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38. Use of Psychopharmacologic Medications in Adolescents With Restrictive Eating Disorders: Analysis of Data From the National Eating Disorder Quality Improvement Collaborative
Abstract
Psychopharmacologic medications are often prescribed to patients with restrictive eating disorders (EDs), and little is known about the frequency of use in adolescents. We examined the use of psychopharmacologic medications in adolescents referred for treatment of restrictive ED, potential factors associated with their use, and reported psychiatric comorbidities.
Retrospective data from the initial and 1-year visits were collected for patients referred for evaluation of restrictive ED at 12 adolescent-based ED programs during 2010 (Group 1), including diagnosis, demographic information, body mass index, prior treatment modalities, and psychopharmacologic medications. Additional data regarding patients' comorbid psychiatric conditions and classes of psychopharmacologic medications were obtained from six sites (Group 2).
Overall, 635 patients met inclusion criteria and 359 had 1-year follow-up (Group 1). At intake, 20.4% of Group 1 was taking psychopharmacologic medication and 58.7% at 1 year (p ≤ .0001). White, non-Hispanic race (p = .020), and prior higher level of care (p < .0001) were positively associated with medication use at 1 year. Among Group 2 (n = 256), serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors use was most common, and 62.6% had a reported psychiatric comorbidity. Presence of any psychiatric comorbidity was highly associated with medication use; odds ratio, 10.0 (5.6, 18.0).
Adolescents with restrictive ED treated at referral centers have high rates of reported psychopharmacologic medication use and psychiatric comorbidity. As more than half of this referral population were reported to be taking medication, continued investigation is warranted to ensure the desired outcomes of the medications are being met.
Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
... However, despite the mostly negative meta-analytic evidence for benefits in adults with AN [20,26,[34][35][36][37][38] and virtually absent data in youth, psychotropic drugs are often prescribed in AN in real-world settings [19,52]. Naturalistic data capture patients who may not be included in RCTs that have strict in-and exclusion criteria. ...
... As many as 30.1% of the youth on psychotropic drugs took two or more medications. However, in this naturalistic setting, there was no significant increase in weight restoration compared to patients without medication [52]. ...
... To our knowledge, that retrospective chart review [52] is the largest naturalistic study assessing the efficacy of antipsychotic treatment of inpatient youth with AN. Based on the relatively frequent use of antipsychotics in youth with AN and limited information on the potential benefits [53], the current retrospective chart review study aimed to assess i) the clinical correlates of antipsychotic use in youth with AN, ii) specific antipsychotic choice during inpatient treatment, and iii) effects of (specific) antipsychotics regarding inpatient weight gain in comparison to unmatched and to carefully matched nonantipsychotic treated youth. ...
Background:
Off-label antipsychotic use is not uncommon in youth with anorexia nervosa (AN), aiming to enhance suboptimal weight restoration, yet its efficacy remains debated, especially in youth.
Methods:
Retrospective chart review of consecutively admitted inpatients (ages 8-18 years) with restricting/binge-purge AN, comparing youth with versus without antipsychotic treatment regarding baseline factors, treatment, and anthropometric outcome characteristics including all patients and matched subgroups. Matched subsamples were also compared regarding faster versus slower weight change (median split). Furthermore, within-subject analyses compared weight gain trajectories before versus after antipsychotic use in antipsychotic-treated youth. These results were then compared in a pre-/post design with the matched control group without antipsychotic treatment, using the mean duration until antipsychotic use in the antipsychotic-treated group as the dividing timeline, controlling for a potential order effect, in that later rather than earlier antipsychotic treatment for AN may be more successful.
Results:
Of 294 youth with AN (median age = 15.2 (interquartile range = 14.0, 16.6) years, females = 96.6%, restricting subtype = 81.0%, hospitalization duration = 98.2 ± 43.2 days), 44 (15.0%) underwent 52 antipsychotic trials (olanzapine = 63.5%). In multivariable analyses, antipsychotic use was independently associated with younger age, childhood physical abuse history, comorbid borderline personality traits, and lower pre-antipsychotic weight gain (p < 0.0001). In unmatched groups, antipsychotic-treated versus non-treated youth had significantly lower discharge anthropometric parameters, longer inpatient treatment, and lower weight change/week (p < 0.001-p = 0.005), without significant differences between olanzapine and non-olanzapine antipsychotics (p = 0.27-0.44). Non-significant antipsychotic effects on weight outcomes were confirmed in (1) matched subgroups of antipsychotic-treated versus non-treated youth (n = 43 each), (2) youth with faster versus slower weight gain (n = 21 vs. n = 22), and (3) antipsychotic-treated youth when comparing weight change before versus after antipsychotic use (n = 31). Moreover, in antipsychotic-treated youth, weight change/week remained significantly lower versus matched non-antipsychotic-treated youth (n = 31) both before (p = 0.053) and after (p = 0.006) the median time (5 weeks) until antipsychotic use.
Conclusions:
In this naturalistic study, clinician's antipsychotic choice, given to a more severely ill subgroup of adolescents with AN, did not significantly improve overall worse weight change trajectories during inpatient treatment, even in matched subgroups. Randomized trials in individuals reflecting real-world samples are needed to evaluate the utility of antipsychotic treatment in youth with AN.
... 10 A retrospective chart review study in the USA investigated the rates of psychopharmacological medication use in adolescents and young people in the USA who were referred to adolescent medicine-based ED programmes for the treatment of EDs. 11 They found that at 1-year follow-up, psychopharmacological medications continue to be prescribed at a high rate (58.7% compared with 20.4% at intake) in adolescents and young people with AN. A more recent study assessing 86 charts of patients with an ED in a tertiary care centre in the USA found 45.3% to be on psychotropic medications. ...
... This is significantly lower than what was reported in a US study that investigated the prescribing practice in EDs, which found that around 60% of patients with restrictive ED were prescribed psychotropic medication, most commonly SSRIs. 11 In our English sample, only a few psychiatrists responded that the proportion of young people with AN on medication lies between 50% and 80%. This difference could be due to the inclusion of restrictive ED in the US sample, which may consist of conditions other than just AN that are associated with higher rates of comorbidities. ...
Objectives
To survey current prescribing practices of psychotropic drugs by child and adolescent eating disorder (CAED) psychiatrists in the treatment of anorexia nervosa (AN).
Design
Cross-sectional self-administered survey.
Setting
All children and young people eating disorder services (CYP EDS) in England during a national training programme.
Participants
44 CAED psychiatrists practising in CYP EDS in England.
Primary and secondary outcome measures
CAED psychiatrists completed a questionnaire regarding the pattern of psychopharmacological care in AN that they provide and the medication treatment pattern at their CYP EDS. Secondary outcome measures included the process of continuing pharmacotherapy from secondary care to primary care.
Results
Of the 77 CYP EDS representing every team in England, 44 teams represented by a CAED psychiatrist responded, despite 13 having no psychiatrists in post at the time of the study (response rate 69%). Most (40%) respondents estimated that <10% of patients with AN were prescribed psychotropic medications. Olanzapine was reported as the most commonly prescribed medication for AN by 38% of the respondents, followed by fluoxetine (29%) and sertraline (10%). The most common minimum olanzapine initiation dose in this study was at 2.5 mg/day for a duration of 2–4 weeks, reaching a maximum dose of 5 mg/day. Most (68%) reviewed medications every week (30%) or every 2 weeks (38%). Over 50% of the respondents reported continuation of olanzapine prescribing within the CYP EDS teams.
Conclusions
This nationally representative survey showed that despite a lack of evidence, psychotropic medications are commonly prescribed to a minority of patients, most frequently, olanzapine. Further evidence is needed on which patients may potentially benefit from pharmacotherapy as an adjunct to psychological interventions.
... The nature of the eating disturbance (e.g., restriction due to unrealistic shape and body weight concerns vs. restriction due to aversion to the sensory properties of food) distinguishes the two disorders [2]. Prior to the introduction of the ARFID diagnosis, individuals with ARFID were often referred to treatment designed for individuals with disordered eating attitudes consistent with restricting anorexia [23]. In a series of retrospective chart reviews up to 2014, 12-22 % of adolescents referred to eating disorder clinics meet criteria for ARFID rather than for a restricting eating disorder associated with weight and shape concerns and body image disturbance (e.g., [23,24]). ...
