Pharmacotherapy remains an important treatment modality for comorbid mood and eating disorders. Given the improvement in mood symptoms with re-nourishment, weight restoration is recommended before evaluation for the need for medication.
SSRIs are effective for the treatment of bulimia nervosa. Fluoxetine was approved by the FDA for the treatment of bulimia nervosa after this agent showed significant efficacy in reducing binge eating and purging behaviors, even in the absence of comorbid depressive disorder.16 Interestingly, fluoxetine was more efficacious for symptoms of bulimia nervosa at a dosage of 60 mg daily than 20 mg daily (the typical dosage for treating depression). However, in a relapse-prevention study in which patients with anorexia nervosa had recently successfully completed full weight restoration through inpatient treatment, fluoxetine was no different than placebo in preventing relapse.17
Bupropion has an FDA “black box” warning for use in patients with bulimia nervosa and anorexia nervosa. It should be generally avoided for treatment of these eating disorders and comorbid depression because it has been linked to a possible increase in seizure risk. In a trial that compared bupropion with placebo for treatment of bulimia nervosa, 4 of 55 women experienced grand mal seizures.18
Other treatment options include lisdexamfetamine, which was approved for the treatment of binge eating disorder after showing efficacy in patients with moderate to severe illness.19 However, clinical trials to date have not compared CBT with lisdexamfetamine in patients with binge eating disorder, and this option may be considered a second- or third-line option after other, more established pharmacotherapies (eg, SSRIs, topiramate) have been ineffective or not tolerated.
Pharmacotherapy for anorexia nervosa and comorbid depression has yielded far less promising results—there is currently no FDA-approved medication for anorexia nervosa. There have been no statistically significant improvements in eating-related or depressive symptoms with antidepressant treatment among individuals with anorexia nervosa.17
In the acute setting, lack of efficacy with antidepressants may be secondary to neurobiological alterations that result from starvation.20 Of mechanistic relevance to this finding may be tryptophan-depletion studies. Patients with depression who were previously in remission with fluoxetine treatment had mood symptom relapse with low tryptophan levels—a nutritional status that may also be caused by malnutrition.21
Dr Uniacke is an upcoming Chief Resident in the department of psychiatry at the Columbia University Medical Center in New York City. Dr Broft is Assistant Professor of Psychiatry at the Columbia University Medical Center; she is also a psychiatrist in private practice in New York City. The authors report no conflicts of interest concerning the subject matter of this article.
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