February 1 to 7 is Provincial Eating Disorders Awareness Week (PEDAW), a BC-wide campaign to raise awareness around prevention and early intervention of eating disorders. To mark this year’s PEDAW, the Daily Scan is spotlighting how COVID-19 has affected people living with eating disorders and the steps the St. Paul’s Provincial Adult Tertiary Eating Disorders Program took to adapt how it delivers care.
The COVID-19 pandemic has been difficult for many people, but for current and former patients of St. Paul’s Provincial Adult Tertiary Eating Disorders Program, the lack of certain foods due to supply chain disruptions and changes to routines have caused high levels of stress and an increase in symptoms. These symptoms were exacerbated in the early days of the pandemic when the program had to close its inpatient unit and its residential outpatient program for several months.
“When the inpatient unit was closed, more patients were admitted to medical units in other parts of hospital system,” says Dr. Theo Elfers, psychologist in the Eating Disorders Program and Psychology professional practice leader.
COVID-19 and living with an eating disorder: the research
A series of European studies of people living with eating disorders found that COVID-19 is associated with worsening symptoms, increased anxiety and depression, loneliness, and a drive for physical activity. Poorer outcomes are associated with less access to resources, enforced isolation, and disrupted routines.
“Like so many of us, people with eating disorders are using the coping strategies with which they are most familiar to manage the stress of the pandemic. People with anorexia nervosa are restricting more and those with bulimia are using compensatory strategies more,” says Dr. Josie Geller, director of research, Eating Disorders Program. “The isolation and loneliness are challenging for everyone but particularly so for people with eating disorders.”
Coping with program closures
The St. Paul’s Eating Disorders Program cancelled all in person programming for several weeks in the spring of 2020 due to concerns about the COVID-19 virus and its transmission, the uncertainty around providing safe programming within inpatient and outpatient areas, and the broader need to create inpatient capacity for other patient populations during the pandemic. The inpatient program was closed from April to June and the residential outpatient program was closed to July.
In those early days, Eating Disorders Program inpatient staff were reallocated to provide virtual care to patients affected by the closures. But staff knew they needed to find a longer-term solution to support their patients and families.
Working with patients and families to adapt
“When the pandemic hit, we collaborated with our patient and family partners to come up with options to support our patients while our physical spaces were closed,” says Dr. Elfers. “We benefitted greatly from their support.”
The Eating Disorders Program has a long history of working with its Patient and Family Advisory Committee. Monthly meetings allow the clinical team to understand what is working for patients and their families and what isn’t.
Using data to inform program changes
The Eating Disorders Program was fortunate to have an embedded research infrastructure that helped adapt care during the pandemic.
“St. Paul’s is unique in having research as part of its clinical practice for eating disorders,” says Dr. Geller. “As part of the intake process, patients complete a psychiatric assessment, a medical exam and a research assessment. As a result, we have 20 years of data to inform our work.”
Given its strong research focus, the team had many questionnaires already available online. Those were quickly adapted, and research assistants contacted patients by phone or Zoom to gather information on how best to provide services during a pandemic.
Transitioning the delivery of care
Working with patients and their families, the clinical team came up with a tailored model of care for each stream within the program. The inpatient unit reopened in June 2020 to support acute patients with high risk of harm. Today, it operates largely the same way as before but with COVID-19 protocols in place. For example, patients now sit physically distant from each other at mealtimes.
Discovery, the residential outpatient program offered in partnership with Vancouver Coastal Health, adopted a hybrid model. Rather than coming to St. Paul’s every day for treatment and travelling back to Vista House at night, patients live at Vista House in their own COVID-19 bubbles. Clinical staff provide care either virtually or in person.
The readiness program, an important component of treatment for all patients, moved to a fully virtual model. Same for follow-up services like occupational therapy, dietary support and psychiatric management, provided for several months after patients finish either the Discovery or inpatient program.
Evaluating the changes
The shift to virtual care was a big change for the clinical team and for patients and families. As the director of research, Dr. Geller wanted to know what was working and what wasn’t. She and her team began surveying patients about virtual services and if there would be benefit to continuing virtually, even after the pandemic. Overwhelmingly, patients were happy to have virtual support, especially during a time when in-person support wasn’t an option.
Listening to patients
Patients were clear which types of supports worked for them in a virtual environment. For example, patients found virtual care for their pre-admission psychiatric assessments valuable and nearly three-quarters of them saw benefit of continuing post-pandemic. In the words of one patient: “It was great that I could do it from the comfort of my own home and did not have to travel.”
Patients say they prefer to do medical assessments in person once it is safe to do so. Virtual meal support also didn’t work as well for patients, many of whom noted how awkward it is to eat a meal while on Zoom and how it made it easier for them to get away with not completing their meals.
Extended periods of screen time caused headaches and exhaustion for some patients but those drawbacks were offset by avoiding the expense and stress of travelling to St. Paul’s for in-person sessions.
“Know your triggers and reach out”
St. Paul’s Provincial Adult Tertiary Eating Disorders Program is part of a province-wide network with secondary eating disorders programs in most regions to support people in their home communities. The network meets monthly to coordinate care and share best practices.
Dr. Geller has already shared data gathered to date with the rest of the network and they are planning to incorporate elements that had strong positive feedback into ongoing care planning.
“My advice if you or someone you love has an eating disorder is to stay connected to your family, your friends and your care providers,” says Dr. Geller. “Go for a physically distant walk or catch up by phone. If you know your loved one has an eating disorder, encourage them to see their GP regularly. If you have an eating disorder, know your triggers and reach out for help when you need it.”