... Prior to the introduction of the ARFID diagnosis, individuals with ARFID were often referred to treatment designed for individuals with disordered eating attitudes consistent with restricting anorexia [23]. In a series of retrospective chart reviews up to 2014, 12-22 % of adolescents referred to eating disorder clinics meet criteria for ARFID rather than for a restricting eating disorder associated with weight and shape concerns and body image disturbance (e.g., [23,24]). In order to show that ARFID is distinct from other restricting eating disorders, it is necessary to show that individuals with self-reported ARFID symptoms can be differentiated from those with self-reported attitudes associated with anorexia and bulimia on the basis of either comorbidity or eating behavior. ...
Background
One presentation of Avoidant/Restrictive Food Intake Disorder (ARFID) is characterized by picky eating, i.e., selective eating based on the sensory properties of food. The present study has two aims. The first is to describe distress and impairment in individuals with ARFID secondary to picky eating. The second is to determine whether eating behaviors hypothesized to be specific to picky eating can differentiate picky eaters with and without ARFID from typical eaters (e.g., individuals not reporting picky or disordered eating) and individuals who strongly endorse attitudes associated with anorexia and bulimia (eating disordered attitudes).
Methods
Participants were recruited from Amazon’s Mechanical Turk (N = 325) and an online support group for adult picky eaters (N = 81). Participants were grouped based on endorsement of picky eating, ARFID symptoms, and elevated eating disordered attitudes on the Eating Attitudes Test (EAT-26). The resulting four eating behavior groups were compared on measures of distress and impairment (e.g., anxiety/depression and, obsessive compulsive disorder symptoms, eating-related quality of life) and on measures of eating behaviors associated with picky eating (e.g., food neophobia, inflexibility about preparation and presentation of preferred foods, sensitivity to sensory stimuli, and eating from a very narrow range of foods). The groups were compared using one way ANOVA with post-hoc Tamhane’s T2 tests.
Results
On measures of distress and impairment, participants with ARFID reported higher scores than both typical eaters and picky eaters without ARFID, and comparable scores to those with disordered eating attitudes. Three of four measures of picky eating behavior, eating inflexibility, food neophobia, and eating from a range of 20 or fewer foods, distinguished picky eaters with and without ARFID form typical eaters and those with disordered eating attitudes. Picky eaters with ARFID reported greater food neophobia and eating inflexibility, and were more likely to eat from a narrow range of foods, compared to picky eaters without ARFID.
Conclusions
Adult picky eaters can be differentiated from those with symptoms of anorexia and bulimia by their stronger endorsement of food neophobia and inflexible eating behaviors, and by eating from a very narrow range of foods. Picky eaters with ARFID symptoms can be differentiated from picky eaters without these symptoms on the basis of these three eating behaviors, and by their higher endorsement of internalizing distress, OCD symptoms, and eating-related quality of life impairment. This study provides evidence that ARFID symptoms exist independently of symptoms of other eating disorders and are characterized by several distinct eating behaviors. In a clinical analogue sample of disordered eaters, ARFID symptoms were associated with distress and impairment at levels comparable to symptoms of anorexia and bulimia.
... It is important to note that studies that tested SSRIs in AN did not comprehensively assess changes in AN-unrelated psychopathology, such as generalized anxiety, major depression, or obsessive-compulsive behaviors. This is a weakness of those studies as more recent research indicates that comorbidity has an impact on mortality and long-term outcomes of AN and needs to be addressed in the treatment plan [35,36]. These data are supported by a recent retrospective study over up to 1 year on the use of psychoactive medication in youth and young adults with AN [37]. ...
Introduction:
Anorexia nervosa (AN) has one of the highest mortality rates of all mental illnesses. No approved pharmacological treatments exist for AN, but novel neurobiological targets show promise.
Areas covered:
Studies show that in individuals with AN, there are alterations in brain neurotransmitter signaling, alongside associated mental rigidity and comorbid anxiety and depression. Available and new therapies could be used to improve alterations in neurobiology and behavior. This narrative review serves as a review of previously published literature assessing the efficacy of traditional pharmacotherapy in treating AN while also exploring novel treatments, including dissociative anesthetics, psychedelics, cannabinoids, hormones, neurosteroids, and ketogenic nutrition.
Expert opinion:
If best practice psychotherapeutic interventions have failed, we recommend a neuroscience and brain research-based medication approach that targets dopamine neurotransmitter receptors to enhance cognitive flexibility and illness insight while reducing dread and avoidance toward food. It is furthermore essential to recognize and treat comorbid conditions such as anxiety, depression, or obsessive-compulsive disorder as they interfere with recovery, and typically do not resolve even with successful AN treatment. Novel strategies have the promise to show efficacy in improving mood and reducing specific AN psychopathology with hopes to be used in clinical practice soon.
... More recently, a variety of selective serotonin reuptake inhibitor (SSRI) antidepressants and second-generation antipsychotics (SGA) have been investigated, yielding mixed results overall. Despite marginal efficacy, SSRIs and SGAs are very commonly prescribed in clinical practice to treat AN [18,19]. While these drugs have some demonstrated efficacy in BN and BED [18] (see below), there is only weak evidence demonstrating efficacy in promoting weight gain, reducing eating disorder symptoms, or preventing relapse in AN [20][21][22][23]. ...
Background:
The current review broadly summarises the evidence base for pharmacotherapies and adjunctive and alternative therapies in the treatment of eating disorders and disordered eating.
Methods:
This paper forms part of a Rapid Review series examining the evidence base in the field of eating disorders. This was conducted to inform the Australian National Eating Disorder Research and Translation Strategy 2021-2030. ScienceDirect, PubMed and Ovid/Medline were searched for included studies published between 2009 and 2021 in English. High-level evidence such as meta-analyses, large population studies and randomised control trials were prioritised, and grey literature excluded. Data from included studies relating to pharmacotherapy, and to adjunctive and alternative therapies in eating disorders, were synthesised and disseminated in the current review.
Results:
A total of 121 studies were identified, relating to pharmacotherapy (n = 90), adjunctive therapies (n = 21) and alternative therapies (n = 22). Some of the identified studies involved combinations of the above (e.g. adjunctive pharmacotherapy). Evidence of efficacy of interventions across all three categories was very limited with few relevant high quality clinical trials. There was a particular scarcity of evidence around effective treatments for anorexia nervosa (AN). With treatment of bulimia nervosa (BN), fluoxetine has exhibited some efficacy leading to regulatory approval in some countries. With binge eating disorder (BED), recent evidence supports the use of lisdexamfetamine. Neurostimulation interventions show some emerging efficacy in the treatment of AN, BN and BED but some, such as deep brain stimulation can be highly invasive.
Conclusion:
Despite widespread use of medications, this Rapid Review has identified a lack of effective medications and adjunctive and alternative therapies in the treatment of EDs. An intensification of high-quality clinical trial activity and drug discovery innovation are required to better assist patients suffering from EDs.
... These issues must be discussed empathetically and comprehensively with patients and, for children and adolescents, with their families as part of shared decision-making. The limited empirical data do not show any advantages of selective serotonin reuptake inhibitors (SSRIs) in terms of weight gain (Barbarich et al. 2004;Fassino et al. 2002;Halmi et al. 2005;Kaye et al. 2001;Ruggiero et al. 2003;Walsh et al. 2006;Yu et al. 2011); however, these medications are commonly used (Garner et al. 2016;Monge et al. 2015), are relatively well tolerated, and may be considered for those with persistent depressive, anxiety, or obsessive-compulsive symptoms. If antidepressants are considered for co-occurring disorders in adolescents and emerging adults, clinicians should attend to the boxed warnings relating to antidepressants and discuss the potential benefits and risks of antidepressant treatment with patients and families (U.S. Food and Drug Administration 2018). ...
... antidepressants, antipsychotics) have been found to be less than adequate in treating AN. To date, no medication has been approved for AN, yet a large proportion of AN are treated with psychotropics (Blanchet et al., 2019;Monge et al., 2015). In 2011, a taskforce on eating disorders (Aigner et al., 2011) reviewed 20 randomised controlled trials (RCTs) in AN and found that no psychopharmacological treatments provided "Level A" evidence (i.e. ...
