Depression and Eating Disorders

Major Depressive Disorder is one of the most common mental health diagnoses to co-occur with eating disorders [1]. Between 50% to 75% of those that struggle with an eating disorder will also experience symptoms of depression [2]. The close relationship between these two disorders makes it important to understand and consider in identifying, diagnosing, and treating eating disorders.

Depression Definition

Major Depressive Disorder, more commonly referred to as “depression,” is a fixture in conversations surrounding mental health. Even so, many may not be aware of what exactly this means and might refer to depression in a more general sense, not recognizing that “feeling depressed” is not the same thing as diagnosable Major Depressive Disorder.

The Diagnostic & Statistical Manual of Mental Illness, Fifth Edition (DSM-5) specifies the criteria necessary for an individual to be formally diagnosed with Major Depressive Disorder. This criteria is as follows:

• “Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
  1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad, empty, hopeless) or observation made by others (e.g.) appears tearful).
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
  3. Significant weight loss when not dieting or weight gain (change of more than 5% body weight in a month), or decrease or increase in appetite nearly every day.
  4. Insomnia or hypersomnia nearly every day.
  5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
  6. Fatigue or loss of energy nearly every day.
  7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
• The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The episode is not attributable to the physiological effects of a substance or to another medical condition [3].”

What are the Signs & Symptoms of Depression?

Signs of depression can sometimes appear as obvious, however, may go under-the-radar if one assumes depressive signs are simply a “bad day” or “bad mood.” If you or a loved one are experiencing any of the following symptoms, it is important to ask more questions:

• Withdrawing and/or isolating oneself.
• Reporting feelings of sadness, hopelessness, helplessness, and/or worthlessness etc. nearly every day.
• Loss of interest in previously pleasurable activities.
• Increased tearfulness.
• Changes in appetite.
• Increased suicidal ideation.
• Engaging in self-harming behaviors.
• Angry outbursts.
• Insomnia.
• Difficulty getting out of bed or completing daily living activities.
• Impaired focus/concentration.
• Slowed speaking, thinking, or body movements.
• Fatigue.

Can Depression Cause Eating Disorders?

This is a simple question without a simple answer. There is no one cause of eating disorders, however, depressive symptoms and behaviors can contribute to eating disorder development.

Depression is a challenging disturbance in mood and those that struggle with it often reach for various behaviors in an attempt to cope. Some of the behaviors they turn to are maladaptive, such as eating disorder behaviors of restricting, binging, and/or purging.

Individuals with depression and eating disorders also share a few symptoms such as feelings of low self-worth, which can contribute to the development or maintenance of both disorders.

Finally, individuals with depression experience varying appetite changes due to their depressive symptoms, which may leave them vulnerable to disordered relationships with food.

Co-Occurring Eating Disorders

Depression co-occurs with every eating disorder, however, the relationship it has with each individual diagnosis may differ.

Are Anorexia & Depression Connected?

Anorexia Nervosa and Major Depressive Disorder are undoubtedly connected, with 42% of those with an eating disorder experiencing co-morbid depression [2].

One of the strongest connections researchers find between these two disorders is the common symptoms of low self-esteem and body dissatisfaction [4]. These feelings can lead to development of either disorder as well as perpetuation of the disorder if untreated.

Related Reading

• Anxiety
• What Should I Eat to Feel Good?

The question of which comes first does not have a clear answer and likely never will. For each individual, the dynamic between depressive and eating disorder symptoms can vary. Some might well experience depressive struggles first and use disordered eating to cope while others might engage in eating disorder behaviors and experience subsequent depressive symptoms due to malnourishment or hopelessness.

Regardless of which comes first, both anorexia nervosa and depression are serious disorders that, when combined, can have dire consequences if not treated.

The Relation of Depression and Binge Eating

46% of those with Binge Eating Disorder (BED) also experience depressive symptoms [2].

BED involves similar feelings of depression such as low self-worth, shame, guilt, and hopelessness.

Some may use binge eating behaviors in an attempt to cope with the emotion dysregulation caused by depression. Depression can also be a side effect of binge eating behaviors, as individuals feel increased symptoms of worthlessness and helplessness as they become “trapped” in the cycle of binge eating.

Bulimia & Depression

Bulimia Nervosa is the eating disorder that co-occurs with Major Depressive Disorder the most, with 70.7% of individuals struggling with bulimia being diagnosed with depression at the same time [2].

Bulimia and depression share similar emotional and cognitive symptoms such as low self-worth, loneliness/isolation, feeling out of control, anger/irritability, and inadequacy. These disorders also have the shared consequence of impaired social and occupational functioning.

Additionally, the impact that purging behaviors has on the brain and body make depressive symptoms more likely to develop and emotion regulation more difficult for the individual.

Similar to anorexia and BED, there is no distinction of which disorder occurs “first,” only the understanding that the two often interact with one another.

