Premorbid Depression Associated With Poor Anorexia Prognosis

Premorbid depression is associated with a poor prognosis in anorexia nervosa, European and American researchers reported in the March International Journal of Eating Disorders.

The lead researcher was Anna Keski-Rahkonen, M.D., Ph.D., an assistant professor in psychiatric epidemiology at the University of Helsinski in Finland.

Out of 2,881 women from the 1975 to 1979 birth cohorts of Finnish twins, the researchers identified 55 with a lifetime DSM-IV diagnosis of anorexia nervosa. Of these women, who were age 26 on average at the time of assessment, 39 had recovered from their eating disorder, and 16 had not. Recovery was defined as restoration of weight, menstruation, and the absence of binging and purging for at least one year prior to assessment. Among the women classified as recovered, the average duration of recovery was seven years.

The unrecovered women were significantly more likely to suffer from depressive symptoms prior to eating-disorder onset, to be unemployed, to be dissatisfied with their current partner or spouse, and to report a high level of perfectionism than were women who had recovered. When age at onset and illness duration were accounted for in the analyses, however, premorbid depression was the sole prognostic factor significantly associated with a decreased likelihood of recovery.

“While our theoretical understanding of the factors that may contribute to the unusual persistence of anorexia nervosa has evolved over the years, our ability to predict and manage chronicity among those who suffer from this devastating illness remains limited,” said Michael Devlin, M.D., co-director of eating disorders research at the New York State Psychiatric Institute, in an interview with Psychiatric News. “This important study brings us a step closer by underscoring the negative impact of depressive symptoms on the goal of full long-term behavioral recovery.”

Commenting on the implication of their findings for psychiatrists, Keski-Rahkonen said, “Major depressive disorder is a severity marker for anorexia nervosa. This means that someone with both anorexia and depression can be ill for longer and is less likely to recover than someone with just anorexia.

“We psychiatrists often look for simple solutions to complex problems. Many psychiatrists hope that a single treatment approach—say, cognitive-behavioral therapy [CBT] or an antidepressant—would relieve both anorexia and depression. Unfortunately, it seems that antidepressive medication does not alleviate symptoms of anorexia, and many patients with anorexia drop out of CBT.”

She noted that she and her colleagues are conducting a study of adolescents with anorexia nervosa and are finding that “if they also have depression, they seem to need more inpatient treatment and more outpatient and emergency room visits; the overall length of treatment appears to be almost four times longer if depression is involved.

“So I think we should accept that anorexia patients with psychiatric comorbidities will be some of our most challenging patients, and their treatment may require a combination of different approaches and a lot of patience.”

The researchers also noted that other studies have found that depressive disorders sometimes precede anorexia nervosa and that depressive disorders are “cross-transmitted” in families with eating disorders. Asked about possible genetic connections between depression and anorexia nervosa, Keski-Rahkonen said, “Major genetic collaborations have to date failed to find susceptibility genes for both depression and anorexia. There is, however, some previous evidence from twin studies that anorexia and depression might share a genetic link.”

The study was funded by the U.S. National Institutes of Health, the European Union, the Academy of Finland, and private foundations. ■

An abstract of “Factors Associated With Recovery From Anorexia Nervosa: A Population-Based Study” can be accessed here.