Questions and Answers: Warning Signs and Risk of Suicide

Q. Is there any useful new research on the risk of suicide among eating disorders patients discharged from inpatient care?  One of my patients, a 22-year-old with AN, has expressed suicide ideation more than once. (J.L., Atlanta).

A. Suicide is a risk following discharge from psychiatric treatment, as seen in a large cohort study of nearly 2.9 million patients discharged from psychiatric hospitals in Sweden (J Clin Psychiatry. 2019; 80:2) In that study, the risk was particularly high among males with depression and acute stress reactions as well as posttraumatic stress disorder. However, this study is somewhat typical of the general psychiatric literature in excluding those with eating disorders from the study.

This is especially unfortunate as we know that suicide is the leading and very important cause of death among people with AN, and patients with BN and BED have an increased risk of suicide compared to the general public or those with many other psychiatric illnesses, as seen in the National Comorbidity Survey Replication and in the Adolescent version of that same Survey. More longer-term studies are needed to identify meaningful warning signs, according to psychologist A.R. Smith and colleagues at Miami University, Oxford, OH and Auburn University, Auburn, AL (Curr Opin Psychol.2018; 22:63).  Smith and colleagues reported that about a fourth to a third of patients with AN, BN, or BED have thought about suicide, and one-fourth to one-third of those with AN and BN have attempted suicide.

A more recent study of suicide attempts among adults in the US with lifetime DSM-5eating disorders identified several distinct risk factors in specific types of eating disorders (BMC Medicine.2019; 17:120). Drs. Tomoko Udo, Sarah Bitley, and Carlos Grilo identified the prevalence and correlates with suicidal attempts among 36,171 respondents in the National Epidemiological Survey on Alcohol and Related Conditions (Soc Psychiatry Psychiatr Epidemiol. 2015; 50:1609). They also examined the prevalence and correlation of suicidal attempts in the two main subtypes of AN, restricting AN and binge-purge type AN.

The authors’ analysis showed that suicide attempts are common among US adults with lifetime diagnoses of AN, BN, and BED. The rates of previous suicide attempts were: 24.9% for AN, 31.4% for BN, and 22.9% for BED. They reported that the rates for suicidal attempts were substantially higher among those with binge-purge type AN—44.1%—compared to 15.7% for those with restrictive-type AN.

The study results also revealed a number of risk factors for suicide among eating disorders patients. For example, among those who had more than one type of lifetime eating disorder diagnosis, the prevalence and odds of such attempts were 41.5% and 10.63%, respectively. It seems unclear if this relates to a diagnostic conversion phenomenon or merely represents a duration of illness effect. In fact, among those with BN or BED, a history of suicide attempts was significantly linked with longer duration and younger age at onset. A history of ED symptoms interfering with daily normal daily activities, or interfering with fulfilling responsibilities were warning signs, and comorbidities were significantly increased in those who ultimately attempted suicide versus those who did not.

Better approaches for identifying and recognizing risk may help enhance suicide prevention strategies, according to Dr. Udo et al. They also expressed concern about certain groups of adults with diagnosable eating disorders in the general population, such as men and ethnic/racial minorities, who often do not seek treatment. Adding routine screening for eating disorders and a history of suicidal attempts could do much to improve treatment planning and referrals, and thus enhance suicide prevention.

– SC

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