The growing rate of depressive disorders causes needs for more effective and more innovative solutions. The modern patients’ challenges make them fail mostly in the treatment compliance. Some reports have described that escitalopram orally disintegrating tablets (ODT) induce faster response and lower dropout rate than oral standard tablets (OST), although both forms have equal bioavailability.

We tried to clarify effectiveness rates between escitalopram ODT and OST treatments in depressive patients.

An open-label, 6-month, randomized, flexible-dose study was conducted for direct comparison of the effects of escitalopram ODT (N16) and OST (N15) on dropout rate and clinical outcomes in patients with major depression.

Outcome measures included Hamilton Depression Rating Scale (HDRS), Drug Attitude Inventory-10 (DAI), Clinical Global Improvement Scale (CGI), and Psychological General Well-Being Scale (PGWB). The tolerability was assessed by the UKU scale. No significant difference was found in HDRS, CGI, PGWB and GAF between the two forms of tablets. No significant difference was found in any tolerability rates. However, dropout rate favored escitalopram ODT group (N5, 31.3%) vs escitalopram OST (N7, 47.0%). DAI-10 outcomes, both in patients’ general attitude and subjective feelings, were significantly improved in ODT group (P = 0.000), comparing with OST.

Escitalopram in its classical form (OST) has become a leader in a group of antidepressants, thanks to safety of use, efficacy and tolerability. In the ODT form, escitalopram can meet additional needs, both clinical and lifestyle. ODT may reduce dropout rate and costs of long-term treatment improving the patients’ compliance.

The authors have not supplied their declaration of competing interest.

Depression is a complex disease associated with sleep, appetite and body weight disturbances as well as with the level of physical activity, all of which may be the risk factors for the development of metabolic disorders. Different physiological mechanisms as well as psychosocial factors such as gender, age, smoking, stress level, nutrition and level of physical activity can affect the metabolic syndrome (MS) development in depressed patients. It is considered that chronic stress causes depression and subsequent poor lifestyle that can lead to the MS development, which results in increased incidence of cardiovascular disease.

To determine the psychosocial and clinical characteristics of depressed patients with MS diagnosis.

Cross-sectional study was conducted on a sample of 80 patients suffering from depressive disorder. The structured socio-demographic questionnaire, MINI questionnaire, Hamilton Rating Scale for Depression (HAMD-17) and the Clinical Global Impression Scale (CGI) were used as diagnostic instruments. MS diagnosis was made according to NCEP/ATP III criteria.

Depressive patients with MS diagnosis had a significantly higher frequency of suicide attempts, while MS diagnosis significantly more frequently was present in female patients. Increased intake of carbohydrates was an important characteristic of the depression as well as MS.

Further studies are needed in order to explain the observed gender differences, and whether interventions focused on the treatment of depression may contribute to the acceptance of healthy lifestyles, particularly in changing of dietary habits, and thus indirectly contribute to the reduction of MS frequency.

The authors have not supplied their declaration of competing interest.

For most individuals, basic life requirements are met through employment. It can satisfy creative urges, promote self-esteem, and provide an avenue for achievement and self-realization.

To assess the level of depression, anxiety and self-esteem in a population of unemployed persons.

It was a cross-sectional study involving unemployed people we met in the office of employment of Sfax in Tunisia. The level of anxiety and depression was assessed by the Beck depression and anxiety inventories. The self-esteem Rosenberg scale allowed us to evaluate the level of self-esteem of our population.

The average age of oursubjects was 33 years six months. The average duration of unemployment of our population was 4 years 7 months and 38.2% of them had never worked before. The anxiety level was moderate in 38.2%, while moderate to severe depression was found in 47%. Self-esteem was low to very low in 47.1%. A low level of depression was positively correlated with a low socioeconomic level (P = 0.000), a low level of anxiety (P = 0.000) and a high self-esteem level (P = 0.000).

People with strong support systems and greater self-esteem seemed to experience less unemployment stress. Identifying those who are at high risk for psychological and physical problems and finding ways of preventing them from suffering the adverse effect of unemployment are important areas for further study.

The authors have not supplied their declaration of competing interest.

Apathy is a transnosographical symptom that is often described in psychiatric and neurological illness. The most known definition, proposed by Marin (1991), is a lack of goal-directed voluntary behavior. Apathy and depression may be present together but they are clinically independent. The confusion between signs of apathy and those of depression might reveal diagnostic and treatment issue. Our aim is to define a clinical profile of apathetic patients (Ap) with depression, hypothesizing there is a different clinic profile than non-apathetic patients (NAp).

