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A Longitudinal Investigation of Mortality in Anorexia Nervosa and Bulimia Nervosa
Debra L. Franko, Ph.D.; Aparna Keshaviah, Sc.M.; Kamryn T. Eddy, Ph.D.; Meera Krishna, B.A.; Martha C. Davis, B.A.; Pamela K. Keel, Ph.D.; David B. Herzog, M.D.
Am J Psychiatry 2013;170:917-925. doi:10.1176/appi.ajp.2013.12070868
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The authors report no financial relationships with commercial interests.

Supported by NIMH grants R01 MH-38333 (to Dr. Herzog) and R03 MH-094832 (to Drs. Eddy and Herzog).

From the Harris Center for Education and Advocacy in Eating Disorders and the Department of Psychiatry, Massachusetts General Hospital, Boston; Department of Counseling and Applied Educational Psychology, Northeastern University, Boston; and Department of Psychology, Florida State University, Tallahassee, Fla.

Presented in part at the 2012 International Conference on Eating Disorders, Austin, Tex., May 3–5, 2012.

Address correspondence to Dr. Franko (d.franko@neu.edu).

Copyright © 2013 by the American Psychiatric Association

Received July 02, 2012; Revised October 24, 2012; Revised November 01, 2012; Revised December 07, 2012; Accepted January 03, 2013.


Objective  Although anorexia nervosa has a high mortality rate, our understanding of the timing and predictors of mortality in eating disorders is limited. The authors investigated mortality in a long-term study of patients with eating disorders.

Method  Beginning in 1987, 246 treatment-seeking female patients with anorexia nervosa or bulimia nervosa were interviewed every 6 months for a median of 9.5 years to obtain weekly ratings of eating disorder symptoms, comorbidity, treatment participation, and psychosocial functioning. From January 2007 to December 2010 (median follow-up of 20 years), vital status was ascertained with a National Death Index search.

Results  Sixteen deaths (6.5%) were recorded (lifetime anorexia nervosa, N=14; bulimia nervosa with no history of anorexia nervosa, N=2). The standardized mortality ratio was 4.37 (95% CI=2.4–7.3) for lifetime anorexia nervosa and 2.33 (95% CI=0.3–8.4) for bulimia nervosa with no history of anorexia nervosa. Risk of premature death among patients with lifetime anorexia nervosa peaked within the first 10 years of follow-up, resulting in a standardized mortality ratio of 7.7 (95% CI=3.7–14.2). The standardized mortality ratio varied by duration of illness and was 3.2 (95% CI=0.9–8.3) for patients with lifetime anorexia nervosa for 0 to 15 years (4/119 died), and 6.6 (95% CI=3.2–12.1) for those with lifetime anorexia nervosa for >15 to 30 years (10/67 died). Multivariate predictors of mortality included alcohol abuse, low body mass index, and poor social adjustment.

Conclusions  These findings highlight the need for early identification and intervention and suggest that a long duration of illness, substance abuse, low weight, and poor psychosocial functioning raise the risk for mortality in anorexia nervosa.

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FIGURE 1. Survival Curve Comparing Female Patients With and Without a Lifetime History of Anorexia Nervosa
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TABLE 1.Summary of Covariates Analyzed for Female Patients With Lifetime Anorexia Nervosaa
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a Other course variables analyzed included the percent of study weeks meeting the following criteria: bulimia psychiatric status rating score ≥5 (percent of weeks dichotomized as above compared with at or below the median); binge eating/purging (including vomiting, laxative use, and diuretic use); other compensatory behavior (including diet pill use, fasting, and vigorous exercise); drug abuse psychiatric status rating score ≥3; hospitalized for an eating disorder; and suicidal gestures or attempts. Also analyzed were sessions of individual therapy received (mean over time) and marital status at last visit (single; married or living with a partner; or separated, divorced, or widowed).

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b A total of 16 patients died during the course of the study; two of the 16 had bulimia nervosa with no history of anorexia nervosa.

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c The ratings for social adjustment were as follows: 1=very good; 2=good; 3=fair; 4=poor; 5=very poor.

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TABLE 2.Clinical Characteristics of 16 Women With an Eating Disorder Who Died During the Course of the Study
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a Participant recovered from eating disorder during follow-up but subsequently relapsed.

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b Participant had recovered from eating disorder by the time of her last study visit.

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TABLE 3.Significant Univariate Predictors of Mortality Among Female Patients With Lifetime Anorexia Nervosa
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a The hazard ratio is calculated for a 5-year increase in the covariate.

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b The hazard ratio is calculated for a 10-unit increase in the covariate.

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* Indicates significance at an alpha level of 0.05; ** indicates significance at a Bonferroni-corrected alpha level of 0.0011.



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