BALTIMORE – Depression frequently co-occurs with eating disorders, making treatment challenging, Dr. Graham W. Redgrave 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 can magnify 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,” he said. Patients can recognize that what they're doing is problematic but have a hard time giving it up.
“Imagine if you have a parallel mood disorder that is making your thoughts about yourself more hopeless and self-deprecating. … How much harder would it be to give up behavior that is rewarding?”, Dr. Redgrave said at the symposium, also sponsored by the Depression and Related Affective Disorders Association.
Treatment for an eating disorder focuses first on behaviors and then on thoughts and feelings. Underlying connections and associations are addressed only when the patient is stabilized. When the patient's health is in jeopardy, “you can't be worried about why this happened, you just have to fix it, and then worry about the why,” he said.
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.