By Rosie Pendrous.
A review of 94 papers published between 2000 and 2018 estimated that approximately 8.4% of women and 2.2% of men experienced an eating disorder (ED) – including anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding, and binge eating disorder – in their lifetime. Global statistics also suggested that the lifetime prevalence of ED diagnoses are widespread, ranging from approximately 2.2% to 4.6% across America, Europe, and Asia. These figures are especially concerning when we also consider the high prevalence of suicide attempts and suicide in those with EDs[2,3,4,5,6]. For example, one study with data from Swedish individuals, estimated (using odds ratios) that people with any type of ED are 5.3 times more likely to attempt suicide and 5.4 times more likely to die by suicide. With these statistics in mind, this blog aims to (i) provide a brief summary of what we currently know about the risk of suicide and suicidal behaviour in those with EDs, and (ii) summarise some recommendations for future research from recently published work in the area.
Who is most likely to be affected by an ED?
Current evidence suggests that approximately 1 in 5 females and 1 in 7 males are likely to be affected by an ED by the time they are in their 40s, with most EDs being first diagnosed before age 25. Moreover, a study from 2019 did not identify differences between ethnicities on prevalence of ED diagnoses (albeit in a sample of female college students). While research generally demonstrates gender differences in rates of ED diagnoses, some research suggests that males and females are at a reasonably equal risk of suicide despite this. Furthermore, although younger people tend to be more likely to be diagnosed with an ED[6,8], this is not to say that EDs cannot also be diagnosed or persist into later life[e.g. 10, 11].
Why is the risk of suicide and suicidal behaviour in those with EDs so high?
Overall, those with EDs may be at greater risk of suicide and suicidal behaviour because of an overlap of possible risk factors, not least including having a family member with an ED , demographic (e.g., sexual orientation), and/or psychological factors (e.g., also having depression). For example, theories of suicidal behaviour such as the Interpersonal Psychological Theory of Suicide and Integrated Motivational Volitional Model may help to explain this risk. One possible risk factor may be having an acquired capability (i.e., an increased capacity for painful experiences and a fearlessness about death). As summarised by Smith and colleagues behaviours which characterise EDs, such as purging and over-exercising, may increase this capability for suicidal behaviour. Similarly, other factors like type of ED diagnosis, depression, a history of self-harm or hospitalisation, suicidal thoughts, and feeling like a burden to others or feeling as though you do not belong in your social group, may also heighten this risk.
The Impact of COVID-19
It is not surprising that COVID-19 may have presented new challenges for those with EDs. Rodgers and colleagues suggested that the restrictions imposed by COVID-19 may have increased the risk of ED symptoms; for example, by restricting eating and exercise routines, this may have exacerbated weight and shape concerns; and by restricting access to potential social support. Indeed, recent qualitative work in the UK has also corroborated this to some degree: the individuals interviewed in the study stated that they needed to re-arrange their lives in light of the COVID-19 lockdowns, but some used the pandemic as a “drive for recovery” (p. 1).
What Do We Not Yet Know?
While the amount of research in this area is growing, there are still several areas where further research (and replication) may be needed.
- Longitudinal research: As discussed in more detail in Smith et al.[5, 18] much of the work so far relies on cross-sectional data which does not tell us about causal relations between EDs and suicide attempt or suicide risk. Indeed, Smith et al. state that “only 14 longitudinal studies in the past 50 years have tested whether an ED factor predicts suicide attempt and death” (p. 9), highlighting a clear need for further and consistently high-quality longitudinal studies.
- Recovery: There may be a need to further understand suicide risk during recovery from an ED. Given that recovery from an ED is challenging to define, and because we cannot always assume that recovery is linear, we may need prospective studies to determine the rates of suicide attempts and overall risk of suicide following people through their recovery from an ED to identify key areas of support.
- Situational factors: There may be a need for further understanding of other proximal/situational factors associated with suicide risk and suicide attempts in those with EDs, such as the long-term impact of COVID-19 (e.g., from potentially reduced access to services, illness, unemployment etc.).
Disclaimer: This blog is not a comprehensive and systematic literature review; rather, this blog aims to be a short summary of some relevant literature in the area for those interested in further reading on the topic.
