This study examined health services use among adult members of a large health maintenance organization who had been diagnosed with an ED in 2003. Overall, about 2/1000 female, and fewer than 2/10 000 male, health plan members received a diagnosis of AN, BN, or EDNOS in 2003 who had not yet been diagnosed with an ED in 2002. EDs are far less common among males than females (Hudson et al. 2007
) and the proportion of men who were found to have been diagnosed with an ED in the target year of the present study is consistent with findings based on a national insurance database (Striegel-Moore et al. 2000
). Moreover, the 12-month ‘prevalence’ estimates (i.e. the number of individuals diagnosed with an ED, regardless of whether they had received an ED diagnosis in the prior year) and the ‘incidence’ estimate (i.e. the number of individuals who received an ED diagnosis for the first time in the target year) observed in the present study are far lower than prevalence estimates of EDs in community samples (there are no published estimates of the incidence of EDs based on US populations). This is consistent with findings from previous studies suggesting that many individuals do not access or receive treatment specifically for an ED (Garvin & Striegel-Moore, 2001
; Striegel-Moore, 2005
The examination of health services use data of female health plan members yielded four major findings. One, 50% of the ED cases were first diagnosed during a primary-care visit, pointing to the critical importance of primary-care providers in identifying EDs, even in a health plan where members have direct access to specialty care including mental health services. Although several screening instruments have been developed to identify those experiencing an ED (e.g. Spitzer et al. 1999
; Stice et al. 2000
), they have not yet been tested in large, unselected populations of primary-care patients against reliable structured interviews nor do they seem to be used in routine clinical practice.
Two, health services use was significantly elevated in all service sectors among those with an ED compared with a randomly selected sample of women who did not have an ED diagnosis, both in the 12 months leading up to, and in the 12 months following, the index visit. The present study cannot disentangle whether the elevated services use reflects the considerable co-morbidity among individuals with an ED or an attempt by the patient to receive care without acknowledging the ED to herself or the healthcare provider. The high levels of co-morbidity observed in this study may in part be due to the fact that the more distressed and more highly co-morbid patients are more likely to have their ED diagnosed. Indeed, epidemiological studies have found an ED is almost never identified without a psychiatric co-morbid disorder having first been recognized but those studies also report that most ED cases meet criteria for another psychiatric disorder even among individuals whose ED has not been treated (Kendler et al. 1991
; Lewinsohn et al. 1993
; Walters & Kendler, 1995
; Hudson et al. 2007
). Major depression was the most common co-morbid mental disorder among women with an ED, probably reflecting both the large number of women with depression as well as ‘true’ co-morbidity (Kraemer, 1995
; Kraemer et al. 2006
). Co-morbid anxiety disorders were also noted in 15% of women with an ED diagnosis at the index visit. In light of the considerable number of women with comorbid depression and anxiety disorder diagnoses, it is not surprising that many were prescribed antidepressant and/or anxiolytic medication in the year prior to diagnosis.
Beyond reflecting clinical need arising from comorbid symptoms, the elevated services use in the year prior to diagnosis also may reflect patients’ efforts to receive help specifically for ED symptoms without acknowledging the symptoms clearly. Denial is a hallmark of AN (Bruch, 1978
) but is also common among individuals with BN, and ED symptoms are often ego-syntonic in the early stages of the disorder. Patients may not attribute their distress to, or acknowledge, body image concerns or disordered eating behavior, making it difficult for the care provider to detect an ED. An additional barrier to detecting EDs may be patients’ shame about their disorder, which may make patients reluctant to give an unambiguous account of their problems; in turn, providers may not be sufficiently familiar with the signs or symptoms of EDs and miss patients’ ‘hints’ that they suffer from disordered eating (Cachelin & Striegel-Moore, 2006
). Our results suggest that physicians screen women for an ED, particularly those who are being treated for an anxiety disorder or for major depression.
Both prior to diagnosis and thereafter, patients with an ED are being treated not only in primary care or mental health care but also receive more services than non-ED patients in the form of telephone consultations, specialty care, and emergency/urgent care. This spectrum of services probably reflects the broad range of physical and psychiatric symptoms associated with EDs (Wonderlich & Mitchell, 1997
). Following diagnosis, service use increases in particular in terms of prescription of antidepressants, telephone consultations, and visits to both mental health and primarycare departments.
