Issue 25 | Comorbidity: Eating Disorders, Depression and Anxiety
About this resource
Issue 25 | October 2014
Welcome to the twenty-fifth edition of the NEDC e-Bulletin. In this month’s issue we are exploring issue related to eating disorders and depression.
Eating Disorders & Depression: Understanding & Addressing Comorbidity
In the field of eating disorders, psychiatric comorbidities, such as mood disorders, are commonly presented with eating disorders or symptoms of eating disorders. Studies have shown that eating disorder patients with comorbid depression are at higher risk of ongoing eating disorder symptoms, poorer health and higher rates of mortality than those without comorbidity (at the 14-year follow up) (Hughes et al., 2013).
In comorbid patients, it can often be difficult for clinicians to determine whether the eating disorder preceded the depression or whether the psychological issues occurred first.
A significant study of females with a history eating disorders has demonstrated that massive depressive disorder and eating disorders occur in the first instance in close proximity, that is, within a 3 year window. In addition, just over 43% of both illnesses occurred together, within 1 year of each other (Fernandez et al., 2007).
Comorbidity and Complexity
Comorbid conditions like depression can make treatment and recovery more challenging, and they can increase illness severity and complexity; they can also increase the risk of relapse. While depression can be an expected consequence of disturbed eating patterns, it can occur at any time during the illness (including during and after the recovery process), hence complicating diagnosis, treatment and recovery.
In a recent 2013 study of children and adolescents, it was discovered that patients who were diagnosed with comorbid depression presented with more complex and severe forms of the illness than those without comorbidity or comorbid anxiety. This was indicated by more frequent binge eating and purging, greater dietary restraint, eating, weight and shape-related concerns, higher levels of depressive symptoms and lowest levels of self-esteem.
Children and adolescents who came from non-intact families were also more likely to present with depression comorbidity than those without or with only comorbid anxiety disorder. However, the correlation between comorbid depression and family stability, and how to treat this, is something that requires further investigation (Hughes et al., 2013).
A Shared Risk Factors Approach
By focusing on shared, modifiable risk factors, an effective public health approach may be possible. Common risk factors of eating disorders and depression include body dissatisfaction, weight/shape concerns, low self-esteem, and bullying and weight-related teasing, the last of which also contributes to heightened suicide ideation and functional impairment in youth sufferers (Becker et al., 2014).
At present, there are no public health programs or universal prevention interventions that seek to simultaneously address eating disorders and depression. Where programs do exist that target commonalities they do not necessarily effectively impact the targeted risk factor/s and there is little evidence that proves the success of these approaches. It is also uncertain whether altering the risk factors will also alter the course of the approach and the end point/outcome for eating disorder and depression patients (Becker et al., 2014).
In a clinical setting, many gaps also exist in treating eating disorder patients with comorbidity. For example, certain third-wave strategies, such as mindfulness-based cognitive therapy, have shown some efficacy in depression treatment and are only starting to be adopted in eating disorders literature (Bailey et al., 2014).
Recognising that many commonalities exist between eating orders and depression is vital in developing effective diagnoses, interventions and treatment approaches. While the relationship between depression and eating disorders requires further research, targeting variable shared risk factors in health initiatives and clinical treatment may be one viable approach in addressing the heightened complexity and severity of the comorbidity and achieving successful treatment outcomes.
Bailey, A. P., Parker, A. G., Colautti, L.A., Hart, L. M., Lieu, P., Hetrick, S. E. Mapping the evidence for the prevention and treatment of eating disorders in young people (2014). Journal of Eating Disorders, 2:5 doi:10.1186/2050-2974-2-5.
Becker, C.B., Plasencia, M., Smith Kilpela, L., Briggs, M., Stewart, T. Changing the course of comorbid eating disorders and depression: what is the role of public health interventions in targeting shared risk factors? (2014). Journal of Eating Disorders, 2:15 doi:10.1186/2050-2974-2-15.
Fernandez-Aranda, F., Poyastro Pinheiro, A., Tozzi, F., Thornton, L. M., Fichter, M. M., Halmi, K. A., Kaplan, A. S., Klump, K. L., Strober, M., Woodside, D.B., Crow, S., Mitchell, J., Rotondo, A., Keel, P., Plotnicov, K. H., Berrettini, W.H., Kaye, W. H., Crawford, S. F., Johnson, C., Brandt, H., La Via, M., Bulik, C. M. Symptom profile of major depressive disorder in women with eating disorders. Australian & New Zealand Journal of Psychiatry (2007) Jan;41(1):24-31.
