Crossed prevalence results between subtypes of eating disorder and bipolar disorder: A systematic review of the literature.

OBJECTIVE: To assess the association between sub-types of bipolar disorder (BD) (types I and II) and sub-types of eating disorders (EDs) (Anorexia Nervosa, Bulimia Nervosa, Binge-eating disorders) as well as their relative order of occurrence. METHODOLOGY: A systematic review of articles estimating prevalence rates for BD among patients with ED and vice versa. We also analysed all articles assessing their relative order of occurrence. RESULTS: Comorbid BD is common among patients with an ED. From 0.6 to 33.3% of bipolar subjects have an eating disorder. Conversely, from 0 to 35.8% of subjects with an ED can present a BD. This co-occurrence has mostly been observed among patients with anorexia of the bulimic/purging type, with bulimia or with binge-eating disorders. The association is less frequent in cases of anorexia of the restrictive type. In contrast, the BD sub-type does not seem to have an impact on the association with EDs. Whilst age at BD onset is earlier in case of a comorbid ED, age at ED onset does not seem to be impacted by the presence of an associated BD. There has been little data on the relative order of occurrence of the two disorders or on the impact of the thymic phase on the expression of EDs. CONCLUSIONS: EDs and BD are frequently comorbid, suggesting the need for crossed screening of these pathologies, in particular for EDs with purging behaviours and for patients with early BD onset.

[Bipolar disorders and anorexia nervosa: A clinical study]. / Troubles bipolaires et anorexie mentale : une étude clinique.

PURPOSE: Anorexia nervosa is often accompanied by comorbid mood disorders, in particular depression, but individual or family history of bipolar disorders has not frequently been explored in anorexia nervosa. The objectives of the present study were: (1) to assess the frequency of bipolar disorders in patients with anorexia nervosa hospitalized in adolescence and in their parents, (2) to determine whether the patients with a personal or family history of bipolar disorders present particular characteristics in the way in which anorexia nervosa manifests itself, in their medical history, in the secondary diagnoses established, and in the treatments prescribed. METHOD: Overall, 97 female patients aged 13 to 20 hospitalized for anorexia nervosa and their parents were assessed. The diagnoses of anorexia nervosa and bipolar disorders were established on the basis of DSM-IV-TR criteria. RESULTS: A high frequency of type II and type V bipolar disorders was observed. The patients with anorexia nervosa and presenting personal or family histories of bipolar disorder had an earlier onset of anorexia nervosa, more numerous hospitalizations, a longer time-lapse between anorexia nervosa onset and hospitalization, more suicide attempts and more psychiatric comorbidities. CONCLUSION: The occurrence of anorexia nervosa-bipolar disorders comorbidity appears to be considerable and linked to the severity of anorexia nervosa, raising the issue of the relationship between anorexia nervosa and bipolar disorders.

Are lifetime affective disorders predictive of long-term outcome in severe adolescent anorexia nervosa?

Depression and anxiety are commonly associated with anorexia nervosa (AN) and contribute to difficulties in social integration, a negative factor for outcome in AN. The link between those disorders and AN has been poorly studied. Thus, our objective was to investigate (1) the link between outcome nine years after hospitalisation for AN and the occurrence of lifetime anxious or depressive comorbidities; (2) the prognostic value of these comorbidities on patient outcome; 181 female patients were hospitalised for AN (between 13 and 22 years old), and were re-evaluated for their psychological, dietary, physical and social outcomes, from 6 to 12 years after their hospitalisation. The link between anxious and depressive disorders (premorbid to AN and lifetime) and the outcome assessment criteria were tested through multivariate analyses; 63% of the participants had good or intermediate outcome, 83% had presented at least one anxiety or depression disorder in the course of their lives, half of them before the onset of AN. Premorbid obsessive compulsive disorders (OCD), BMI at admission, and premenarchal AN all contribute to poor prognosis. Social phobia and agoraphobia affect the subjects' quality of life and increase eating disorder symptoms. These results encourage a systematic assessment of, and care for, anxiety and depression comorbidities among female adolescent patients with a particular focus on premorbid OCD.

[Depressive symptoms during anorexia nervosa: State of the art and consequences for an appropriate use of antidepressants]. / Manifestations dépressives au cours de l'anorexie mentale : données de la littérature et implications pour une utilisation adaptée des antidépresseurs.

