Policy changes may affect access to services.

Gaining access to treatment for eating disorders may take years, or may not happen at all. Many obstacles stand in the way, including geography, cost, and lack of insurance coverage. Recently, the results of a global study propose ways to improve access to treatment for patients, and to increase early intervention.

A team led by Karina L. Allen, from the Eating Disorders Outpatient Department at Maudsley Hospital, London, have proposed a series of policy changes and services to help improve early intervention for eating disorders (Eur Eat Disord Rev. 2023. 31:320). Despite the fact that eating disorders carry a disease burden similar to anxiety and depression (Butterfly Foundation for Eating Disorders; https://butterfly.org.au), costing billions of dollars each year, little investment has been made to research the reasons behind this, according to Dr. Allen and her colleagues.

Why is this important?

Early intervention for those with suspected eating disorders leads to better outcomes (World Psychiatry. 2020. 19:233; Canadian J Psychiatry. 2020.64: 492). The authors’ study also showed that most individuals do not accept evidence-based treatment until many years after their symptoms first occur. The interval between the first signs or symptoms and seeking treatment ranged from 2.5 years for AN and 6.0 years for binge eating disorder, or BED (European Eat Disord Rev. 2021.29:329).

Several reasons may produce the delay. Individuals may not be aware of the problem or have little motivation to change or to seek help. Clinicians may not detect an eating disorder or even when they do, they may take a ‘wait and see’ attitude, according to the authors. Another factor in delayed detection is lack of accessibility to services, including long waiting times for treatment, leading to worsening symptoms and poorer outcome when treatment does become available (Behav Res Ther. 2012. 50:487).

Few studies on early intervention are available.

Germany and Great Britain have been leaders in efforts to lessen the time between initial diagnosis and treatment, and to improve earlier intervention. Most information has come from the First Episode Rapid Early Intervention for Eating Disorders, or FREED program. This program was developed for emerging adults (16- to 25-year-olds) who have had an eating disorder for less than 3 years.

The PSYCHNET public health intervention in Germany is designed to change the delay between diagnosis and early treatment of eating disorders by using health literacy campaigns, school prevention efforts, specialized outpatient services for AN patients, an internet health guide, and a multidisciplinary network of healthcare professionals.

In Australia, early intervention has used a modified FREED approach. In Canada, the authors report that largely due to territorially mandated public health care, eating disorders services vary widely across the country’s 10 provinces and 3 territories. One way to get eating disorders services into the community more quickly may be through primary care settings, according to the authors.

And, finally, in the US, insurance coverage is a key determinant of access. Commercial and government-funded insurance plans vary by state, which becomes a major barrier to early intervention among those without sufficient insurance. According to the authors, one approach is to use low-intensity and community-based programs. For example, they cite use of interpersonal psychotherapy, an evidence-based treatment for BED and BN. This is provided through college counseling centers. The Body Project for patients with established eating disorders involves 8 weekly 1-hour group therapy sessions that aim at decreasing the thin-ideal (The Body Project/| National Eating Disorders Association). Student Bodies-Eds has an early intervention focus, and has also been successfully used in Germany.

Study recommendations

The study found wide variations in how eating disorders treatment is accessed and provided worldwide. First, services and policy makers can use early, evidence-based eating disorders intervention. Insurance barriers can delay care and prevent the early stages of an eating disorder if symptoms are defined as too early or too mild.

Changing the emphasis on the long-term cost benefits may also help. Early intervention needs to provide continuous care for 12- to 25-year-olds, the population at greatest risk for developing an eating disorder. The authors also urge clinicians to apply early intervention throughout the lifespan for adults older than 25. This may be accomplished with swift entry to care through active outreach, self-referral options, and strong links to other relevant organizations and services.