Eating Disorders and Suicide

Anorexia is the most lethal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders. On average, between 5% and 10% of patients diagnosed with anorexia will be dead within ten years. Of those deaths, 20-30% are from suicide.

Unfortunately, other types of eating disorders do not appear to completely escape these elevated risks. One of the most recent analyses found that binge-purge behaviors have a strong correlation with attempted suicide. While patients with the restricting subtype of anorexia were found to have a 9.3% lifetime risk of attempted suicide, patients struggling with the binge-purge subtype of anorexia were found to have a 25% risk. The potential risks for attempted suicide were also shown to be high in bulimia nervosa and binge eating disorder at 20% and 11.4% respectively (Mandelli 2019).

These statistics are deeply troubling, and often go unanswered and ignored during standard eating disorder treatment. And yet, through the use of Functional Medicine, these risks can be addressed and reduced.

There are therapeutic interventions that have been shown to help. The evidence that lithium reduces risks for suicide is overwhelming. Studies have consistently shown that naturally occurring lithium found in tap water—at low nutritional levels—can significantly lower suicide rates in the community. Other studies on patients taking lithium for bipolar disorder have also shown reductions in suicide. In fact, a recent review concluded that the data suggests that lithium has an “intrinsic anti-suicidal property (Del Matto 2020).”

While not well studied for use in anorexia, my own experience using nutritional lithium for mood stabilization and suicide prevention has convinced me of its bedrock utility. In the vast majority of cases, I recommend a nutritional dose of lithium on a daily basis to help address suicide risks, improve irritability and stabilize mood.

Nutritional lithium is safe, effective and underutilized in modern medicine. Evidence strongly suggests a dietary need for at least one milligram of lithium per day (Schrauzer 2002). While psychiatrists have focused on high-dose lithium for bipolar disorder, the research on the benefits of low-dose, nutritional lithium has been categorically ignored.

And along with lithium, omega-3 fatty acids can also play a role in suicide prevention in patients struggling with eating disorders. Deficiencies in essential fats have been linked to depression and suicide. Studies on suicide in active-duty military personnel found that low blood levels of the omega-3 docosahexaenoic acid (DHA) were correlated with death from suicide. In men, the risk of death from suicide was 62% higher in those with the lowest DHA levels (Lewis 2011). A study out of China on patients who attempted suicide found lower levels of red blood cell eicosapentaenoic acid (EPA)—another essential omega-3 fatty acid—as compared to controls (Huan 2004). A study in depressed patients also found that deficiencies in omega-3 fats correlated with future suicide risk (Sublette 2006).

Clinical trial data assessing the effects of omega-3 supplementation on suicide and self-harming behaviors is extremely sparse. While some trials have shown improvements, others have not, likely due to small sample size and methodological challenges. One trial in patients with borderline personality disorder found that the addition of omega-3 fatty acids reduced the “Self-Harm Inventory” by almost half as compared to just 15% with valproate alone (Bellino 2014). An earlier small trial on patients with recurrent self-harming behaviors also found reduced suicidality in the group receiving omega-3 supplementation (Hallahan 2007).

Omega-3 fatty acids are crucial for brain health. Yet, since many patients with eating disorders have an immense fear of gaining weight, they often shun all fat, including omega-3s. This can worsen aspects of mental health further in those struggling with eating disorders, further entrenching the condition. In patients with eating disorders, due to their dietary patterns, supplementation with omega-3 fatty acids is often an essential component of restoring health and decreasing suicide risks.

The levels of suicide in patients struggling with eating disorders is overwhelmingly tragic. And the problems are only made worse by the neglect from mainstream medicine in addressing the issue. The current research, and years of my own clinical experience with thousands of patients, has shown me that proper assessment and treatment through Functional Medicine can help lower the risk of suicide in patients with eating disorders. Lithium and omega-3 essential fatty acids are often key.

Eating Disorders and Non-Suicidal Self-Injury

Yet, when addressing suicide risk overall, you have to assess for and address self-harming behaviors. Individuals that attempt suicide typically engage in other types of self-harm first. Often referred to as non-suicidal self-injury (NSSI), these types of self-harming behaviors are strongly correlated with the risk of attempted suicide.

Approximately one-quarter of patients struggling with eating disorders engage in self-harming behaviors (Cucchi 2016). As mentioned previously, binge-purge behaviors appear to have an especially strong correlation with suicide attempts (Mandelli 2019).

