Eating disorders and risk of death.

Eati ng disorders are common and well known to be associated with a variety of medical complications and elevated risk of mortality. For anorexia nervosa, these associations have been known as far back as some of the earliest descriptions of the illness. For example, in 1689, Richard Morton (1) described two cases of what in retrospect appear to have been anorexia nervosa; one of the two patients died, apparently of the illness. Similarly, in describing and naming anorexia nervosa, Sir William Gull (2) (in 1874) included mortality in his description. A substantial body of more recent work has systematically documented high mortality, including suicide risk (3, 4). However, while these relationships are well known, the timing of mortality risk across the course of the illness remains unclear. One could imagine a scenario of elevated mortality early in the illness, wherein those particularly prone to medical complications from malnutrition would be at high risk for death. Conversely, risk of death might climb after prolonged illness as complications of starvation mount. Similar predictions about the timing of suicide risk might be made as well. A number of potential predictors of mortality, including certain medical complications, severity of weight loss, severity of co-occurring psychopa-thology, and severity of the eating disorder symptoms themselves, may be important. However, our knowledge of predictors of mortality in eating disorders is limited (5). In this issue of the Journal, Franko et al. (6) report on a long-term follow-up study of a cohort of individuals with eating disorders. The report examines mortality both in those with anorexia nervosa and in those with bulimia nervosa. The main findings of the study were that mortality was concentrated mostly in those with anorexia nervosa. Notably, standardized mortality ratios were high early in the study (7.7 in the first 10 years) but dropped with increasing length of follow-up. On the other hand, standardized mortality ratios increased with duration of illness (3.2 for duration under 15 years and 6.6 for duration over 15 years). The authors had previously reported very elevated standardized mortality ratios for suicide in this sample (greater than 50), but over the course of this much longer follow-up period, no further suicides occurred. Thus, the standardized mortality ratios for suicide remained high for the sample as a whole (25.2) but appeared to decrease with time. This study has many strengths. The sample was well defined, and participants underwent careful follow-up assessment. …