The aim of this study was to compare the immediate and long-term effect of a cognitive-behavior therapy program for anorexia nervosa inpatients with and without concomitant Major Depressive Episodes (MDE). The program has been adapted from the “enhanced” form of Cognitive Behavior Therapy (CBT) for eating disorders. Sixty-three consecutive underweight adult patients with severe eating disorder were treated with inpatient CBT. MDE was assessed with the structured clinical interview for DSM-IV. The Eating Disorder Examination, and the Brief Symptom Inventory were recorded at entry, at the end of treatment, and 6 and 12 months later. MDE was present in 60.3% of participants. No significant differences were observed in the demographic and baseline clinical variables between patients with and without MDE. Significant improvements in weight, and in eating disorder and general psychopathology were showed. There were no differences between participants with and without MDE in terms of treatment outcome, and the severity of depression was not associated with changes in global Eating Disorder Examination score. These findings suggest that a diagnosis of MDE does not influence the outcome of inpatient treatment for anorexia nervosa patients, and that the severity of depression cannot be used to predict the success or failure of such treatment.
Anorexia nervosa has high rates of co-morbidity with other psychiatric disorders, especially major depressive disorder. Indeed, several studies have found that major depressive disorder is the most common co-morbid diagnosis in these patients (Herzog et al., 1992 and Kaye, 2008), with lifetime rates ranging between 50% and 75% (American Psychiatric Association, 2006). In the existing literature, clinical depression has been linked with worse anorexia nervosa outcome (Lowe et al., 2001), higher rates of suicide attempt (Bulik et al., 2008 and Franko et al., 2004) and suicide-related mortality (Crow et al., 2009). However, hard data on the role of clinical depression in anorexia nervosa treatment outcome is scarce, and a general consensus still appears remote. For instance, while a few studies have found that pretreatment depression is predictive of poor immediate or long-term outcome of cognitive behavior therapy in patients with bulimia nervosa (Agras et al., 2000, Bossert et al., 1992 and Bulik et al., 1998) no such link has been found in anorexia nervosa patients (Collin et al., 2010 and Herpertz-Dahlmann et al., 1995).
Clinical trials evaluating antidepressant efficacy in the treatment of eating disorders found that antidepressants reduced significantly the number of binge eating and self-induced vomiting episodes in bulimia nervosa and in binge eating disorder participants regardless the presence of comorbid depression (Goldstein et al., 1999). However, in another study on binge eating disorder participants, cognitive behavior therapy produced a significant higher reduction of depression and overevaluation of shape and weight than antidepressants (Grilo et al., 2012). Finally, antidepressants have not been associated with major depressive disorder recovery in anorexia nervosa participants (Mischoulon et al., 2010).
Despite the paucity of evidence, NICE guidelines, erring on the side of caution, list severe depression as one of the contraindications for eating disorder treatment, and recommend that such treatment be postponed until the depression has been dealt with (National Institute of Clinical Excellence, 2004). Cognitive behavioral theorists are also of the opinion that clinical depression should be treated with full-dose antidepressants prior to launching the psychological treatment (Fairburn et al., 2008).
However, some clinicians have suggested that it is, instead, preferable to focus initially on the treatment of eating disorders, the goal being to normalize weight and food intake before assessing and prescribing any treatment for co-existing psychiatric disorders (Garner, 1993 and Mattar et al., 2012). The rationale behind this recommendation is based on the observation that many of the symptoms postulated to be a sign of psychiatric co-morbidity, including clinical depression, may actually result from low body weight and calorie restriction (American Psychiatric Association, 2006).
In order to shed some light on the issue, we set out to investigate the prevalence and associated features of ongoing clinical depression in a large group of inpatients with eating disorders, and to assess whether it influences treatment outcome.