Anorexia nervosa (AN) is a severe, biological brain disorder with significant medical risks and a tenacious development over time. Unfortunately, few treatments show efficacy in people with AN although numerous therapies including pharmacological have been explored. Zinc deficiency has been implicated in AN and zinc is important in a large range of processes in the brain. In particular, it is an allosteric modulator of NMDA receptors – the maintenance of zinc levels within a normal, narrow range is essential for glutamatergic functioning. Chronic zinc deficiency increases neuronal stores of calcium and reduces direct modulation of NMDA receptors which collectively lead to overactivation and upregulation of NMDA receptors. This may facilitate pathologically high levels of glutamate, calcium influx and subsequent excitotoxicity, which can disrupt synaptogenesis and synaptic plasticity. While studies of zinc supplementation in AN have shown some promise, the efficacy of this treatment is limited. This may be due to AN illness chronicity and the significant changes already made, as well as a reduced potency of zinc to inhibit NMDA receptors in a pathological state. Thus, we propose that the safe (at low doses) yet more potent NMDA receptor antagonist, ketamine, may act to normalise a perturbed glutamatergic system and increase synaptogenesis in the short term. This ‘kickstart’ via ketamine could then allow zinc supplementation and other forms of treatment to enhance recovery in AN.
... A strength of this study is that it allows examination of rates of comorbid psychiatric diagnoses during FBT in the context of psychotropic medication use. Rates in this sample were similar to rates of medication use in other U.S. samples (Lock et al., 2010;Monge et al., 2015), suggesting the findings are generalizable to other research and clinical samples. At least for some patients, medication may be used to effectively manage psychiatric comorbidities during FBT for AN. ...
Objective:
Rates of psychiatric comorbidity are elevated in adolescents with anorexia nervosa, but little is known about how psychiatric comorbidity changes following family-based treatment (FBT).
Methods:
Adolescents with anorexia nervosa (N = 107) enrolled in a randomized controlled trial comparing two forms of FBT completed the Mini International Neuropsychiatric Interview for Children and Adolescents at baseline and end of treatment. Analyses tested whether baseline comorbid diagnoses predicted the presence of comorbid diagnoses at end of treatment and if baseline eating disorder psychopathology impacted this association.
Results:
Rates of comorbid diagnoses decreased from 54% at baseline to 26% at end of treatment. Logistic regression analyses indicated that individuals with multiple comorbid diagnoses at baseline were more likely to meet criteria for a comorbid condition at end of treatment (b = 2.00, p < .05). Individuals with reported psychotropic medication use were less likely to meet criteria for a comorbid condition at end of treatment (b = -1.63, p = .04). Diagnostic rates for major depressive disorder, generalized anxiety disorder, and panic disorder/agoraphobia decreased following FBT.
Conclusions:
Findings suggest that FBT for adolescent anorexia nervosa may aid in the resolution of some co-occurring psychiatric diagnoses. Continued research is needed to understand factors contributing to comorbid symptom improvement throughout treatment.
... On the other hand, some studies 41 have proposed that substance abuse in patients with ADHD symp-toms aggravates and sometimes masks ED in adolescence. Although our conclusion is drawn from a sample in which purgative forms predominated, some evidence suggests that it is the restrictive forms that have a history of psychiatric comorbidity and previous psychopharmacological treatment 42 . ...
Introduction:
Eating disorders (ED) have been linked to attention deficit hyperactivity disorder (ADHD) because they present some symptoms in common. The aim of this study was to explore the influence on ED of symptoms suggestive of adult ADHD and how these symptoms affect the clinical presentation of adult patients. A further aim was to assess the impact of ADHD symptoms on quality of life and feelings of disability.
Method:
Participants comprised 89 patients diagnosed with ED according to DSM-5 criteria. The ASRS v.1.1 was used to divide them into two groups depending on whether they presented symptoms suggestive of adult ADHD or not, using a cut-off point of 4. Subsequently, we administered the EAT-40, BITE, BIS-11, SDI and Q-LES-Q scales.
Results:
Patients diagnosed with ED who also had symptoms suggestive of ADHD presented a higher number and severity of eating disorder symptoms, greater motor and cognitive impulsivity, increased dysfunction and a poorer quality of life.
Conclusions:
The results indicate that on average, patients with eating disorders and ADHD symptoms presented more and worse eating disorder symptoms, greater impulsivity, increased dysfunction and a poorer quality of life. It is therefore important to assess the presence of ADHD symptoms in patients with ED due to the implications for prognosis and progression.
... Influencia de los síntomas del trastorno por déficit de atención con hiperactividad en adultos en la calidad de vida y funcionalidad de los trastornos de conducta alimentaria Francisco Ferre, et al.TCA en la adolescencia. Aunque esta conclusión de nuestro trabajo se extrae de una muestra donde predominan las formas purgativas, hay datos que apuntan a que son las formas restrictivas las que tienen más antecedentes de comorbilidad psiquiátrica y de tratamiento psicofarmacológico previo42 . ...
... In general, treatment effectiveness for AN is limited [9] and, in particular, no medication has been approved for this disorder [10]. On the other hand, a large proportion of individuals with AN are treated with psychotropic medications [11], which raises the question of what place medication interventions may have in its treatment. ...
Anorexia nervosa (AN) is a severe psychiatric disorder without approved medication intervention. Every class of psychoactive medication has been tried to improve treatment outcome; however, randomized controlled trials have been ambiguous at best and across studies have not shown robust improvements in weight gain and recovery. Here we review the available literature on pharmacological interventions since AN came to greater public recognition in the 1960s, including a critical review of why those trials may not have been successful. We further provide a neurobiological background for the disorder and discuss how cognition, learning, and emotion-regulating circuits could become treatment targets in the future. Making every effort to develop effective pharmacological treatment options for AN is imperative as it continues to be a complex psychiatric disorder with high disease burden and mortality.
Background
Despite widespread use of higher levels of care in treating eating disorders in adolescents, research supporting the use of these treatments remains limited by small sample sizes and a predominant focus on anorexia nervosa. Further, existing data regarding predictors of outcome have yielded mixed findings. In the current study, we evaluated treatment outcomes and predictors of outcome among a large sample of adolescents with eating disorders presenting to inpatient, residential, partial hospitalization programs, and intensive outpatient programs across the United States.
Methods
Adolescents (N = 1,971) completed self-report measures of eating disorder symptoms, depression, and anxiety at treatment admission, stepdown, and discharge. Using linear mixed effect models, we evaluated changes in symptoms over treatment separately among youth admitted to inpatient/residential treatment and those admitted to partial hospitalization/intensive outpatient programs, and used established metrics to gauge frequency of reliable (i.e., statistically reliable) and clinically significant change.
Results
Results suggested decreases in eating disorder symptoms, depression, and anxiety from intake to discharge. Around 50% of the sample reported reliable decreases in eating disorder symptoms at stepdown and discharge, with 30% of the sample reporting reliable reductions in depression and anxiety. Psychiatric comorbidity, primary diagnosis, age, and eating disorder symptoms at admission consistently predicted treatment-related change, although patterns in findings varied across symptoms.
Conclusions
Data from our sample are consistent with past work suggesting that adolescents enrolled in higher levels of care report clinical benefit; however, these effects are heterogenous, and a significant portion of individuals may not report reliable change in symptoms. Ultimately, ongoing work is required to better understand how and for whom higher levels of care may achieve their benefit and to identify the optimal approach for improving outcomes for adolescents with eating disorders.
When it comes to anorexia nervosa (AN), there have been significant epidemiological changes over
the past years; an increase in the incidence has been recorded, shift to younger age groups, and “new” subtypes of
the disease with atypical features have been recognized. Subsequently, there have been changes in the classification of disorders and specific disorders have been defined. One of them is atypical anorexia nervosa (AAN) which
is in all aspects the same as classic AN except in terms of body weight which can be normal or even higher in
comparison with peers. Due to the fact that they are not obviously skinny, these patients are often not taken seriously enough, although their medical complications can be just as serious and clinically challenging as in patients
with classic AN. In fact, complications of AAN can be even more severe with more prominent psychoemotional
problems compared to patients suffering from the classic type of AN. The aim of this article is to familiarize readers
with this new term of an old eating disorder and explain the similarities and differences it shares with the classic
type of AN.
