Eating disorders are serious illnesses that affect millions of people and require treatment by a team of specialists. If one of your patients has an eating disorder, you have a number of different types of treatment to refer them to, and it can be difficult to parse all the options. One relatively new but increasingly popular option is virtual outpatient treatment. Read on to learn more about virtual outpatient care for eating disorders, and how to know if it’s right for your patient.

The problem

As healthcare providers, we’re faced with a serious problem: the extensive reach and acuity of eating disorders, and the need for new ways to help people.

Eating disorders are a public health crisis, affecting millions of people each year. In this year alone, 5.5 million Americans will develop an eating disorder, and rates are rising. The COVID-19 pandemic dramatically worsened the problem: there was a 70% surge in reports of eating disorders in the early part of the pandemic. Since the pandemic began in 2020, there has also been a spike in eating disorder acuity, with a 2x increase in hospitalizations and length of stay, and over half of eating disorder patients experiencing increased symptoms.

All of this is particularly alarming given that eating disorders can be life-threatening, and negatively impact every organ of the human body. Here are some of the dire physical effects of eating disorders:

• Heart: Slowed heart rate, low blood pressure, irregular heartbeat
• Brain: depressed or anxious mood, obsessive thoughts about food or exercise
• Skin: dry skin, hair loss
• Gut: abdominal pain, liver inflammation, constipation, bloating
• Hormones: irregular periods, decreased bone mass
• Blood: low white blood cells, anemia, low platelets

Eating disorders can also lead to fatigue, blood electrolyte changes, and vitamin deficiencies, among other issues.

What’s more, despite being completely treatable, most people struggling with eating disorders go without effective care. In fact, just 23% of people with eating disorders will get treatment, and an even smaller fraction will get evidence-based treatment that works. For comparison, up to 77% of people with depression get treatment.

There are a number of reasons for this, one of the primary being that many people with eating disorders live in treatment deserts. There are only 5,000 eating disorder providers across the United States, and the average American lives more than two hours away from an eating disorder treatment center, making in-person care inaccessible or disruptive to life. Even for those who live near a treatment center, treatment generally requires patients to take time off from school or work.

Some of the other barriers to effective treatment include:

• Location and transportation limitations: Patients live too far from treatment centers and/or don’t have a way to get to one.
• Cost and limited insurance coverage: In-person treatment can cost thousands of dollars a day, and is not always covered by insurance. When it is covered, insurance authorization often runs out before a patient is fully recovered.
• Lack of eating disorder providers and coordinated care: Many patients can’t find an eating disorder provider at all. Among those who do, the care is often not coordinated, with the patient needing to serve as middle man between providers (physician, dietitian, therapist, etc).
• Lack of family support: In-person treatment generally includes minimal family support, which can increase the risk of relapse once a patient is discharged.
• Lack of affirming care: Most traditional treatment programs are based on young, cisgender, white females, letting people with marginalized identities slip through the cracks.
• Missed diagnosis: Because of pervasive stereotypes about who gets eating disorders, many people go without treatment. This includes people in larger bodies, BIPOC populations, LGBTQIA+ folk, and other marginalized identities.
• Lack of diversity among care providers: When patients don’t see themselves reflected in any care options, it can lead them to not get care at all. Language barriers can also be a problem.

The emergence of virtual care for eating disorders

Virtual mental health care in general has become more common since the start of the pandemic. In one study of military servicemen and women, telehealth visits made up about 15% of outpatient mental health visits before the pandemic, and increased 275% to their peak in April 2020. Telehealth visits have decreased since then, but still remain above pre-pandemic levels.

This increase in virtual mental health care has given us plenty of opportunities to look at its effectiveness, and the research shows that there are equivalent outcomes for telehealth and in-person care. Both telehealth and in-person care resulted in similar reductions in eating disorder and depression symptoms and similar weight restoration rates, and telehealth is feasible and acceptable for patients with eating disorders.

Benefits and common concerns around virtual eating disorder treatment

Virtual eating disorder treatment is still relatively new, and so many providers understandably have concerns about it. Some of these are addressable, and some might lead you to question whether or not virtual care is right for your patient. Some of the most common concerns providers have include:

• Issues around privacy: Patients or providers might worry that they will not be able to find a private place. Some homes have lots of people and not enough rooms to afford privacy; workplaces can be hard, too.
• Lack of full engagement from patients and families: When you are at your computer, there are a myriad of ways to be distracted: other browsers, your cell phone, a delivery person coming to your door, your dog barking. This can be particularly hard when working with a teen who may be reluctant to start treatment.
• Internet and connection problems: Internet and connection problems can interrupt or completely block sessions
• Self-view on telehealth platforms may be a concern for some patients: It might be difficult for patients to see themselves on video platforms, like Zoom.
• Inability to get objective measurements of vitals: You may worry that you will not be able to get objective measures of vitals (weight, blood pressure) or do a full physical exam.
• Patient safety: Safety can also be a concern. What happens if a patient engages in behaviors in session, or leaves a session when distressed?

