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
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.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
2. Kaye WH, Walsh BT. Psychopharmacology of eating disorders. In: Davis K, Charney D, Coyle J, Nemeroff C, eds. Neuropsychopharmacology. The Fifth Generation of Progress. Philadelphia: Lippincott Williams & Wilkins; 2002:1675-1683.
3. American Psychiatric Association. Practice Guideline for the Treatment of Patients With Eating Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 2006.
4. Bacaltchuk J, Hay P. Antidepressants versus placebo for people with bulimia nervosa. Cochrane Database Syst Rev. 2003;(4):CD003391.
5. Nakash-Eisikovits O, Dierberger A, Westen D. A multidimensional meta-analysis of pharmacotherapy for bulimia nervosa: summarizing the range of outcome in controlled clinical trials. Harv Rev Psychiatry. 2002;10:193-211.
6. National Institute for Clinical Excellence. Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders. London: British Psychological Society; 2004.
7. Fluoxetine Bulimia Nervosa Collaborative Study Group. Fluoxetine in the treatment of bulimia nervosa: a multicenter, placebo-controlled, double-blind trial. Arch Gen Psychiatry. 1992;49:139-147.
8. Goldstein DJ, Wilson MG, Thompson VL, et al. Long-term fluoxetine treatment of bulimia nervosa. Fluoxetine Bulimia Nervosa Research Group. Br J Psychiatry. 1995;166:660-666.
9. Fichter MM, Kruger R, Rief W, et al. Fluvoxamine in prevention of relapse in bulimia nervosa: effects on eating-specific psychopathology. J Clin Psychopharmacol. 1996;16:9-18.
10. Schmidt U, Cooper P, Essers H. Fluvoxamine and graded psychotherapy in the treatment of bulimia nervosa: a randomized, double-blind, placebo-controlled multicenter study of short-term and long-term pharmacotherapy combined with a stepped care approach to psychotherapy. J Clin Psychopharmacol. 2004;24: 549-552.
11. Milano W, Siano C, Petrella C, Capasso A. Treatment of bulimia nervosa with fluvoxamine: a randomized controlled trial. Adv Ther. 2005;22:278-283.
12. Milano W, Petrella C, Sabatino C, Capasso A. Treatment of bulimia nervosa with sertraline: a randomized controlled trial. Adv Ther. 2004;21:232-237.
13. Erzegovesi S, Riboldi C, Di Bella D. Bulimia nervosa, 5-HTTLPR polymorphism and treatment response to four SSRIs: a single-blind study. J Clin Psychopharmacol. 2004;24:680-682.
14. Leombruni P, Amianto F, Delsedime N, et al. Citalopram versus fluoxetine for the treatment of patients with bulimia nervosa: a single-blind randomized controlled trial. Adv Ther. 2006;23:481-494.
15. Fava M, Copeland PM, Schweiger U, Herzog DB. Neurochemical abnormalities of anorexia nervosa and bulimia nervosa. Am J Psychiatry. 1989;146: 963-971.
16. Brambilla F. Aetiopathogenesis and pathophysiology of bulimia nervosa: biological bases and implications for treatment. CNS Drugs. 2001;15:119-136.
17. Kruger S, Kennedy SH. Pharmacotherapy of anorexia nervosa, bulimia nervosa and binge-eating disorder. J Psychiatry Neurosci. 2000;25:497-508.
18. Fassino S, Daga GA, Boggio S, et al. Use of reboxetine in bulimia nervosa: a pilot study. J Psychopharmacol. 2004;18:423-428.
19. El-Giamal N, de Zwaan M, Bailer U, et al. Reboxetine in the treatment of bulimia nervosa: a report of seven cases. Int Clin Psychopharmacol. 2000;15: 351-356.
20. Malhotra S, King KH, Welge JA, et al. Venlafaxine treatment of binge-eating disorder associated with obesity: a series of 35 patients. J Clin Psychiatry. 2002;63:802-806.
21. Hazen E, Fava M. Successful treatment with duloxetine in a case of treatment refractory bulimia nervosa: a case report. J Psychopharmacol. 2006;20: 723-724.
22. Horne RL, Ferguson JM, Pope HG Jr, et al. Treatment of bulimia with bupropion: a multicenter controlled trial. J Clin Psychiatry. 1988;49:262-266.
23. Pope HG Jr, McElroy SL, Keck PE Jr, et al. Electrophysiologic abnormalities in bulimia and their implications for pharmacotherapy: a reassessment. Int J Eat Disord. 1989;8:191-201.
24. Goldstein DJ, Wilson MG, Ascroft RC, al-Banna M. Effectiveness of fluoxetine therapy in bulimia nervosa regardless of comorbid depression. Int J Eat Disord. 1999;25:19-27.
25. Brewerton TD, Mueller EA, Lesem MD, et al. Neuroendocrine responses to m-chlorophenylpiperazine and L-tryptophan in bulimia. Arch Gen Psychiatry. 1992;49:852-861.
