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Deciding not to eat sounds to most people the very definition of suicide. It is perhaps no surprise then that a new study concludes that when anorexics choose to take their own lives, they tend to employ some of the most lethal methods available. Yet, in many ways, the new research conducted at the University of Vermont represents a landmark shift in how doctors understand suicidal tendencies in patients suffering from anorexia nervosa.

Anorexia has the highest mortality rate of any psychiatric disorder. But psychologists previously believed that those high rates of death were due to patients' already deteriorated physical state. The hypothesis was that these are people already on the verge of death — they were so malnourished and underweight that even the slightest suicide attempt could easily lead to death.

The new study's authors have shown this assumption is wrong in most cases. Extrapolating from nine case studies of anorexics in Germany and Boston, they concluded that such suicides are not simply a call for help gone wrong, but that anorexics are genuinely determined to die when they attempt to kill themselves. Some of the disturbing means the nine patients profiled used included jumping in front of moving trains, ingesting dangerous household cleaners and setting oneself on fire. These patients also tended to isolate themselves before their suicide attempt, most likely in order to reduce the possibility they would receive life-saving help. "We established that these patients' death had little to do with their low body weight," says lead author Jill Holm-Denoma, a professor of clinical psychology at Vermont and an expert on treating eating disorders. "The methods that they chose could have killed anyone."

Holm-Denoma's work reaffirms, among many others, a 2003 Harvard University study that concluded anorexic women are, by nature of their illness, self-destructive, leading them to have a likelier propensity toward suicide as well as alcohol abuse. That study of about 250 women suffering eating disorders showed the risk of death by suicide among by anorexic women to be as much as 57 times the expected rate of a healthy woman. Research on suicide in 2006 by psychologist Thomas Joiner at Florida State University took those conclusions one step further and suggested anorexics habituate to pain, making them fearless of death, and thus more likely choose a more lethal means to end their lives. Holm-Denoma's research, however, is one of the first studies of the specific methods that suicidal anoxerics use. The gruesome methods they chose as well as how they isolated themselves from rescue, Holm-Denoma says, leaves little doubt that they wished to die.

The new findings, to be published this spring in the Journal of Affective Disorders, come during this year's National Eating Disorder Awareness Week. As many as 10 million women and one million men in the United States suffer from an eating disorder such as anorexia or bulimia, according to the National Eating Disorder Association (NEDA). Females between the ages of 15 and 24 are 12 times more likely to die from anorexia than all other causes of death, the NEDA reports. And suicide is the primary cause of death for anorexics, greater even than starvation. Holm-Denoma stresses her research highlights how seriously treatment providers must take suicide risks amongst those suffering from eating disorders. "The likelihood of whether a patient wants to lethally hurt herself must be assessed right away," Holm-Denoma says, adding, "Addressing psychiatric needs must be paramount."

For the families of anorexics, Holm-Denoma's research only affirms their worst fears. One of the biggest frustrations these families face when their loved one is diagnosed with anorexia is how they can obtain affordable psychiatric help. Insurers rarely pick up the bill. Most health plans argue that eating disorders require mental health treatment not covered by most policies and therefore refuse to pay for long-term care. In the direst cases, health plans will often cover a brief hospitalization to stabilize a patient's weight. But once she begins to gain weight again, she will be sent home. "The biological crisis may have passed," says Barbara Anthony, a Boston-based lawyer and executive director of Health Law Advocates, an organization that aids families. "But hospitals and health plans have done little to provide these patients with the mental health care they desperately need."

Meanwhile, costs related to in-patient treatment for an eating disorder can range from $25,000 to $30,000 a month. Many families are forced to take out second mortgages or deplete savings. Such situations are tragic, Holm-Denoma says. "Anorexia is one of the most serious psychiatric diseases our society faces," she says. "Our work shows even further that more needs to be done to prevent it."

• Kathleen Kingsbury
• A study shows that suicidal anorexics go beyond their disease in search of a way to die