Erin Reynolds had struggled with bulimia since childhood, but the weeks before she entered treatment were some of her worst. At 22, she was preparing to leave her home in Helena, Montana for an inpatient program in New Jersey with 24-hour medical care.
Looking back six years later, Reynolds said seeking help was one of the hardest parts of the recovery process. “I kept gorging and purging because I was so stressed out,” she said. “I’m leaving my job that I love, I’m leaving all my friends and my city and I’m saying goodbye to normal life.”
Eating disorders, including anorexia, bulimia and binge eating disorder, are among the deadliest mental illnesses. Still, treatment options are scarce, especially in rural states like Montana.
ER visits for teenage girls struggling with eating disorders have doubled nationwide during the pandemic, according to a study from the Centers for Disease Control and Prevention. The same report notes that the rise could be linked to reduced access to mental health services, an even more acute barrier in rural states.
the National Eating Disorders Association the vendor database shows just two certified vendors in all of Montana, the nation’s fourth-largest state, measured in square miles. By comparison, Colorado, which is nearly three-quarters the size of Montana but has five times the population, has nine providers.
That means many people like Reynolds have to leave Montana for treatment, especially for those seeking higher levels of care, or drive for hours to attend therapy. It also means that more people are not being treated because they are unable to give up gainful employment or leave loved ones behind.
“Many people cannot access treatment, given the state’s geography and vast rurality,” said Caitlin Martin Wagarassistant professor and psychologist at the University of Montana, specializing in research on eating disorders.
The most intense treatment involves hospitalization or partial hospitalization programs, ideal for those who need round-the-clock care and acute medical stabilization. Residential treatment is a step from there, usually outside of a hospital in a location similar to a rehabilitation center.
Once a recovering person can manage with less hands-on care, a variety of outpatient options may include therapy, meal support, or group counseling. “Finding people with these specialties and availability is often a challenge,” said Lauren Smolar, vice president of outreach and education at the eating disorder association.
When Reynolds sought treatment in 2016, no Montana facility offered inpatient care, residential treatment or partial hospitalization. Only one came close: the Montana Eating Disorders Centera Bozeman-based treatment program established in 2013.
Jeni Gochin, who co-founded the center, said there were many barriers to starting an eating disorder treatment center in Montana, where there were none. There was no licensure process and challenges abounded, from insurance coverage to the high level of specialization required to provide appropriate care.
The Eating Disorder Center of Montana added a partial hospitalization program in 2017, which provides housing for out-of-towners and requires five to seven days of an almost all-day treatment program led by a team of experts. The center also plans to open an outpatient therapy center 200 miles west of Missoula later this year.
A third of people with eating disorders are men, an underdiagnosed and undertreated group. Although Black, Indigenous and other people of color are no less likely to develop an eating disorder, they are half as likely be diagnosed or receive treatment.
Some studies have shown a higher rate of eating disorders in urban centers, but it is unclear whether this is due to reduced stigma and more treatment options in metropolitan areas compared to rural settings.
“We know that the rates of eating disorders are quite high,” Martin-Wagar said. “We’ve seen them increase fairly consistently, so it’s not a niche or specialty issue. It’s something that affects a lot of people.”
The pandemic has made telehealth treatment options more common, which could reduce bottlenecks at treatment facilities. For example, the Eating Disorder Center of Montana is launching virtual outpatient care for any Montana resident this month. Emily Wish Treatment Center in Great Falls, Montana, provides telehealth appointments for individual, family and group therapy. But telehealth treatment of eating disorders is limited in its effectiveness. Many interventions are better in person, such as supporting meals and helping people establish healthier eating habits.
Cost is a barrier to treatment everywhere, but especially in a place like Montana, where about 1 in 5 residents are covered by Medicaid or Healthy Montana Kids, the state’s children’s health insurance program. It can cost thousands of dollars and take several months for a person to receive adequate care, whether they are insured or not. And there is no formula for how long treatment will take or how many times a patient will have to move up and down the scale of care levels.
Few insurance companies offer meaningful coverage. Their reimbursement may expire after only a few weeks – much sooner than the average treatment – or may not cover it at all.
Martin-Wagar, a researcher at the University of Montana, said research on eating disorders also receives very little funding compared to other mental health issues. Without federal and state funds directly devoted to treatment and research, symptoms of eating disorders cannot be identified early in adolescents, the easiest way to reduce overall treatment costs; stigma is more difficult to combat; and there are few incentives for new providers to establish treatment programs in locations outside of urban areas with well-documented demand.
“Even though we’re creating more eating disorder centers, if people can’t afford them, we’re only serving the most privileged in our society,” Martin-Wagar said. “And that means we’re not doing a good job.”
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