Seventy adults diagnosed with depression were included in a comparative, non-randomized and open cohort, since November 2014. Clinical assessments targeted clinical scale evaluations (MINI, AES, MADRS, STAI, SHAPS). Patients were separated in two groups, Ap VS NAp, using a 42 points cut-off at AES score.

Ap represent 30%; n(Ap)= 21, n(NAp)= 49. Depressive severity scores (MADRS) are lower in the Ap group; W-test= 672, P= 0,044. State anxiety scores (STAI-A) are lower in Ap group; W-test= 739, P = 0,004. Anhedonia scores (SHAPS) are lower in Ap group; W-test= 412, P= 0,004. Pearson test show negative correlation between AES/STAI-A (r = -0,27; P= 0,02); AES/SHAPS (r= -0,45; P= 0,001).

Apathetic patients suffering from depression seem to present different clinical pattern in term of anxiety and anhedonia. These results are high of interest for therapeutic and further studies focus on pathophysiological issues.

The author has not supplied his/her declaration of competing interest.

Major depressive disorder (MDD) is a chronic mental illness with a considerable lifetime prevalence in adult men and women. Only a third of MDD patients remit following adequate antidepressant treatment, while most suffer from significant core depressive or residual symptoms during their clinical course. Augmentation treatment with second-generation antipsychotics (SGAs) has been one of the suggested approaches to overcome this shortage of efficacy of antidepressant therapy.

To review the role of SGAs as an augmentation strategy to antidepressant therapy in MDD.

A search of the MEDLINE/Pubmed database was conducted for articles from 2010 to 2015, using the MeSH terms “antypsichotics”, “depression” and “treatment”.

There is a general consensus in the literature that antidepressant augmentation treatment with SGAs is more effective than placebo in the management of patients with MDD who failed to respond adequately to antidepressant therapy alone. The majority of studies found no significant differences between the different studied drugs (namely, aripiprazole, quetiapine, olanzapine and risperidone). On the other hand, discontinuation rates due to adverse effects are also higher with SGAs versus placebo. However, it remains unclear if augmentation with SGAs is more effective than other therapeutic strategies, such as combination or switching to other antidepressant or augmentation with other psychotropics.

There is strong evidence that SGAs augmentation is an effective and generally safe therapeutic approach to patients with MDD who respond poorly to antidepressants. Nevertheless, more studies are needed to understand the efficacy of this treatment comparing other therapeutic approaches.

The authors have not supplied their declaration of competing interest.

Hyponatremia is one of the electrolytic disorders most comonly observed among general hospitalized populations (2% of hospitalized patients). A form of hyponatremia is the syndrome of inappropriate antidiuretic hormone secrection (SIADH). One of its diverse causes is medication. Selective serotonine reuptake inhibitors (ISRSs) can cause hyponatremia due to SIADH, particularly among elderly population.

A 81-year-old female treated with paroxetine 20 mg/day because of depression. Two weeks later she starts feeling nausea, somnolence and motor inhibition. The sodium level previous to the onset of treatment was normal but after two weeks it has decreased to 121 mEq/L, pointing to SIADH induced by ISRSs.

The incidence of hyponatremia among elderly patients treated with antidepressants of ISRSs class has increased. The prevalence varies between 0.5 and 25%. Although half of the patients are asymptomatic, the mortality is rate may reach 25%. It generally develops during the first month of treatment and is reversible between 2 and 28 days after the suspension of the ISRSs.

The authors have not supplied their declaration of competing interest.

It has been suggested that neuroinflammation and inflammatory mediators may play a crucial role in the pathophysiology of both major depression and suicidal behavior. Immunological differences have been reported between both subjects with major affective disorders and suicidal behavior.

The main objective of this review was to deeply investigate the nature of the association between inflammatory cytokines in depression and suicidal behavior. Aims: The study aimed to conduct a systematic review of the current literature to investigate the association between inflammatory cytokines, depression, and suicidal behavior.

Generally, an imbalance between pro-inflammatory and anti-inflammatory cytokines has been documented in both major depression and suicidal behavior. The presence of major depressive disorder (MDD) with suicidal ideation/attempts was associated with differences in inflammatory cytokine profile when compared to that without suicidal ideation/attempts. However, not all studies demonstrated a positive correlation between inflammatory cytokines and suicidal behavior.

