Virtual Versus In-Person Intensive Outpatient Treatment for Eating Disorders During the COVID-19 Pandemic in United States–Based Treatment Facilities: Naturalistic Study

Abstract

Background:While virtual therapy has proven effective in treating eating disorders (EDs), little work has examined virtual therapy at higher levels of care, which are treatment options providing more support than weekly outpatient therapy including intensive outpatient (IOP) treatment.

Objective:This study aimed to add to the limited research on in-person versus virtual treatment at a higher level of care by comparing treatment outcomes between an in-person IOP and a virtual IOP (VIOP) for patients with EDs. We hypothesized that there would be no differences in improvements between VIOP and in-person IOP groups.

Methods:This study has a nonrandomized multiple cohort design. Patients with EDs receiving treatment who completed both admission and discharge questionnaires in VIOP treatment (n=231) and in-person IOP treatment (n=39) between 2021 and mid-2022 within a large ED health care system in the United States were included. The Eating Disorder Examination–Questionnaire (EDE-Q) was used to measure ED symptoms. The Patient Health Questionnaire-9 (PHQ-9) was used to measure depression, and item 9 of the PHQ-9 was used to measure suicidal ideation. Welch t tests on admission, discharge, and raw change scores were conducted. Logistic regressions were conducted predicting treatment program (reference group VIOP vs in-person IOP) from the residualized change in each outcome and were adjusted for all significantly different factors between groups.

Results:VIOP patients were significantly older (mean 28.03, SD 11.09) than in-person IOP patients (mean 19.51, SD 6.98) and displayed significantly different numbers of ED diagnoses and more comorbid psychiatric diagnoses (VIOP: mean 1.23, SD 1.12; in-person IOP: mean 0.33, SD 0.84) but no differences in race (VIOP: 175/231, 75.6% White; in-person IOP: 30/39, 76.9% White), gender (VIOP: 196/231, 84.8% female; in-person IOP: 35/39, 89.7% female), or length of stay (VIOP: mean 58.84, SD 26.69; in-person IOP: mean 57.33, SD 19.67). When compared to in-person IOP patients, controlling for age, diagnosis, number of comorbid diagnoses, and admission scores, VIOP patients did not exhibit significantly different improvements in ED symptom scores (EDE-Q Global: b=0.01, SE 0.18, t=0.04, odds ratio [OR] 1.01, 95% CI 0.71-1.43; P=.97). However, VIOP patients exhibited significantly greater improvements in depression scores (PHQ-9: b=–0.14, SE 0.05, t₂₃₀=–2.85, OR 0.87, 95% CI 0.79-0.96; P=.004) and the PHQ-9 suicidal ideation item (PHQ-9 item 9: b=–0.72, SE 0.34, t₂₃₀=–2.13, OR 0.49, 95% CI 0.25-0.93; P=.03).

Conclusions:ED outcomes were similar for VIOP and in-person IOP patients. Contrary to our hypotheses, depression and suicidal ideation outcomes improved more for VIOP patients than for in-person IOP patients. Furthermore, treatment access for non-White and older adults does not appear descriptively worse for VIOP treatment compared to in-person IOP treatment, though these trends should be further explored. VIOP treatment may improve treatment access in an equitable fashion without reducing treatment quality.