For more mental health resources, see our National Helpline Database. Although medical complications related to malnutrition are the leading cause of death among individuals with anorexia nervosa, suicide is believed to follow closely behind. Suicidal behavior is elevated in patients with anorexia nervosa, bulimia nervosa, and binge eating disorder, the three eating disorders that have been most studied. Eating disorders have the highest mortality rate of any mental disorder. While studies have shown varying results, patients with eating disorders appear to be between 1.5 and 14 times more likely than same-aged peers to die. Mortality rates are the highest for patients with anorexia nervosa but are high for any person with an eating disorder. In a recent comprehensive study of mortality in eating disorders, researchers found that suicide was the most common non-natural cause of death. Two-thirds of the non-natural deaths among patients with anorexia nervosa and all of those among patients with bulimia nervosa and binge eating disorder were from suicide, leading the researchers to conclude that “suicide is a major concern not only in [anorexia nervosa] but in all eating disorders.”
Suicidality
Suicidality refers to a wide range of thoughts and behaviors. It can range from passive ideation (passive thoughts about not wanting to live anymore) to lethal attempts. There is also nonsuicidal self-injurious behavior which refers to acts of self-harm such as cutting, burning, scratching, or harming the skin. These behaviors, which less often reflect a true desire to die and more often a mechanism for managing emotional distress, will not be discussed in this article. Rates of suicide and suicidal ideation differ for the types of eating disorders:
Anorexia Nervosa
Between 20 and 43 percent of those with anorexia nervosa report current suicidal ideation. One study showed that 23 percent of adults with a lifetime diagnosis of anorexia nervosa reported suicidal ideation—this is in comparison to adults in the general population, who report lifetime suicidal ideation in the range of 5 to 15 percent. Patients with anorexia are also two to nine times more likely than peers to attempt suicide. One study showed that patients with anorexia were 18 more times likely to die by suicide than in a comparison group.
Bulimia Nervosa
There are comparatively fewer studies on suicide and bulimia nervosa. The results we have seem to show that the estimates of suicidal ideation and attempts among patients with bulimia nervosa are similar or greater than among patients with anorexia nervosa, but the risk of suicide death is somewhat lower. Between 15 and 23 percent of those with bulimia nervosa report current suicidal ideation. Lifetime suicidal ideation is between 26 to 38 percent among patients with bulimia nervosa. Female patients with bulimia nervosa are seven times more likely to die by suicide than females in the general population.
Binge-Eating Disorder (BED) and Other Specified Feeding and Eating Disorder (OSFED)
There is even less research on suicidality in BED and OSFED. Current suicidal ideation among patients with BED or OSFED is estimated to be between 21 and 23 percent. One study has shown that patients with BED were five times more likely to have attempted suicide than peers without eating disorders. One study found that patients with OSFED were four times more likely to die by suicide than gender and age-matched peers.
Risk Factors
Although suicidal behavior can occur with any type of eating disorder, research suggests it may be more common among patients with certain presentations. Suicide attempts appear to be more common among patients with anorexia binge-purge subtype compared to the restrictive subtype. Some studies have shown that suicide attempts are correlated with purging behaviors including laxative abuse and self-induced vomiting. The risk for suicide attempts is higher when the eating disorder occurs with other disorders such as depression or substance abuse. One study showed that 80 percent of people with anorexia nervosa who attempted suicide reported their attempt occurred while they were depressed. Suicidality might also be more common among eating disorder patients with a history of childhood abuse. Genetic studies have shown that anorexia nervosa and suicidality occur together because of shared genetic factors. Research shows that individuals who have attempted suicide two or more times are at greater risk for a future attempt and previous attempters are at the most risk approximately six months to two years after their attempt.
Warning Signs
Warning signs of suicide may include:
A change in behavior or the emergence of new behaviors, especially relevant if it occurs after a painful event or lossTalk about wanting to kill themselves, feeling hopeless, being a burden, feeling trapped, or pain that can’t be dealt withBehaviors such as increased alcohol or drug use, searching for means to end their lives, withdrawal, and social isolation, sleep changes, calling or visiting people to say goodbye, giving away important possessions, aggression, and fatigueMoods such as depression, anxiety, apathy, shame, anger, irritability, or sudden relief
Assessment
Because of the elevated risk of suicide, a routine suicide risk assessment should be a part of eating disorder treatment. Two empirically validated and accessible suicide measures include the Joiner’s Suicide Risk Assessment (JSRA) and the Linehan Risk Assessment and Management Protocol (LRAMP). The JSRA, which is based on the interpersonal theory of suicide, is a semi-structured interview that results in an individual being classified into a risk category (low, moderate, severe, or extreme). The LAMP provides a structured checklist for assessing, managing, and documenting suicide risk and guides the clinician to provide appropriate clinical intervention. Clinicians should also screen eating disorder patients for a family history of suicide.
Treatment
Psychiatric hospitalization can be considered for the treatment of suicidality in eating disorders because it provides increased security for the patient. Other strategies for the short-term management of crises can include increased monitoring and social support, removal of lethal methods, and the treatment of acute psychiatric symptoms. When a patient indicates that he or she is suicidal, the focus of treatment should be preventing suicide. Dialectical behavior therapy (DBT) is an empirically validated treatment that was developed specifically for patients with suicidality and self-harm. It has also been successfully applied to the treatment of eating disorders. In DBT, behaviors are targeted according to a hierarchy. Suicidal behaviors are considered the highest priority for treatment.
Getting Help
If you are having thoughts about suicide, it’s extremely important to reach out for help. Family and friends can often help you through a crisis. There are also many additional resources available for you or a loved one to talk to. If you are worried that someone close to you may be having thoughts about suicide, don’t be afraid to ask them, “Are you having thoughts about suicide?” Research shows that directly asking someone does not put the idea in their head or increase their risk of making an attempt. By contrast, it is often experienced as an empathic concern.
The Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals.
Crisis Text Line: Text TALK to 741-741
The text line provides a free, 24 hour a day, 7-day a week confidential text message service for people in crisis.
If you or a loved one are in immediate danger, call 911. Keep them safe, remove access to lethal items if you can, and engage with and listen to them. Share your concern for them and let them know you care. Help them connect with professional help or a suicide hotline.
A Word From Verywell
If you (or a loved one) are in crisis or experiencing any suicidal thoughts, plans, or attempts, it is important to reach out for help. When you feel bad it is common to believe that you will always feel bad. It can be hard to remember that feelings are temporary and that things can get better. You are not the only one who has felt this way. Let others help you through this tough time. Also, remember that eating disorders are treatable.