The mentioned association between inflammatory cytokines, depression, and suicidal behavior does not imply the existence of a causal relationship. Further additional studies should clarify the molecular mechanisms of the immune activation pathways underlying depression and suicidality.

The authors have not supplied their declaration of competing interest.

In the last decades, multiple studies have suggested evidences of disturbances within the glutamate system in depressed patients. The first clinical study using ketamine in depression treatment was conduct fifteen years ago. Since then several studies tried to understand the mechanisms underlying the antidepressant effects of ketamine, as well as discover new drugs with better pharmacodynamic profiles.

Review the literature on the role of glutamate system in depression and novel approaches with glutamate N–methyl–D–aspartate receptor antagonists in depression.

Search and review of scientific literature on PubMed database with the keywords.

“major depressive disorder”, “depression”, “ketamine”, “glutamate”, “NMDA”, “neuroplasticity”.

Abnormalities of the glutamate clearance at synaptic space and astrocytic dysfunction associated with glutamate metabolism have been associated with depressive symptomatology. In depressed patients, reduced levels of glutamate have been described by magnetic resonance spectroscopy in multiple cortical areas, amygdala and hippocampus, supportting the hypothesis of glutamate system involvement in the neurobiology of depression. Indeed, in the last 15 years, multiple clinical studies using ketamine provided some evidence that glutamate N–methyl–D–aspartate receptor antagonism could be an approach for refractory forms of depression. However, regardless all of the evidences, no drug targeting specifically the glutamate system has been approved for depression treatment.

The glutaminergic system plays a role in the pathophysiology of depression, why it's a possible therapeutic target. So, it's of utmost importance that future studies keep the focus in this area, looking for new drugs active in this system.

The authors have not supplied their declaration of competing interest.

The last years it is became clear that disturbances in molecular processes in pathological conditions can be connected with conformational changes in protein structure.

Investigation of blood albumin conformation in patients with melancholic depression.

There were investigated 19 patients with melancholic depression (12 women and 7 men) and 25 health volunteers. Patient's state according to ICD-10 criteria was defined as a depressive episode in the frame of bipolar depressive disorder (type 2) (F32) and in the structure of recurrent depressive disorder (F33). Subnanosecond laser time resolved fluorescence spectroscopy (SLTRFS) (subnanosecond diapason) with K-35 fluorescent probe was used for the investigation of albumin conformation.

There were revealed 3 binding sites in albumin molecule with fluorescent decay time of 1, 3 and 9 nanoseconds (A1, A3 and A9 sites, respectively) in healthy volunteers using SLTRFS approach. There were found significant differences between albumin binding sites of volunteers and patients with melancholic depression, respectively, А1–117 ± 7 и 142 ± 10; А3–358 ± 14 и 420 ± 26; А9–371 ± 16 и 433 ± 29.

These findings point out that melancholic depression is followed by conformational changes of albumin molecule that can affect its functional properties. We can hypothesized that albumin binding properties can serve as a biomarker of the efficacy of psychopharmacotherapy.

The authors have not supplied their declaration of competing interest.

Adjustment disorder (AD) is a condition that includes both emotional or/and behavioral symptoms and occurs when individual is unable to cope with stress. It is a common diagnosis but few studies have been done due to controversial diagnosis related to their diagnostic criteria definition. It is often difficult to establish differential diagnosis with condition such as depressive and anxiety disorders or even normal reaction to stressful situations. There are limited tools to evaluate such condition and its definition is focused or based on lack of severity.

Study objective target is to analyse the differences between two groups, a first group with AD and another one with Major Depressive Disorder (MDD) (with different sociodemographic, clinical and triggering individual factors such as vulnerability or copying management).

We try to have a better comprehension and management of depressive conditions.

Two groups that belongs to Mental Health Community Team are compared. The first one with a diagnosis of AD, and another group with the diagnosis of MD. They have been diagnosed through a structured clinical interview and standard questionnaires to evaluate personality copying management. Other pathologies (such as psychotic, organic,…) were excluded through a structured clinical interview. We analyzed variables considered through variance analysis.

Significant differences between groups were found in some of the variables considered.

This study have important implications regarding evaluation, differential diagnosis and psychotherapeutic approach to patients with AD and MD.

The authors have not supplied their declaration of competing interest.

The author has not supplied his/her declaration of competing interest.

