Eating Disorders and Depression

From the WebMD Archives

Eating disorders often begin with the best of intentions -- a desire to lose weight and control eating. But in some people, those good intentions go badly wrong, resulting in anorexia nervosa, bulimia, binge eating, or other disorders.

Why some people are at risk for eating disorders isn’t clear. But surveys show that depression is often a factor. In a 2008 study by researchers at the University of Pittsburgh Medical Center, for example, 24% of bipolar patients met the criteria for eating disorders. An estimated 44% had trouble controlling their eating.

As many as half of all patients diagnosed with binge eating disorder have a history of depression, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Binge eating afflicts 3% of adults in the U.S., making it the most common eating disorder.

Depression also plagues many people with anorexia, another common eating disorder. People with anorexia fail to eat enough food to maintain a healthy weight. The results can be tragic. Studies show that anorexics are 50 times more likely than the general population to die as a result of suicide.

The Link Between Depression and Eating Disorders

Depression may lead to eating disorders, but there’s also evidence that eating disorders can result in depression. “Being severely underweight and malnourished, which is common in anorexia, can cause physiological changes that are known to negatively affect mood states,” says Lisa Lilenfeld, PhD, an associate professor of clinical psychology at Argosy University in Arlington, Va., who specializes in eating disorders.

Depression in people with eating disorders typically has its own unique features, according to Ira M. Sacker, MD, an eating disorders specialist at Langone Medical Center at New York University and author of Regaining Your Self: Understanding and Conquering the Eating Disorder Identity.

“People who develop eating disorders feel as people that they’re not good enough,” Sacker says. “They become obsessed with perfectionism. That perfectionism begins to focus on what they eat. But underlying it is depression and anxiety. Often, these patients have suffered a lot of emotional trauma.”

People with binge eating disorder are frequently overweight or obese, for instance. This can lead them to feel chronically depressed about the way they look. After succumbing to an episode of binge eating, they may feel disgusted with themselves, worsening their depression.

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To determine if depression is part of an eating disorder, doctors use a well-tested battery of questions that tease out the most common symptoms of depression. These include:

  • Feelings of sadness or unhappiness
  • Loss of interest in activities that once were pleasurable
  • Loss of libido
  • Irritability or anger
  • Sleep problems
  • Loss of appetite

Diagnosing serious depression is relatively easy, experts say. But finding an effective treatment for combined depression and eating disorders can be a challenge.

Treatment Approaches to Depression and Eating Disorders

Two very different approaches have been shown to help some patients. One approach is the use of antidepressant medications or mood stabilizers. In a 2001 study of 35 patients with anorexia who had managed to eat enough to achieve a healthy weight, for instance, the antidepressant Prozac (fluoxetine) was shown to reduce the risk of relapse.

For binge eating disorder, two different kinds of medications are sometimes prescribed by doctors -- antidepressants and an anticonvulsant drug called Topamax (topiramate). These drugs have been shown to reduce bingeing, either alone or in combination. Unfortunately, over time, many patients relapse.

Another approach is cognitive behavioral therapy, or CBT. The goal is to change the way people think about food and eating and encourage healthier eating behaviors. One CBT method is called dissonance therapy. People with eating disorders who have become obsessed with the idea that they must be extremely thin to be attractive are encouraged to reject this unattainable image in favor of a more realistic ideal. Studies show that this approach can significantly reduce symptoms of bulimia, especially bingeing and vomiting in some patients.

Researchers have also had success encouraging some patients to adopt healthier eating habits. This approach uses a combination of education about healthy food choices and techniques for monitoring change, such as keeping food diaries. When appropriate, patients are also encouraged to become more physically active.

Evidence shows that CBT can be effective. In a 2003 study of 33 patients with anorexia nervosa, only 22% of who received CBT relapsed over the following year, compared to 53% of patients who received nutritional counseling only.

CBT has also been shown to help people control binge eating. In a study published in 2010, researchers at Wesleyan University in Connecticut tested an eight-session course of CBT in 123 patients with binge-eating disorders. The therapy helped patients restrain their binge eating behavior and reduced their symptoms of depression.

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Tailoring Treatment to Your Needs

Which approach is best? Both medication and cognitive behavioral therapy have distinct advantages and disadvantages, experts say. Medication is easy to take. Its effects typically show up relatively quickly.

Cognitive behavioral therapy, on the other hand, may take longer to work. Most patients require three to six months of therapy, according to Lilenfeld. Some may need even more. But CBT has the advantage of offering a more reliable long-lasting cure.

“When people stop taking medications, they are more likely to have a relapse than when they’ve done cognitive behavioral therapy,” Lilenfeld tells WebMD. That’s not surprising, she points out. “The problem with medication is that once you stop taking it, it’s gone. With CBT you can permanently change the way people perceive themselves and the world. That kind of perceptual change can be especially helpful with eating disorders combined with depression.”

Especially for bulimia and binge eating, a combination of CBT and medication may work best. In a study of 30 patients with binge eating disorder, for instance, researchers at Sacco Hospital in Milan, Italy, found that those receiving both CBT and a combination of drugs, including setraline and Topamax, reduced their bingeing behaviors and lost weight.

Tailoring treatments to patients is essential. “Some people are receptive to medication,” Sacker says. “Others aren’t. Some people do well with nutritional counseling. Others need intensive counseling to change the way they think about eating and food. Treatment is often a matter of trial and error.” Indeed, researchers are testing a variety of cognitive behavioral therapies specifically designed for eating disorders.

Finding Help for Eating Disorders and Depression

There is no magic bullet for treating eating disorders coupled with depression. Even intensive research treatment programs have a high drop rate. Patients who do well for a period of time often relapse.

“Still, there’s a lot that we can do to treat underlying depression and change the way people think about themselves and their relationship to food,” Sacker says. The first step is finding a psychiatrist or psychologist with extensive experience in treating eating disorders, experts agree. After that, success depends on a patient’s willingness to change.

WebMD Feature Reviewed by Brunilda Nazario, MD on July 16, 2010

Sources

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Lisa Lilenfeld, PhD, associate professor of clinical psychology, Argosy University, Arlington, Va.

Ira M. Sacker, MD, Langone Medical Center, New York University.

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