Hospital admission and mortality rates in anorexia nervosa: experience from an integrated medical-psychiatric outpatient treatment

Long-term mortality in anorexia nervosa: a report after an 8-year follow-up and a review of the most recent literature

OBJECTIVE

To evaluate long-term mortality rate of anorexia nervosa (AN) patients in a southern Italy population compared to the most recent literature.

DESIGN

Retrospective and review setting.

PATIENTS AND INTERVENTIONS

One hundred and forty-seven female AN patients, consecutively admitted from 1994 to 1997 to the Outpatient Unit, were re-examined between June and November 2003. Our data are compared with 10 other studies published since 1988.

RESULTS

One hundred and twenty-three deaths in 2240 patients, amounting to a total mortality rate of 5.25% were reported in the literature. Deaths due to suicide, AN-related and AN-unrelated diseases were 1.20, 3.07 and 0.98%, respectively. After correcting for unrelated deaths, mortality rate was 4.27%. In our 8-year follow-up, we found a mortality rate of 2.72% (1.82% after correcting for unrelated deaths). Standardized mortality ratio was 9.7.

CONCLUSION

We interpret our favourable findings as a consequence of an integrated, clinical-nutritional and psychiatric approach. Finally, considering AN demographic characteristics, that is young female subjects in Westernized societies, mortality rate is confirmed to be dramatically high.

Mortalidade em pacientes psiquiátricos: revisão bibliográfica

OBJETIVO: Avaliar as informações referentes às taxas de mortalidade em pacientes psiquiátricos publicadas na literatura científica. MÉTODOS: Nesta revisão bibliográfica (bases de dados, sites e periódicos especializados) foram selecionados estudos descritivos e interpretativos que avaliaram as seguintes dimensões: caracterização sociodemográfica, co-morbidades clínicas, tempo de tratamento e diagnósticos relacionados à mortalidade psiquiátrica. As bases de dados avaliadas foram Medline, SciELO e LILACS. RESULTADOS: Os estudos selecionados sobre o tema sugerem que indivíduos com transtornos mentais maiores têm menor tempo de sobrevida em relação à população geral, e há diferenças significativas de mortalidade entre pacientes institucionalizados e aqueles que freqüentam serviços extra-hospitalares. A política de desinstitucionalização do paciente psiquiátrico, que se iniciou no último século, tem causado redução dos leitos psiquiátricos em todos os países; seus efeitos para a saúde geral dos doentes mentais ainda não estão muito claros e necessitam de mais investigações. CONCLUSÃO: É necessária a implantação de intervenções preventivas e terapêuticas que visem à saúde geral dos pacientes psiquiátricos em todos os níveis de assistência de saúde mental.

Cardiac findings in adolescents with anorexia nervosa at diagnosis and after weight restoration

The aim of this study was to compare heart abnormalities in a group of young women with anorexia nervosa at diagnosis and after weight restoration. A total of 40 young women with anorexia nervosa were evaluated, at baseline, (diagnosis) and follow-up (9 to 18 months later) and matched with 40 healthy women of the same age and of normal weight. QT interval was measured from surface electrocardiograms. QT dispersion was defined as the difference between maximum QT and minimum QT occurring in any of the 12 leads. Left ventricular end-diastolic diameter, left ventricular end-systolic diameter, left ventricular mass, left ventricular mass index, cardiac output, fractional shortening and fractional ejection, were measured by echocardiography. In anorexia nervosa patients, corrected QT interval and QT dispersion, significantly decreased from baseline to follow-up. Left ventricular end-diastolic dimension, left ventricular mass index, and cardiac output, in anorexia nervosa were significantly lower at diagnosis than at follow-up after weight restoration.

CONCLUSION

Adolescents with anorexia nervosa have significant functional and structural cardiac abnormalities; weight gain was associated with improvement. Appropriate attention should be paid to cardiac involvement.

Early detection of cardiac dysfunction in patients with anorexia nervosa by tissue Doppler imaging

BACKGROUND

Cardiac damage is a major complication of chronic starvation. The aim of this study was to evaluate the changes of left ventricular function in patients with anorexia nervosa by means of pulsed tissue Doppler imaging.

METHODS

A total of 20 females (age 22.4+/-4.3 years) with overt anorexia nervosa, 20 matched healthy thin females with body mass index < 19 kg/m2 and 20 matched healthy normal-weight females underwent both standard echocardiography and tissue Doppler imaging. Myocardial systolic wave (Sm) and early (Em) and atrial (Am) diastolic waves were measured on the basal lateral segment and the basal interventricular septum from the apical four-chamber view.

RESULTS

When compared with control groups, the anorexia nervosa group showed lower left ventricular mass (p < 0.0001), lower Sm peak of both lateral wall (6.5+/-0.9 vs. 9.4+/-2.1 and vs. 9.5+/-1.9 cm/sec, p < 0.001) and septum (5.6+/-1.5 vs. 8.6+/-1.6 and vs. 8.8+/-1.5 cm/sec, p < 0.001), and comparable Em, Am and Em/Am ratio. The ratio between transmitral peak E and Em was significantly greater in anorexic patients than in controls (lateral wall: 8.1+/-0.1 vs. 6.8+/-0.2 and vs. 6.9+/-0.2, p < 0.001; septum: 10.8+/-0.4 vs. 8.8+/-0.5 and vs. 8.8+/-0.3, p < 0.001). No differences were observed between thin and normal-weight females. In the anorexia nervosa group, S(m) peak was significantly related to left ventricular mass indexed, at both septum (r = 0.55, p < 0.02) and lateral wall (r = 0.49, p < 0.03) levels.