Objective
Currently, there is debate in the eating disorders field regarding how to define atypical anorexia (AAN), how prevalent it is in community and clinical settings, and how AAN rates compare with low‐weight AN. This systematic review assesses AAN literature from 2007 to 2020, to investigate: (a) the demographic characteristics of AAN studies, (b) the prevalence of AAN compared with AN, (c) the range of operational definitions of AAN and the implications of these definitions, and (d) the proportion of patients with AAN and AN represented in consecutive admission and referral samples.
Method
PsychINFO, CINAHL, PubMed, Greylit.org, and ProQuest databases were searched according to methods for Preferred Reporting Items for Systematic Reviews and Meta‐Analyses systematic reviews, yielding 3,184 potential articles. Seventy‐five eligible studies were coded for sixty‐one variables.
Results
Clinical samples predominantly included younger, female, white samples with limited diversity. In epidemiological designs, AAN was typically as common or more common than AN, and AAN rates varied significantly based on the population studied and operational definitions. In consecutive clinical samples, AAN was frequently less represented.
Discussion
Although AAN appears to occur more frequently than AN in communities, fewer patients with AAN are being referred and admitted to eating disorder specific care, particularly in the United States. Given the significant medical and psychosocial consequences of AAN, and the importance of early intervention, this represents a crucial treatment gap. Additionally, results suggest the need for fine‐tuning diagnostic definitions, greater diversity in AAN studies, and increased screening and referral for this vulnerable population.
IntroductionWe aimed to evaluate the bone mineral density (BMD) z scores of adolescents with atypical anorexia nervosa (AAN) and investigate the potential predictors of low BMD risk.Materials and methodsPotential factors that might have an effect on the femoral neck and lumbar spine dual energy X-ray absorptiometry data of adolescents (11–18 years) with AAN were retrospectively evaluated.ResultsAmong adolescents with AAN, 13 (34.2%) had a z score lower than − 1 and 25 (65.8%) had a z score equal or greater than − 1. When adolescents with a BMD score lower and higher than − 1 were compared, normal BMD group had a significantly higher mean lifetime maximum BMI (p = 0.0035). Similarly previous overweight history was significantly higher in the normal BMD group (p = 0.005). A positive correlation was found between femoral neck (p = 0.002, r: 0.546) and lumbar spine (p: 0.002, r: 0.505) z scores and lifetime maximum BMI. There was also a positive correlation between lumbar spine BMD scores and BMI at admission (p = 0.001, r: 0.540). Lumbar spine z scores and amenorrhea duration were negatively correlated (p: 0.002, r: − 10.867).Conclusion
In the adolescent period similar to AN, AAN cases are also at risk for disordered bone health. In adolescents with AAN, BMI prior to the illness was estimated to be the significant parameter for the risk of low BMD. Special attention should be paid to the bone health of adolescents with AAN, especially for those who do not have a previous overweight history.
Eating disorders are serious, potentially life-threatening illnesses afflicting individuals through the life span, with a particular impact on both the physical and psychological development of children and adolescents. Because care for children and adolescents with eating disorders can be complex and resources for the treatment of eating disorders are often limited, pediatricians may be called on to not only provide medical supervision for their patients with diagnosed eating disorders but also coordinate care and advocate for appropriate services. This clinical report includes a review of common eating disorders diagnosed in children and adolescents, outlines the medical evaluation of patients suspected of having an eating disorder, presents an overview of treatment strategies, and highlights opportunities for advocacy.
Objective:
Psychotropic medication use in youth with eating disorders (EDs) is poorly understood despite high co-occurrence of psychiatric disorders. This study examined characteristics associated with medication use in treatment-seeking youth with EDs.
Method:
Youth up to age 18 reported on medication use when presenting to an academic medical center outpatient ED service in the United States. Data presented were collected between 1998-2015.
Results:
The sample (N = 604) was predominantly female (90.6%) with a mean age of 15.3 years (SD = 2.3). Approximately one-third (30%, n = 173) were taking psychotropic medications (40%, n = 70, were taking multiple medications). Antidepressant use was most common (26%, n = 152), followed by atypical antipsychotics (8%, n = 43). Adjusting for co-occurring psychiatric disorders, non-Hispanic Whites who had received prior treatment (psychotherapy, hospitalization) were significantly more likely to be using medication. Longer illness duration and prior treatment were associated with greater antidepressant use. For atypical antipsychotics, prior hospitalization was associated with greater use.
Conclusions:
Findings confirm moderate psychotropic medication use among young patients with EDs despite a lack of clarity regarding optimally effective pharmacologic interventions in this population. Pharmacological trials examining the efficacy of medications for young patients with EDs are warranted to inform future prescribing practice.
PurposeTo assess psychotropic use patterns and possible associations with age, eating disorder diagnosis and psychiatric comorbidity in adolescents and young adults with a primary eating disorder. MethodsA retrospective chart review of 86 consecutive patients with a primary eating disorder from August 2012 to December 2014 was conducted. Patients presented for a multidisciplinary evaluation at a United States-based academic program for eating disorders. ResultsNearly half (45.3%) of the patients reported being on a psychotropic medication. Antidepressants were the most reported category, prescribed in 38.4% of the patients evaluated. There was a significant association between the type of eating disorder and the number of psychotropics prescribed. Patients with a diagnosis of other specified feeding or eating disorder reported more prescriptions upon presentation than patients with anorexia nervosa. Despite the finding that a significant minority of patients had a psychiatric comorbidity, this did not appear to increase the likelihood of psychotropic usage over those diagnosed with an eating disorder alone. In addition, patients with a longer duration of illness and patients with a history of non-suicidal self-injury were more likely to present to treatment on psychotropic medications. Conclusions
Psychotropic medications appear to be commonly prescribed among individuals evaluated in a tertiary care center for an eating disorder. Given that psychotropics are not recommended as the primary intervention for eating disorders, the frequency may be indicative of practitioners not following research-informed practice guidelines. The differences observed may also reflect complexities related to clinical features or illness history. Level of evidenceLevel V: Descriptive study.
Human brain imaging can help improve our understanding of mechanisms underlying brain function and how they drive behavior in health and disease. Such knowledge may eventually help us to devise better treatments for psychiatric disorders. However, the brain imaging literature in psychiatry and especially eating disorders has been inconsistent, and studies are often difficult to replicate. The extent or severity of extremes of eating and state of illness, which are often associated with differences in, for instance hormonal status, comorbidity, and medication use, commonly differ between studies and likely add to variation across study results. Those effects are in addition to the well-described problems arising from differences in task designs, data quality control procedures, image data preprocessing and analysis or statistical thresholds applied across studies. Which of those factors are most relevant to improve reproducibility is still a question for debate and further research. Here we propose guidelines for brain imaging research in eating disorders to acquire valid results that are more reliable and clinically useful.
Purpose of review:
We reviewed the recent literature on prevalence rates, and application of evidence-based treatments for eating disorders among Hispanics/Latinos residing in the United States.
Recent findings:
Lifetime prevalence rates of anorexia nervosa are lower among Hispanic/Latinos than non-Hispanic Whites. There are comparable rates of bulimia nervosa and binge eating disorder (BED) among Hispanic/Latinos and non-Hispanic Whites. BED is the most common eating disorder among Hispanic/Latinos. Evidence-based treatments have begun to be implemented with Hispanics/Latinos. The core concepts of cognitive behavioral therapy for bulimia nervosa and BED apply to this population. Culture-specific adaptations include strengthening the collectivistic framework within an individualistic treatment, psychoeducation of immediate and extended family, and adjustment of meal plans that incorporated cultural foods.
Summary:
There are more similarities than differences in the prevalence of eating disorders across Hispanics/Latinos and non-Hispanic Whites. However, the social context such as immigration status and acculturation is important to consider in the development of eating disorders. In addition, the Westernization of Latin America may change the future relationship of immigration status and development of eating disorder within the United States. Overall, cultural adaptations of evidence-based treatments involved the inclusion of family within treatment, acculturation-related issues, and managing family conflicts that arise because of the changes in eating patterns.
Eating disorders are severe conditions, but little is known about the prevalence or correlates of these disorders from population-based surveys of adolescents.
To examine the prevalence and correlates of eating disorders in a large, reprefentative sample of US adolescents.
Cross-sectional survey of adolescents with face-to-face interviews using a modified version of the Composite International Diagnostic Interview.
