Evidence Against Palliative Care in Long-term Eating Disorders
Continued symptom improvement and meaningful recovery are possible in anorexia nervosa beyond the first decade of follow-up.
Because recovery from eating disorders is often a long process, and fewer than half of adults end up recovering from anorexia or bulimia, some have argued that eating disorders can become chronic and that after the eating disorder has been present for a decade, care should focus on quality of life, rather than on symptom remission.
However, results from a study conducted at Massachusetts General Hospital in Boston, investigating early and long-term recovery of those with anorexia and bulimia, provide evidence against beginning palliative care in most cases.
Because of a lack of studies investigating recovery beyond 20 years of follow-up, Kamryn T. Eddy, PhD, from Massachusetts General Hospital and Harvard Medical School in Boston, and colleagues assessed women with anorexia or bulimia at both 9 years and 20 to 25 years of follow-up (mean [SD], 22.10 [1.10] years; 1987-2013). The women were participants in the Massachusetts General Hospital Longitudinal Study of Anorexia and Bulimia Nervosa with structured clinical interviews (Longitudinal Interval Follow-Up Evaluation of Eating Disorders [LIFE-EAT-II]).
Of an initial sample size of 246 participants, 18 died before 20 to 25 years' follow-up. Of the 228 survivors, 176 (77%) participated in the 20- to 25-year follow-up study, 37 (16%) were contacted but declined participation, and 15 (7%) were lost to follow-up (vital status was confirmed through the National Death Index, but the participants could still not be located or invited for follow-up).
During wave 1 of the study, which began in 1987, participants were interviewed every 6 to 12 months for a mean of 9.1 (1.6) years. During wave 2 of the study, which began in 2011, surviving participants were contacted between 20 to 25 years after study entry for a 1-time follow-up.
The researchers found that at 22-year follow-up, 68.2% of those with bulimia and 62.8% of those with anorexia had recovered. At 9-year follow-up, 68.2% of those with bulimia had recovered, but only 31.4% of those with anorexia had recovered. Early recovery was associated with a higher likelihood of long-term recovery in anorexia (odds ratio [OR], 10.5; 95% confidence interval [CI], 3.77-29.28; McNemar χ21 = 31.39; P <.01), but not in bulimia (OR, 1.0; 95% CI, 0.49-2.05; McNemar χ21 = 0; P =1.0).
"Approximately half of those with anorexia nervosa who had not recovered by 9 years progressed to recovery at 22 years," the authors wrote.
At 22 years, about two-thirds of those with anorexia and bulimia had recovered. Although recovery from bulimia happened earlier, recovery from anorexia continued long-term even in those who were not recovered at 9 years. This finding "[argues] against the implementation of palliative care for most individuals with eating disorders," the authors wrote.
"In contrast to the extant literature characterizing eating disorders as chronic illnesses, our longitudinal data demonstrate that continued symptom improvement and meaningful recovery are possible in anorexia nervosa beyond the first decade of follow-up. For bulimia nervosa, if recovery is not observed by 9-year follow-up, it is less likely to occur in the subsequent decade," the researchers concluded.
- The study population was predominantly white and based in Massachusetts, and sought treatment.
- The sample was first gathered between 1987 and 1991, so it is not known what effect more modern treatments would have had on the participants.
- The researchers lack specific treatment data and do not know what aspects of treatment may have influenced recovery.
- Those who completed wave 1 but did not complete wave 2 may have had more severe illness than those who completed both study waves.
- Recall bias from the interviews is a possibility.
- There are no data on symptoms between 9- and 22-year follow-up.
Eddy KT, Tabri N, Thomas JJ, et al. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. J Clin Psychiatry. 2016; doi:10.4088/JCP.15m10393