Self-harming behaviors are a challenging and concerning component of any eating disorder. And when present, like the risk of suicide, NSSI is often not well addressed by standard treatment approaches. Unfortunately, research on the treatment and prevention of self-harming behaviors is virtually non-existent. A German study in 2016 concluded that there was no research-based approach for reducing NSSI in adolescents (Plener 2016).

Generally, self-harming behaviors are seen as a misguided approach to achieve emotional regulation. Risk factors include mental illness, bullying and a history of neglect or abuse (Plener 2018). One of the strongest indictors for the risk of attempted suicide in eating disorders has been shown to be the frequency of NSSI (Perez 2019).

While the published clinical data on reducing self-harming behaviors is thin, when combined with my years of clinical experience with thousands of eating disorder patients, I can attest to the efficacy of a Functional Medicine treatment approach. Reducing NSSI in eating disorders takes a comprehensive strategy that often includes three nutrients: zinc, amino acids and vitamin B12.

Before discussing each individual nutrient, it’s worth noting a common thread. In patients that either closely or completely adhere to a vegan diet, levels of zinc, amino acids and vitamin B12 are often deficient. Vegan diets in patients with eating disorders can easily create a vicious circle, where a diet low or deficient in key nutrients found in animal products, including zinc, amino acids and vitamin B12 further compounds and worsens the mental, emotional and physical aspects of the eating disorder. It is imperative in patients with eating disorders to get them to give up restrictive diets that are low in key nutrients.

Zinc has well-known correlations with depression and mental health. One small study found that the most zinc-deficient psychiatric patients had a common constellation of symptoms that included aggression, self-harm and substance abuse (Joe 2018). Zinc deficiency also has striking similarities to anorexia nervosa, including appetite loss, digestive disturbances, depression, meat intolerance and increased vulnerability to stress. And not surprisingly, zinc is commonly deficient in patients with eating disorders since it is most readily available in high-calorie foods that are commonly avoided, like meat and poultry.

Recognition and treatment of zinc deficiencies is one of the most important components of a Functional Medicine approach to treating anorexia, and in patients engaging in self-harming behaviors, even more so. Correcting zinc imbalances often improves appetite, mood and the propensity for self-harm. In my experience, it is a powerful and often overlooked tool for helping eating disorder patients recover.

Similar to zinc, amino acids are often deficient in patients struggling with eating disorders. This can be due to a combination of factors, including the avoidance of meat and other high-calorie, protein-rich food sources and problems with digestion and absorption, from low stomach acid to poor digestive function overall.

Amino acids provide the building blocks for neurotransmitters that are needed for core brain function. Without amino acids, neurotransmitters like serotonin, dopamine and norepinephrine cannot be produced in adequate amounts and mental health suffers.

Research has shown that individuals with anorexia often have changes in levels of amino acids and amino acid availability when compared to healthy controls. In patients with anorexia, lower levels of serotonin and available tryptophan may impede recovery, with higher levels having been shown to correlate with reduced depression and anxiety (Gauthier 2014). Other neurotransmitter systems are also likely impacted by the poor protein intake or poor digestion present in many patients with eating disorders.

Treating these deficiencies with a free-form amino acid supplement has been one of the simplest and most effective strategies I’ve found for improving mental state and decreasing self-harming behaviors, especially in those with marked amino acid deficiencies upon testing. A free-form supplement, where the individual amino acids are free or unbound to other proteins, typically yields the best results. In my personal experience, improvements with this one simple intervention can often be profound.

Of the other nutrients, I’ve found that vitamin B12 often has a role to play in helping reduce NSSI as well. Low vitamin B12 levels are known to contribute to depression. And low B12 levels are also common in eating disorders due to the fact that meat and animal products are typically the best source of the vitamin but often shunned by individuals with anorexia. Research has also found that higher B12 levels are correlated with better outcomes during depression treatment.

All of these factors combined likely contribute to the clinical benefits I’ve seen with B12 supplementation in patients with eating disorders and self-harming behaviors. Checking vitamin B12 levels, through serum B12 and functional markers, like homocysteine and methylmalonic acid can go a long way to identify patients that are deficient. In those in need of B12, injections or sublingual supplementation can restore levels to achieve benefits.

