When 18-year-old Echuca dancer Molli Johns needed help for her eating disorder during Victoria's rolling lockdowns, she had to wait a whole year to see a psychologist.
There were ups and downs, good days and bad, over those interminable months battling to keep the illness at bay.
WARNING: This article contains content about eating disorders that may be triggering for some readers.
"It was worrying because you didn't know when you were going to be able to get help," Ms Johns said.
"All of the things that help me, things like dance, being with my friends, I didn't have.
"It definitely made me feel isolated from everyone – I felt like I was losing my friends when that wasn't true."
Ms Johns was diagnosed with atypical anorexia, after developing an eating disorder in her early teens.
In the midst of her illness, she felt like she had nowhere to turn until a caring and perceptive teacher with her own history of disordered eating gently guided her into therapy.
Her story resonates with other regional teens struggling with eating disorders because of the scarcity of services for young people in some rural areas.
'Throwing a hand grenade' into a health system under strain
A survey by national charity the Butterfly Foundation last year found 94 per cent of respondents with an eating disorder in regional and remote areas believed the place they called home was an obstacle to getting help
Eating disorders like anorexia nervosa have the highest mortality rate of any mental illness and come with a 32-fold increased risk of suicide.
National Mental Health Commission data shows a 25 to 50 per cent surge in the number of people being treated for eating disorders across the public health system during the COVID-19 pandemic.
There have been dramatic increases in both new diagnoses and relapses, leaving some patients waiting between three and six months for their first appointment.
Some private clinics – which are unaffordable for many – have been forced to close their doors to new patients.
GP Jenny Conway, who specialises in eating disorders, said she had been losing sleep over the scale of the crisis, likening COVID-19 to "throwing a hand grenade" into a health system already under immense strain.
"It's almost like you have to wait until you're so sick that you need to be hospitalised to access support. It shouldn't be that way."
During the first school term of the year, demand for the Butterfly Foundation's prevention services increased by 150 per cent, compared to the same pre-pandemic period in 2019.
Chief executive Kevin Barrow said almost 15,000 people sought help between January and June this year, 30 per cent of whom did so for the first time.
"COVID has obviously been a perfect storm for someone with an eating disorder," he said
The Royal Children's Hospital, Austin Health and Monash Health provide specialist child and adolescent eating disorders services for young people up to the age of 18.
Barwon Health also has a service for teens under 18.
The Royal Children's adolescent health centre director Susan Sawyer said the hospital had been inundated by eating disorder referrals, with an estimated three-fold increase in the number of cases this year compared to 2019.
"The challenge is that there is this huge increase in demand everywhere, including regional Victoria, where they often have fewer professionals able to do the work."
Eating disorders are not a lifestyle choice, but complex mental illnesses that can thrive in the isolation of lockdown, changes to routines, and the amplified uncertainties of life in a pandemic.
They are curable, but early intervention and timely treatment are paramount.
The longer an illness is left untreated, the harder it is to recover.
For this reason, Professor Sawyer said the Royal Children's has dramatically changed its model of care by offering group-based family treatment, instead of individual therapy.
Patients can receive rebates for up to 40 psychological and 20 dietetic sessions a year under the Medicare Benefits Schedule.
Shortage of medical staff in regional areas
But Jenny Conway said the overwhelming demand, coupled with a shortage of trained clinicians like psychologists and dieticians, means many patients cannot get an appointment.
She said overworked country GPs were often reluctant to treat people with eating disorders, because of a lack of training and the complexity of the cases.
"There aren't enough medical staff in regional areas and there certainly aren't the people who have the expertise in dealing with eating disorders," she said.
More than 500 staff from Goulburn Valley Health have been furloughed because of the Shepparton coronavirus outbreak, demonstrating the difficulties in managing both the immediate crisis and patients wrestling with their mental health.
Rural Doctors Association of Victoria (RDAV) vice president Skye Kinder said regional teens were relying heavily on GPs for mental health care, because of the shortage of specialists like psychiatrists outside metropolitan Melbourne.
Dr Kinder said it was counter-intuitive for them to travel long distances for life-saving hospital treatment away from family and friends.
"Sometimes that transfer to a metropolitan area can involve multiple ambulance transfers, and in some cases like Albury-Wodonga, up to seven hours of travel," Dr Kinder said.
Eating Disorders Victoria (EDV) runs a mental health clinic that has been closed to new patients for most of the past 18 months because of the huge demand.
But chief executive Belinda Caldwell said the pandemic had demonstrated the value of telehealth for regional patients because it created more opportunities for treatment by city clinicians.
"People in rural and regional areas have been able to access so many more of our services since covid, provided they have an internet connection," she said.
While acknowledging the importance of telehealth, Skye Kinder said it should not be the primary solution to providing better mental health care in the regions.
"If we don't continue to build local capacity in the workforce, we will still see people traveling to metropolitan areas for care, even if they might be able to access other parts of their care via telehealth," she said.
National Mental Health Commission chief executive Christine Morgan cited the importance of better training for GPs and other staff to help them recognise, diagnose and refer people with eating disorders, along with single-session interventions for those on long waiting lists.
"Training, training, training – it's a really critical thing," she said.
Long-term sufferers at risk
In January the Victorian Government announced an additional $2 million in funding to help people with eating disorders, including $1.5 million for specialist mental health clinicians across six metropolitan health services.
The remaining $500,000 went to support the work of EDV, including expanding its telehealth nurse, counseling, and peer support programs.
But Belinda Caldwell fears people with eating disorders will suffer for years, even as the country charts a path out of the pandemic.
"Some people can be almost fine and eight weeks later be in the thick of an eating disorder. It takes a good two to three years, even longer sometimes, to really get back out of that predicament," she said.
For now, Ms Johns is enjoying the liberation that has come from beating her illness and moving to Melbourne to study dance.
"I feel like I have a lot more freedom now," she said.
