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April 10, 2009 — Insurers, national-health administrations, and other gatekeepers to treatment often fail to classify eating disorders as serious mental illnesses, resulting in an ongoing healthcare crisis for sufferers and their families.

The Academy for Eating Disorders (AED) has waded into the fray with a new position paper explaining the scientific rational for identifying eating disorders as serious mental illnesses. The position paper was published in the March issue of the International Journal of Eating Disorders.

Senior author Edward Tyson, MD, medical director of Cedar Springs Austin Eating Disorder Center, in Texas, told Medscape Psychiatry that there were both clinical and political reasons the Academy issued the new position paper at this time.

"The position paper is especially important now because patients are being denied insurance coverage in some states, and even in other countries, on the grounds that an eating disorder is not a 'serious mental illness,' or is not a 'biologically based mental illness.' Since anorexia, for example, has the highest mortality rate of any psychiatric illness, this is a serious problem," Dr. Tyson said.

The position paper points out that the laws in some states, such as New Jersey, actually exclude eating disorders from conditions considered to be serious or biologically based mental illnesses. Dr. Tyson also said that some eating-disorders experts are worried that the ongoing discussion about some type of national health-insurance program for the United States might have similar limitations.

Biologic Basis
The AED provides 4 arguments for classifying eating disorders as biologically based serious mental illnesses. First, there is evidence that anorexia nervosa and bulimia nervosa are as heritable as other psychiatric conditions, such as schizophrenia, bipolar disorder, and depression. Second, the behaviors of restricting food intake, binging, and purging alter brain structure, metabolism, and neurochemistry in ways that make it difficult for individuals to discontinue the behaviors. Third, eating disorders are associated with impaired emotional and cognitive functioning that limits life activities. And finally, eating disorders are life-threatening.

"Eating disorders are associated with the highest level of mortality and medical complications of any psychiatric condition. It is imperative that eating disorders receive the same level and breadth of healthcare coverage that is available for treatment of medical disorders and other psychiatric conditions," AED president Judith Banker said in a statement.

"We expect the position paper to be immediately helpful to clinicians because it provides access to expert consensus statements and a thorough review of the research supporting our finding that eating disorders are serious mental illnesses," Dr. Tyson said. "This might be helpful to clinicians who need to convince a patient's third-party payer that these are serious illnesses that need to be treated."

Dr. Tyson predicted that the position paper would also be helpful in counseling patients and families about eating disorders. "There is sometimes a lot of denial in families, who don't want to think of their child's problem as severe. As eating-disorders specialists, it is time that we emphasize the full impact of where the disease comes from and what it can lead to, and transmit that information to the public, and especially to patients and families."

"Clinicians and the general public need to understand that an eating disorder is not just bad behavior and will not be resolved by telling patients to eat more. Eating disorders have a biologic basis and biologic forms predominate in triggering these syndromes," Dr. Tyson said.

Biologic Factors Not the Whole Story
Linda Smolak, PhD, research advisor for the National Eating Disorders Association, agreed that insurance companies, physicians, legislators, and the general public need to be informed that anorexia nervosa and bulimia nervosa have serious medical complications, many of which are chronic.

She said that the fact that standardized mortality rates in anorexia nervosa are the highest of any psychiatric disorder and are 12 times higher than the annual death rate from all causes in females 15 to 24 years of age "is the most important point in the paper." However, Dr. Smolak pointed to some weakness in the position paper's analysis.

"The paper was written because so many states (and other countries) are unwilling to require health-insurance companies to cover [eating disorders] as they do physical illnesses and, increasingly, other psychiatric illnesses. These authors have argued in other places that a principle reason for this refusal is that eating disorders are perceived as voluntary choices made by vain girls. As such, legislators, insurers, and others believe that these girls and women can more or less choose to get better.

The authors aim to demonstrate that eating disorders are more complex than this and, importantly, may have a biologic basis. The paper therefore emphasizes neurologic and genetic causes of [eating disorders] while completely excluding sociocultural factors," Dr. Smolak said.

Experimental and longitudinal prospective data have identified sociocultural factors, particularly media and peer influences, that also play an important role.

"It is unfortunate that the AED paper has opted to give no attention to these variables because [those factors] and others, such as sexual abuse, are almost certainly involved in the development of [eating disorders]. The risk of only emphasizing the neurologic components is that physicians and insurers will think that psychopharmacology is an adequate treatment plan. In fact, there is currently no effective drug treatment to eliminate symptoms, although some may reduce symptoms or maintain successful interventions," Dr. Smolak said.


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