It’s the perfect storm’: Why are people with eating disorders at risk of suicide? A qualitative study

Aims: Eating disorders (EDs) are associated with elevated all-cause mortality, with suicide cited as the second leading cause of death among individuals with EDs. Evidence suggests that individuals with anorexia nervosa are 18 times, and those with bulimia nervosa seven times more likely to die by suicide, relative to gender- and aged-matched comparison groups. Limited research has focused on why people with EDs experience such high rates of suicidality. The study aims to gather perspectives from people with lived experience of any ED and clinicians working with EDs to understand suicidality among people with EDs. Methods: Using a qualitative design, we conducted semi-structured interviews with people with lived experience of an ED (n=30), and clinicians who work with people with EDs (n=19). Participants with lived experience presented with a range of ED. Clinicians worked across a range of service settings as well as adolescent and adult services. We used a multi-perspective reflexive thematic analysis to code the data and develop the themes. Results: Key themes identified include ‘I don’t want to live like this - the burden and impact of having an eating disorder’, ‘Eating disorders don’t stand in isolation - comorbidity and complexity’, ‘There’s a dark side to recovery - recovery as a risk factor’, ‘Suicide isn’t talked about… I felt alone and weird - silence, isolation and stigma’, and 'The only risk they see is weight: suicide as overlooked within services’. These findings underscore the complex and multifaceted reasons why people with EDs are at risk of suicide, acknowledging the unique risk factors associated with the illness itself as well as the various risk periods that affect those with EDs.Conclusion: These findings provide insight into key mechanisms underlying the association between EDs and suicidality. Results are novel and are currently not accounted for within current theoretical models of suicide. As such, these findings are early evidence to help us develop a new theory of suicidality for people with EDs, as well as potential intervention targets.