increased onward referral from generic CAMHS exposed to unmanageable demand. Data collected from the CAMHS linked to the FBT team saw a dramatic 50% increase in both routine and urgent referrals from September 2020 compared to previous years (2018/2019), with the highest increase in November 2020 (180%). [14] Clinic activity also increased from September 2020, with double the number of out-patient appointments offered compared to previous years and significantly lower rates of non-attendance. [14] This increased CAMHS demand might have triggered increased FBT referrals.
Early on in the pandemic, public health advice regarding health promotion was offered as adaptive coping strategies during lockdown, with a focus on healthier eating, regular exercise, and increasing quality time with family by cooking and eating. Phillipou et al examined changes in eating and exercise behaviors during the Covid-19 pandemic [5]. Of the 5469 responders, 180 self-identified as having a past or current ED, mainly AN. Increase in food restriction and binge eating were reported by respondents with an ED history (67.1% and 20.5%) compared to (27.6%). Increased purging (18.2%) and exercise (48.9%) was also noted in the ED cohort. Approximately one third of the general population sample (34.8%) reported more exercise while almost half (43.4%) reported reduced exercise following the onset of the pandemic [5] The findings of this study highlight the varied nature of eating and exercise responses during the pandemic, and suggest a more deleterious effect in those already at risk. [5] Other studies have suggested eating and exercise being used as positive coping strategies. In one study, 40% of children cited exercise as a positive coping strategy, and 25% reported an increase in consumption of healthy foods during Covid-19. [15] It is possible, and reported, that initial adaptive coping strategies may become excessive over time, and lead to engagement in excessive exercise regimes, calorie counting, or restrictive eating. [7] Deschasaux-Tanguy and colleagues also reported on mixed changes in diet and physical activity with half (52.8%) of their sample reporting a decrease in physical activity, early weight gain reported by a third (35%) while weight loss was reported by almost a quarter (23%). [16]
The extent and nature of psychological difficulties in youth during Covid-19 is complex, mixed and unequal [17] In the current study, many youth (80%) self-declared Covid-19 as having had an adverse effect on their overall wellbeing and this was viewed as contributory to their ED pathology. Reduced peer support, school attendance, and inability to engage in usual sporting and academic endeavors were reported by youth to have contributed to increased anxiety and low mood, prompting self-doubt and poor self-image, including body dissatisfaction. Periods at home, in unstructured settings offered an easy opportunity to be exposed to food, and to engage in binge-purge cycles and to over indulge in exercise routines. However, 3 youth felt that their pre-existing eating disorders had improved, linked to reduced peer and academic pressure, increased parental meal supervision and an overall increase in family quality time. Further research is warranted investigating how the pandemic may both positively and negatively impact the psychological functioning of children and adolescents and the nature by which food and exercise are used to cope with adversity.