Consistent with a previous report based on a national insurance consortium database (Striegel-Moore et al. 2000
), in-patient treatment was uncommon. Focusing specifically on privately insured adolescent patients, Martin & Leslie (2003)
showed that from 1997 to 2000, psychiatric in-patient and outpatient treatment declined 20% and 11.3% respectively. They also noted a shift toward increased use of medication compared with ‘talking’ therapies. This trend is of particular concern in EDs where, to date, no specific medication has been identified for the treatment of AN, and where medication is less effective than cognitive behavioral therapy in the treatment of BN and binge eating disorder (Wilson & Shafran, 2005
Three, with the possible exception of older women with AN, elevated service use did not appear to vary significantly by type of ED. Of particular note is the finding that the group of patients with EDNOS did not have lower use of health services than those with AN or BN. This result is consistent with several studies suggesting that patients with EDNOS do not appear to represent individuals with a ‘less severe’ type of ED (Fairburn & Bohn, 2005
). Our results underscore the importance of the EDNOS population both in terms of the absolute numbers of individuals who are being treated as well as their impact on the healthcare system in terms of greater service utilization.
Finally, although service use was elevated for those with an ED diagnosis compared with the controls, and increased significantly among the women with an ED in the year following diagnosis, inspection of average service use estimates suggests that this population is being under-treated. Specifically, the average number of mental health visits was well below the number of sessions of evidence-based psychotherapy (16–20) provided in randomized clinical trials of cognitive behavior therapy or interpersonal psychotherapy (Wilson & Shafran, 2005
). It is important to note that the relatively modest number of mental health visits was observed in a health plan that provides such services without restricting the number of sessions. Our data do not permit us to ascertain the reasons for the under-treatment of EDs in this population. Other studies have shown that under-utilization of mental health services is common among patients with mental health disorders in general (Wang et al. 2005
; Alonso et al. 2007
) and that the under-utilization is the result of a complex interplay of external (e.g. insurance plan restrictions) and internal (e.g. reluctance to seek care) factors. Both patients and providers should be encouraged to engage in a more sustained treatment effort than is reflected in the average number of mental health sessions (4–5) received by the individuals whose data were examined in this study.
Several limitations of the study need to be considered. Men comprise a minority of individuals who develop an ED (Hudson et al. 2007
) and are especially unlikely to receive treatment for an ED (Striegel-Moore et al. 2000
). In the present study, only 19 men were found to have received health services for an ED during the calendar year of 2003; therefore, our sample was too small for further analyses concerning health services use among men. Only a small number of women with AN were identified. That individuals with AN comprise a minority among the population of individuals with EDs has been repeatedly documented in epidemiological and clinical studies (Hoek, 2006
; Hudson et al. 2007
). The large heterogeneity in health services use in women with AN, especially among those aged >35 years where one individual accounted for much of the significantly elevated health services use, raises questions of how best to test hypotheses about differential health services use. We considered but rejected censoring health services use or omitting from analysis the one case with particularly high service use because the small number of women with AN aged >35 years in our sample made it impossible to determine with conviction what values, if any, represent true outliers. Nonetheless, we caution that our finding that AN disproportionately contributed to elevated services use observed among women with an ED needs to be replicated in unrelated samples.
Institutional data are limited by the fact that diagnoses cannot be verified. Cases might have been treated for an ED for some time before providers finally entered the diagnosis into the patient record. Because providers may not apply diagnostic criteria with the rigor typically employed in research, each of the ED groups may have included cases experiencing a different ED and this lack of precision may have obscured differences among ED groups in health services use. The comparison sample may include some individuals whose ED had not yet been detected or labelled. As has been found in previous studies, health services use varied considerably among individuals with an ED. It is unclear to what extent this variability reflects true differences in clinical need versus lack of consistency in the provision of care for EDs. Finally, we caution that our findings may not generalize to individuals with more restrictive or no health insurance plans.
The study’s limitations are offset by several strengths, including the availability of objectively measured service use data that are probably more comprehensive and accurate than data that are based on self-reported service use (Garvin & Striegel-Moore, 2001
; Marshall et al. 2001
), the inclusion of a very large sample, and the availability of health services data over multiple years rather than the shorter time period of 12 months or less used in previous studies.