Medication Choices to Assist in the Treatment of Eating Disorders

A psychiatrist can be an important component of the eating disorder treatment team. Eating disorders are brain-based disorders and often co-occur with other disorders. A study posted on NEDA’s (National Eating Disorders Association) website looked at 2400 people hospitalized for an eating disorder and found that 97% had at least one co-occurring condition, including:

  • 94% had co-occurring mood disorders, mainly major depression
  • 56% had been diagnosed with anxiety disorders
  • 20% had obsessive-compulsive disorder
  • 22% had post-traumatic stress disorder
  • 22% had a substance or alcohol use disorder

Additionally, it is well documented that suicide is a significant concern in the eating disorder population, especially with Anorexia Nervosa. According to the National Institute of Mental Health (NIMH), many young women and men with Anorexia Nervosa die of suicide. In women, suicide is much more common in those with Anorexia Nervosa than with most other mental disorders (1).

Due to the prevalence and severity of co-occurring illnesses in individuals with eating disorders, a psychiatric evaluation can help determine the correct treatment plan to address the presenting problems most effectively.

There are many different classes of medications to be considered. However, there are only two medications that the U.S. Food and Drug Administration (FDA) has approved for eating disorders: Prozac (fluoxetine) for Bulimia Nervosa and Vyvanse (lisdexamfetamine) for Binge Eating Disorder.

It is worth noting that Wellbutrin (bupropion) is not recommended for use in patients diagnosed with Anorexia Nervosa or Bulimia Nervosa due to lowering the seizure threshold in individuals who purge or restrict their daily dietary intake.

Anorexia Nervosa

Pharmacotherapy (medication treatment) is not an initial or primary treatment for Anorexia Nervosa. Various psychotherapy modalities (i.e. Cognitive Behavioral Therapy, Family-Based Therapy, etc) have far more supportive evidence. No medication has yet been FDA-approved for the treatment of Anorexia Nervosa. Studies show that antidepressants were no more effective for weight gain than placebo. Three trials studied tricyclic antidepressants, while the fourth studied the selective serotonin reuptake inhibitor, Prozac (2,3,4,5).

Remeron (mirtazapine), which has not been studied in trials with Anorexia Nervosa, is often used in patients with Anorexia Nervosa (especially if there is co-occurring depression or anxiety) due to its ability to help with sleep and increase appetite, thereby potentially increasing weight gain.

Additionally, antidepressants are helpful in treating Major Depressive Disorder and anxiety disorders that are often present in Anorexia Nervosa. Focusing on stabilizing an individual’s mood is an important aspect of that individual’s treatment outcomes.

A key point to remember about pharmacotherapy and eating disorders is that the individual must have improved nutritional status for medications to work. In a fasting or malnutrition state, the individual is not producing neurotransmitters (i.e. serotonin, norepinephrine, dopamine) at a level where there can be maximum therapeutic benefit. Medications are less effective until re-feeding has taken place.

Some antipsychotic medications have been used to increase weight gain and help stabilize mood in individuals focused on weight restoration. Studies of the drug, Zyprexa (olanzapine) suggest a marginal benefit. Studies compared Zyprexa (olanzapine) with placebo in 94 patients and found that the change in body mass index was greater with olanzapine than placebo; however, the difference was not proven to be from the medication alone (6). There is little evidence that other second-generation antipsychotics such as Risperdal (risperidone), Seroquel (quetiapine), and Abilify (aripiprazole) help restore weight in patients with Anorexia Nervosa.

Due to the appetite suppressant effects of psychostimulants (i.e. Adderall, Ritalin, Vyvanse), it is often recommended to limit their use with patients who have co-occurring ADHD and Anorexia Nervosa.

Bulimia Nervosa

One of the most effective treatments for Bulimia Nervosa is Cognitive Behavioral Therapy for eating disorders (CBT-E) due to the focus being on regular and structured eating. The primary goal of treatment for Bulimia Nervosa is stopping the bingeing and purging. Psychiatric medications have also shown to be helpful in the treatment of Bulimia Nervosa.

Prozac (a Selective Serotonin Reuptake Inhibitor) is the only antidepressant approved for Bulimia Nervosa. One study compared two doses of Prozac (fluoxetine) with placebo in 387 patients with BN for eight weeks and found that the frequency of vomiting episodes decreased significantly more in patients who received fluoxetine 60 mg per day, compared with either fluoxetine 20 mg or placebo (7). Additionally, even though Prozac (fluoxetine) is the only FDA approved medication for Bulimia Nervosa, evidence for the efficacy of other SSRIs exist. Trials suggest that Zoloft (sertraline) and Luvox (fluvoxamine) were significantly more efficacious than placebo in reducing the number of bingeing and purging episodes (8,9,10).

There is insignificant evidence to support antipsychotic use in Bulimia Nervosa. There are no randomized trials to evaluate the efficacy of atypical antipsychotics.

ADHD has been linked to Bulimia Nervosa. The gold standard of treatment for ADHD is psychostimulant medication (i.e. Adderall, Ritalin, Vyvanse). Symptoms of ADHD include inattention, hyperactivity, and impulsivity. It has been theorized that inattention can lead to binging and impulsivity or hyperactivity can lead to purging in someone with Bulimia Nervosa. Therefore, treating ADHD symptoms with psychostimulant medication may lead to a decrease in binging and purging found in Bulimia Nervosa (11,12,13).

