Telepsychotherapy and Eating Disorders in Adolescents: Comparison
Please note this is a comparison between Version 1 by Pasquale Caponnetto and Version 2 by Peter Tang.

Telemedicine is the provision of health services, where distance is a critical factor, by all health professionals who use information and communication technologies for the exchange of valid information for the diagnosis, treatment and prevention of diseases, research and evaluation, and for the continuous training of health professionals, all in the interest of advancing the health of individuals and their communities.

  • telepsychotherapy
  • e-health
  • prevention of eating disorders
  • adolescents
  • anorexia nervosa
  • bulimia nervosa

1. Introduction

According to the WHO definition, “telemedicine is the provision of health services, where distance is a critical factor, by all health professionals who use information and communication technologies for the exchange of valid information for the diagnosis, treatment and prevention of diseases and injuries, research and evaluation, and for the continuous training of health professionals, all in the interest of advancing the health of individuals and their communities” [1], as it allows a constant and interactive communication in real time between patient and therapist, at any time, overcoming the physical distance.
For several years, the use of the Internet and telemedicine for the treatment of psychological disorders has spread, exploiting advances in technology to make prevention programs and therapeutic interventions more accessible and feasible.
These therapeutic interventions could improve the treatment and prevention of eating disorders, as they are generally easier to disseminate, cheaper and extended to individuals who otherwise would not have the opportunity to access specialized care [2].
Better access to care and stress reduction with the use of telemedicine can also increase patient satisfaction [3].
They may be appropriate for working with adolescents, adaptable to the individual needs of each patient and require less use of skilled personnel, thereby disposing of the workload of healthcare [4][5][6][7][4,5,6,7].
However, a variable that affects virtual therapeutic interventions is the extent and frequency with which the interaction between people takes place in certain conditions [8]; it is important that at least a short and regular therapeutic contact is provided, otherwise it is more likely that high rates of abandonment and a reduced effectiveness of treatment will occur [9].
Following the COVID-19 pandemic, telemedicine has become the standard therapy for the treatment of psychological disorders, including eating disorders (through video conferences, telephone support, e-mail, mobile apps, training on online platforms) [10], except in those more serious cases where direct hospital intervention was necessary.
Importantly, research carried out during the COVID-19 pandemic identifies telemedicine as a promising alternative for the provision of outpatient care [11].
In addition, an Australian study, aimed at detecting the effects of the transition from classic face-to-face therapy (CBT-ED or FBT, the latter adopted with adolescents) to sessions conducted through telepsych, showed that patients achieved great improvements in the reduction in primary symptoms related to the eating disorder and secondary symptoms (anxiety and depression), positively evaluating the quality of treatment and the therapeutic alliance [12].
The COVID-19 pandemic represents a global catastrophe with serious economic, political, social and above all, health consequences, causing the death of millions of people worldwide [13].
In addition to the morbidities and mortality of those infected, the pandemic has had a strongly negative impact on the mental health of the population, not only with the increase in psychic distress in people with pre-existing psychopathologies, but also in health workers and in the general population; in particular, increases in depression, anxiety and post-traumatic stress disorder (PTSD) symptoms have been detected [14][15][14,15].
The negative effects of the pandemic have also spread to people with eating disorders: 40% of individuals reported a worsening of symptoms after a couple of weeks of the lockdown, due in part to the interruption of the day hospital treatments they needed, and about 60% manifested anxiety symptoms in comorbidity [16]. In a survey conducted in Australia starting in April 2020, it was found that, in the group of participants with eating disorders, 35.5% reported an increase in binge eating, while 18.9% reported an increase in food elimination behaviors [17].
Adolescents represent an extremely vulnerable part of the population in the development of psychological disorders since they are more exposed to the negative effects of the pandemic, social isolation and imposed restrictions, at a stage of life in which the relationship and comparison with peers are crucial for the construction of their identity.
In addition, the confinement due to the pandemic has greatly increased the time spent by adolescents on social networks, showing that the latter are related to eating disorders in this age group [18][19][20][18,19,20].
The pandemic has also had negative consequences on the mental health of children and adolescents. Several studies found, the increase in anxiety and depressive symptoms, respectively 37.4% and 43.7%, in young people aged between 12 to 18 years, as well as in adults [21], and an incidence of somatic symptoms of 2.39% among Chinese primary school students [22].
Nutrition and eating disorders often arise precisely in the period of adolescence, spreading especially in Western societies [23], with the tendency to persist and worsen in adulthood, sometimes evolving into a psychiatric disorder if one does not intervene promptly before this phase of life.
A cohort study evaluated 48 adolescents between 9 and 17 years old during the pandemic period (April to October 2020), comparing them with the data that the care center recorded in the year before COVID-19, and in 40% (n = 19) of participants, the effects of the pandemic and the subsequent lockdown were identified as the direct triggers for the onset of patients’ pathology and arrival at the emergency room, with a greater impairment of physical health and a more acute onset of the disease, compared with those who did not indicate the effects of the pandemic among the causes of their eating disorder (duration of the disease 5.59 months vs. 11.63 months).
In addition, the significant impact of the pandemic on the increase in eating disorders in adolescents was measured by comparing the number of urgent hospitalizations during the same period with the previous year, which increased by 63% [24]. The increase in visits and hospitalization compared to the year before COVID-19 was detected in a study involving children and adolescents with eating disorders in order to evaluate the effectiveness of treatments combined with telepsychotherapy for outpatients of a day-hospital. Participants previously assisted by the day hospital required a significantly greater number of medical consultations (both telematics and in presence), with 41.9% of patients experiencing confinement, which showed a reactivation of the psychopathological symptoms associated with the disease, such as food restriction, excessive exercise, worries and fear of gaining weight. In addition, increased mood disorders, self-aggressive behaviors and suicide risk were the main causes of hospitalization [25].
There is much evidence in clinical practice attesting the benefits and improvements in health in patients with Bulimia Nervosa (BN) who are treated with Cognitive Behavioral Therapy (CBT) and family therapies [26][27][28][26,27,28]. A recent randomized clinical trial [29] conducted with adolescents with BN compared the effects of CBT-A adapted for adolescents [30], and a specific form of familial treatment with Family-Based Treatment Bulimia Nervosa (FBT-BN) [31], which showed that at the 12-month follow-up, there were no statistically significant differences in the abstinence rate of binge eating, while at the end of treatment and at the 6-month follow-up, there was a significantly higher abstinence rate of binge eating in the FBT-BN group.
Comparable effects between CBT and FT were also achieved for the treatment of Anorexia Nervosa (AN) in young adults in another randomized clinical trial [32], in which an increase in the BMI from baseline to end of treatment was detected in both treatment groups, showing that both treatments are highly effective in young adults with AN in terms of restoring weight-reducing eating disorders and improving psychological well-being.
To the best of our knowledge, the evidence for the acceptability and efficacy of e-health interventions in DIs is limited. Self-monitoring functions offer control and analysis of ED-related symptoms and thus help increase patients’ conscious involvement in treatment [33]. Among existing e-health interventions, Internet-based cognitive behavioral therapy and guided self-help are considered two of the most effective approaches in reducing the psychopathology named eating disorder, also considering the frequent interaction between individuals with ED in the online health communities [34][35][34,35].
There are multiple pieces of evidence in the literature of the actual benefits of telepsychotherapy applied to the various forms of CBT for the treatment of eating disorders, but the majority of these studies are based on adults [36][37][38][36,37,38] or include both adolescents and adults in the sample [39].
A recent RCT study [40], in which intervention in patients with ED was evaluated through a fully automated feedback and self-monitoring system, found statistically significant reductions in ED symptomatology but also in psychiatric comorbidities (anxiety, depression and persevering thinking) compared to the waitlist control group.

2. Current Insights

Considering the studies examined, it is possible to maintain that at present, e-health therapies for eating disorders have yet to be refined or prove to be more engaging both for those who develop forms of anorexia and for the family figures who play the role of caregiver for these patients. Despite these premises, a particular acceptance and satisfaction was observed, as well as the observation of significantly satisfactory parameters for those therapies provided in the study by Anderson et al. [41][54], which also involves the family of the patients, must find a way to guarantee that the latter will follow guidelines for the clinical and psychological improvement of the participants of the experimental sample.
The possibility of including treatment programs based on e-health work guarantees continuity of care and continuous monitoring by clinicians as well as a considerable decrease in the demand for treatments in outpatient services in the area [42][48]. Modern e-health treatments for eating disorders provide potential bases of continuous assistance and decidedly less burdensome costs of territorial services in the case that these are not identified as necessary.
The research of Heinicke et al. [43][42] and Anderson et al. [41][54] seems to be the most complete and most significant in terms of effective clinical results. The first study [43][42] focused its intervention on the use of an application that allows a good therapeutic alliance between patient and psychologist in the long term that promoted an increase in weight parameters and a decrease in depressive aspects.
The second study [41][54] focused on the direct support of not only patients but also the entire family unit, which plays a fundamental role in the process of taking charge and looking after the patient, as well as instigating and holistic improvements in the AN.
Similarly to other therapies, there are also limitations and disadvantages related to telepsychotherapy. These can differ extensively among individuals, as everybody has different inclinations for care. Hence, some disadvantages should be considered, such as extra interruptions in telepsychotherapy due to contextual noise, and the prompts in telepsychotherapy, which are more diverse than prompts in face-to-face psychotherapy since the psychologist and patient are communicating through a screen, and this may take time to get used to. Finally, some individuals may miss this absence of a face-to-face relationship.
People have positive perceptions about telepsychotherapy, and factors that may affect its impact include type of equipment and technology, education, cultural aspects, the ease-of-use of technology used, knowledge of the benefits of telehealth, privacy and costs [44][45][70,71].
Rapid telehealth conversion is achievable across a broad scope of subspecialty care for adolescents [46][67], eating disorders being one of the most complicated psychopathological disorders to treat in normal conditions even without the recent COVID-19 outbreak. Additionally, a recent case series used long-distance treatment (telepsychotherapy) conducted by an integrated team of dietitians, psychotherapists and psychiatrists to help the parents and patients with eating at home and showed a deterioration in the condition of the four adolescents at the start of the COVID-19 quarantine. The use of multi-professional, long-distance treatment showed an improvement in the condition of three of the four adolescents living in well-organized families with the motivation and ability to adjust to the new conditions, but the one girl who did not show improvement, whose family experienced more problems [47][65], emphasized once again that the role of the family is fundamental, even when the intervention is done at a distance.

3. Conclusions

The risks related to the exclusive use of technological tools for the care and treatment of ED could lead to high drop-out rates of subjects since the face-to-face relationship that these subjects require for the correct psychological support is not guaranteed. Despite this, it seems appropriate to focus attention also on these new opportunities for intervention, especially to avoid sudden aggravations and to create potential channels of intervention that in particular circumstances may be difficult to apply.
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