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Pharmacotherapy for Patients With Eating Disorders

(PSYCHIATRIC TIMES) - Eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED), remain one of the most complex and clinically challenging groups of mental disorders in our nomenclature. There are no easy solutions, and the bottom line of this article is that pharmacological agents are not the primary treatment of choice. Although a number of agents have been found in randomized controlled trials to be beneficial, they are by and large insufficient as stand-alone treatments. Space does not allow a comprehensive overview of this topic, but the reader is referred to a recent review by Steinglass and Walsh (2004). In addition, the revised American Psychiatric Association practice guidelines for the treatment of eating disorders (APA, 2000) and the recently released National Institute of Clinical Excellence (NICE) Guidelines (2004) are useful resources regarding the use of drug therapy within the context of a comprehensive treatment approach.

Anorexia Nervosa

No pharmacological agents have ever been shown in double-blind, placebo-controlled trials to significantly improve AN when given outside a structured, inpatient program. Food remains the "drug of choice" for this population, for reasons that will be elaborated below. Of course, administering food in the interest of weight restoration is much easier said than done, given the profound denial and resistance typical of this disorder. There are a handful of drugs found to be statistically better than placebo in randomized controlled trials, but there is little clinical significance of these findings. Lithium (Eskalith, Lithobid) was shown in one controlled trial to be statistically better than placebo in a small group of patients being treated at the National Institute of Mental Health on an intensive, highly structured, specialized treatment unit (Gross et al., 1981). However, the effect was small, and eating disorder specialists generally deem the potential risks of lithium treatment in this population to be far greater than the possible benefits, largely due to the danger of lithium toxicity secondary to dehydration and electrolyte imbalances from starvation, compulsive exercising and/or purging. Another study found amitriptyline (Elavil) statistically better than placebo for patients who are both bulimic and anorexic, while cyproheptadine (Periactin) was better for restricting anorexia (Halmi et al., 1986). However, other studies have had mixed results.

Although the use of antidepressant medications in AN seems theoretically sound, the results from randomized controlled trials have been dismal. In addition, the cardiac effects of tricyclic antidepressants include prolongation of the QTC interval, which can already be prolonged in patients with AN, a setup for sudden death. Selective serotonin reuptake inhibitors might seem applicable given their safety profile and usefulness in major depression and obsessive-compulsive disorder, as well as the profound central serotonergic disturbances reported in AN (Brewerton, 1995; Brewerton and Jimerson, 1996). Fluoxetine (Prozac) has been shown to have absolutely no effect on weight, body image, anxiety or mood in low-weight patients with AN (Attia et al., 1998). However, once patients are weight-recovered, one controlled trial indicated that relapse (which is common) can be significantly reduced with fluoxetine in comparison to placebo, presumably due to its antiobsessional effects (Kaye et al., 2001).

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