Erin Reynolds had battled bulimia since childhood, but the weeks before she entered treatment were among her worst. At 22, she was preparing to leave her home in Helena, Montana, for an inpatient program in New Jersey with round-the-clock medical care.
Looking back six years later, Reynolds said seeking help was one of the most difficult parts of the recovery process. “I just kept bingeing and purging because I was so stressed,” she said. “I’m leaving my job that I love, leaving all my friends and my town and saying goodbye to normal life.”
Eating disorders, including anorexia, bulimia, and binge-eating disorder, are some of the most fatal mental illnesses. Yet treatment options are sparse, particularly in rural states such as Montana.
Emergency department visits for teenage girls dealing with eating disorders doubled nationwide during the pandemic, according to a study from the Centers for Disease Control and Prevention. The same report notes that the uptick could be linked to reduced access to mental health services, a hurdle even more acute in rural states.
The National Eating Disorders Association’s provider database shows only two certified providers across all of Montana, the country’s fourth-largest state as measured by square miles. By comparison, Colorado, which is nearly three-quarters of the size of Montana but has five times the population, shows nine providers.
That means many people like Reynolds must leave Montana for treatment, particularly true for those seeking higher levels of care, or drive for hours to attend therapy. It also means more individuals go untreated because they lack the flexibility to give up a paying job or leave loved ones behind.
“A lot of people are not able to access treatment, just given the geography and vast ruralness of the state,” said Caitlin Martin-Wagar, a University of Montana assistant professor and psychologist who specializes in eating disorder research.
The most intense treatment involves inpatient or partial hospitalization programs, best for those in need of round-the-clock care and acute medical stabilization. Residential treatment is a step down from there, usually outside a hospital setting at a place akin to a rehab facility.
Once a person in recovery can manage with less hands-on care, a variety of outpatient options may include therapy, meal support, or group counseling. “Finding people with those specialties and availability is often a challenge,” said Lauren Smolar, vice president of mission and education at the eating disorders association.
When Reynolds sought treatment in 2016, not one facility in Montana offered inpatient care, residential treatment, or partial hospitalization. Only one came close: the Eating Disorder Center of Montana, a treatment program based in Bozeman and established in 2013.
Jeni Gochin, who co-founded the center, said there were many barriers to starting an eating disorder treatment facility 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 nearly all-day treatment programming led by a team of experts. The center also plans to open an outpatient therapy facility 200 miles west in Missoula later this year.
A third of people with eating disorders are men, a group that is underdiagnosed and undertreated. Although Black, Indigenous, and other people of color are no less likely to develop an eating disorder, they are half as likely to be diagnosed or receive treatment.
A few studies have shown a higher rate of eating disorders in urban centers, but it’s difficult to know whether that’s due to reduced stigma and more treatment options in metropolitan areas compared with rural settings.
“We know eating disorder rates are quite high,” Martin-Wagar said. “We’ve been seeing them rise pretty consistently, so this isn’t a niche or specialty issue. It’s something that’s impacting lots and lots of folks.”
The pandemic has made telehealth treatment options more common, which could relieve 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 for eating disorders is limited in its effectiveness. Many interventions are best in person, such as meal support and helping people establish healthier patterns around eating.
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 many months for a person to receive adequate care, whether a person is insured or not. And there’s no formula to know how long treatment will take, or how many times a patient will have to move up and down the ladder of levels of care.
Few insurance companies provide meaningful coverage. Their reimbursement might time out after only a few weeks — far sooner than the average course of treatment takes — or not cover it at all.
Martin-Wagar, the University of Montana researcher, said that eating disorder research also receives very little funding relative to other mental health concerns. Without federal and state dollars going directly into treatment and research, eating disorder symptoms can’t be identified early in adolescents, the easiest way to drive down the costs of overall treatment; stigma is harder to combat; and there’s little incentive for new providers to create treatment programs in places outside urban areas with well-documented demand.
“Even if we create more eating disorder centers, if people can’t afford them, then we are only servicing the most privileged in our society,” Martin-Wagar said. “And that means we are not doing a good job.”