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WEDNESDAY, July 9, 2003 (HealthDayNews) -- Young women seeking treatment for eating disorders may be thinner and have more psychological problems than 10 years ago.
This troubling trend may be symptomatic of changes in the U.S. health-care system during that same time period, suggests a study in the August issue of Eating Behaviors.
"The most striking finding was that people with anorexia were more likely to have a BMI below 15, which is indicative of severe underweight," says study author Suzanne Mazzeo, an assistant professor of psychology at Virginia Commonwealth University. "They weren't sicker on every indicator, but on a very important indicator we found something very disturbing."
In addition, the study found women with bulimia nervosa seemed to exhibit more psychological problems than in the past.
People with anorexia starve themselves and exercise compulsively, while those with bulimia tend to have episodes of binge eating followed by self-induced vomiting or laxative abuse. Anorexia has the highest mortality rate of any psychiatric disorder, Mazzeo says.
The good news is outreach efforts for eating disorders have increased dramatically. The bad news involves changes in the mental health-care landscape. Inpatient care has become less available, even while the duration of outpatient care has decreased. One study found the average length of a hospital stay for a patient with anorexia at one hospital decreased from 149.5 days in 1984 to 23.7 days in 1998. Perhaps not surprisingly, readmissions at that hospital increased from one in 1984 to 53 in 1998.
"It's getting more and more difficult [to get] insurance companies to authorize treatment, the number of days they authorize is going down, and the consequence is that readmissions are going up," says study co-author Roberta Sherman, co-director of the eating disorders program at Bloomington Hospital in Indiana, where the data was analyzed.
Sherman says many insurance companies will not authorize treatment for a category of patients diagnosed with "Eating Disorder Not Otherwise Specified," generally considered less severe than anorexia or bulimia.
"From our point of view as an outpatient provider, that doesn't make much sense even from a cost-cutting perspective," Sherman says. "The earlier you treat a problem, the easier it is to treat. If you tell someone to go home and wait until the problem gets worse, logically it doesn't make any sense."
To see if these changes in health-care were affecting symptoms, the study authors reviewed data on 334 women with an average age of 22 who had sought treatment for eating disorders between 1988 and 1998. The participants were divided into two groups, based on when they had their intake evaluation. The first group, consisting of 166 people, covered the period 1988 and 1992. The second group went from 1993 to 1998 and was comprised of 168 people.
Patients in the later group were more likely than those in the earlier group to have a dangerously low BMI.
Patients with bulimia had more problems on the "Eating Disorder Inventory" (EDI), a measure of psychological problems associated with both anorexia and bulimia. Specifically, patients with bulimia in the later group had higher scores on the interpersonal distrust scale.
At the same time, rates of exercising, fasting and laxative and diuretic use remained stable for both groups of women.
No one can say for sure why these changes are taking place. "We can't tell from this study why we found that result," Mazzeo says. "We can speculate that maybe people are having a harder time getting treatment."
It's also important to note the study was limited primarily to white women in the Midwest seeking only outpatient care, so the results may not be applicable to the general population.
"It's really important for us to investigate this empirically because we're never going to be able to say this much treatment is needed until we have empirical evidence that people are sicker," Mazzeo says. "Are people seeking treatment not being able to get it for various reasons? What are those reasons and what are their outcomes?"
Speaking from experience, Sherman already sees the issues clearly. "The challenges are being allowed to treat the person for sufficient amounts of time instead of putting a Band-Aid on and sending them out the door," she says.
Good treatment is multidimensional and involves a team approach with a physician, psychiatrist, dietician and psychologist or mental-health provider, Sherman says.
"In that sense, treatment is perhaps a little bit more complicated but I've been dong this since the mid 1980s, and certainly then the proper treatment was much less clear. We know a lot more than we did 25 years ago," she says. "It's just that we're not getting the time to do it."
Dr. Ira Sacker is author of Dying To Be Thin and founder and director of Helping to End Eating Disorders (HEED) in Plainview, N.Y. "What's happening is that insurance companies are not paying for long enough hospitalization and these people are being sent home without any transitional program. There are no step-down programs," he explains.
How does this affect recovery prospects?
Many people do get better, Sacker says, but "the more times you continue to have complications and the more times you relapse, the greater chance of that becoming your ultimate identity."
More information
For more on eating disorders, visit the Harvard Eating Disorders Center or the National Eating Disorders Association.