Combined household and school adolescent samples.
Nationally representative sample of 10,123 adolescents aged 13 to 18 years.
Prevalence and correlates of eating disorders and subthreshold conditions.
Lifetime prevalence estimates of anorexia nervosa, bulimia nervosa, and binge-eating disorder were 0.3%, 0.9%, and 1.6%, respectively. Important differences were observed between eating disorder subtypes concerning sociodemographic correlates, psychiatric comorbidity, role impairment, and suicidality. Although the majority of adolescents with an eating disorder sought some form of treatment, only a minority received treatment specifically for their eating or weight problems. Analyses of 2 related subthreshold conditions suggest that these conditions are often clinically significant.
Eating disorders and subthreshold eating conditions are prevalent in the general adolescent population. Their impact is demonstrated by generally strong associations with other psychiatric disorders, role impairment, and suicidality. The unmet treatment needs in the adolescent population place these disorders as important public health concerns.
Eating disorders are complex, chronic disorders that are difficult to treat. In addition, the 2 primary eating disorders, anorexia nervosa and bulimia nervosa, may have acute, life-threatening consequences. Medication trials for eating disorders have been hampered by high dropout rates, high placebo response, short trial duration, insufficient doses, and difficult outcome measures. Only 1 medication has been FDA approved for any eating disorder to date, and that is for fluoxetine in the treatment of bulimia. Clearly, new large-scale, independent studies using novel agents, and studying the use of medications for both short- and long-term outcomes, are needed.
This paper aims to review the research literature on the use of medication for eating disorders in children and adolescents.
The literature was reviewed on the pharmacotherapy of anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS). The PubMed database was searched for all articles on medication use in the child and adolescent population using the terms medication, antipsychotic, antidepressant, child, adolescent, eating disorders, anorexia nervosa and bulimia nervosa.
Very little literature exists on the use of medication for the treatment of eating disorders in children and adolescents. There is one retrospective study on the use of SSRIs and some case reports on atypical antipsychotics for children and adolescents with AN, and one small open trial on SSRIs for adolescent BN.
Evidence-based pharmacological treatment for children and adolescents with eating disorders is not yet possible due to the limited number of studies available. It appears that olanzapine and other atypical antipsychotics may prove to be promising for AN at low body weights. It remains uncertain whether SSRIs are helpful in preventing relapse in AN. For children and adolescents with BN, the first line pharmacological option is fluoxetine given the large evidence base of this drug with the adult population and a small open trial of adolescents with BN.
DESCRIPTION. This is an update of the 2002 US Preventive Services Task Force recommendation on screening for child and adolescent major depressive disorder. METHODS. The US Preventive Services Task Force weighed the benefits and harms of screening and treatment for major depressive disorder in children and adolescents, incorporating new evidence addressing gaps in the 2002 recommendation statement. Evidence examined included the benefits and harms of screening, the accuracy of primary care-feasible screening tests, and the benefits and risks of treating depression by using psychotherapy and/or medications in patients aged 7 to 18 years. RECOMMENDATIONS. Screen adolescents (12-18 years of age) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up (B recommendation). Evidence is insufficient to warrant a recommendation to screen children (7-11 years of age) for major depressive disorder (I statement). Pediatrics 2009; 123: 1223-1228
Purpose:
The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year.
Methods:
Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed.
Results:
At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration.
Conclusions:
The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.
Given that atypical antipsychotic medications have been increasingly prescribed for improving weight gain in anorexia nervosa (AN), we conducted a systematic review and meta-analyses to estimate the influence of atypical antipsychotics on BMI, eating disorder, and psychiatric symptoms in individuals with AN.
Independent reviewers selected studies and extracted study characteristics, methodologic quality, and outcomes for the intention-to-treat group from randomized clinical trials comparing the effect of atypical antipsychotic use to placebo or an active control treatment on BMI.
Compared with placebo, atypical antipsychotics were associated with a nonsignificant increase in BMI (weighted mean difference, WMD = 0.18, 95% CI: −0.36, 0.72; I2 = 26%) and a nonsignificant effect on the drive for thinness and body dissatisfaction. Compared with placebo or active control, these medications led to an increase in anxiety and overall eating disorder symptoms. However, there was a significant reduction over placebo or active control on level of depression. © 2012 by Wiley Periodicals, Inc. (Int J Eat Disord 2013)
Objective To evaluate the prevalence, demographic and clinical correlates, and specificity of classes of psychotropic medications indicated for mental disorders.
Design Cross-sectional survey.
Setting Direct household interviews of combined household and school samples representative of the general population of adolescents in the United States.
Participants Ten thousand one hundred twenty-three adolescents aged 13 to 18 years who participated in the National Comorbidity Survey Adolescent Supplement.
Main Exposures Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) mental disorders and neurodevelopmental disorders.
Outcome Measure Psychotropic medication use in the past 12 months.
Results Among youth with any DSM-IV mental disorder, 14.2% reported that they had been treated with a psychotropic medication in the past 12 months. Strong associations emerged between specific disorders and classes of medications with evidence for efficacy. Antidepressants were most frequently used among those with primary mood disorders (14.1%); stimulant use was most common among those with attention-deficit/hyperactivity disorder (20.4%); and antipsychotic use was infrequent and mostly seen among those with serious developmental disorders. Less than 2.5% of adolescents without a 12-month mental disorder had been prescribed psychotropic medications, and most had evidence of psychological distress or impairment reflected in a previous mental disorder, subthreshold condition, or developmental disorder. Appropriate medication use was significantly more frequent among those in treatment in the mental health specialty sector than general medicine or other settings.
Conclusions These findings challenge recent concerns over widespread overmedication and misuse of psychotropic medications in US youth. In fact, these data highlight the need for greater recognition and appropriate treatment of youth with mental health disorders.
This review discusses the evidence base for medications that are currently used for obesity and eating disorders, including their Food and Drug Administration approval status by disorder and age group, contraindications, and major adverse effects. Investigational agents currently being considered, issues related to psychiatric and medical comorbidity, limitations of pharmacologic strategies, and recommendations for treatment are also addressed.
Objective
The purpose of this double-blind, placebo-controlled exploratory pilot study was to evaluate the safety and efficacy of risperidone for the treatment of anorexia nervosa.Method
Forty female subjects 12 to 21 years of age (mean, 16 years) with primary anorexia nervosa in an eating disorders program were randomized to receive risperidone (n = 18) or placebo (n = 22). Subjects completed the Eating Disorder Inventory 2, Color-A-Person Test, Body Image Software, and Multidimensional Anxiety Scale for Children at baseline and regular intervals. Weight, laboratory values, and electrocardiograms were monitored. Study medication was started at 0.5 mg daily and titrated upward weekly in 0.5-mg increments to a maximum dose of 4 mg until the subject reached a study endpoint.ResultsThe mean dose for the risperidone group was 2.5 mg and for the placebo group was 3 mg for a mean duration of 9 weeks. Subjects taking risperidone had a significant decrease on the Eating Disorder Inventory 2 Drive for Thinness subscale over the first 7 weeks (effect size, 0.88; p = .002), but this difference was not sustained to the end of the study (p = .13). The Eating Disorder Inventory 2 Interpersonal Distrust subscale decreased significantly more in subjects taking risperidone (effect size, 0.60; p = .03). Subjects taking risperidone had increased prolactin levels (week 7; p = .001). There were no significant differences between groups at baseline or the end of the study for the other rating scales, change in weight, or laboratory measurements.Conclusions
This study does not demonstrate a benefit for the addition of risperidone in adolescents with anorexia nervosa during the weight-restoration phase of care. Clinical trial registration information—A Double-Blind, Placebo-Controlled Study of Risperidone for the Treatment of Anorexia Nervosa, http://www.clinicaltrials.gov, NCT00140426.
To assess the utility of antipsychotics for weight gain and improvement of illness-related psychopathology in patients with anorexia nervosa.
PubMed, the Cochrane Library databases, and PsycINFO citations from the inception of the databases until March 27, 2012, were searched without language restrictions using the following keywords: randomized, random, randomly, and anorexia nervosa. In addition, we hand-searched for additional studies eligible for inclusion in this meta-analysis and contacted authors for unpublished data.
Included in this study were randomized placebo- or usual care-controlled trials of antipsychotics in patients with anorexia nervosa.
