ajp.psychiatryonline.org Am J Psychiatry 166:12, December 2009
(Am J Psychiatry 2009; 166:1342–1346)
otherwise specified; the use of clinical follow-up to ascer-
tain vital status; and (in some but not all studies) relatively
short follow-up periods. Thus, several important questions
remained unanswered. Is the rate of mortality (and in par-
ticular suicide) in bulimia nervosa really nearly zero? What
mortality risks are associated with eating disorder not oth-
erwise specified? And finally, little is known about the lon-
gitudinal course of mortality risk in eating disorders. Does
mortality persist at an elevated level throughout the course
of the illness, or even after recovery? Does it drop after re-
covery? Alternatively, does the risk of mortality increase as a
result of late complications of eating disorders?
Our goal in this study was to describe mortality associ-
ated with eating disorders in a large, diagnostically diverse
sample followed up after an extended period through
computerized record linkage to death records. We hy-
pothesized that mortality rates would remain persistently
high in anorexia nervosa; that there would be an increased
mortality risk in bulimia nervosa; and that modest eleva-
tions of mortality would be observed in eating disorder
not otherwise specified.
The patients in this study all presented for evaluation at the
Outpatient Eating Disorders Clinic at the University of Minnesota
T he mortality from eating disorders is known to be ele-
vated. This is true for both all-cause mortality and suicide,
and there is evidence to suggest that suicide mortality may
be higher in eating disorders than in any other psychiatric
Most mortality research in the eating disorders literature
has focused on anorexia nervosa, in which suicidal behavior
and mortality rates are particularly high (1, 2). The limited evi-
dence to date suggests that the mortality risk is low for buli-
mia nervosa (3). This is somewhat surprising, given the medi-
cal complications associated with vomiting, laxative abuse,
and other purging behaviors (4). It is also surprising that ob-
served suicide rates in bulimia nervosa have not been higher,
given the association with impulsivity and the high rates of
comorbidity with mood, anxiety, and substance use disorders
typically observed in bulimia nervosa (5, 6). Although eating
disorder not otherwise specified (a catch-all DSM-IV diagno-
sis for patients with significant features of eating disorders
not meeting criteria for anorexia nervosa or bulimia nervosa)
is the most common eating disorder diagnosis in nearly all
community and clinic-based studies of the epidemiology of
eating disorders (7–9), virtually nothing is known about the
course or complications associated with eating disorder not
otherwise specified, including mortality.
The literature on mortality in eating disorders generally
has several limitations, including relatively small numbers
of study subjects with bulimia nervosa or eating disorder not
Scott J. Crow, M.D.
Carol B. Peterson, Ph.D.
Sonja A. Swanson, Sc.M.
Nancy C. Raymond, M.D.
Sheila Specker, M.D.
Elke D. Eckert, M.D.
James E. Mitchell, M.D.
Objective: Anorexia nervosa has been
consistently associated with increased
mortality, but whether this is true for
other types of eating disorders is unclear.
The goal of this study was to determine
whether anorexia nervosa, bulimia ner-
vosa, and eating disorder not otherwise
specified are associated with increased
all-cause mortality or suicide mortality.
Method: Using computerized record
linkage to the National Death Index, the
authors conducted a longitudinal assess-
ment of mortality over 8 to 25 years in
1,885 individuals with anorexia nervosa
(N=177), bulimia nervosa (N=906), or
eating disorder not otherwise specified
(N=802) who presented for treatment at
a specialized eating disorders clinic in an
academic medical center.
Results: Crude mortality rates were 4.0%
for anorexia nervosa, 3.9% for bulimia
nervosa, and 5.2% for eating disorder not
otherwise specified. All-cause standard-
ized mortality ratios were significantly
elevated for bulimia nervosa and eating
disorder not otherwise specified; suicide
standardized mortality ratios were elevat-
ed for bulimia nervosa and eating disor-
der not otherwise specified.
Conclusions: Individuals with eating
disorder not otherwise specified, which
is sometimes viewed as a “less severe”
eating disorder, had elevated mortality
risks, similar to those found in anorexia
nervosa. This study also demonstrated an
increased risk of suicide across eating dis-
Increased Mortality in Bulimia Nervosa and Other Eating
This article is featured in this month’s AJP Audio and is discussed in an editorial by Dr. Kaye (p. 1309).