If they are taking syrup of ipecac to induce vomiting, patients with AN may suffer irreversible myocardial damage and can die of congestive heart failure.
Because patients with AN do not want to be treated, few participate in treatment trials. According to Halmi, there are fewer than 15 randomly assigned, controlled studies for AN treatment in the medical literature.
"[Individuals with AN] will not enter treatment trials, and when they do, they will frequently drop out after two or three weeks or they develop medical complications and have to be withdrawn," she said. "In all of literature, [there are] only five randomized, placebo-controlled trials with antidepressants [e.g., Kaye et al., 2001], and only one of these had more than 40 patients." Additionally, most of the trials were conducted in a hospital environment designed to encourage weight gain among the patients, which is not really a good environment to determine the effectiveness of the drug.
Some studies have sought to compare nutritional counseling with cognitive-behavioral therapy (CBT) for AN, Halmi said. In a study by Pike et al. (2003), 33 patients with AN posthospitalization were randomly assigned to one year of outpatient CBT or nutritional counseling. The overall treatment failure rate (relapse and dropping out combined) was significantly lower for CBT (22%) than for nutritional counseling (73%).
"The message here is that CBT is the treatment of choice, and nutritional counseling should be made a part of the CBT," said Halmi.
However, she warned that patients with AN generally will not accept medication treatment alone, nor would she advise it. She cited an example of an unpublished collaborative study conducted by Stanford University, the University of Minnesota and Cornell University in which researchers randomly assigned patients with AN who were within 80% of their target weight to fluoxetine(Drug information on fluoxetine) (Prozac), a manualized form of CBT or a combination of the two. Dropout rates among study participants were high: 23 patients (66%) receiving fluoxetine dropped out compared to 18 (49%) receiving CBT and 19 (53%) receiving the combination.
Moving the discussion from AN to BN, Halmi said the treatment of BN is complicated by the frequent presence of comorbid psychiatric conditions. She cited one study that found that 84% of a clinical sample of women with BN had a lifetime affective disorder, and 44% had a lifetime alcohol(Drug information on alcohol) or substance abuse disorder (Bushnell et al., 1994). She also cited a study that looked at comorbidity in a sample of 59 female patients with BN (Brewerton et al., 1995). Three-quarters of the patients had a mood disorder (63% had major depressive disorder), 36% had an anxiety disorder and 20% had a substance abuse disorder. Bulimia nervosa has been found to be comorbid with Axis II disorders as well (Braun et al., 1994).
"Thus, one is never treating just binge/purge behavior," Halmi said.