Depression Statistics

Major Depressive Disorder has been around for some time, therefore, a great deal of research has been conducted to further knowledge of this dangerous mental illness.

• In 2017, 17.3 million, 7% of US adults had at least one major depressive episode [5].
• Women are more likely to experience depressive episodes more than men [5].
• Individuals ages 18-25 are at the highest risk of experiencing a major depressive episode [5].
• Those that identify as two or more races are most likely to struggle with depression [5].
• In 2017, 11 million adults ages 18 or older experienced a depressive episode that resulted in severe impairment [5].
• 63.8% of adults that go through a major depressive episode experience severe impairment in daily life [5].
• 3.2 million adolescents ages 12 to 17 experienced a major depressive episode in the year 2017 [5].
• Similar to adults, female adolescents are more likely to experience depression than male adolescents and those adolescents that identify as 2 or more races are most at-risk [5].
• 70.77% of adolescents that struggle with a depressive episode experience severe impairment in daily life [5].
• 2% of those treated for depression on an outpatient basis will die from suicide [6].
• 4% of those that receive inpatient treatment for depression will die from suicide [6].
• Those treated on an inpatient basis for depressive symptoms and suicidal thoughts are 3 times more likely to die from suicide than those treated on an outpaitent basis [6].
• While women are more likely to struggle with depression, 7% of men will die from depression-related-suicide versus 1% of women [6.

Treatment for Eating Disorders & Depression

The key to treating co-occurring eating disorder and depressive symptoms is to acknowledge that neither is more or less urgent and that both must be treated simultaneously. There is one caveat to this, however. If the physical impact of an individual’s eating disorder is so severe as to make them medically unstable, they must first go to inpatient hospitalization for medical stabilization. During this hospital stay, they may address the impact of their depression on their eating disorder, however, the primary focus is to support physical stabilization. As the individual steps down in levels of treatment, they can then focus on the more psychological aspects of their eating disorder which will undoubtedly involve exploration and treatment of depression symptoms.

Additionally, medication can be used to treat depressive symptoms and therapy can be used to treat both eating disorders and depressive symptoms. The most effective method of treatment for co-occurring depression and eating disorders is to utilize both medication and therapy.

Medication

There are numerous medications approved by the United States Food & Drug Administration to treat major depressive disorder. Some of these include Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs), Tricyclic & Tetracyclic antidepressants, among many others [7]. To see what medications are FDA-approved to treat Major Depressive Disorder, you can check this link (https://www.fda.gov/consumers/free-publications-women/depression-medicines). Always ask your doctor and/or psychiatrist what medication might be best for you and do not hesitate to ask any questions to learn all you can about your medication options.

While there are no medications to treat eating disorders directly, medication that treats co-occurring disorders can help to treat the symptoms from these disorders that contribute to eating disorder behaviors such as low self-worth, anxiety, sadness, etc.

Therapy

Therapy is an effective and key aspect to the treatment of both eating disorders and major depressive disorder. Therapy can support an individual in identifying the emotions, lack of coping skills, cognitions, and environmental circumstances that contribute to their symptoms and assist them in learning skills to combat or alter these. Some of the most effective treatments for both eating disorders and major depressive disorder are Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), family-based treatments, psychodynamic therapy, and interpersonal therapies.

Relapse Prevention & Aftercare Support

Eating disorders and depression, regardless of severity of either, are absolutely treatable through the use of both medication and therapy.

The most important aspects to recovery often involve continued maintenance of treatment, meaning the individual continues to attend outpatient treatment and/or engage in support groups to maintain recovery.

It is also important for individuals to continuously utilize their effective coping skills, not just when they are needed, but daily. This allows skills to stay sharp so that they will be more helpful in moments when they are needed.

For those experiencing comorbid depression and eating disorder symptoms, do not allow hopelessness to poison your focus on recovery. It is possible to overcome both illnesses and live a fulfilling life.

Resources

[1] Mischoulon, D. et al. (2011). Depression and eating disorders: treatment and course. Journal of Affective Disorders, 130.

[2] Unknown (2021). Eating Disorders. National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/statistics/eating-disorders.

[3] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

[4] Voderholzer, U. et al. (2019). Comparing severity and qualitative facets of depression between eating disorders and depressive disorders: analysis of routine data. Journal of Affective Disorders, 257.

[5] Unknown (2021). Major Depression. National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/statistics/major-depression.

[6] Unknown (2014). Does depression increase the risk for suicide? U.S. Department of Health & Human Services. Retrieved from https://www.hhs.gov/answers/mental-health-and-substance-abuse/does-depression-increase-risk-of-suicide/index.html.

[7] Unknown (2019). Depression medicines. U.S. Food & Drug Administration. Retrieved from https://www.fda.gov/consumers/free-publications-women/depression-medicines.

Page last updated and reviewed on September 24, 2021 by Jacquelyn Ekern, MS, LPC
Published on EatingDisorderHope.com, Online Resource for Eating Disorders