Many of these concerns can be addressed by following the best practices for virtual eating disorder treatment. Here’s what best practice virtual outpatient care looks like:

• Follows structure and frequency of in-person evidence-based care: The structure and frequency should align with the type of treatment being used (weekly for FBT and CBT-E, 2x/week for CBT-E when working on weight restoration). It should include multidisciplinary involvement from a therapist, registered dietitian, and medical provider, and psychiatrist if needed.
• Uses a HIPAA-compliant web conferencing platform: There are many HIPAA-compliant web and video teleconferencing platforms, including Zoom, Doxy, Vsee, and SimplePractice.
• Includes patient contact information and plan to ensure patient safety: The treatment team collects information including patient address, phone number, emergency contact for someone, and 911 for their local area.
• Begins with a medical evaluation and includes plans for medical monitoring: Patients are cleared for medical stability before beginning treatment, and a medical provider is part of the treatment team. This could be a fully virtual medical provider on your team, or someone who will have in-person meetings with the patient. Medical check-ins can include weekly weight check, orthostatic pulse and orthostatic blood pressure, and, in cases of purging, serum electrolytes.
• Takes into account insurance, legal, and regulatory considerations: Ensure that the patient’s insurance covers telehealth codes and that there is appropriate licensure for the state where the patient lives. .
• Is conducted in a private location with “listening” devices turned off: The patient and provider should both be in private areas and ensure that Alexa, Siri, and other listening devices are turned off.

According to the APA guidelines, patients may need to seek a higher level of care if weight control behaviors or eating disorder symptoms are worsening or if progress isn’t seen over 6 weeks (e.g., an average weight gain of 0.5-1 lb/week in patients with anorexia, 50% decrease in purging behaviors for people with bulimia). Careful monitoring is essential in virtual outpatient settings.

In addition to the concerns outlined above, virtual eating disorder treatment also has unique benefits:

• Accessibility and convenience: It’s easier for providers to meet with patients and their supports. It’s easier to schedule appointments (e.g., a provider on the West Coast can see a patient on the East Coast). It’s easier for patients in treatment deserts to connect with specialists. Patients can get care from any location (car, conference room at school or work, private office).
• Cost and insurance coverage: There is less overhead for families, and more insurance companies are covering telehealth sessions. Overall costs are also much lower for patients paying out of pocket.
• Integrated with everyday life: Patients may feel less reluctant to go to treatment. Providers get a better understanding of patients’ environments and home life. Patients heal at home while focused on what matters to them in their everyday lives.

Considerations for referring a patient to virtual outpatient treatment

When deciding where to refer a patient with an eating disorder, there are a lot of factors to think about. Considerations to take into account include:

• For medically stable patients, outpatient treatment is the best place to start. A higher level of care can be more disruptive and costly.
• Early intervention predicts better outcomes.
• Evidence-based outpatient treatments are as effective online as they are in person.

Once a patient is deemed medically stable, there are several other things to consider when deciding if virtual treatment is the right choice for them (learn more about assessing medical stability here). In order for virtual treatment to be a smart choice for a patient, they need to have the following elements in place:

• Access to stable Internet and a device that can support online conferencing
• Access to a private space
• Local medical provider who can partner with virtual treatment team
• Openness to working online with a provider or team of providers
• No suicide risk, self-harm, psychosis, or aggressive behaviors
• No co-occurring conditions that would significantly alter treatment needs (like diabetes or substance use disorders)

Our 2022 study showed that virtual treatment works for eating disorders. The research found that if vitals were stable and labs normal, most eating disorder patients can be managed as outpatients. Evidence also shows that it’s a myth that more time spent in care is associated with better outcomes.

The bottom line is that for medically stable eating disorder patients, virtual outpatient care can be as effective and more accessible than in-person treatment. This increased accessibility means that there’s a greater opportunity to help fill the massive gap in eating disorder treatment, and begin to address this public health crisis.

Each patient has unique circumstances, and it’s important to consider your particular patient’s needs and their ability to use this modality—but virtual eating disorder treatment is an evidence-based, accessible option that has the potential to save many lives.

Schedule a call with our team to refer a patient or learn more about Equip’s virtual outpatient eating disorder treatment.