Hughes, E. K., Goldschmidt, A. B., Labuschagne, Z., Loeb, K. L., Sawyer, S. M., & Le Grange, D. (2013). Eating Disorders with and without Comorbid Depression and Anxiety: Similarities and Differences in a Clinical Sample of Children and Adolescents. European Eating Disorders Review, 21(5), 386-394.
Pan, J. (2009). Eating Disorders and Comorbidity in Childhood and Adolescence: A Comparison between Children and Adolescents Diagnosed exclusively with an Eating Disorder and those Diagnosed with another Comorbid Condition in addition to the Eating Disorder: Final Outcomes Report. McMaster University, June 20 2009.
Wider Mental Health Perspective on Eating Disorders, Depression & Anxiety
Many people concerned about a friend or family member who they think has an eating disorder say they don’t know the best way to initiate a conversation about it.
Like anyone experiencing a mental health problem, it is important to approach them in a supportive and helpful way.
To help people learn more about the signs and symptoms of eating disorders and the links between eating disorders and other conditions such as anxiety and depression, beyondblue has developed a factsheet and online resources.
About four in every 100 Australians has anorexia or bulimia nervosa, and eating disorders can affect people from any age group, gender or socioeconomic and cultural background.
Eating disorders involve an unhealthy preoccupation with eating, exercise and body weight/shape, and several signs are often apparent, such as weight loss or fluctuations, feeling anxious or depressed or being sensitive to comments about food, exercise or body shape.
beyondblue CEO Georgie Harman said the best course of action for people worried about a loved one is to learn about eating disorders and symptoms to watch out for, and encourage the person to see their doctor.
“It is very important to let the person know you are there to support them, help them follow their recovery plan and encourage them to do things they would normally enjoy,” she said.
Our fact sheet, available here, includes information on eating disorders, treatment options, where to get help and what family and friends can do to provide support.
beyondblue’s new website (beyondblue.org.au/conversations) has videos and factsheets that provide general advice on how to talk to someone you’re concerned about or alternatively how you can talk to someone if you are having a tough time.
What are the treatments for eating disorders, anxiety and depression?
There is no one proven way that people recover from an eating disorder, anxiety or depression and it’s different for everybody. However, there is a range of effective treatments and health professionals who can help people on the road to recovery.
There are also many things that people with anxiety, depression and an eating disorder can do to help themselves to recover and stay well. The important thing is finding the right treatment and the right health professional that works for you.
Different types of anxiety or depression require different types of treatment. This may include physical exercise for preventing and treating mild anxiety and depression, through to psychological and medical treatment for more severe episodes.
The treatment for anxiety and depression in someone with an eating disorder involves a coordinated approach that monitors and treats the symptoms of anxiety, depression and the eating disorder.
Professional treatment for eating disorders involves managing physical health (including nutritional advice) and promoting mental health. In addition, medication, support groups and some alternative therapies may be helpful.
Read more information in the Beyond Blue Fact Sheet
Knowledge Hub Roundup
The National Eating Disorders Collaboration collects and provides the latest evidence based research and information available on eating disorders from Australia and around the world. The topics included in our Research & Resources are wide ranging and recognise the physical, social and emotional aspects and the broad spectrum of eating disorders. This month we’re highlighting content relating to eating disorders and depression.
Anxiety and depression among caregivers of patients with eating disorders and their change over 1 year.
Limited data are available on the difficulties experienced over time by caregivers of patients with eating disorders (CPED). The aim of this study was to describe changes in anxiety and depression among such caregivers over 1 year and to identify factors predicting any change in both.
Find out more
Pregnancy and post-partum depression and anxiety in a longitudinal general population cohort: the effect of eating disorders and past depression.
This study investigated the effect of past depression, past and current eating disorders (ED) on perinatal anxiety and depression in a large general population cohort of pregnant women, the Avon Longitudinal Study of Parents and Children (ALSPAC).
Find out more
A comparison of stigma toward eating disorders versus depression.
This study found that stigma toward individuals with eating disorders is greater than stigma toward depression and includes unique features such as attitudes of envy. Implications of these results for the understanding of mental disorder stigma and eating disorders are discussed.
Find out more
Find more eating disorders research.
NEDC Resource Highlight
NEDC have developed a professional resource for GPs to support their role in the treatment of eating disorders which can encompass prevention, identification, medical management and referral. This resource is divided into three sections covering screening and assessment, referral to appropriate services and ongoing treatment and management. The resource encourages General Practitioners to act as an approachable ‘first base’ for those seeking help.
As General Practitioner is likely to be one of the first health professionals a person with an eating disorder will come in contact with. A General Practitioner’s role in the treatment of eating disorders can encompass prevention, identification, medical management in a primary care setting and referral.
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