OBJECTIVE: Depressive comorbidity is often associated with anorexia nervosa (AN), and antidepressant medication is widely used although it does not rely on any convincing data in the scientific literature. Our objectives were: to summarize the epidemiological, physiological, psychopathological literature about the relation between AN and manifestations of depression, and to focus on the clinical trial data assessing the use of antidepressant medication in AN in order to clarify the strategy for the use of antidepressant in AN during adolescence. METHOD: A manual computerised search (Medline) was performed for relevant published studies assessing the association between depressive signs or Major Depressive Disorder (MDD) and AN. Another manual computerised search (Medline) listed clinical trials assessing antidepressant in AN. RESULTS: On the one hand, depressive symptoms are common during the course of AN and could have different meaning. Indeed, firstly, we can distinguish symptoms that are inherent to AN and which can be mistaken for depressive signs (for instance: low self-esteem, reduced social contacts). Secondly, long-term undernourishment can be held responsible for numerous psychological distortions, including anxiety and depression symptoms such as insomnia, impaired concentration, or social isolation. Thirdly, the natural course of AN can also lead to "depressive moments", in particular when switching to a "purging type" AN, or when recovery mobilizes control and narcissistic issues. On the other hand, MDD is also highly prevalent among AN patients and is a negative prognosis factor. Thus, it is complex to differentiate MDD from isolated depressive symptoms that could be inherent of the AN symptomatology which raises the question of the role of antidepressant medication in treatment of depression in AN. No significant benefit of antidepressant medication in AN has been shown in clinical trials, and according to international guidelines it should be prescribed only as a second-line treatment, after appropriate refeeding, and in case of an authentic depressive disorder. Those data appear to be in contradiction with the frequent use of those drugs in clinical practice. DISCUSSION: Nevertheless, clinical trials assessing antidepressant treatment in AN suffer from methodological weakness concerning the size of the sample, the choice of the population or the evaluation criterion. This lack of proof must raise our vigilance concerning antidepressant medication in AN but should not categorically prevent the clinician from using it when necessary. We do believe that there are some indications for prescribing antidepressant in patients with AN. The clinical challenge lies in the differentiation of the depressive symptoms that are transitory and likely to improve without medication from those that signal the presence of an MDD. Three criterion could be indicative of MDD: familial history of mood disorder, as it is a major risk factor for MDD among relatives; the chronology of appearance of both disorders, when MDD pre-exists AN; a few specific symptoms cannot be attributed to undernourishment or reactive depressive signs, such as morning insomnia, daily variation of depressive symptoms, suicidal attempts or ideation and guilt ideation. Thus, in integrating the data from the literature review, we propose a pragmatic therapeutic strategy for the use of an antidepressant in AN during adolescence that lies in 3 main categories for depressive manifestations in AN: therapeutic emergencies: when an obvious and severe MDD is comorbid to AN, immediate antidepressant would be required; isolated and non-specific depressive sign: no medication would be relevant as they are supposed to improve with refeeding and psychotherapeutic support; intermediary patterns which is probably the most frequent situation. In the last case, it would be relevant to abstain from prescribing medication in first line, but an antidepressant medication should be quickly considered in the presence of one (or several) criterion listed above and its persistence despite refeeding. The general medical state of this fragile population of patients should be evaluated (standard blood test, ECG) before and during treatment.

Predictive factors of dropout from inpatient treatment for anorexia nervosa.

BACKGROUND: Patients with severe Anorexia Nervosa (AN) whose condition is life-threatening or who are not receiving adequate ambulatory care are hospitalized. However, 40 % of these patients leave the hospital prematurely, without reaching the target weight set in the treatment plan, and this can compromise outcome. This study set out to explore factors predictive of dropout from hospital treatment among patients with AN, in the hope of identifying relevant therapeutic targets. METHODS: From 2009 to 2011, 180 women hospitalized for AN (DSM-IV diagnosis) in 10 centres across France were divided into two groups: those under 18 years (when the decision to discharge belongs to the parents) and those aged 18 years and over (when the patient can legally decide to leave the hospital). Both groups underwent clinical assessment using the Morgan & Russell Global Outcome State questionnaire and the Eating Disorders Examination Questionnaire (EDE-Q) for assessment of eating disorder symptoms and outcome. Psychological aspects were assessed via the evaluation of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). Socio-demographic data were also collected. A number of factors identified in previous research as predictive of dropout from hospital treatment were tested using stepwise descending Cox regressions. RESULTS: We found that factors predictive of dropout varied according to age groups (being under 18 as opposed to 18 and over). For participants under 18, predictive factors were living in a single-parent family, severe intake restriction as measured on the "dietary restriction" subscale of the Morgan & Russell scale, and a low patient-reported score on the EDE-Q "restraint concerns" subscale. For those over 18, dropout was predicted from a low depression score on the HADS, low level of concern about weight on the EDE-Q subscale, and lower educational status. CONCLUSION: To prevent dropout from hospitalization for AN, the appropriate therapeutic measures vary according to whether patients are under or over 18 years of age. Besides the therapeutic adjustments required in view of the factors identified, the high dropout rate raises the issue of resorting more frequently to compulsory care measures among adults.

Mood disorders in eating disorder patients: Prevalence and chronology of ONSET.

OBJECTIVES: In a clinical population, we estimated the frequency of mood disorders among 271 patients suffering from Anorexia Nervosa (AN) and Bulimia Nervosa (BN) in comparison to a control group matched for age and gender. METHOD: The frequency of mood disorders was measured using the Mini International Neuropsychiatric Interview (MINI), DSM-IV version. RESULTS: Mood disorders were more frequent among eating disorder (ED) patients than among controls, with a global prevalence of the order of 80% for each ED group. The majority of the mood disorders comorbid with ED were depressive disorders (MDD and dysthymia). The relative chronology of onset of these disorders was equivocal, because mood disorders in some cases preceded and in others followed the onset of the eating disorders. LIMITATIONS: Our sample was characterized by patients with severe ED and high comorbidities, and thus do not represent the entire population of AN or BN. This also may have resulted in an overestimation of prevalence. CONCLUSION: Mood disorders appear significantly more frequently in patients seeking care for ED than in controls. These results have implications for the assessment and treatment of ED patients, and for the aetio-pathogenesis of these disorders.