Psychiatric comorbidity as a risk factor for mortality in people with anorexia nervosa

  • Hubertus Himmerich
  • Matthew Hotopf
  • Hitesh Shetty
  • Ulrike Schmidt
  • Janet Treasure
  • Richard D. Hayes
  • Robert Stewart
  • Chin-Kuo ChangEmail author
Original Paper


Anorexia nervosa (AN) is found associated with increased mortality. Frequent comorbidities of AN include substance use disorders (SUD), affective disorders (AD) and personality disorders (PD). We investigated the influence of these psychiatric comorbidities on all-cause mortality with demographic and socioeconomic factors considered as confounders in the observation window between January 2007 and March 2016 for 1970 people with AN, using data from the case register of the South London and Maudsley (SLaM) NHS Foundation Trust, an almost monopoly-secondary mental healthcare service provider in southeast London. We retrieved data from its Clinical Records Interactive Search (CRIS) system as data source. Mortality was ascertained through nationwide tracing by the UK Office for National Statistics (ONS) linked to CRIS database on a monthly basis. A total of 43 people with AN died during the observation period. Standardized Mortality Ratio (SMR) with England and Wales population in 2012 as standard population for our study cohort was 5.21 (95% CI 3.77, 7.02). In univariate analyses, the comorbidity of SUD or PD was found to significantly increase the relative risks of mortality (HRs = 3.10, 95% CI 1.21, 7.92; and 2.58, 95% CI 1.23, 5.40, respectively). After adjustment for demographic and socioeconomic covariates as confounders, moderately but not significantly elevated risks were identified for SUD (adjusted HR = 1.39, 95% CI 0.53, 3.65) and PD (adjusted HR = 1.58, 95% CI 0.70, 3.56). These results suggest an elevated mortality in people with AN, which might be, at least partially, explained by the existence of the comorbidities SUD or PD.


Anorexia nervosa Comorbidities Affective disorder Substance use disorder Personality disorder 


Author contributions

HH, MH, UD, JT, RDH, RS and CKC designed the study. HH, MH, HS, RDH, RS and CKC contributed to the statistical analysis; HH and CKC drafted the manuscript; all authors contributed to the interpretation of the results, revised the first draft of the manuscript and approved its final version.


This study was funded by the National Institute of Health Research (NIHR), the National Health Service (NHS), the Department of Health and Social Care, the South London and Maudsley NHS Foundation Trust (SLaM) and the King’s College London (KCL). US and MH are supported by an NIHR Senior Investigator Award. All authors received salary support from the NIHR Mental Health Biomedical Research Centre, SLaM or KCL. The funding sources did not have any influence in the study design, the collection, analysis and interpretation of data, in the writing of the manuscript, and in the decision to submit the article for publication. The views expressed in this article are those of the authors.

Compliance with ethical standards

Conflict of interest

The authors declare no conflict of interest relevant to this paper.

Supplementary material

406_2018_937_MOESM1_ESM.docx (18 kb)
Supplementary material 1 (DOCX 18 KB)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Psychological MedicineKing’s College LondonLondonUK
  2. 2.South London and Maudsley NHS Foundation TrustLondonUK
  3. 3.Department of Health and WelfareUniversity of TaipeiTaipeiTaiwan

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