- Galmiche, M., Déchelotte, P., Lambert, G., & Tavolacci, M. P. (2019). Prevalence of eating disorders over the 2000–2018 period: A systematic literature review. The American Journal of Clinical Nutrition, 109(5), 1402-1413. https://doi.org/10.1093/ajcn/nqy342
- Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: A meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724-731. https://doi.org/10.1001/archgenpsychiatry.2011.74
- Lipson, S. K., & Sonneville, K. R. (2020). Understanding suicide risk and eating disorders in college student populations: Results from a National Study. International Journal of Eating Disorders, 53(2), 229-238. https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.23188
- Pisetsky, E. M., Thornton, L. M., Lichtenstein, P., Pedersen, N. L., & Bulik, C. M. (2013). Suicide attempts in women with eating disorders. Journal of Abnormal Psychology, 122(4), 1042. https://doi.org/10.1037/a0034902
- Smith, A. R., Zuromski, K. L., & Dodd, D. R. (2018). Eating disorders and suicidality: what we know, what we don’t know, and suggestions for future research. Current Opinion in Psychology, 22, 63-67. https://doi.org/10.1016/j.copsyc.2017.08.023
- Zerwas, S., Larsen, J. T., Petersen, L., Thornton, L. M., Mortensen, P. B., & Bulik, C. M. (2015). The incidence of eating disorders in a Danish register study: Associations with suicide risk and mortality. Journal of Psychiatric Research, 65, 16-22. https://doi.org/10.1016/j.jpsychires.2015.03.003
- Yao, S., Kuja-Halkola, R., Thornton, L. M., Runfola, C. D., D’Onofrio, B. M., Almqvist, C., … & Bulik, C. M. (2016). Familial liability for eating disorders and suicide attempts: Evidence from a population registry in Sweden. JAMA Psychiatry, 73(3), 284-291. https://doi.org/10.1001/jamapsychiatry.2015.2737
- Ward, Z. J., Rodriguez, P., Wright, D. R., Austin, S. B., & Long, M. W. (2019). Estimation of eating disorders prevalence by age and associations with mortality in a simulated nationally representative US cohort. JAMA Network Open, 2(10), e1912925-e1912925. https://doi.org/ 10.1001/jamanetworkopen.2019.12925
- Cheng, Z. H., Perko, V. L., Fuller-Marashi, L., Gau, J. M., & Stice, E. (2019). Ethnic differences in eating disorder prevalence, risk factors, and predictive effects of risk factors among young women. Eating Behaviors, 32, 23-30. https://doi.org/10.1016/j.eatbeh.2018.11.004
- Lapid, M. I., Prom, M. C., Burton, M. C., McAlpine, D. E., Sutor, B., & Rummans, T. A. (2010). Eating disorders in the elderly. International Psychogeriatrics, 22(4), 523-536.
- Samuels, K. L., Maine, M. M., & Tantillo, M. (2019). Disordered eating, eating disorders, and body image in midlife and older women. Current Psychiatry Reports, 21(8), 1-9. https://doi.org/10.1007/s11920-019-1057-5
- Ahn, J., Lee, J. H., & Jung, Y. C. (2019). Predictors of suicide attempts in individuals with eating disorders. Suicide and Life‐Threatening Behavior, 49(3), 789-797. https://doi.org/10.1111/sltb.12477
- Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner Jr, T. E. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575.
- O’Connor, R. C., & Kirtley, O. J. (2018). The integrated motivational–volitional model of suicidal behaviour. Philosophical Transactions of the Royal Society B: Biological Sciences, 373(1754), 20170268. https://doi.org/10.1098/rstb.2017.0268
- Smith, A. R., Dodd, D. R., Forrest, L. N., Witte, T. K., Bodell, L., Ribeiro, J. D., … & Bartlett, M. (2016). Does the interpersonal–psychological theory of suicide provide a useful framework for understanding suicide risk among eating disorder patients? A test of the validity of the IPTS. International Journal of Eating Disorders, 49(12), 1082-1086. https://doi.org/10.1002/eat.22588
- Rodgers, R. F., Lombardo, C., Cerolini, S., Franko, D. L., Omori, M., Fuller‐Tyszkiewicz, M., … & Guillaume, S. (2020). The impact of the COVID‐19 pandemic on eating disorder risk and symptoms. International Journal of Eating Disorders, 53(7), 1166-1170. https://doi.org/10.1002/eat.23318
- Brown, S., Opitz, M. C., Peebles, A. I., Sharpe, H., Duffy, F., & Newman, E. (2021). A qualitative exploration of the impact of COVID-19 on individuals with eating disorders in the UK. Appetite, 156, 104977. https://doi.org/10.1016/j.appet.2020.104977
- Smith, A. R., Velkoff, E. A., Ribeiro, J. D., & Franklin, J. (2019). Are eating disorders and related symptoms risk factors for suicidal thoughts and behaviors? A meta‐analysis. Suicide and Life‐Threatening Behavior, 49(1), 221-239. https://doi.org/10.1111/sltb.12427
- Bardone-Cone, A. M., Hunt, R. A., & Watson, H. J. (2018). An overview of conceptualizations of eating disorder recovery, recent findings, and future directions. Current Psychiatry Reports, 20(9), 1-18. https://doi.org/10.1007/s11920-018-0932-9