26. Appolinario J, McElroy SL. Pharmacological approaches in the treatment of binge eating disorder. Curr Drug Targets. 2004;5:301-307.
27. Hoopes S, Reimherr F, Hedges D. Treatment of bulimia nervosa with topiramate in a randomized, double-blind, placebo-controlled trial, part 1: improvement in binge and purge measures. J Clin Psychiatry. 2003;64:1335-1341.
28. Hedges D, Reimherr F, Hoopes S. Treatment of bulimia nervosa with topiramate in a randomized, double-blind, placebo-controlled trial, part 2: improvement in psychiatric measures. J Clin Psychiatry. 2003;64:1449-1454.
29. Nickel C, Tritt K, Muehlbacher M. Topiramate treatment in bulimia nervosa patients: a randomized, double-blind, placebo-controlled trial. Int J Eat Disord. 2005;38:295-300.
30. McElroy SL, Kotwal R, Keck PE Jr. Comorbidity of eating disorders with bipolar disorder and treatment implications. Bipolar Disord. 2006;8:686-695.
31. Faris PL, Kim SW, Meller WH, et al. Effect of decreasing afferent vagal activity with ondansetron on symptoms of bulimia nervosa: a randomised, double-blind trial. Lancet. 2000;355:792-797.
32. Jonas JM, Gold MS. The use of opiate antagonists in treating bulimia: a study of low-dose versus high-dose naltrexone. Psychiatry Res.1988;24:195-199.
33. Igoin-Apfelbaum L, Apfelbaum M. Naltrexone and bulimic symptoms. Lancet. 1987;2:1087-1088.
34. Mitchell JE, Christenson G, Jennings J, et al. A placebo-controlled, double-blind crossover study of naltrexone hydrochloride in outpatients with normal weight bulimia. J Clin Psychopharmacol. 1989;9:94-97.
35. Alger SA, Schwalberg MD, Bigaouette JM, et al. Effect of a tricyclic antidepressant and opiate antagonist on binge-eating behavior in normoweight bulimic and obese, binge-eating subjects. Am J Clin Nutr. 1991;53:865-871.
36. Hsu LK, Clement L, Santhouse R, Ju ES. Treatment of bulimia nervosa with lithium carbonate. A controlled study. J Nerv Ment Dis. 1991;179:351-355.
37. Kaplan AS, Garfinkel PE, Darby PL, Garner DM. Carbamazepine in the treatment of bulimia. Am J Psychiatry. 1983;140:1225-1226.
38. Dunican KC, DelDotto D. The role of olanzapine in the treatment of anorexia nervosa. Ann Pharmacother. 2007;41:111-115.
39. Newman-Toker J. Risperidone in anorexia nervosa. J Am Acad Child Adolesc Psychiatry. 2000;39: 941-942.
40. Powers PS, Bannon Y, Eubanks R, McCormick T. Quetiapine in anorexia nervosa patients: an open label outpatient pilot study. Int J Eat Disord. 2007;40: 21-26.
41. Bosanac P, Kurlender S, Norman T, et al. An open-label study of quetiapine in anorexia nervosa. Hum Psychopharmacol. 2007;22:223-230.
42. Mehler-Wex C, Romanos M, Kirchheiner J, Schulze UM. Atypical antipsychotics in severe anorexia nervosa in children and adolescents—review and case reports. Eur Eat Disord Rev. 2008;16:100-108.
43. Philip NS, Carpenter LL, Tyrka AR, Price LH. Augmentation of antidepressants with atypical antipsychotics: a review of the current literature. J Psychiatr Pract. 2008;14:34-44.
44. Gebhardt S, Haberhausen M, Krieg JC, et al. Clozapine/olanzapine-induced recurrence or deterioration of binge eating-related eating disorders. J Neural Transm. 2007;114:1091-1095.
45. Romano SJ, Halmi KA, Sarkar NP, et al. A placebo-controlled study of fluoxetine in continued treatment of bulimia nervosa after successful acute fluoxetine treatment. Am J Psychiatry. 2002;159:96-102.
46. McElroy SL, Kotwal R, Keck PE Jr. Comorbidity of eating disorders with bipolar disorder and treatment implications. Bipolar Disord. 2006; 8:686-695.
47. Kaye W, Strober M, Jimerson D. The neurobiology of eating disorders. In: Charney DS, Nestler EJ, eds. The Neurobiology of Mental Illness. New York: Oxford University Press; 2004:1112-1128.
48. Steinglass JE, Walsh T. Psychopharmacology of anorexia nervosa, bulimia nervosa, and binge eating disorder. In: Brewerton TD, ed. Clinical Handbook of Eating Disorders: An Integrated Approach. New York: Marcel Dekker; 2004:489-508.
49. Walsh BT, Hadigan CM, Devlin MJ, et al. Long-term outcome of antidepressant treatment for bulimia nervosa. Am J Psychiatry. 1991;148:1206-1212.