Two independent evaluators extracted data. The primary outcome of interest was body weight, expressed as the standardized mean difference (SMD) between the 2 groups in baseline to endpoint change of body mass index (BMI), endpoint BMI, or daily weight change. SMD, risk ratio (RR), and number needed to harm (NNH) ± 95% confidence interval (CI) were calculated.
Across 8 studies (mean duration = 9.6 weeks; range, 7-12 weeks), 221 patients (mean age = 22.5 years, 219 [99.1%] females) with anorexia nervosa were randomly assigned to olanzapine (n = 54), quetiapine (n = 15), risperidone (n = 18), pimozide (n = 8), sulpiride (n = 9), placebo (n = 99), or usual care (n = 18). Both individually (P = .11 to P = .47) and pooled together (SMD = 0.27, 95% CI, -0.01 to 0.56; P = .06, I2 = 0%; 7 studies, n = 195), weight/BMI effects were not significantly different between antipsychotics and placebo/usual care. Moreover, pooled antipsychotics and placebo/usual care did not differ regarding scores on questionnaires related to anorexia nervosa (P = .32, 5 studies, n = 114), body shape (P = .91, 4 studies, n = 100), depressive symptoms (P = .08, 4 studies, n = 103), and anxiety (P = .53, 4 studies, n = 121). Individually, quetiapine (1 study, n = 33) outperformed usual care regarding eating disorder attitudes (P = .01) and anxiety (P = .02). While rates of dropout due to any reason (P = .83, I2 = 0%) and due to adverse events (P = .54, I2 = 5%) were similar in both groups, drowsiness/sedation occurred significantly more often with antipsychotics than placebo/usual care (RR = 3.69, 95% CI, 1.37-9.95; I2 = 67%, P = .01; NNH = 2, P = .001; 5 studies, n = 129), but most other adverse effects were only sparsely reported.
Although limited by small samples, this meta-analysis failed to demonstrate antipsychotic efficacy for body weight and related outcomes in females with anorexia nervosa.
Objective
To assess the long-term course of recovery and relapse and predictors of outcome in anorexia nervosa. Method: A naturalistic, longitudinal prospective design was used to assess recovery and relapse in patients ascertained through a university-based specialty treatment program. Patients were assessed semiannually for 5 years and annually thereafter over 10–15 years from the time of their index admission. Recovery was defined in terms of varying levels of symptom remission maintained for no fewer than 8 consecutive weeks. Results: Nearly 30% of patients had relapses following hospital discharge, prior to clinical recovery. However, most patients were weight recovered and menstruating regularly by the end of follow-up, with nearly 76% of the cohort meeting criteria for full recovery. Relapse after recovery was relatively uncommon. Of note, time to recovery was protracted, ranging from 57–79 months depending on definition of recovery. Among restrictors at intake, nearly 30% developed binge eating, occurring within 5 years of intake. A variety of predictors of chronic outcome and binge eating were identified. There were no deaths in the cohort. Conclusion: The course of anorexia nervosa is protracted. Predictors of outcome are surprisingly few, but those identified are in keeping with previous accounts. The intensive treatment received by these patients may account for the lower levels of morbidity and mortality when considered in relation to other reports in the follow-up literature. © 1997 by John Wiley & Sons, Inc. J Eat Disord 22: 339–360 1997.
Depression, anxiety and obsessive-compulsive disorder are frequently reported to co-occur with anorexia nervosa (AN). There is clinical consensus that depressive symptoms and anxiety may in part be sequelae of malnutrition in AN. However, evidence-based data are still very rare. The present study among severe AN patients investigates links between these psychological variants and nutritional status at admission and subsequent to nutritional rehabilitation. Twenty-four women with AN diagnosed according to the Diagnostic and Statistical Manual IV (DSM-IV) were included prospectively and consecutively at hospitalisation. Nutritional status was assessed by body mass index (BMI). Several psychological aspects were assessed using various scales for depression, anxiety, social phobia, obsessive and eating behaviour symptoms. Follow-up weights and heights at 4-12 years after hospital discharge were measured in 18 patients. BMI and all the scores except the Yale-Brown obsessive-compulsive scale (Y-BOCS) showed significant improvement between admission and discharge. This study highlights the fact that some of the depressive and anxiety symptoms at least partially decrease with nutrition rehabilitation. The improvement in the scores on the psychometric scales between admission and discharge was not correlated with BMI improvement. Psychometric scores at admission and at discharge were not correlated with BMI at follow-up. BMI at follow-up was correlated with minimum lifetime BMI (r=0.486, P=0.04). Future studies should use a better indicator for nutritional status than BMI alone, and should also consider the initial degree of weight loss and the rate at which weight was lost.
Dropout from treatment has serious implications for patients, clinicians, and researchers. The aim of this study was to examine rates of dropout from outpatient treatment for anorexia nervosa (AN) and critically examine the various definitions of dropout used.
A systematic review was conducted, including pharmacological and psychological interventions. All articles in PubMed, Web of Science, and the Cochrane Library were considered, and screened against a priori inclusion/exclusion criteria. Relationships between treatment outcome and dropout rate were examined across studies.
Nineteen relevant studies were identified, with dropout rates ranging from 4.8% (family therapy) to 100% (dietary advice). In most cases, dropout was in the range of 20-40%. Definitions of dropout used varied widely. A significant negative correlation was found between rate of dropout and body mass index (BMI) at 1 year, but this did not remain significant when differences in BMI at baseline were taken into account.
High rates of dropout from treatment for AN have serious implications for recovery, research, and the development of new treatments. A suggested reporting structure is proposed, with the aim of increasing the consistency of dropout reporting and facilitating greater understanding of this phenomenon.
This quality improvement project collected and analyzed short-term weight gain data for patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED programs nationally.
Data on presentation and treatment of low-weight ED patients aged 9-21 years presenting in 2006 were retrospectively collected from 11 independent ED programs at intake and at 1-year follow-up. Low-weight was defined as < 90% median body weight (MBW) which is specific to age. Treatment components at each program were analyzed. Risk adjustment was performed for weight gain at 1 year for each site, accounting for clinical variables identified as significant in bivariate analyses.
The sites contained 6-51 patients per site (total N = 267); the mean age was 14.1-17.1 years; duration of illness before intake was 5.7-18.6 months; % MBW at intake was 77.5-83.0; and % MBW at follow-up was 88.8-93.8. In general, 40%-63% of low weight ED subjects reached ≥90% MBW at 1-year follow-up. At intake, patients with higher % MBW (p = .0002) and shorter duration of illness (p = .01) were more likely to be ≥90% MBW at follow-up. Risk-adjusted odds ratios controlled for % MBW and duration of illness were .8 (.5, 1.4)-1.3 (.3, 3.8), with no significant differences among sites.
A total of 11 ED programs successfully compared quality improvement data. Shorter duration of illness before intake and higher % MBW predicted improved weight outcomes at 1 year. After adjusting for risk factors, program outcomes did not differ significantly. All adolescent medicine-based ED programs were effective in assisting patients to gain weight.
The objective of this study was to explore whether the addition of olanzapine versus placebo increases weight gain and improves psychological symptoms in adolescents with anorexia nervosa-restricting type who are participating in a comprehensive eating disorders treatment program.
Twenty underweight females participated in this 10-week, double-blind, placebo-controlled pilot study of olanzapine. The primary efficacy measure was change in percentage of median body weight measured at baseline and weeks 5 and 10. Secondary efficacy measures included clinician-rated and self-reported measures of psychological functioning measured at 2-week intervals and eating disorder symptoms measured at baseline and weeks 5 and 10 as well as laboratory assessments (including indirect calorimetry), which were also performed at baseline and weeks 5 and 10. A mixed models approach to repeated measures analysis of variance was utilized to detect any treatment-by-time interaction.
Fifteen of 20 enrolled females (median age, 17.1 years; range, 12.3-21.8 years; mean body mass index, 16.3) completed this 10-week pilot study. Change in % median body weight did not differ between the treatment groups at midpoint or end of study. Both groups gained weight at a similar rate and had similar improvements in eating attitudes and behaviors, psychological functioning, and resting energy expenditure. A trend of increasing fasting glucose and insulin levels was found only in the olanzapine group at week 10.