Recognizing and addressing any self-harming behaviors and the risk of suicide should always be a part of eating disorder treatment. NSSI is common among patients with eating disorders and is strongly associated with suicide risks. In many cases, self-harm is likely connected to common nutrient deficiencies present in patients struggling with eating disorders. Treating these deficiencies, as part of a comprehensive approach, can often reduce risks and improve long-term treatment outcomes in patients.

Utilizing the nutritional tools available as part of a comprehensive approach for reducing the risks of suicide and self-harm, including lithium, omega-3 fatty acids, zinc, amino acids and vitamin B12, could easily be the beginning of a foundation for properly addressing the epidemic of NSSI and suicide in eating disorder patients. The consequences of continuing to ignore the problem and disregarding potential solutions are too high to do otherwise. Patients are in desperate need of help and my own experience has shown me that proper treatment can provide relief. As healthcare providers, we must do better to reduce the staggering epidemic of suicide in eating disorder patients. Functional Medicine can help guide the way.

For additional information on this topic and the Functional treatment of anorexia nervosa, see my updated book Answers to Anorexia, now available on Amazon.

References

Mandelli L, Arminio A, Atti AR, De Ronchi D. Suicide attempts in eating disorder subtypes: a meta-analysis of the literature employing DSM-IV, DSM-5, or ICD-10 diagnostic criteria. Psychol Med. 2019;49(8):1237-1249. doi:10.1017/S0033291718003549

Del Matto L, Muscas M, Murru A, et al. Lithium and suicide prevention in mood disorders and in the general population: A systematic review. Neurosci Biobehav Rev. 2020;116:142-153. doi:10.1016/j.neubiorev.2020.06.017

Schrauzer GN. Lithium: occurrence, dietary intakes, nutritional essentiality. J Am Coll Nutr. 2002;21(1):14-21. doi:10.1080/07315724.2002.10719188

Lewis MD, Hibbeln JR, Johnson JE, Lin YH, Hyun DY, Loewke JD. Suicide deaths of active-duty US military and omega-3 fatty-acid status: a case-control comparison. J Clin Psychiatry. 2011;72(12):1585-1590. doi:10.4088/JCP.11m06879

Huan M, Hamazaki K, Sun Y, et al. Suicide attempt and n-3 fatty acid levels in red blood cells: a case control study in China. Biol Psychiatry. 2004;56(7):490-496. doi:10.1016/j.biopsych.2004.06.028

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Cucchi A, Ryan D, Konstantakopoulos G, et al. Lifetime prevalence of non-suicidal self-injury in patients with eating disorders: a systematic review and meta-analysis. Psychol Med. 2016;46(7):1345-1358. doi:10.1017/S0033291716000027

Mandelli L, Arminio A, Atti AR, De Ronchi D. Suicide attempts in eating disorder subtypes: a meta-analysis of the literature employing DSM-IV, DSM-5, or ICD-10 diagnostic criteria. Psychol Med. 2019;49(8):1237-1249. doi:10.1017/S0033291718003549

Plener PL, Brunner R, Fegert JM, et al. Treating nonsuicidal self-injury (NSSI) in adolescents: consensus based German guidelines. Child Adolesc Psychiatry Ment Health. 2016;10:46. Published 2016 Nov 29. doi:10.1186/s13034-016-0134-3

Plener PL, Kaess M, Schmahl C, Pollak S, Fegert JM, Brown RC. Nonsuicidal Self-Injury in Adolescents. Dtsch Arztebl Int. 2018;115(3):23-30. doi:10.3238/arztebl.2018.0023

Pérez S, Ros MC, Folgado JEL, Marco JH. Non-suicidal Self-injury Differentiates Suicide Ideators and Attempters and Predicts Future Suicide Attempts in Patients with Eating Disorders. Suicide Life Threat Behav. 2019;49(5):1220-1231. doi:10.1111/sltb.12521

Joe P, Getz M, Redman S, et al. Serum zinc levels in acute psychiatric patients: A case series. Psychiatry Res. 2018;261:344-350. doi:10.1016/j.psychres.2017.12.082

Gauthier C, Hassler C, Mattar L, et al. Symptoms of depression and anxiety in anorexia nervosa: links with plasma tryptophan and serotonin metabolism. Psychoneuroendocrinology. 2014;39:170-178. doi:10.1016/j.psyneuen.2013.09.009