Drug Therapy
Drug Therapy for Bulimia Nervosa

Because of the high incidence of depression in patients with bulimia, antidepressant medication is often recommended. A one-year study determined, however, that when an antidepressant was used without accompanying cognitive-behavioral therapy, the success rate was only 18%. The most common antidepressants prescribed for bulimia are imipramine (Tofranil), desipramine (Norpramin), and drugs known as selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), venlafaxine (Effexor), and fluvoxamine (Luvox). About 20% withdraw from treatment because of side effects. Prozac is effective at higher doses (60 mg) but has little impact on the binge-purge cycle at low doses (20 mg). Some trials are using naltrexone or naloxone, medications that are used against drug addiction, and one indicated that it reduced bingeing. Researchers hope that such drugs will reduce natural opioids that may be released during binges.

Drug Therapy for Anorexia.

No drug therapy has been proven to be very effective in treating anorexia or the depression that usually accompanies and perpetuates the disorder. The effects of starvation intensify side effects and reduce the effectiveness of antidepressant drugs. In addition, most antidepressants suppress appetite and contribute to weight loss. SSRI antidepressants (see above) are now recommended as the first line of treatment for obsessive-compulsive disorder and may help some people with anorexia who also have OCD. In one study, however, Prozac, the most commonly prescribed SSRI, offered no long-term benefits compared to intensive and sustained team efforts. Some physicians recommend cyproheptadine (Periactin), an antihistamine, that may stimulate appetite. There is no evidence to date, however, that any drug treatment has particular benefit for anorexia nervosa, and, in most cases, depression and thought disorders improve with weight gain.

Restoring Hormonal Function and Bone Density.

Normalizing reproductive hormone balances is more important than weight gain in restoring menstrual function. The use of estrogen therapy to reverse osteoporosis, however, has been discouraging. One study reported that an estrogen-progesterone combination increased bone density in women with exercise-induced menstrual disorders after two years, while another found no positive effect from estrogen therapy on bone growth in women with severe bone loss from abnormal menstruation (this group included both those who exercised and those who did not).

Everyone who has encountered an eating disorder knows how difficult it can be to treat. It has one of the highest overall mortality rates of all psychiatric illnesses and is often associated with one or more co-morbid conditions, including depression, obsessive compulsive disorder (OCD), alcohol or substance abuse, anxiety disorders, post-traumatic stress disorder (PTSD), and attention deficit disorder.
  
Although there is varying data and limited studies on the specific benefits of medication in alleviating eating disorder symptoms, there is clear data that medication can often help with these associated conditions and thereby help long-term recovery.

Perhaps the most frequently used group of medications in the treatment of eating disorders included the antidepressants known as selective serotonin reuptake inhibitors (SSRI), which include Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), Luvox (fluvoxamine), and Celexa (citalopram). These increase the level of serotonin in the body and have been found helpful in the treatment of many types of depression, OCD, PTSD, and various types of anxiety disorders. There is also evidence, much of it anecdotal, that in higher dose ranges the SSRI's may help reduce the urge to binge and purge. Other studies, thus far conducted primarily with Prozac, also indicate improvement in the long-term recovery of anorexia with these medications.

Side effects can include some early jitteriness or nausea, sedation, and sexual dysfunction relating primarily to decreased sexual interest or delayed orgasm. Most side effects tend to be temporary or can be controlled by adjusting the medication. Although some weight gain can occur with most antidepressants, this is generally not a major issue with these, and regular visits with a dietitian for weight monitoring should be part of all eating disorder treatment plans. Some maintain that one should wait to start these medications until the patient is at least to 90% of ideal body weight because of the need for a certain amount of body fat for them to be maximally effective. However, it has been my experience as staff psychiatrist at Remuda Ranch that benefits may be realized before that occurs. It should be remembered that it might take 3-6 weeks to see therapeutic benefit from these medications, even after a dosage change. Potential benefits include improvement in mood, decreased anxiety, and decreased obsessive thinking and compulsions, whether related primarily to the eating disorder or associated OCD symptoms.

Another useful antidepressant is Effexor XR (venlafaxine), which can be very effective alone or in combination with an SSRI. It may provide some stimulation and increased energy but is often very effective in also decreasing anxiety. Serzone and Remeron are used as adjuncts with other antidepressants or by themselves and may also be used specifically for sleep. Remeron should probably be used primarily with lower weight patients, as weight gain can be a significant side effect. Trazadone is an antidepressant frequently used in lower doses specifically for sleep, and the advantage of using antidepressants for sleep over some other sleep medications is that these are not habit forming. Anagranil is an older antidepressant of the tricyclic group. Although it can be very effective with OCD or as an adjunct with an SSRI, it does tend to have more side effects such as dry mouth, sedation, and at times difficulty with urination. Wellbutrin has been somewhat controversial in its use with eating disorders.

Although it can be very effective as a relatively non-sedating antidepressant and may be especially helpful with bulimia, some early studies indicated that it might increase the likelihood of seizures in this population. Although it "officially" is not recommended for use with eating disorders, many question the validity of these early studies and are beginning to use it. If it is used, it should be started fairly low and advanced slowly with patients informed of the potential risk. It should probably also be used only in the time released (SR) form, as this seems to lessen the seizure potential.

Another group of medications being used increasingly with eating disorders are called the "atypical anti-psychotics". These include Risperdal, Zyprexa, Seroquel, and most recently Geodon. Although they can be used to treat psychosis in their normal dose ranges, in low doses they are often helpful with the anxiety that accompanies the obsessions related to fear of weight gain, body image, or compulsive exercising. Weight gain can be a problem with the Zyprexa and Risperdal when used longer term, although some would recommend these with low weight anorexic patients even before starting an SSRI.

There are a number of other medications that are often useful in treating eating disorders or their associated conditions, but time does not permit reviewing them all in this article. Although medications are not the cure for eating disorders, they do represent an important and helpful tool as part of one's overall recovery program.
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