These preliminary findings do not support a role for adjunctive olanzapine for underweight adolescent females with anorexia nervosa-restricting type who are receiving standard care in an eating disorder treatment program (clinical trials.gov; no. NCT00592930).
The paper presents a critical review (with search date 2010) of the major psychotropic medications assessed in eating disorders, namely antipsychotics, antidepressants, mood-stabilizing medications, anxiolytic and other agents. The evidence of efficacy of drug treatments is mostly weak or moderate. In addition, attrition rates are usually higher than for psychotherapies. However, there is support for use of antidepressants, particularly high-dose fluoxetine in bulimia nervosa, and anticonvulsants (topiramate) for binge-eating disorder. Low-dose antipsychotic medication may be clinically useful as adjunct treatment in acute anorexia, particularly where there is high anxiety and obsessive eating-related ruminations and failure to engage, but more trials are needed. Drug therapies such as topiramate and anti-obesity medication may aid weight loss in obese or overweight patients with binge-eating disorder; however, common or potentially serious adverse effects limit their use.
Anorexia nervosa (AN) is a serious psychiatric illness associated with significant morbidity and mortality. There is little empirical support for specific treatments and new approaches are sorely needed. This two-site study aimed to determine whether olanzapine is superior to placebo in increasing body mass index (BMI) and improving psychological symptoms in out-patients with AN.
A total of 23 individuals with AN were randomly assigned in double-blind fashion to receive olanzapine or placebo for 8 weeks together with medication management sessions that emphasized compliance. Weight, other physical assessments and measures of psychopathology were collected.
End-of-treatment BMI, with initial BMI as a covariate, was significantly greater in the group receiving olanzapine [F(1, 20)=6.64, p=0.018]. Psychological symptoms improved in both groups, but there were no statistically significant group differences. Of the 23 participants, 17 (74%) completed the 8-week trial. Participants tolerated the medication well with sedation being the only frequent side effect and no adverse metabolic effects were noted.
This small study suggests that olanzapine is generally well tolerated by, and may provide more benefit than placebo for out-patients with AN. Further study is indicated to determine whether olanzapine may affect psychological symptoms in addition to BMI.
Eating disorders are serious psychiatric illnesses that often present during adolescence and young adulthood. They are associated with medical as well as psychological disturbances, and pediatricians play an important role in their identification, diagnosis, and management. There has been a paucity of treatment research that specifically focuses on children and adolescents with eating disorders. This article reviews the scientific evidence for the use of psychotropic medication in the treatment of children and adolescents with eating disorders.
The incidence and prevalence of eating disorders in children and adolescents has increased significantly in recent decades, making it essential for pediatricians to consider these disorders in appropriate clinical settings, to evaluate patients suspected of having these disorders, and to manage (or refer) patients in whom eating disorders are diagnosed. This clinical report includes a discussion of diagnostic criteria and outlines the initial evaluation of the patient with disordered eating. Medical complications of eating disorders may affect any organ system, and careful monitoring for these complications is required. The range of treatment options, including pharmacotherapy, is described in this report. Pediatricians are encouraged to advocate for legislation and policies that ensure appropriate services for patients with eating disorders, including medical care, nutritional intervention, mental health treatment, and care coordination.
We examined the course of major depressive disorder (MDD) and predictors of MDD recovery and relapse in a longitudinal sample of women with eating disorders (ED).
246 Boston-area women with DSM-IV anorexia nervosa-restricting (ANR; n=51), AN-binge/purge (ANBP; n=85), and bulimia nervosa (BN; n=110) were recruited between 1987 and 1991 and interviewed using the Eating Disorders Longitudinal Interval Follow-up Evaluation (LIFE-EAT-II) every 6-12 months for up to 12 years. 100 participants had MDD at study intake and 45 developed MDD during the study. Psychological functioning and treatment were assessed.
Times to MDD onset (1 week-4.3 years), recovery (8 weeks-8.7 years), and relapse (1 week-5.2 years) varied. 70% recovered from MDD, but 65% subsequently relapsed. ANR patients were significantly less likely to recover from MDD than ANBP patients (p=0.029). Better psychological functioning and history of MDD were associated with higher chance of MDD recovery. Higher baseline depressive severity and full recovery from ED were associated with greater likelihood of MDD relapse; increased weight loss was somewhat protective. Adequate antidepressant treatment was given to 72% of patients with MDD and generally continued after MDD recovery. Time on antidepressants did not predict MDD recovery (p=0.27) or relapse (p=0.26).
Small ED diagnostic subgroups; lack of non-ED control group.
The course of MDD in EDs is protracted; MDD recovery may depend on ED type. Antidepressants did not impact likelihood of MDD recovery, nor protect against relapse, which may impact on treatment strategies for comorbid MDD and EDs.
The present study assesses the prevalence of subclinical eating disorders and examines their comorbidity with mood and anxiety disorders in a sample of adolescent girls. A DSM-III-R computerized self-reported interview was administered to 833 adolescent girls (mean age=15.7±0.5 years) from a population sample to assess the prevalence of subclinical eating disorders, major depression, dysthymia, separation anxiety, and generalized anxiety disorders. The prevalence of subclinical anorexia nervosa (restricting subtype) was 3.5%, 13.3% for weight concerns (restricting subtype), 3.8% for subclinical bulimia nervosa, and 10.8% for subclinical binge eating disorder. Girls with subclinical anorexia nervosa had a higher prevalence of separation anxiety diagnosis, and they reported significantly more major depressive and generalized anxiety symptoms compared with girls reporting no eating disorders. Girls with weight concerns reported significantly more major depressive, separation, and generalized anxiety symptoms compared with girls reporting no eating disorders. Girls with subclinical bulimia nervosa or binge eating disorder had a higher prevalence of mood disorders (major depression and dysthymia) compared with girls reporting no eating disorders. Furthermore, girls with subclinical bulimia nervosa or binge eating disorder also reported significantly more anxiety symptoms (separation anxiety and generalized anxiety) compared with girls reporting no eating disorders. In summary, adolescent girls suffering from subclinical eating disorders should be investigated concomitantly for mood and anxiety disorders while those suffering from mood and anxiety disorders should be investigated simultaneously for subclinical eating disorders.
This study examined factors that contributed to patient's eligibility and participation in a randomized controlled trial involving olanzapine for the adjunctive treatment of anorexia nervosa (AN). Factors involving patient eligibility and willingness to participate were systematically recorded for all patients approached to participate. Of the 92 patients that were assessed and treated over the study timeframe, only 27 patients (29%) met full criteria for inclusion, of which just 7 enrolled (26%). The most common reasons for study refusal related to fears associated with medication effects and refusal to consider medication as a treatment option (70%). Factors affecting recruitment in psychopharmacological studies involving AN in youth are discussed.
Anxiety disorders are a potentially disabling group of disorders which are prevalent in childhood and adolescence. The recognition of the early onset of anxiety disorders, and their successful treatment with medication in adults, has led to the growing interest in using medication for paediatric anxiety disorders.
To assess the efficacy and tolerability of medication for treating paediatric anxiety disorders.
We searched the Cochrane Depression, Anxiety & Neurosis Group specialised register (CCDANCTR-Studies), MEDLINE (via PubMed 1966 to August 2008), EMBASE (1966 to August 2008), and PsycINFO (1972 to August 2008). Various electronic registers were searched for unpublished studies. Reference lists of retrieved articles were searched for additional studies.
All randomised controlled trials (RCTs) of pharmacotherapy in childhood/adolescent anxiety disorders.
Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin reuptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were undertaken.
22 short-term (<= 16 weeks) RCTs were included in the analysis (2519 participants). The majority of the trials assessed the efficacy of the SSRIs (N = 15).Medication and placebo response occurred in 58.1% and 31.5% of patients, respectively (Number of studies (N) = 14, Number needed to treat (NNT) = 4). Medication was more effective than placebo in reducing overall symptom severity in OCD in a post-hoc comparison (N = 7, Weighted Mean Difference (WMD) = -4.45, 95%CI = -5.94, -2.97, n = 765). Medication was less well tolerated than placebo overall, though the absolute proportion of participants who withdrew due to drug-related adverse events was low (4.9%).
