Preliminary communication
Depression and eating disorders: Treatment and course

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Abstract

Background

We examined the course of major depressive disorder (MDD) and predictors of MDD recovery and relapse in a longitudinal sample of women with eating disorders (ED).

Methods

246 Boston-area women with DSM-IV anorexia nervosa-restricting (ANR; n = 51), AN-binge/purge (ANBP; n = 85), and bulimia nervosa (BN; n = 110) were recruited between 1987 and 1991 and interviewed using the Eating Disorders Longitudinal Interval Follow-up Evaluation (LIFE-EAT-II) every 6–12 months for up to 12 years. 100 participants had MDD at study intake and 45 developed MDD during the study. Psychological functioning and treatment were assessed.

Results

Times to MDD onset (1 week–4.3 years), recovery (8 weeks–8.7 years), and relapse (1 week–5.2 years) varied. 70% recovered from MDD, but 65% subsequently relapsed. ANR patients were significantly less likely to recover from MDD than ANBP patients (p = 0.029). Better psychological functioning and history of MDD were associated with higher chance of MDD recovery. Higher baseline depressive severity and full recovery from ED were associated with greater likelihood of MDD relapse; increased weight loss was somewhat protective. Adequate antidepressant treatment was given to 72% of patients with MDD and generally continued after MDD recovery. Time on antidepressants did not predict MDD recovery (p = 0.27) or relapse (p = 0.26).

Limitations

Small ED diagnostic subgroups; lack of non-ED control group.

Conclusions

The course of MDD in EDs is protracted; MDD recovery may depend on ED type. Antidepressants did not impact likelihood of MDD recovery, nor protect against relapse, which may impact on treatment strategies for comorbid MDD and EDs.

Introduction

Eating disorders (EDs) have high rates of comorbidity with other mental illnesses, especially major depressive disorder (MDD). Multiple studies indicate that MDD is the most common comorbid diagnosis in patients with EDs (Herzog et al., 1992, Fichter and Quadflieg, 2004, Kaye et al., 2008); the American Psychiatric Association has reported that lifetime rates of MDD in individuals with EDs range between 50% and 75% (American Psychiatric Association Workgroup on Eating Disorders, 2006); and MDD comorbid with EDs has been associated with worse ED outcome (Lowe et al., 2001, Berkman et al., 2007), including high rates of suicide attempts (Franko et al., 2004, Bulik et al., 2008, Forcano et al., 2009) and suicide-related mortality (Crow et al., 2009).

Despite the overlap between EDs and depression, FDA-approved antidepressants have not shown promise in alleviating depression in patients with EDs. Although fluoxetine has been approved to treat bulimia nervosa (BN), the drug has shown mixed efficacy in reducing MDD in this group (Pope et al., 1983, Fichter et al., 1991, Fluoxetine Bulimia Nervosa Collaborative Study Group, 1992, Goldbloom and Olmsted, 1993, Beumont et al., 1997, Walsh et al., 1997, Romano et al., 2002). Moreover, antidepressant treatment does not result in improvement in depressive symptomatology in anorexia nervosa (AN) treatment trials (Attia et al., 1998, Walsh et al., 2006). In view of the high rates of suicide and treatment resistance in individuals with comorbid MDD and ED, characterizing the course of MDD and identifying predictors of MDD recovery and relapse in individuals with EDs are important avenues for research.

In 1987 we initiated a prospective longitudinal study of treatment-seeking women with AN and BN to map the course and outcome of EDs. We have previously examined psychiatric comorbidity and found high rates of MDD in this sample (Herzog et al., 1992). Depression severity was associated with increased risk for attempted suicide in AN participants (Franko et al., 2004). By a median of 9 years of follow-up, 11 women had died (Keel et al., 2003). In this study we address the following questions about MDD: (a) What is the course of MDD?; (b) What variables are associated with recovery from and relapse to MDD?; and (c) What types of antidepressant medications do women with EDs receive for MDD and are these treatments adequate by current standards? We hypothesized that the course of MDD would be longer if there was no recovery from ED. Likewise, we expected that women who received antidepressants would be more likely to recover from MDD, even if their ED did not significantly improve.

Section snippets

Participants

Five hundred and fifty-four women who sought treatment at Massachusetts General Hospital and other treatment centers in the Boston area between 1987 and 1990 were screened to determine whether they met criteria for AN or BN set forth in the 3rd Revised Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987). Two hundred and twenty-five women originally agreed to participate in the study, and in 1991, 21 additional participants

Results

Of the 145 patients with MDD included in the analysis, 102 (70%) recovered from MDD over the course of the study, but 66 (65%) of these 102 patients subsequently relapsed to MDD. The mean and median follow-up time for the analysis population was 8.8 and 10.0 years, respectively (range = 3 months–12 years). Time from MDD onset to recovery (8 weeks–8.7 years) and time from MDD recovery to relapse (1 week–5.2 years) varied greatly, as did time from study entry to new onset of MDD (1 week–4.3 years) for

Discussion

To our knowledge, this is the first prospective investigation of the course of MDD in an ED sample, derived from the largest and longest prospective, naturalistic longitudinal follow-up of women with EDs. Consistent with previous reports of MDD in ED samples (Brewerton et al., 1995, Godart et al., 2004, Fernandez-Aranda et al., 2007, Herzog and Eddy, 2007), we found that 59% of the 246 patients recruited had one or more episodes of depression, a prevalence much greater than the 15% or so that

Role of funding source

This work was supported by the National Institute of Mental Health grant 5R01 MH 38333 05 (DBH) and the Rubenstein Charitable Foundation, Boston MA. Sponsors had no further role in the study design, collection, analysis and interpretation of data, writing of the report, and the decision to submit the paper for publication.

Conflict of interest

Dr. Mischoulon has received research support from Laxdale (Amarin), Nordic Naturals, Ganeden, and SwissMedica. He has served as a consultant to Bristol-Meyers-Squibb Company. He has received speaking honoraria from Pamlab, Virbac, and Nordic Naturals. He has received writing honoraria from Pamlab. He has received royalties from Back Bay Scientific for PMS Escape, and royalties from Lippincott Williams & Wilkins, for textbook “Natural Medications for Psychiatric Disorders: Considering the

Acknowledgments

None to report.

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