Date: 3rd October 2005
Reference: Costin C., The Eating Disorder Sourcebook 2nd Edition (1999) Lowell House, Illinois
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 symbolises to any given individual. The act of taking mind-altering medication symbolises 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 medications have been tried for various reasons, with a report here and there about the effectiveness of 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.
And encouraging study was reported by Dr. Walter Kaye at the International Association of Eating Disorder Professional conference in August 1995. The breakthrough was discovered in placebo-controlled medication trial of fluoxetine (Prozac) with anorexics. Prozac, and less so straline (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, flouxetine (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 behavioural 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 that 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 20-33 percent) have complete remission of symptoms, and others have significant reductions in bingeing and purging behaviours.
The class of antidepressnats known as the SSRIs, discussed above, such as Prozac, Zoloft, and so on, are the newer versions on 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. Amitryiptyline (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 effcts of eating disorders, especially lowered potassium in the body (hypokalemia).
The MAOIs such as tranylcypromine (Parnate) and phenelzine (Nardil) show efficacy in reducing bulimic symptoms, However, individuals take 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 behaviour, without undue side effects.
Binge Eating Disorder (BED) and Medication
As has been previously stated, the research on BED (including drug studies) is minimal but growing. However, several investigators believe that binge eating is less a matter of willpower than brain chemistry. In some cases, clinicians and researchers are using SSRIs with binge eating disorder for the same reasons they use it for bulimia. Serotonin helps us feel full, so it is theorised that people with binge eating disorders like bulimia nervosa may want to eat all the time because they have too little of the neurotransmitter serotonin and thus never feel satisfied (satiated).