Eating disorders have among the highest mortality rates of any psychiatric illness and remission rates among patients with eating disorders are, by some estimates, as low as 29%.
New treatment modalities are urgently needed to improve outcomes, especially for people with severe and enduring eating disorders, industry insiders told Behavioral Health Business.
Despite this, funding for eating disorder research remains low. Federal support for eating disorder research equated to $0.73 per affected person in 2015. In contrast, autism research received $58.65 per affected person, and schizophrenia received $86.97 per affected person.
While research dollars are scant, new research methods are on the horizon to improve outcomes for people with eating disorders.
Innovation is also needed to treat the wide variety of patients who have eating disorders. New treatment pathways, or updating existing modalities, may help improve outcomes for a wider population.
“We have to think outside of the box in terms of cultural inclusivity,” Dr. Erikka Taylor, chief medical officer at Arise, told BHB. “There’s so much work to do. Whenever I speak, I usually try to encourage those who are in research to look at other types of interventions.”
Virtual eating disorder provider Arise focuses on providing inclusive eating disorder treatment through a care team model that includes a care advocate, therapist, dietitian and others. Arise is seeking partnerships with research institutions to foster innovation in the industry.
Psychedelics
Psychedelics have increasingly become part of behavioral health providers’ lexicons and offer significant promise as a new eating disorder treatment pathway. The mental health and substance use disorder (SUD) treatment industries have already begun to incorporate psychedelics into treatment modalities.
Research suggests that psychedelics may be able to break down eating disorder patients’ negative beliefs about their body and shape, normalize reward processing, reduce rigid thought and behavioral patterns and help process trauma.
“Psychedelics is the [treatment] I’m most excited about,” Taylor said. “We do have Vyvanse, for instance, that has been FDA approved for the treatment of binge eating disorder. But since that medication has been approved we haven’t had any of our medications approved for the treatment of eating disorders. I would love to see progress in that regard.”
Psychedelics are generally safe in controlled settings and have low toxicity rates even in uncontrolled settings. Researchers do have some potential concerns, however.
Since many eating disorder cases typically occur between 16 and 21 years old, and early intervention is crucial, the lack of research on the long-term effects of psychedelics on cognitive development “should warrant caution.”
Having low body weight may also increase the potential for adverse effects, making careful monitoring necessary when treating some patients with eating disorders who have low body weights.
Specific comorbidities may make psychedelics an unwise treatment choice for patients with eating disorders. For example, patients who also have bipolar disorder could have exacerbated mania if treated with psychedelics.
More large-scale studies are needed before psychedelics can be widely used in clinical settings, however.
“It’s definitely still in the preliminary stages,” Dori Steinberg, vice president of research at eating disorder provider Equip, said. “It moved its way from animal models to some case studies, which are showing some interesting promising results. But for it to be used more widely in treatment does require larger scale studies. … Whether it should be used widely as part of guidelines and clinical care is yet to be determined.”
San Diego-based Equip provides virtual, evidence-based eating disorder treatment in all 50 U.S. states. The provider recently moved into treating adults as well as adolescents and received a $20 million investment from General Catalyst.
Alternative approaches like psychedelics would be considered after less invasive options, Steinberg said.
Other alternative treatments may also pick up steam in the eating disorder industry, following in the footsteps of the SUD industry, Allan Benham, CEO of Alsana, told Behavioral Health Business.
“The hallucinogens, Ibogaine, ketamine, transcranial stimulation, if those are showing impact in the substance abuse world, I just have to naturally wonder if they would impact the eating disorder world also,” Benham said.
Westlake Village, California-based Alsana offers residential, partial hospitalization (PHP) and intensive outpatient (IOP) programs in Alabama, California and Missouri as well as virtual programs nationwide. Benham was named CEO in April.
Virtual reality treatment
New pharmaceuticals are not the only advancement providers are eyeing as potential treatment game-changers.
“We already know that exposure therapy is such a core part of [eating disorder] treatments, particularly, as an example, for patients with [avoidant/restrictive food intake disorder (ARFID)],” Steinberg said.
ARFID, similarly to anorexia, involves avoidance and aversion to eating, but its motivations are based in anxiety or phobia of food or eating, sensitivity to texture, smell or taste or lack of interest in food. Exposure therapy can also be helpful for anorexia patients.