CONCLUSIONS

These results show that anorexia nervosa is associated with left ventricular systolic dysfunction, which is related with the reduction of cardiac mass. Tissue Doppler imaging can give useful information in the identification of regional left ventricular dysfunction, in addition to traditional parameters.

Integrated medical-psychiatric treatment of the "crisis phase" in severe protein-energy malnutrition secondary to major eating disorders

C.A., a 23-year old male was admitted in the clinical nutrition medical ward for severe, complicated protein-energy malnutrition (PEM) [body mass index (BMI) 11.08 kg/m2; body weight kg 35.81 due to major eating disorders. C.A.'s personality was narcissistic, with a rigid psychic structure. During hospitalitation (lasted 72 days) two acute episodes (a possibly self-inflicted damage and a persecution feeling) occurred that we consider as part of the "crisis phase", the period in which the patient's restrictive behaviour is no longer able to keep his personality equilibrium stable. The patient was treated by an integrated medical and psychiatric approach, including periods of never forced parenteral nutrition, nutritional and intensive psychoterapeutic interventions. For a short period the patient received also a pharmacological support (aloperidol orally). Treatment was successful and the patient was discharged completely autonomous and followed up on an outpatient basis. After about one year follow-up he is still in good clinical condition and in sufficient psychological equilibrium.

Risk factors for anorexia nervosa: a national cohort study

OBJECTIVE

To identify possible risk factors for anorexia nervosa through national registers.

METHOD

The study includes the entire Swedish population of 989,871 individuals born between 1973 and 1982. Patients with anorexia nervosa were identified through the Swedish Hospital Discharge Register from November 1990 to December 1999. Information about sociodemographic, perinatal, and psychosocial variables was obtained from different national registers. Attributable risk (AR) was calculated for potential risk factors.

RESULTS

Females had the highest AR for hospital admission because of anorexia nervosa (89.2%). Another important risk factor was having parents born in northern, central, or eastern Europe (AR: 49.3%). Psychosocial risk factors also were associated with an increased risk for anorexia nervosa (AR: 7.6%), whereas perinatal complications had an AR of only 3.6%.

DISCUSSION

The most important risk factors were related to the sociocultural context of the individual, thus supporting hypotheses of a sociocultural etiology of anorexia nervosa.

Outcome predictors in the short-term treatment of anorexia nervosa: an integrated medical-psychiatric approach

OBJECTIVES

Factors predicting clinical outcome in the short-term treatment of anorexia nervosa.

DESIGN

Longitudinal follow-up study.

SETTING

Department of Clinical and Experimental Medicine, "Federico II" University of Naples.

PARTICIPANTS

Fifty-eight young anorectic women consecutively attending the outpatient Unit between January 1997 and December 2000.

MAIN OUTCOME MEASURES

Body weight changes over six months' follow-up.

RESULTS

Body weight changes in the short term was exclusively predicted by the prevalent underlying psychiatric disorder, being increased in the patients with prevalently depressive traits, decreased in those with psychotic features and unchanged in those with a prevalently narcissistic personality.

CONCLUSIONS

The prevalent psychiatric disorder seems to predict clinical outcome in the short term. Body weight gain per se cannot always be the main target of medical intervention, at least in the early phase of the treatment of malnutrition secondary to major eating disorders.

Reduced hemodynamic load and cardiac hypotrophy in patients with anorexia nervosa

BACKGROUND

Anorexia nervosa is associated with lower left ventricular mass (LVM) and systolic dysfunction. Whether these abnormalities reflect chronic protein-energy malnutrition or are primarily related to lower cardiac workload is unclear.

OBJECTIVE

The objective of the study was to verify whether low LVM in anorexia nervosa is explained by low hemodynamic load.

DESIGN

Ninety-one women with anorexia nervosa [macro x +/- SD age: 20.5 +/- 6.1 y; body mass index (in kg/m(2)): 15.6 +/- 1.9; group 1] and 62 normal-weight female control subjects (age: 22.5 +/- 5.5 y; body mass index: 20.9 +/- 1.2; group 2) underwent Doppler echocardiography. LVM was evaluated as the percentage predicted by body height, sex, and stroke work (systolic blood pressure x stroke volume).

RESULTS

The left ventricular chamber dimension was smaller and the chamber walls were thinner in group 1 than in group 2, which resulted in significantly lower LVM and LVM indexes (P < 0.0001). Ejection fraction, heart rate, stroke volume, and cardiac output were significantly (P < 0.007) lower in group 1, but peripheral resistance was substantially higher (P < 0.0001). The deviation of LVM from predicted values was lower and the proportion of subjects with inadequate LVM was significantly higher in group 1 than in group 2 (P < 0.0001). This difference was attenuated after adjustment for body weight and heart rate. There were no relations between LVM and laboratory tests in group 1.

CONCLUSIONS

Anorexia nervosa is a condition of low hemodynamic load that leads to low LVM. Even with adjustment for stroke work, however, LVM is lower than would be predicted by height, because of the effect of body weight reduction (ie, wasting of lean body mass).