Written by Annabella Hochschild, BA, Laurel Mayer, MD, and Deborah R. Glasofer, PhD.
Seeking treatment for an eating disorder can be hard – sometimes due to resources, misconceptions about the treatment process, or because of the nature of the disorders themselves – and research has shown that over 40% of individuals with an eating disorder don’t get the help they might need.
When it comes to treatment options, sometimes people don’t even realize that psychotropic medications are a possibility to consider. Psychotropic medications are those that affect your mind – your emotions and your behavior – typically by altering the balance of the chemicals in your brain called neurotransmitters. Precisely how changes in neurotransmitter levels lead to changes in how people feel and how they behave remains quite mysterious.
The main classes of drugs used in psychiatric treatment are known by the names associated with the condition the medication was first used to treat. For example, antidepressants are named as such because they were initially tested as a treatment for depression, but they are now used to target a range of mood, anxiety, and eating problems.
The Current Landscape
The strongest evidence-base for the use of medications is for eating disorders involving binge eating, including bulimia nervosa and binge eating disorder.
For example, more than a dozen studies have compared an antidepressant medication to placebo in people with bulimia nervosa and virtually all have found that patients taking the antidepressant were much more likely to reduce their binge eating and purging. Fluoxetine (Prozac®) is perhaps the most rigorously studied and has an FDA-indication for the treatment of this disorder. The recommended target dose of fluoxetine in the treatment of bulimia nervosa is 60mg, which is higher than the dosage typically found to be effective in the treatment of depression.
Based on multiple randomized controlled trials of several medications in this class, it is clear that antidepressant medications are also helpful in controlling binge eating for people with binge eating disorder. On average, these antidepressant medications don’t have much of an effect on weight.
For individuals with binge eating disorder for whom weight loss is a treatment goal shared by clinician and patient, other medications are sometimes prescribed. Weight loss medications like sibutramine (Meridia®, no longer available) have been shown to decrease binge eating. The stimulant medication lisdexamfetamine (Vyvanse®), which is used to treat ADHD, has been found to significantly reduce cravings and binge eating, and to be associated with some weight loss, has received FDA approval to treat this eating disorder. However, consistent with its being a stimulant, lisdexamfetamine use is associated with mild increases in pulse and blood pressure which could be problematic for individuals with cardiovascular disease. Long-term effects of lisdexamfetamine on cardiovascular health are an area for further study, especially given the potential cardiovascular complications associated with obesity.
Like individuals with bulimia nervosa and binge eating disorder, those with anorexia nervosa have a number of symptoms, including significant anxiety and depression, which theoretically would seem readily improved by psychotropic medication. It is therefore surprising (and somewhat confusing) that antidepressant medications appear basically useless for this disorder, both when people are underweight and after weight has returned to normal. However, as anxiety and mood symptoms are also known to be exacerbated by the state of starvation, many people with anorexia nervosa experience an improvement in these symptoms with restoration to and maintenance of a healthy weight.
Medication trials in anorexia nervosa have been limited by relatively small sample sizes and high dropout rates, and those which have been conducted all seem to agree that no medication is particularly useful. The medications most frequently prescribed in the treatment of anorexia nervosa are SSRIs (selective serotonin reuptake inhibitors), of which fluoxetine (Prozac®) is the best-studied. Again, however, in randomized controlled trials, fluoxetine has not proven to be significantly helpful in treating anorexia nervosa.
It is a similar story with anti-anxiety medications. These medications are appealing, in theory, because people with anorexia nervosa generally experience high levels of anxiety around mealtimes. Anti-anxiety medications, like alprazolam (Xanax®), have sometimes been used to help alleviate mealtime anxiety and help people to eat more, but they don’t appear to be dramatically helpful.
Another class of drugs considered potentially useful in treating anorexia nervosa is a category referred to as second generation, or atypical, antipsychotic medications. Clinical researchers, including our team here at Columbia, have considered antipsychotic medications as possibly helpful because of their ability to relieve anxiety and compulsive thinking about body shape and weight, and because these medications are associated with weight gain in people without eating disorders who take them.
In the last decade or so, sufficient evidence has accumulated to support that the antipsychotic medication olanzapine (Zyprexa®) provides a bit of assistance in helping people with anorexia nervosa gain weight. Recently published findings from the largest study to date – a multi-site trial led by our team at Columbia – indicate that adults with anorexia nervosa prescribed olanzapine gained about a pound more per month compared to those taking a placebo. On the other hand, olanzapine had little impact on psychological symptoms. While the overall weight gain was small in the olanzapine group, and therefore not the “magic pill” for which people might be hoping, olanzapine may be of some help during the weight gain process.
To date, there are no published medication trials for the treatment of avoidant restrictive food intake disorder (ARFID).
To determine if a medication might be useful – and which one – the first step is to meet with a clinician with expertise in treating patients with eating disorders who can prescribe medications. Psychiatrists are medical doctors who specialize in treating individuals in need of psychotropic medications, and are therefore in the best position to have an in-depth discussion about the relative merits and risk of specific medicines following an evaluation of current symptoms, as well as medical and psychiatric history.
If you choose to try a medication and are confused or concerned about your prescriber’s recommendations, ask questions so that you understand his or her rationale and the treatment plan.