Depression Common in Eating Disorders, Complicates Tx


BALTIMORE — Depression frequently co-occurs with eating disorders, making treatment challenging, Graham W. Redgrave, M.D., said at a symposium on mood disorders sponsored by Johns Hopkins University.

“There are high rates of concurrent major depressive disorder in anorexia,” said Dr. Redgrave of the Johns Hopkins University in Baltimore. Among patients with the restricting type of anorexia, 15%–50% also have major depressive disorder (MDD). The rates among patients with the binge-eating/purging type of anorexia are even higher at 46%–80%. The rates are higher still when these patients are asked whether they have ever had depression.

Numbers like these suggest that anorexia might simply be a behavioral manifestation of an underlying mood disorder. However, controlled family studies have provided good evidence that these disorders are different and independent, Dr. Redgrave said.

One reason so much overlap exists between anorexia and MDD is that starvation produces a host of psychiatric conditions in the body, such as mood lability, irritability, anxiety, apathy, obsessiveness, poor concentration, social withdrawal, and decreased libido.

Patients with anorexia aren't the only ones suffering from comorbid depression. Among patients with bulimia, 30%–60% have concurrent MDD and 50%–65% have had a lifetime occurrence of depression.

In patients with bulimia, starvation magnifies feelings of guilt, shame, and hopelessness, Dr. Redgrave said. Increased frequency in the binge and purge cycles decreases the ability to concentrate, because the fear of being overweight increases in importance.

Depression also is high among patients with binge-eating disorder, with 36%–60% of these patients also having MDD. In addition, 48% of obese women who binge also have MDD, compared with only 26% of obese women who do not binge. “It's not just the obesity. There's something about the psychopathology of depression and the binge eating that seems to be related,” Dr. Redgrave said.

Treatment of patients with eating disorders and depression can be a challenge because “when you are treating an eating disorder, you are asking your patient to give up something that is very rewarding.” Patients can recognize that what they're doing is problematic but have a hard time giving it up, Dr. Redgrave said at the sympo- sium, also sponsored by the Depression and Related Affective Disorders Association.

Treatment for an eating disorder focuses on behaviors and then on thoughts and feelings. Underlying connections and associations are addressed only when the patient is stabilized.

Pharmacotherapy is primarily an adjunctive treatment for patients with anorexia. Antidepressants are of modest but important benefit in bulimia nervosa, Dr. Redgrave said. Fluoxetine at high doses is especially useful, though most antidepressants can be useful in this population. Bupropion is contraindicated because of the risk of seizures.

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