Some temperament characteristics of personality seem to be modulated by oxytocin. Patients suffering from eating disorders (EDs) display aberrant personality traits.

We investigated the relationships between plasma oxytocin levels and personality dimensions of patients with anorexia nervosa (AN) and bulimia nervosa (BN) and compared them to those of healthy controls.

Plasma oxytocin levels were measured in 23 women with AN, 27 women with BN and 19 healthy controls and assessed their personality traits by means of the Cloninger's Temperament and Character Inventory-Revised (TCI-R).

AN patients showed plasma levels of the hormone significantly lower than BN and healthy controls. In healthy women, plasma oxytocin levels resulted significantly correlated negatively with novelty seeking scores and positively with both harm avoidance (HA) scores and the attachment subscale scores of the reward dependence: these correlations explained 82% of the variability in circulating oxytocin. In BN patients, plasma oxytocin resulted negatively correlated with HA, whereas no significant correlations emerged in AN patients.

These findings confirm a dysregulation of oxytocin secretion in AN but not in BN and show, for the first time, that the association of circulating oxytocin to patients’ temperament traits is totally lost in underweight patients with AN and partially lost or even inverted in women with BN. These findings suggest a role of oxytocin in certain deranged behaviours of ED patients, which are influenced by the subjects’ personality traits.

The authors have not supplied their declaration of competing interest.

Early life experiences can influence hypotalamus-pituitary-adrenal (HPA) axis regulation and adult attachment styles. Furthermore, several studies showed that in patients with eating disorders (EDs) there is a prevalence of insecure attachment. However, the relationship between adult attachment style, HPA axis functioning and onset of EDs is largely unknown.

In order to evaluate possible associations between attachment styles and HPA axis functioning in EDs, we investigated Cortisol Awakening Response (CAR) in ED patients with different attachment styles.

Twenty adult patients with EDs were classified in three groups, according to the Experience in Close Relationship questionnaire (6 with secure attachment, 6 with anxious attachment and 8 with avoidant attachment). Saliva samples were collected at awakening and 15, 30 and 60 minutes after.

There was a significant difference among the groups in both awakening and post-awakening cortisol concentrations. In particular, compared to secure and avoidant groups, the anxious group exhibited lower cortisol concentrations at awakening and post-awakening with a preservation of the timing of the CAR.

Present findings demonstrate that anxious attachment style is linked to flattened CAR in EDs. This pattern has been associated with other psychiatric disorders. Therefore, attachment style could influence the HPA functioning and it could play, although not specifically, a role in pathophysiology of EDs.

The authors have not supplied their declaration of competing interest.

Expressed Emotion (EE) can be described as a measure of the emotional temperature of the family climate and plays a role in disease course and outcome, especially in chronic illnesses. Overweight and obesity are severe problems with serious implications as far as health risks are concerned. The literature suggests having a high EE caregiver correlates with a worse treatment compliance in obese patients.

To measure level of EE, stressful events and anxiety in obese patients and their caregivers; to investigate the possible correlations between treatment compliance and EE.

We recruited 190 obese patients and 125 caregivers. Socio-demographic features were recorded. Assessment included: Level of Expressed Emotion Scale (LEE), one version for patients and one for relatives in order to evaluate 4 dimensions: Intrusiveness, Emotional Response, Attitude toward Disease, Tolerance and Expectation; the Paykel's Interview for Recent Life Events; STAI Y1 concerning state anxiety and STAI Y2 concerning trait anxiety; BMI (Body Mass Index) was measured at T0 and after 3,6 and 9 months.

We have found a correlation between gender and trait anxiety, and an inverse correlation between age and trait anxiety both in patients and caregivers. The decrease of BMI during follow-up is statistically significant and this reduction seems to be affected by tolerance and expectation perceived by patients and the emotional response on behalf of caregivers.

Levels of EE should be considered when planning treatment interventions to enhance compliance in obese patients and to support change in their life-style.

The authors have not supplied their declaration of competing interest.

The recently published DSM-5 defines Eating Disorders (ED) as “a persistent alteration in the food supply or food-related behavior leading to an alteration in the consumption or absorption of food and cause a significant deterioration in health or psychosocial functioning” and, nevertheless, it does not include obesity as an ED due to the lack of enough evidence to include it. However, everyday more evidence supports that disordered eating could be a significant factor, at least, in development and maintenance of obesity.

Describe the eating behavior of a 180 obese sample.

