A Longitudinal Study Examines Mortality Risk in AN and BN

Anorexia nervosa (AN) produces higher mortality rates than other psychiatric disorder, and there is still only limited information about the timing and predictors of death in eating disorders. Enter Debra L. Franko and colleagues, who recently published the results of their long-term study of mortality among patients with eating disorders (Am J Psychiatry. 2013; 170: 917).

In 1987 Dr. Franko and her colleagues began a long-term study of 246 female patients with AN or bulimia nervosa (BN) who sought treatment for their eating disorders. The women were interviewed every 6 months for a median of 9.5 years to establish weekly ratings of eating disorder symptoms, comorbidities, participation in treatment programs, and psychosocial functioning. The women were participants in the Massachusetts General Hospital Longitudinal Study of Anorexia and Bulimia Nervosa between 1987 and 1991.

Death rate, suicides were higher among those with AN

Overall, 16 deaths (6.5%) occurred among the 246 women in the study. The highest death rate, 7.5% (14 patients), occurred among the 186 individuals with a lifetime history of AN. Among the 60 study participants who had BN and no history of AN, 2 patients (3.3%) died. Four (25%) of the deaths were suicides, and all occurred in patients with AN. Risk of premature death appeared to decrease over time among women with lifetime AN. Within the first 10 years of the follow-up, the annual mortality rate for this group was 5.49 deaths per 1000 person-years. The authors noted that 7 of the 10 patients with a longer duration of illness died within the first decade of the study. Patients with lifetime AN had higher premature mortality rates than the general population, and the risk of premature death was highest in the first 10 years of follow-up.

Implications of the study

The authors noted that the age and cause of death in their sample of patients were noteworthy because all deaths occurred in middle adulthood and all but 3 deaths occurred between the ages of 35 and 48 years. Their findings highlight the need for early identification and intervention and suggest the risk for death increases substantially among those with a long duration of illness, particularly when substance abuse, low weight, or poor psychosocial functioning are also present. Assessing the quality of relationships, the capacity for work and play, and the degree of impairment in psychosocial functioning is vital when working with patients with AN.

In an editorial in the same issue,Scott Crow MD, of the University of Minnesota, and a member of the EDR Editorial Board, noted that the study results further reinforce the public health importance of eating disorders. The temporal course of death observed is a strong argument for increased emphasis on early identification of persons with eating disorders and the potential importance of early treatment of these disorders (Am J Psychiatry. 2013; 170:824). Suicide mortality risk may be concentrated early in the illness, and intensive monitoring of suicidality early in the illness may be critical Dr. Crow also pointed out that psychotherapies for AN and BN delivered in adolescence, as opposed to adulthood (particularly family-based therapies) could reduce overall mortality through earlier intervention.