Binge Eating Disorder

Although medication can be effective for treating Binge Eating Disorder, it is generally regarded as less effective than psychotherapy. Cognitive Behavioral Therapy is widely regarded as the most effective psychotherapy modality for Binge Eating Disorder. It has been more widely studied than any other treatment.

However, antidepressants can serve as adjunctive therapies to psychotherapy (“talk therapy”). Multiple studies compared SSRIs with a placebo for remission of symptoms and found a significant but clinically small advantage favoring SSRIs over other medications (14). Binge episodes can be triggered by restriction, emotional eating, obsessional thinking, or depressed and anxious moods. SSRI’s help stabilize mood and can potentially lessen binge episodes related to changes in mood.

For patients with binge eating disorder who do not respond to one to two courses of a SSRI, either an antiepileptic [i.e. Topamax (topiramate)] or a medication typically used for attention deficit hyperactivity disorder, Vyvanse (lisdexamfetamine), have been studied. Topamax (topiramate) is the medication most likely used for Binge Eating Disorder. Two studies found that abstinence from binge eating episodes occurred in more patients treated with Topamax (topiramate) than placebo (15).

Vyvanse (lisdexamfetamine) is FDA approved for Binge Eating Disorder. Three trials found that abstinence from binge eating episodes occurred in more patients treated with Vyvanse (lisdexamfetamine) than a placebo.(15) However, psychotherapy is also indicated and often more beneficial than medication-induced appetite suppression alone.

Eating Disorder Medications

In conclusion, medications are not typically the primary mode of treatment for an eating disorder. Medications carry risks of side effects and should be used after careful examination by a psychiatrist. Oftentimes, medications are used to lessen the intensity and frequency of depression and anxiety that one may experience in conjunction with an eating disorder.

Psychotherapy and oversight by a dietitian remain key components in treating an eating disorder. Ultimately, restoring the patient’s ability to eat regularly remains the best “medication” for someone with an eating disorder.

Author’s note:

The decision to start a medication in the treatment of an eating disorder should be made by a psychiatrist that is uniquely aware of an individual’s case. The above information serves as a general guide and should not be used as medical advice.

 

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About The Author:

Brad Zehring, D.O. is an attending psychiatrist who completed his residency training in Psychiatry at the University of Arizona College of Medicine – Phoenix Campus. After residency, he opened his private practice, Arizona Restorative Psychiatry, in Gilbert, AZ. Dr. Zehring is passionate about treating individuals with eating disorders and co-occurring disorders. He seeks to develop a treatment team for each of his patients as he understands the importance of wrap-around services and the additional support that is needed to help his patients recover from eating disorders and maintain their recovery.

References:

  1. NIH – Eating Disorders
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  3. Claudino AM, Hay P, Lima MS, et al. Antidepressants for Anorexia Nervosa. Cochrane Database Syst Rev 2006; :CD004365.
  4. Mayer LE. Psychopharmacology of Anorexia Nervosa and Bulimia Nervosa. Eating Disorders and Obesity, Brownell KD, Walsh BT (Eds), The Guilford Press, New York.
  5. Kaplan AS, Howlett A. Pharmacotherapy for Anorexia Nervosa in the Treatment of Eating Disorders: A Clinical Handbook, Grilo CM, Mitchell JE (Eds), The Guilford Press, New York 2010. p.175.
  6. Dold M, Aigner M, Klabunde M, et al. Second-generation Antipsychotic Drugs in Anorexia Nervosa: A Meta-Analysis of Randomized Controlled Trials. Psychother Psychosom 2015; 84:110.
  7. Fluoxetine in the treatment of Bulimia Nervosa. A multicenter, placebo-controlled, double-blind trial. Fluoxetine Bulimia Nervosa Collaborative Study Group. Arch Gen Psychiatry 1992; 49:139.
  8. American Psychiatric Association. Treatment of patients with eating disorders, third edition. American Psychiatric Association. Am J Psychiatry 2006; 163:4.
  9. Hay P, Chinn D, Forbes D, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry 2014; 48:977.
  10. NICE National Institute for Health and Care Excellence. Eating Disorders: Core interventions in the treatment and management of Anorexia Nervosa, Bulimia Nervosa and related eating disorders. Clinical guideline 9. January 2004. (Accessed on January 10, 2018).
  11. The Role of Impulsivity, Inattention, and Co-morbid ADHD in Patients with Bulimia Nervosa. Published May 20, 2013
  12. Surman, CBH, Randall, ET, Biederman, J. Association Between Attention-Deficit/Hyperactivity Disorder and Bulimia Nervosa: Analysis of 4 Case-Control Studies. J Clin Psychiatry March 2006; 67:3.
  13. Fernandez-Aranda, F, Aguera, Z, Castro, R, et. al. ADHD symptomatology in eating disorders: a secondary psychopathological measure of severity? BMC Psychiatry June 2013; 13:66.
  14. Reas DL, Grilo CM. Review and meta-analysis of pharmacotherapy for binge-eating disorder. Obesity (Silver Spring) 2008; 16:2024.
  15. Brownley KA, Berkman ND, Peat CM, et al. Binge-Eating Disorder in Adults: A Systematic Review and Meta-analysis. Ann Intern Med 2016; 165:409.

Written – 2018

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