One hundred and eighty patients with obesity that went to the endocrinology service in order to lose weight are referred to the Psychiatry department to be assessed. To explore the eating behavior it was administered the Bulimic Investigatory Test of Edinburgh, BITE.

A total of 68.7% of patients showed a disordered eating pattern, 71.6% tend to eat a lot when feeling anxious, 63.8% eat rapidly large amounts of food, 72.8% worry about not to have control over how much eat, 40.5% consider that their pattern of eating severely disrupt their life, 40.7% eat sensibly in front of others and make up in private, 59.1% cannot stop eating when they want to and 58.3% admit binges of large amounts of food.

Most of our patients showed a pattern of disordered eating, and then our findings support the idea of disordered eating as a significant factor in the development and maintenance of obesity. Therefore, obesity requires a multidisciplinary approach that goes beyond the traditional nutritional guidance.

The authors have not supplied their declaration of competing interest.

Binge eating disorder (BED) is prevalent, associated with obesity and elevated psychiatric co-morbidity, and represents a treatment challenge.

A controlled comparison of multi-modal, stepped-care versus behavioral-weight-loss (BWL) for BED.

One hundred and ninety-one patients (71% female, 79% white) with BED and co-morbid obesity (mean BMI 39) were randomly assigned to 6 months of BWL (n = 39) or stepped-care (n = 152). Within stepped-care, patients started BWL for one month; treatment-responders continued BWL while non-responders switched to cognitive-behavioral-therapy (CBT) and all stepped-care patients were additionally randomized to anti-obesity medication or placebo (double-blind) for five months. Independent assessments were performed by research-clinicians at baseline, throughout treatment, and post-treatment (90% assessed) with reliably-administered structured interviews.

Intent-to-treat analyses of remission rates (0 binges/month) revealed BWL and stepped-care did not differ significantly overall (74% vs 64%); within stepped-care, remission rates differed (range 40% - 79%) with medication significantly superior to placebo (P < 0.005) and among initial non-responders switched to CBT (P < 0.002). Mixed-models analyses of binge eating frequency revealed significant time effects but BWL and stepped-care did not differ overall; within stepped-care, medication was significantly superior to placebo overall and among initial non-responders switched to CBT. Mixed models revealed significant weight-loss but BWL and stepped-care did not differ overall; within stepped-care, medication was significantly superior to placebo overall and among both initial responders continued on BWL and non-responders switched to CBT.

Overall, BWL and stepped-care treatments produced improvements in binge-eating and weight loss in obese BED patients. Anti-obesity medication enhanced outcomes within a stepped-care model.

The author has not supplied his/her declaration of competing interest.

Binge-eating disorder (BED) is associated with obesity and with elevated rates of co-occurring major depressive disorder (MDD) but the significance of the diagnostic comorbidity is ambiguous—as is the significance of the onset sequence for MDD and BED.

We compared eating-disorder psychopathology and psychiatric comorbidity in three subgroups of BED patients: those in whom onset of BED preceded onset of MDD, those with onset of MDD prior to onset of BED, and those without MDD or any psychiatric comorbidity.

A consecutive series of 731 treatment-seeking patients meeting DSM-IV-TR research criteria for BED were assessed reliably by doctoral-clinicians with semi-structured interviews to evaluate lifetime psychiatric disorders (SCID-I/P) and ED psychopathology (EDE Interview).

Based on SCID-I/P, 191 (26%) patients had onset of BED preceding onset of MDD, 114 (16%) had onset of MDD preceding onset of BED, and 426 (58%) had BED without co-occurring disorders. Three groups did not differ with respect to age, ethnicity, or education, but a greater proportion of the group without MDD was male. Three groups did not differ in body-mass-index or binge-eating frequency, but groups differed significantly with respect to eating-disorder psychopathology, with both MDD groups having significantly higher levels than the group without co-occurring disorders. The group having earlier onset of MDD had elevated rates of anxiety disorders compared to the group having earlier onset of BED.

MDD in combination with BED—with either order of onset—has a meaningful adverse effect on ED psychopathology and overall psychiatric co-morbidity.

The authors have not supplied their declaration of competing interest.

Monitoring patient with anorexia nervosa (AN) include clinical, biological and psychological factors. In recent years many researchers criticize the BMI as useful measure for controlling evolution of AN.

Bioelectrical impedance analysis (BIA) is one of the main methods for nutritional status assessment.