Although more studies are needed, exposure therapy has been found to be effective for specific types of eating disorders, especially in decreasing body dissatisfaction. Virtual reality shows promise to make exposure therapy more accessible and feasible in clinical settings.
Simulations can include visuals of different food items that may be triggering for patients. For example, if a patient has concerns about food textures, visualizations may begin with something like peanut butter, then something more solid like a banana.
Virtual reality can also simulate a person’s body getting larger to address the fear of gaining weight among eating disorder patients. In these cases, an avatar of a person can be virtually enlarged and demonstrate going about in the world in a larger body.
Virtual reality is still in the developmental phase, Steinberg said, rather than in the stages where researchers will seek to determine the most effective types of exposures.
Screening
Providers and researchers have begun to roll out new approaches to eating disorders which can be used before the treatment phase.
“The screeners that we use for eating disorders are unfortunately very biased because they screen for the eating disorder from a lens of anorexia nervosa or restricting disorders,” Taylor said. “They may ask some about binging and purging but they seem to be more centered around a desire for weight loss or desire to be thinner. While that can certainly be a part of an eating disorder, a lot of individuals may not necessarily have that drive for thinness.”
For example, men with eating disorders may focus more on muscularity, which may not be captured on a screener.
One of Arise’s dieticians is working on a research project to develop more inclusive eating disorder screeners.
Equip is also focusing on screeners. There is currently no validated or researched screening tool that can be used for children as young as 6, Steinberg said.
“Our research team, in collaboration with all our clinical experts, developed this screener. We validated it in a pilot test and now we’re interviewing 300 to 500 parents of 6 to 12-year-olds to really know if this tool could help diagnose someone with an eating disorder,” Steinberg said. “Once we find out if it’s really predictive we’re going to send it out to the market to the masses. Everyone can use it so we can start to get more screenings happening in primary care.”
Innovating on current models
While not deriving from cutting-edge research, other innovations in the field of eating disorders involve modifying or updating existing treatment models.
Family-based therapy (FBT) is a first-choice treatment modality for children and adolescents with anorexia nervosa. In this model, family members are intimately involved with the treatment process and help their family member with an eating disorder recover.
FBT is a core part of Equip’s model.
“It’s rooted in the idea that families and caregivers really know best how to feed their child,” Steinberg said. “There’s a tremendous amount of evidence that indicates it is the gold standard approach for treating children, adolescents and young adults.”
Arise incorporates some FBT behavioral interventions into its treatment pathways but does not use the full model as the basis for its programming, opting for modalities suitable for a wider range of patients.
“I think it’s a great modality but … the research that was done validating FPT [was] oftentimes in white populations, white women, from affluent backgrounds with anorexia nervosa,” Taylor said. “We do see individuals with anorexia nervosa, but we’re seeing all genders and all different types of eating disorders. [FBT] may not necessarily be a great fit for some, so that’s why we were pretty intentional about not doing that.”
Arise is also working to add internal family systems, a psychotherapy approach that utilizes a trauma-informed lens to treatment, to its repertoire. While there has not been much research on the treatment’s efficacy among eating disorders, the company is hoping to offer it to its patients in the future. The company is also considering adding emotion-focused family therapy, a psychotherapy approach that works to restore connections among family members, to its treatment options.
Equip has also updated existing treatment approaches. Treatment manuals often recommend that patients are informed of their body weight at weigh-ins and at the start of treatment, a process called open weighing. Patients, however, often express a desire to not know their weight, preferring a closed weighing.
“What the research team did was look at who is choosing open or closed and are there differences in their outcomes,” Steinberg said. “We found in our research that there wasn’t really any difference between open and closed.”
Deviating from the original modality, when utilizing updated research and patient opinions, results in more patient-centered care, Steinberg said.
While updated versions of tried and tested treatment pathways may already be at work at some providers, it will take time before new treatment modalities like psychedelics and virtual reality are implemented widely.
However, the wait may not be as long as some people think.
“The substance abuse world has so embraced alternative treatments … that I think that it won’t be long before we’re seeing the actual implementation of some of those in eating disorder treatment in a very logical and intentional way,” Benham said. “The challenge in that will be making sure that insurance pays for it.”
