We have had more success in starting patients on the generally weight-neutral antipsychotics aripiprazole and ziprasidone. Our patients who find these medications helpful describe a reduction in distress around eating, more willingness to attempt their prescribed meal plans, fewer obsessional thoughts about food, exercise, weight, and body image, and less tendency to dwell on these thoughts when they do occur. For some, reductions in bingeing, purging, and restrictive eating behaviors have been demonstrated clinically. Mood tends to improve as well. However, it must be emphasized that without trial data, use of the atypical antipsychotics in BN remains experimental. Any desired benefit must be weighed against potential adverse effects, including the unlikely but possible risk of tardive dyskinesia.

Long-term pharmacological management
There are minimal controlled trial data on long-term efficacy of pharmacotherapy for BN. A relatively large study designed to isolate long-term potential benefits of antidepressant medication, conducted in 2002, was hampered by significant rates of attrition in both study drug and placebo arms. The trial began with 232 patients who received an 8-week course of fluoxetine, 60 mg/d, under single-blind treatment conditions. Of this group, 150 patients were considered responders (ie, a 50% or greater decrease in weekly vomiting episodes), and were randomly assigned to continued fluoxetine treatment or placebo for a 1-year double-blind relapse prevention phase.

Findings included a lower rate of relapse for the fluoxetine group, but the investigators noted a worsening on all measures of efficacy over time. They concluded that pharmacotherapy alone may not be adequate treatment after acute response for most patients.45 Perhaps even more concerning was a less than 20% acute-phase remission rate in this study. This result, which is described as consistent with data from other trials, reveals that the vast majority of responders were still bingeing and purging at the beginning of maintenance therapy, which indicates that the idea of relapse prevention may be dubious for most trial participants.

Pharmacological management of BN in adolescents
It should be mentioned that data regarding pharmacological treatment of BN have been gathered almost exclusively from adult patients. One small open trial of fluoxetine in adolescents with BN suggested it was useful and well tolerated,46 but in general, clinicians are left to extrapolate from the adult trial literature in treating young patients. Because of the physical and psychological morbidity and risk of chronicity when BN remains poorly treated, we tend to use the same criteria (Table) in initiating SSRIs in adolescents, with the full informed consent of both patients and their parents.

Treatment combining medication and psychotherapy
At least 6 controlled trials have assessed direct comparisons of outcome for patients with BN treated with psychotherapy, pharmacotherapy, or a combination.3,47 In general, results showed a greater decrease in the frequency of bingeing and purging episodes with cognitive-behavioral therapy than with antidepressant medication when each was used alone. With treatments used in combination, the results to date have been mixed. Although several trials indicate that medication conferred no significant benefit beyond that achieved with psychotherapy, on balance, study results slightly favored the addition of medication to psychotherapy for many patients.48 In the clinical community, there is a consensus that an approach including both psychotherapy and medication is worth considering in most cases.3

Future directions
Psychotropic medications, especially the SSRIs, are helpful for some patients with BN, at least in the short term. More than a decade has elapsed since the FDA approved fluoxetine for use in adult patients with BN, and few notable developments in medication management have taken place since that time. The extent of efficacy of SSRIs and other medications has been questioned since relatively few individuals abstain from binge eating and purging behaviors, and relapse during treatment is common.2,49 Medications that have received some attention but are in need of further investigation include the SNRIs, topiramate, and possibly ondansetron. Augmentation of antidepressants also has not been investigated, and the atypical antipsychotics should be studied for this use.

 
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