The aim of this study was the assessment of the nutrition status in a group of patients with anorexia nervosa in comparison to healthy population (HP).

The study involved 37 participants: 21 patients with AN and 16 healthy volunteers constituting the control group (HP). The patients were divided into two groups according a BMI: I group 14 < BMI < 15,5 (n = 11; age 18.0 ± 4.37) and II group: 15,5 < BMI < 17,5 (n = 10; age 17.82 ± 3.68). The mean age of HP was 17.68 ± 1.57 and BMI 20.56 ± 1.16 kg/m2. BIA was performed by using ImpediMed bioimpedance analysis SFB7 BioImp. The parameters: phase angle (PA), TBW%, ECW, ICW, ECW/ICW were analyzed.

PA was decreased significantly in the I (4.5°±0,6) and II group (4.7°±0,6) of AN patients’ in comparison with HP (5.6°±0,7). TBW was 9% higher in I group and ECW was increased 6% in the both AN groups compared with HP (P < 0.01). Additionally ECW/ICW ratio indicated the higher transfer of water into the extracellular compartment in AN group (P < 0.01).

BIA is accurate tool to indicate the valuable indicators of detecting malnutrition in AN. Further studies are needed to validate the significance of these parameters for the full identification of the nutrition status of AN patients’.

The authors have not supplied their declaration of competing interest.

Anorexia Nervosa (AN) is an important cause of morbidity and mortality in hospitalized patients. While AN has been extensively studied in the past, the contemporary data for impact of AN on cost of hospitalization are largely lacking.

We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (HCUP-NIS) dataset between 1998-2011 using the ICD-9 codes for AN. Severity of co-morbid conditions was defined by Deyo modification of Charlson co-morbidity index. Primary outcome was in-hospital mortality and secondary outcome was total charges for hospitalization. Using SAS 9.2, chi-square test, t-test and Cochran-Armitage test were used to test significance.

28,150 patients were analyzed. 93.94% were female and 6.06% were male (P < 0.0001). 88.67% were white, 2.93% were black and 8.4% were of other race (P < 0.0001). Rate of hospitalization decreased from 1530/million to 1349.5/million from 1998-2011. Overall mortality was 0.78% and mean cost of hospitalization was 25,829.82$. The in-hospital mortality reduced from 0.95% to 0.44% (P < 0.0001) and mean cost of hospitalization increased from 11,956.55$ to 39,831.51$. Total yearly spending on AN related admissions increased from $145.33 million/year to $420.61 million/year.

While mortality has slightly decreased from 1998 to 2011, the cost has significantly increased from $145.33 million/year to $420.61 million/year, which leads to an estimated $275.28 million additional burden to the US health care system. In the era of cost conscious care, preventing AN related Hospitalization could save billions of dollars every year. Focused efforts are needed to establish preventive measures for AN related hospitalization.

The authors have not supplied their declaration of competing interest.

Bulimia Nervosa (BN) is an important cause of morbidity and mortality in hospitalized patients. While BN has been extensively studied in the past, the contemporary data for impact of BN on cost of hospitalization are largely lacking.

We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (HCUP-NIS) dataset between 1998-2011 using the ICD-9 codes. Severity of co-morbid conditions was defined by Deyo modification of Charlson co-morbidity index. Primary outcome was in-hospital mortality and secondary outcome was total charges for hospitalization. Using SAS 9.2, chi-square test, t-test and Cochran-Armitage test were used to test significance.

19,441 patients were analyzed. 94.13% were female and 5.87% male (P < 0.0001). 85.72% were white, 4.55% black and 9.73% of other race (P < 0.0001). Rate of hospitalization decreased from 1136.99/million to 802.47/million from 1998-2011. Overall mortality was 0.20% and mean cost of hospitalization was 15,496.82$. The in-hospital mortality reduced from 0.23% to 0.15% (P < 0.0001) and mean cost of hospitalization increased from 8,194.53$ to 22,547.86$. Total spending on BN related admissions have increased from $73.96 million/year to $139.93 million/year over the last decade.

While mortality has slightly decreased from 1998 to 2011, the cost has significantly increased from $73.96 million/year to $139.93 million/year, which leads to an estimated $65.97 million/year additional burden to US health care system. In the era of cost conscious care, preventing BN related Hospitalization could save billions of dollars every year. Focused efforts are needed to establish preventive measures for BN related hospitalization.

The authors have not supplied their declaration of competing interest.