Medication treatments can be effective in paediatric anxiety disorders, acting to reduce core symptoms, and should be considered as part of the treatment of these disorders. The greatest number of trials showing efficacy to date have assessed the SSRIs in treating paediatric OCD.There is no clear evidence to show that any particular class of medication is more effective or better tolerated than any other. As quantitative data was only available for the SSRIs and venlafaxine the routine use of benzodiazepines cannot be recommended, especially given concerns of dependency and treatment -related emergent adverse events associated with this class of drugs.Future RCTs could help identify potential clinical moderators of treatment efficacy. Studies of the long-term efficacy of medication treatment, optimal dosage, as well as direct comparisons of pharmacotherapy and psychotherapy are also warranted.
To review selected issues regarding the development of drug treatments for anorexia nervosa (AN).
The existing pharmacotherapy literature for AN is reviewed, and the theoretical and practical considerations are discussed.
A very wide variety of drugs have been examined in AN, generally with negative results. There are a number of potential reasons for this finding, including compliance, nutritional deficits, selection of the wrong targets or the wrong outcome measures, use of monotherapy, lack of animal models, or factors intrinsic to AN.
Pharmacotherapy provides little benefit in the treatment of AN at present. Several strategies might lead to the identification of more effective agents, including new measurement strategies, identification of novel pharmacologic targets, and consideration of a clinical trials network.
To assess the long-term course of recovery and relapse and predictors of outcome in anorexia nervosa.
A naturalistic, longitudinal prospective design was used to assess recovery and relapse in patients ascertained through a university-based specialty treatment program. Patients were assessed semiannually for 5 years and annually thereafter over 10-15 years from the time of their index admission. Recovery was defined in terms of varying levels of symptom remission maintained for no fewer than 8 consecutive weeks.
Nearly 30% of patients had relapses following hospital discharge, prior to clinical recovery. However, most patients were weight recovered and menstruating regularly by the end of follow-up, with nearly 76% of the cohort meeting criteria for full recovery. Relapse after recovery was relatively uncommon. Of note, time to recovery was protracted, ranging from 57-79 months depending on definition of recovery. Among restrictors at intake, nearly 30% developed binge eating, occurring within 5 years of intake. A variety of predictors of chronic outcome and binge eating were identified. There were no deaths in the cohort.
The course of anorexia nervosa is protracted. Predictors of outcome are surprisingly few, but those identified are in keeping with previous accounts. The intensive treatment received by these patients may account for the lower levels of morbidity and mortality when considered in relation to other reports in the follow-up literature.
Few pharmacotherapy trials have been undertaken in young people with anxiety disorders. Of those conducted, few are placebo-controlled or blinded, and often sample size is small, making interpretation of the data difficult.
Case report and uncontrolled trial data generally support the efficacy of pharmacotherapy in many of the anxiety disorders seen in young people. However, most attempts to confirm these impressions in controlled trials have not been as encouraging. Further controlled studies in larger, diagnostically homogeneous samples are needed. At present, the decision as to whether or not to use medication in this patient population must be made on clinical grounds. Evidence is accumulating to suggest that anxiety disorders in young people can become chronic and cause at least moderate functional impairment in some individuals. This possibility has to be weighed against the potential for adverse effects of many of the drugs used clinically. Serious adverse effects appear only in a minority of patients; however, there does not seem to be a reliable method of predicting which patients might be at risk.
Benzodiazepines are used to treat anxious children, notwithstanding concerns about dependence, behavioural disinhibition, cognitive impairment and mood changes. The tricyclic antidepressants (TCAs) are generally well tolerated, but their effects on cardiac conduction at higher plasma concentrations are well documented and there have been sporadic reports of sudden death associated with their use in children. Toxicity in overdose is an added concern.
The use of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors in children and adolescents is widespread, but few rigorous supportive trials have been conducted. The occurrence of both potentially serious adverse effects and other less serious, but troublesome, adverse effects and a possible discontinuation syndrome may complicate the use of these agents in younger patients. However, their relative safety in overdose and the apparent reversibility of adverse effects may favour their use over the TCAs.
Other drugs used in this setting include buspirone and β-blockers. No controlled trials are available at this time, but their adverse effect profiles appear to be relatively favourable and further study is warranted, given the promising nature of the uncontrolled data. The reversible monoamine oxidase inhibitors may be useful in younger anxious patients, but controlled data are needed.
The decision to use pharmacotherapy should be made after consideration of multiple factors, and firm recommendations for the use of drug therapy in anxiety disorders in children and adolescents await more rigorous data.
Although selective-serotonin-reuptake-inhibitors (SSRI) have been of limited efficacy in the treatment of eating disorder psychopathology and comorbid symptoms of malnourished patients with anorexia nervosa (AN), there is recent data suggesting that SSRI may play a role in preventing relapse among weight-restored patients. Though some previous studies included patients in late adolescence, the vast majority of investigated subjects have been adults. The aim of our retrospective study was to assess the effects of SSRI treatment in partially weight-restored children and adolescents with AN. Thirty two females with AN (mean 14.5+/-1.4 years) were investigated three times during inpatient treatment and at 3- and 6-month follow-up for BMI, eating disorder psychopathology, depressive symptomology, and obsessive-compulsive symptomology. Medication history during inpatient and outpatient treatment was reconstructed at the 6-month follow-up. Nineteen patients received SSRI treatment, while 13 subjects were non-medicated. In comparison to the non-SSRI group, the SSRI group had similar BMI and obsessive-compulsive scores, but higher levels of core eating disorder psychopathology and depressive symptoms at the start of medication. Rates of re-admissions were similar in both groups (SSRI group: 36%, non-SSRI group: 31%, Phi: p=0.72). Repeated measures ANOVA revealed no significant group with time interactions for BMI-SDS (p=0.84), core eating disorder symptoms (ANIS, p=0.79), depression (DIKJ, p=0.75), and obsessive-compulsive (CY-BOCS, p=0.40) scores indicating minimal or no effects of SSRI medication on the course of these variables. In conclusion, our results challenge the efficacy of SSRI medication in the treatment of eating disorder psychopathology as well as depressive and obsessive-compulsive comorbidity in adolescent AN. Clinicians should be chary in prescribing SSRI in adolescent AN unless randomized controlled trials have proofed the benefit of these drugs.
Anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED) comprise the currently recognised eating disorders. Although distinct diagnostic entities, they share certain forms of comorbid psychopathology, particularly anxiety and mood disorders. BN and BED have been studied most intensively as targets for pharmacotherapy. The list of drugs tested in eating disorders is substantial; however, the number of therapeutic classes of medications tested in these conditions is relatively modest. Antidepressant medications, including tricyclic antidepressants, selective serotonin re-uptake inhibitors, as well as some of the novel antidepressants, have shown evidence of some therapeutic value in both BN and BED. Their efficacy in AN, however, has been disappointing. The pharmacological options for AN are very limited. The number of controlled trials that have been conducted is small, and the research that has been successfully completed has generally failed to demonstrate medication efficacy. Patients with BN typically show reduced binge eating and purging frequency in medication trials, but rarely attain abstinence. In BED, patients often measure the value of their medication therapy by its ability to stimulate weight loss, which is another area on which future pharmacotherapy may improve. Novel pharmacological interventions are needed for each of these conditions. Peptide hormones are increasingly being evaluated for eating disorder treatment, including ghrelin agonists, neuropeptide Y1 and -5 antagonists, orexin receptor antagonists, corticotropin-releasing factor receptor 2 antagonists, histamine 3 antagonists, melanocortin 4 receptor antagonists, beta3-adrenoceptor agonists, 5-hydroxytryptamine-2A antagonists and growth hormone agonists. Although these compounds are in early phases of clinical testing for eating disorder treatments, data from these studies will be instructive in the quest for effective pharmacotherapy for these conditions. An overview of the current pharmacotherapy options for eating disorders is presented with a discussion of the emerging potential treatments.
Are antipsychotics effective for the treatment of anorexia nervosa? Results from a systematic review and meta-analysis
- T Kishi
- V Kafantaris
- S Sunday
Kishi T, Kafantaris V, Sunday S, et al. Are antipsychotics effective for the
treatment of anorexia nervosa? Results from a systematic review and
meta-analysis. J Clin Psychiatry 2012;73:e757e66.
Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement
Screening and treatment for major depressive disorder in children and
adolescents: US Preventive Services Task Force Recommendation Statement. Pediatrics 2009;123:1223e8.