Presented by Dr. Sam S. Moss, MD
There are currently only two medications that are FDA-approved for the treatment of eating disorders: Fluoxetine (Prozac) for bulimia nervosa and Lisdexamfetamine (Vyvanse) for binge eating disorder. With eating disorders affecting 9% of the US population at some point in their lifetime,1 why are so few medications approved for treatment?
One possible reason is how Federal research dollars are being allocated. For example, Federal support for schizophrenia works out at $86.97 per individual, and for autism, it is $58.65 per individual. By contrast, for eating disorders, this figure is just $0.73 per affected individual.
This is not to say that autism and schizophrenia research doesn’t require the funding it receives. These figures simply highlight the “lack of attention” eating disorder research receives from the Federal Government. While these are U.S. figures, these numbers are mirrored across the globe.
The figures also illustrate the significant gap between the public health burden of eating disorders and the current state of research to investigate novel treatments.
In this article, we look at the use of medications in eating disorders in the treatment of co-occurring disorders, as well as clinical considerations that should be made and personalizing treatment to the client.
Anorexia nervosa (AN) is a chronic and severe mental illness. It has the highest mortality rate in psychiatry, is associated with frequent relapse, and has a high disease burden and high treatment cost. Despite this, no medication has been approved for the treatment of AN, yet a large proportion of individuals with AN are treated with psychotropic medications.
The lack of a medication suitable for AN is not from a lack of trying. Since the 1970s, almost every class of medication has undergone a research trial to assess its viability as a treatment for AN, including:
Unfortunately, none have yielded substantial benefits to be recommended for treating AN.
Higher rates of comorbidity often mean greater severity, treatment resistance, and poor outcomes in eating disorders. Common co-occurring conditions include:
Research indicates that 55 to 97% of people diagnosed with an eating disorder also receive a diagnosis for at least one more psychiatric disorder.2
Anxiety disorders are the most commonly occurring mental health disorders in the U.S., and they are also particularly prevalent among those diagnosed with an eating disorder. Research indicates that anxiety disorders are present in:3
Research shows that eating disorders are deeply connected to mood disorders. One recent large-scale study of 2,400 participants with eating disorders discovered 94% had a co-occurring mood disorder.3 Major depressive disorder is a common mood disorder co-occurring with eating disorders, believed to be suffered by:3
Impulse control disorders, such as attention-deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), and post-traumatic stress disorder (PTSD), often occur alongside eating disorders.
Substance use disorders and eating disorders co-occur at significantly higher rates than either condition does on its own in the general population. Research shows that up to 50% of individuals struggling with an eating disorder also have issues with substance use.7 Common comorbid substance use disorders include:
Suicide rates are also higher amongst those living with eating disorders than in the general population. Individuals with anorexia are 18 times more likely to die by suicide, and those struggling with bulimia are 7 times more likely.8
Five classes of psychotropic medications can be used in the treatment of co-occurring psychiatric disorders:
The first line of treatment for co-occurring anxiety disorders is SSRIs, used in combination with therapy, typically cognitive behavioral therapy (CBT). Examples of SSRIs include:
SNRIs are sometimes used interchangeably with SSRIs but are associated with slightly higher side effects. Examples of SNRIs include:
Due to the complexity of the brain, the exact mechanism of action of SSRIs is unclear. It is hypothesized that SSRIs increase the availability of serotonin, which is thought to positively influence mood, emotions, and sleep.
After carrying a message, serotonin is usually reabsorbed by the nerve cells. SSRIs work by blocking the reabsorption (reuptake) of serotonin at the synapse, meaning more serotonin is available to pass further messages between nearby nerve cells.9 It typically takes 4-6 weeks before the effects of SSRIs are felt, but it can take longer.
Most people will only experience a few mild side effects when taking SSRIs, which generally improve with time. Common side effects of SSRIs include:9
Other medications that can be used for the treatment of co-occurring anxiety include, but are not limited to:
Medications for co-occurring psychosis are used to treat and manage the symptoms of bipolar disorder, schizophrenia/schizoaffective disorders, major depressive disorder, OCD, bipolar disorder, and substance-induced symptoms. Antipsychotic medications may also reduce eating disorder ruminations and compulsions.
There are two main classes of antipsychotic medications, both of which have a length of onset of just a few hours:
Due to the clinical considerations of ADHD medications, it’s important to screen for eating disorders before treating ADHD. There are two classes of medications used to treat co-occurring ADHD:
Many psychiatric medications can have an impact on appetite and, therefore, may help facilitate eating disorder treatment, as well as address co-occurring psychiatric disorders.
Whenever an eating disorder patient is prescribed medication for a co-occurring psychiatric disorder, there are considerations to be aware of:
There is no one-size-fits-all approach in psychiatry; not every patient will benefit from medications. It’s normal for individuals to be anxious about taking psychiatric medications, particularly for the first time. It’s important to address fears and concerns and answer any questions patients may have.
Patient nonadherence to medication is a significant barrier to effective treatment. With ambivalence about taking the medication being the norm and not the exception, creating a good therapeutic alliance between patient and clinician is so important. Other ways to support the integration of medication in treatment are to:
Family history and genetics can play a role in how an individual will respond to medications. Pharmacogenomic testing provides a metabolic profile for psychotropic medications, which can help guide dosages, as well as give an insight into the severity of potential side effects.
While pharmacogenetic testing does not determine which medication will work best, it can be helpful for those with an extensive history of medication failures, sensitivities to certain medications, and who have experienced significant side effects.
Deprescribing is a phenomenon that arose in the field of child and adolescent psychology, but it also applies well to adults. It involves a structured approach to identify and discontinue medications when risks outweigh potential benefits.
Before medication is prescribed, there should be a comprehensive psychiatric assessment and review of past psychiatric treatment where possible. Plus, there should be cohesive communication between prescribers to prevent polypharmacy, which can increase the risk and severity of side effects.
Deprescribing should be considered when a medication(s):
So, what is next when it comes to using medications to treat co-occurring disorders in eating disorder clients? There are certainly a lot of challenges, such as:
Despite these challenges, there are some promising breakthroughs. For example, Olazapine has demonstrated some positive outcomes in weight restoration among patients with anorexia. However, it comes with side effects; the gains can be short-lived, and artificial weight gain can cause weight gain anxiety.
Some additional new drug interventions have shown promise, including: