Anorexia Nervosa and Depression: Screen and Document

Anorexia nervosa and depression symptom map

Educational content for licensed therapists, not clinical, legal, or crisis advice. Adapt every call to presentation, medical status, and your setting. If a client is in immediate danger, follow local emergency protocol. In the US, the 988 Suicide and Crisis Lifeline is reachable by call or text at 988.

A.R. scores 18 on the PHQ-9. She has been restricting for eleven months. You could write “MDD, moderate” and reach for a thought record. That note would be tidy. It would also treat starvation as a mood disorder.

You are looking at anorexia nervosa and depression in the same hour. Anorexia and depression often share a waiting room. Your job is the differential and the sentence that records it, not a second treatment-plan rewrite.

Kalm and Semba (2005) describe the Minnesota starvation experiment: 36 conscientious objectors in a semistarvation study, most of whom lost more than 25% of their weight. Many experienced fatigue, apathy, extreme weakness, and irritability. Pollice and colleagues (1997) later found depression, anxiety, and obsessionality highest in underweight women with anorexia nervosa. Scores fell after weight restoration in that clinical sample, though milder elevations persisted after long-term restoration compared with healthy controls. Mattar and colleagues (2011) reviewed seven studies on malnutrition and depression or anxiety in anorexia nervosa and found the results inconsistent.

Hudson and colleagues (2007) found lifetime major depressive disorder in 39.1% of US adults with lifetime anorexia nervosa in the National Comorbidity Survey Replication (household sample, 2001 to 2003, n = 9,282; odds ratio 2.7). That is a community figure. Godart and colleagues’ 2007 review of eating-disorder and mood-disorder comorbidity studies found methods uneven and results scarce or conflicting. Do not paste a household rate onto the person in front of you. Use Hudson to justify screening, then write what you saw.

When to screen and which measure

Screen anorexia nervosa and depression at intake. Screen again when restriction, vitals, labs, or BMI change. Screen a third time after partial weight restoration, when starvation copies of mood often recede and a remaining episode is easier to name. Do not wait for a “true” depression before you ask about suicide.

Kroenke, Spitzer, and Williams (2001) built the PHQ-9 as a nine-item depression screen that scores each DSM-IV depression criterion from 0 to 3. Those criteria include sleep, energy, and appetite, which also move with starvation. In this hour, do not treat the total as an MDD diagnosis while the client is starved. Read the items. Treat appetite change as a medical fact until intake is stable. Weigh low energy against meals completed. Keep guilt, concentration with examples, psychomotor change, and death or self-harm thoughts in the mood column because they still have to be asked; they are not starvation by default.

Pollice’s underweight elevation, and the drop after restoration, is why you re-screen after partial weight restoration instead of locking MDD from a starved total. If cognitive-affective symptoms clearly predated restriction, or they persist after nutritional rehabilitation, name a mood disorder with the evidence. If you cannot tell yet, write both possibilities and the date you will re-evaluate.

If the mood episode is real and the client is medically stable enough for cognitive work, sequence it with CBT techniques for depression. Restriction, regular eating, and referral thresholds stay on eating disorder therapy techniques. Do not run a thought record as a substitute for refeeding.

How suicide risk changes

Suicide risk does not wait for a cleaner mood diagnosis. Arcelus, Mitchell, Wales, and Nielsen (2011) pooled 36 studies covering 166,642 person-years of anorexia nervosa: all-cause standardized mortality ratio 5.86, weighted mortality 5.1 deaths per 1,000 person-years, and one in five of those who died had died by suicide. Preti, Rocchi, Sisti, Camboni, and Miotto (2011) pooled 40 anorexia nervosa studies covering 16,342 patients (mean follow-up 11.1 years; 245 suicides) and reported a suicide SMR of 31.0 (Poisson 95% CI 21.0 to 44.0). Those are cohort and meta-analytic figures, not a prediction for A.R. They are why you still ask.

Ask even when the client attributes every low day to food. Denial of a plan is not a screen. Posner and colleagues (2011) validated the Columbia-Suicide Severity Rating Scale for ideation severity and behavior; use it, then put the answers in the chart. The full structure of that write-up lives on the suicide risk assessment template. This page only records how the AN picture changes the screen: medical fragility changes means and lethality, isolation around meals can hide preparatory behavior, and a covering clinician cannot see “denied SI” as a completed assessment.

If risk is acute, stop the differential and follow your setting’s safety protocol. A mood formulation does not outrank that hour.

Keep the mood differential in the note

What the note records

Write the observations that would let next week’s covering clinician make the same call. Do not write a slogan such as “depression secondary to anorexia.”

Copy-ready fields for the next hour:

The standing team document (dietitian, medical clinician, stabilization threshold) belongs on the eating disorder treatment plan template. Keep this note to the differential you ran today.

Download the co-occurring disorders worksheet pack to organize the mood, eating-disorder, and risk questions before the next session.