Medication for Treating Eating Disorders

The Psychiatrist's Role And Medication

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Frustrated researchers became excited when studies on bulimia nervosa indicated that it may be closely related to mood disorders, particularly depression. Some researchers reported that as many as 80 percent of the bulimic patients studied had major mood disorders at some point during their lives. There was also a high incidence in their family histories. This led to the argument that heredity and genetics play a major role in depression and bulimia nervosa and that both could be the result of the same type of biological disorder that runs in families. Further convincing evidence showed up in the treatment response, since a high percentage of bulimics responded positively to antidepressant medication even when not depressed.

The use of pharmacological agents in the treatment of eating disorders is undergoing increasing exploration and research and will most likely be a continuing factor in the treatment of a variety of eating disorder components. However, when reviewing studies on the effectiveness of certain medications, it is important to keep in mind that not just effectiveness but comparative effectiveness with other drugs or techniques, as well as side effects, must be considered.

For example, studies using fluoxetine (Prozac) with bulimia nervosa have shown a high degree of effectiveness; however, cognitive behavioral therapy shows a greater degree of effectiveness with fewer side effects and longer-lasting results! Most experts and treatment programs tend to use a combination of the two. Additionally, medications that can cause weight gain, such as clomipramine (Anafranil), used for obsessive-compulsive disorder, or lithium, used for manic depression, may backfire when the individual becomes even more restrictive with eating, loses trust, and becomes noncompliant with the medication.

Other medications, such as naltrexone (Trexan), an opiate antagonist that eliminates the euphoric effects of opioids used with addicts and alcoholics to curb cravings and reduce the beneficial "high" they get from their drugs, have shown promise in the treatment of eating disorders, especially anorexia nervosa. Controlled studies are now under way. Medications used to influence hunger and satiety have been ineffective overall in treating anorexia nervosa and bulimia nervosa, partly due to side effects.

As far as treating cognitive behavioral disturbances, there are certain drugs that can help improve thought processes and clear thinking. These include a wide variety, ranging from antianxiety agents, such as lorazepam (Ativan), to medicine for attention deficit hyperactivity disorder, such as methylphenidate (Ritalin), to antipsychotic (also known as neuroleptic) medications for hallucinations or delusional thinking such as risperdone (Risperdal) or haloperidol (Haldol).

Various medications such as neuroleptics or antianxiety agents are used to reduce sensitivity to stress and resultant anxiety, such as klonazepam (Klonopin) and lorazepam (Ativan). These can work well in the short term for general anxiety, provide immediate relief, and may have some usefulness as premeal agents to alleviate distress associated with eating. However, these agents do not successfully treat the core issues of an eating disorder and are usually best used in conjunction with antidepressants, which also reduce anxiety and sensitivity to stress, and are the preferred drug treatment.

The role of medication in preventing relapse has become increasingly more interesting and promising with information from the newest studies, particularly those involving anorexia nervosa, which will be discussed below. The following material will summarize the current information on the use of medication in treating various eating disorders.

The Meaning of Medicine

Aside from the possible direct beneficial and adverse effects of medication of any kind, there is the important issue of what taking medication means or symbolizes to any given individual. The act of taking mind-altering medication symbolizes different things to different people, but commonly it means that "I'm sick" or "defective" or "imperfect" or "bad" or "crazy" or "out of control."

Since issues of control and self-worth are already predominant in people with eating disorders, often this becomes an obstacle to effective treatment, particularly in cases with significant coexisting problems, and even in cases in which medications have clearly proved effective. When patients with eating disorders begin to feel better, they frequently want to stop the medicine(s) when it may be an important reason why they are better.

This only ends up contributing to the already high relapse rate in eating and related disorders. Patients need help in understanding that medication is best thought of as a powerful tool that a person with an eating disorder can choose to use in the struggle for full recovery.

Anorexia Nervosa and Medication

Despite what many think, anorexia nervosa has so far been shown to be relatively resistant to treatment with drugs. Many medicines have been tried for various reasons, with a report here and there about the effectiveness of a certain medicine in certain cases, but overall none has been shown in controlled studies to have any particular effectiveness with the core issues of anorexia nervosa. Even tetrahydrocannabinol (marijuana) was clinically tried in hopes of stimulating appetite (causing the "munchies") but it produced only unhappy moods instead.

An encouraging study was reported by Dr. Walter Kaye at the International Association of Eating Disorder Professionals conference in August 1995. The breakthrough was discovered in a placebo-controlled medication trial of fluoxetine (Prozac) with anorexics. Prozac, and less so setraline (Zoloft), fluvexamine (Luvox), and paroxetine (Paxil), are the most commonly known of the group of antidepressants referred to as selective serotonin reuptake inhibitors (SSRIs). Until recently even these medications, the drugs of choice for the treatment of bulimia nervosa, showed no efficacy with anorexia nervosa.

However, according to Walter Kaye, fluoxetine (Prozac) did show significant results in anorexia, but with a crucial difference in how it was used. When administered after nutritional rehabilitation and weight restoration, fluoxetine showed significant advantages over a placebo in preventing the all-too-common relapse. This appears to work by the drug's causing a significant reduction in obsessions and compulsions related to food and body image. More research needs to be done, but for now it seems that initially behavioral and nutritional therapy should be the foundation of treatment for anorexia nervosa, with the use of fluoxetine and perhaps even other SSRIs as an adjunct to prevent relapse once weight gain has been achieved.

Bulimia Nervosa and Medication

The use of psychotropic agents in treating bulimia nervosa has been much more promising than in treating anorexia nervosa. Most drug trials have been with antidepressants, particularly the newer SSRIs, which have shown significantly greater improvement in binge/purge frequency compared to placebo. Antidepressant medication doesn't work for everyone; some patients (about 20 to 33 percent) have complete remission of symptoms, and others have significant reductions in bingeing and purging behaviors.

The class of antidepressants known as the SSRIs, discussed above, such as Prozac, Zoloft, and so on, are the newer versions of antidepressants since the original tricyclics and MAOIs (mono-amine oxidase inhibitors). Tricyclics such as desiprimine and imipramine showed effectiveness but had many side effects, such as weight gain, which were not well tolerated by eating disordered patients. Amitriptyline (Elavil) was studied but was no better than placebo.

Additionally, tricyclic overdose is the third leading cause of death in emergency rooms and, as such, is extremely dangerous in depressed patients, the very ones it most effectively treats. The lethality of tricyclic overdose is only enhanced by the medical effects of eating disorders, especially lowered potassium in the body (hypokalemia).

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The MAOIs such as tranylcypromine (Parnate) and phenelzine (Nardil) show efficacy in reducing bulimic symptoms. However, individuals taking MAOIs must be on a very restrictive low tyrosine (an amino acid) diet that, if broken, can cause a hypertensive crisis (very high blood pressure, possibly resulting in serious side effects such as stroke or death). Of the SSRIs, only Prozac has really been shown to decrease bulimic symptoms such as poor regulation of hunger and satiety, sensitivity to stress, and obsessive thinking and behavior, without undue side effects. For more information on SSRIs and their side effects, refer to the section on page 222 that describes the psychotropic medications most commonly used in eating disorders.

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By Carolyn Costin, MA, M.Ed., MFCC - Medical Reference from "The Eating Disorders Sourcebook"

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