Depression and Eating Disorders: The Connection Explained

January 18, 2022

Weight gain or weight loss, fatigue and insomnia are common symptoms of both depression and eating disorders. How can you tell if someone is experiencing one or the other or both at the same time?

“Often times eating disorders and depression are co-occurring,” says Allison Chase, PhD, CEDS-S, Regional Clinical Director, Eating Recovery Center (ERC), Texas. She explains that eating disorder behaviors often surface when someone is trying to manage underlying emotional issues.

Someone who has an eating disorder may also experience anxiety, as well as behaviors like self-harm and substance use, but depression is typically the main underlier. Multiple studies indicate that major depressive disorder is the most common co-occurring diagnosis for people with eating disorders. More frequently, eating disorder behaviors are used as a way to cope with depression than the other way around.

Eating Disorder and Depression Statistics

Between 50% to 75% of those living with an eating disorder – anorexia nervosa, bulimia nervosa, binge eating disorder – will experience symptoms of depression, according to the National Institute of Mental Health (NIMH). Research points to a clear association between eating disorders and depression.

A diagnosis of major depressive disorder with eating disorders has been associated with high rates of suicide attempts and suicide-related mortality. [1]
Eating disorders are among the deadliest mental illnesses, second only to opioid overdose. [2]
A majority of adults (50.0%–63.2%) with anorexia nervosa, bulimia nervosa, and binge eating disorder received treatment for emotional problems at some time in their lives, based on data from the National Comorbidity Survey Replication.

How Different Eating Disorders Interact with Depression

“An inability to regulate emotions is common in our patient population,” says Ileana Calinoiu, MD, Child, Adolescent, and Adult Psychiatrist, ERC Bellevue. “This serves as a transdiagnostic risk and maintenance factor involved in many mental health disorders, including anxiety, depression and eating disorders.”

The etiology—causes and origins—of eating disorders are quite complex involving genetic and biological factors, as well as environmental factors like sociocultural pressures, life stressors and social relationships. Dr. Chase emphasizes that “eating disorders are really about 'mismanaged' or unhealthy coping for negative underlying emotions.” And because not all eating disorders are the same, recognizing their differences and how depression affects each one is important.

Anorexia and Depression

Anorexia nervosa is an eating disorder characterized by weight loss, difficulties maintaining an appropriate body weight for height, age, and stature and, for many, having a distorted body image. One study found that the comorbidity of anorexia nervosa and major depression is likely due to genetic factors that influence the risk for both disorders.

According to 2021 research, people who live with depression often have more severe symptoms on the anorexia spectrum, including lower BMI, increased number of hospitalizations, reduced quality of life and a longer time living with an eating disorder.

Bulimia and Depression

Bulimia nervosa is characterized by a cycle of binge eating and compensatory behaviors such as self-induced vomiting designed to undo or compensate for the effects of binge eating. It is the one eating disorder that co-occurs with major depressive disorder the most, with 70.7% of individuals who live with bulimia diagnosed with depression at the same time. People with bulimia tend to feel shame and guilt about their inability to control compulsive behaviors which can worsen preexisting depression.

Binge Eating Disorder and Depression

Binge Eating Disorder (BED) is characterized by frequent overeating at least once a week over a period of three months. These binge episodes are also combined with feeling a lack of control and intense feelings of distress; more than half of adults diagnosed with BED experience depressive symptoms. A recent study suggests that for those living with BED, symptoms of depression can reduce self-control and decision-making ability, making BED symptoms harder to regulate.

How to Tell the Difference Between Depression Symptoms & an Eating Disorder

A primary feature of major depressive disorder is a period of two weeks during which there is either depressed mood most of the day nearly every day or loss of interest or pleasure in nearly all activities.

“The focus of depression is feeling down and lacking interest in activities you typically enjoy,” says Dr. Chase. “And while there are symptoms like loss of appetite and loss of weight or overeating episodes and weight gain, what differentiates them from eating disorders is where the focus is when it comes to body image issues and lack of concern of health surrounding weight loss.”

With depression, someone may exhibit signs of sadness and withdrawal that are more noticeable to those in their close circle, while eating disorders are what Steven F. Crawford, MD, Medical Director, ERC and Pathlight, Baltimore, refers to as “illnesses of secrets.” He explains, “A lot of times the individual has worked hard to not disclose what's going on.” Dr. Crawford says that it is important not to take a “wait and see approach” before seeking treatment for these individuals because research has shown that people do much better with early intervention.

This table lists 5 common symptoms of each disorder, with the titles linking to resources that include a more extensive list and information about each.

Anorexia Symptoms	Bulimia Nervosa Symptoms	Binge Eating Disorder Symptoms	Depression Symptoms
Persistent food restriction	Bingeing	Eating rapidly	Persistent sad, anxious, or "empty" mood
Bradycardia	Purging	Eating until feeling uncomfortably full	Feelings of hopelessness, or pessimism
Hair Thinning/Loss	Use of laxatives or diuretics	Eating large amounts of food even when not hungry	Moving or talking more slowly
Hypotension and Orthostasis	Fear of gaining weight	Eating alone due to feelings of embarrassment	Loss of interest or pleasure in hobbies and activities
Behaviors such as calorie restriction	Failing performance at school, work, activities	Feeling disgusted with oneself, depressed or guilty after eating	Thoughts of death or suicide, or suicide attempts

Treatment for Eating Disorders and Depression

“The key is which diagnosis to focus on,” says Dr. Chase of treating comorbid depression and eating disorders. “It is the one that is causing the most significant impairment in functioning and impacting one’s health. Often due to the medical and physical complications of eating disorders it is so important to address treatment to resolve those unhealthy behaviors and symptoms.”

When an eating disorder is present as well as depressive symptoms, it is important that the focus stay consistent in addressing eating disorder behaviors in a diagnosis such as anorexia. This is because the patient who is often ambivalent to challenge the eating disorder might aim to push the focus to the depression as a distraction. Dr. Chase says, “While we can address depressive symptoms while working on the eating disorder behaviors, it is imperative to continue treating the eating disorder behaviors.”

To better identify, understand and work towards managing and shifting negative feelings and behaviors, Dr. Chase explains that treatment for depression involves all the evidence-based strategies and skills from approaches like:

As the eating disorder symptoms are resolved however, depression symptoms may worsen. “The eating disorder is almost like a coping skill for those with a comorbid diagnosis, and then when you remove the eating disorder, the [comorbid] diagnosis gets worse,” says Dr. Crawford, adding that one of the key elements of having patients in a higher level of care for eating disorders is having the ability to manage this sort of behavior and diagnosis and treat comorbid disorders.

It is important to note again that rates of death by suicide among individuals with eating disorders are elevated compared to other mental health disorders, including depression.

Learn more about managing suicidality in eating disorder patients.

Help is available

Do you or someone you know need help with an eating disorder and/or depression? We understand that you can struggle with dual diagnosis and specialized treatment is needed to develop the skills and tools needed for long-lasting recovery. You can reach out to us here.

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Sources:

[1] Löwe B, Zipfel S, Buchholz C, Dupont Y, Reas DL, Herzog W, Psychol Med. 2001 Jul; 31(5):881-90.

[2] Arch Gen Psychiatry. 2011;68(7):724-731. doi:10.1001/archgenpsychiatry.2011.74