This article presents an innovative care for eating disorders in the Child and Adolescent Psychiatry Unit of the Academic Erasme Hospital of the Free University of Brussels during COVID-19 pandemic lockdown measure.
Until now, the duration of the inpatient care for adolescents presenting anorexia nervosa lasts several months, mean of 6 to 8 months. Severity of patient’s trouble at the admission is extreme with a Body Mass Index (BMI) lower than 15 kg/m2 (307.59 – F50.01 [1]). Considering that a BMI above 17.5 kg/m2 was targeted, the discharge could take a long time to be organized.
This Child and Adolescent Psychiatry Unit, part of a general Hospital, is not an exclusive eating disorder Unit; admissions consist of adolescents aged form 13 to 18 years old presenting various types of psychopathology.
Under normal circumstances, the inpatient pluridisciplinary care for eating disorders consists of psychiatric treatment, individual psychotherapy and weekly family meetings. Dietician adjusts daily each patient’s nutritional plan. Patients are guided to improve their own eating process throughout a smartphone application to monitor the feeding speed, which slows down as well as the clinical evolution is positive. Patients also benefit from daily group psychotherapy and activities.
During the COVID-19 pandemic period, the number of adolescents in need of urgent psychiatric care was progressively increasing. A wide recent review highlighted emerging psychological consequences of lockdown measures such as anxiety, post-traumatic stress disorder, depression, suicidal or addictive behaviours and domestic violence. The importance to focus on eating disorders was stressed out [2].
The infection-preventing measures have been applied in the inpatient care, such as social distancing and interdiction of relatives’ visits to the hospital. In addition, Psychiatric Units for adolescents in Brussels were obliged to decrease the admissions to flatten the COVID-19 diffusion. Thus, innovative care protocol had to be structured for patients suffering from eating disorders who were discharged earlier than normal.
Admission for eating disorders continued even during this period. Distant synchronous videoconferencing allowed carrying out the usual outpatient evaluations to organize the hospitalisation.
From the beginning of the inpatient care, each patient was paired to a binomial association of psychiatrist and nurse. They structured together the plan of inpatient care. The final weight to discharge was fixed throughout a mutual negotiation with the patient.
During this pandemic period, BMI at discharge was accepted to be at 16 kg/m2 if laboratory tests were reassuring. At that moment, the home-based care could begin.
Home-based care included two weekly visits to the department where the patient received a medical examination with weighting, verifying medical parameters and a psychiatric or a family interview. The protocol consisted in a full time reintegration in case of weight loss. The individual psychologist, the psychiatrist and the nurses proposed videoconference interviews for the five remaining days of the week. The dietician assured the follow-up of the nutritional plan.
This new care protocol was introduced in mid-march and gave very promising clinical results. One month after the beginning of the home-based care, the patients reached their healthy weight and managed to keep it stable.
The authors assume that parents were reassured when patients started the home-based care phase. They did not act in a controlling manner during mealtimes because they knew that the team was managing it remotely. They felt safe and they knew they could reach the hospital 24h/24h in case of crisis. This particular situation offered the family the opportunity to focus on their relationship outside of the symptom, which has already appeared to be beneficial in therapeutic terms in literature [3]. This way of working put the patient and the family as proactive agents for the treatment. A striking contrast was remarkable compared with the frequent passive attitude during long hospitalization. Both parents and patients shared daily difficulties as well as therapeutic evolution in family session. All of this add a new depth to family therapies, a key treatment for anorexic patients [4].
The videoconference interviews also helped the psychotherapeutic process, as the patient seemed to talk freer via this media.
Since many years, this technique of telepsychiatry is already exploited in underserviced communities to extend psychiatric care independently to geographic distance [5,6]. Before the COVID-19 pandemic outbreak, telepsychiatry was underemployed in the metropolitan area of Brussels. Accessible and available psychiatric face-to-face services seemed to meet all needs in mental health of the population.
Strict lockdown measures made therapists realize the importance of telepsychiatry during this period. Belgian Ministry of Health rapidly reacted to encourage teleconsultation with specific invoicing system: this allowed to both limit patients access to the hospitals and to continue patient care at home. A recent review about telepsychiatry in acute settings showed that it is correlated with decreased admissions to psychiatric inpatient units and that the clinical interaction quality is similar to that in face-to-face care [7]. These arguments lead the authors to suggest an implementation of telepsychiatry in ordinary practice.
In summary, this new way of working in child psychiatry, with shorter inpatient care followed by videoconferencing sessions as part of a home-based care protocol, has very convincing therapeutic effects and research should be pursued outside the pandemic period. This conclusion joins new studies already questioning the need for long-term inpatient care for patients presenting anorexia nervosa [8,9].
The other crucial conclusion relies in the need to continue Child and Adolescent Psychiatry care during pandemic times. Indeed, the psychic pain of children and adolescents does not disappear during pandemic.
The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors received no financial support for the research, authorship, and/or publication of this article.
Simone Marchini, 
https://orcid.org/0000-0002-0432-5705
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