Medications in the treatment of eating disorders.

Effective planning for medication treatment in patients with bulimia nervosa and anorexia nervosa is based on a comprehensive clinical assessment, including a careful review of comorbid psychiatric disorders and response to treatments for previous episodes of the disorder. Although most patients with bulimia nervosa are offered a trial of psychotherapy, significant results of controlled trials have contributed to an increased role for medications in the treatment of patients with this disorder. Pharmacologic treatment of anorexia nervosa has similarities to that of treatment-resistant depression, with the clinician turning to open trials and clinical reports for clues to rational management. As described in this article, considerations of potential side effects and medical complications are likely to play an important role in guiding the choice of medication used for treatment of patients with eating disorders.

Comorbidity of axis I psychiatric disorders in bulimia nervosa.

BACKGROUND: The coexistence of other psychiatric disorders in patients with bulimia nervosa is of major clinical and theoretical interest. We therefore studied a group of consecutively evaluated bulimic patients. METHOD: The Structured Clinical Interview for DSM-III-R (SCID) was administered to a sample of 59 female patients with DSM-III-R-defined bulimia nervosa. RESULTS: The following frequencies of lifetime Axis I comorbid diagnoses were found (in decreasing frequency): any affective disorder (75%), major depressive disorder (63%), any anxiety disorder (36%), any substance abuse disorder (20%), social phobia (17%), generalized anxiety disorder (12%), and panic disorder (10%). In the 44 cases with an affective disorder, 27 (61%) had the onset of affective disorder, 27 (61%) had the onset of their affective disorder prior to the onset of their bulimia, 15 (34%) afterward, and 2 (5%) concurrently. In the 21 cases with any anxiety disorder, 15 (71%) had the onset of their anxiety disorder prior to the onset of their bulimia, 4 (19%) afterward, and 2 (10%) concurrently. CONCLUSION: These data confirm previous reports of a strong association between bulimia nervosa and affective illness, which in most cases precedes the eating disorder. In addition, a high frequency of anxiety disorders, particularly social phobia, is seen in bulimic patients.

Pharmacologic approaches in the treatment of eating disorders.

Important advances in the treatment of eating disorders, particularly bulimia nervosa, have been made during the past decade. Controlled trials for bulimia nervosa have demonstrated significant benefit from short-term pharmacotherapy with antidepressant medications and from short-term individual and group psychotherapies. Despite these advances, treatment of a patient often involves complex clinical decisions around such issues as choice of initial treatment modality, incomplete resolution of symptoms, and the role of long-term maintenance treatment. To address these questions, this review focuses primarily on summarizing results of published controlled trials of pharmacotherapy in patients with bulimia nervosa. In addition, it outlines the more limited literature on controlled pharmacotherapy trials for anorexia nervosa and for the provisionally identified syndrome of binge eating disorder.

A clinical guide to antipsychotic drugs.

Antipsychotic medications have altered the treatment of psychosis. The effect of typical agents is presumed to be associated with dopamine D2-receptor blockade. Response to these drugs can be evaluated by measuring target symptoms. Behavioural symptoms are generally first to respond, followed by affective symptoms, and then symptoms of disturbed cognition and perception. Predictors of response include age of onset, premorbid function, family history, cognitive function, ventricle size, and levels of homovanillic acid. As all conventional antipsychotic medications of comparable dose are generally of equivalent efficacy (with the exception of clozapine), choice is based on past response and the patient's tolerance of adverse effects. When antipsychotic agents are administered in the short term to control agitated dangerous behaviour, they can be given intramuscularly and augmented with benzodiazepines. For the ongoing treatment of psychosis, haloperidol 5 mg/day, or its equivalent, is usually sufficient. Continuation of treatment after an acute episode may be decided on the basis of chronicity of the psychotic illness. Relapse rates are higher when patients do not continue to receive medication. Lower maintenance doses may result in higher relapse rates but fewer adverse effects. Long-acting intramuscular depot preparations may be used to aid compliance in long term therapy. Adverse reactions correlate with potency. High potency drugs (i.e. those with greater D2 postsynaptic receptor affinity) are generally associated with extrapyramidal symptoms, including acute dystonic reactions, akathisia, tardive dyskinesia and Parkinsonism. Neuroleptic malignant syndrome is associated with all neuroleptic drugs. Low potency agents may cause orthostatic hypotension, sedation and anticholinergic effects. Clozapine has been shown to be effective in 30 to 40% of patients resistant to previous treatment. It does not cause extrapyramidal symptoms, but does have side effects similar to those of low potency agents and may cause agranulocytosis; it is therefore reserved for those patients who have not responded to therapy with 2 other agents. Several other atypical drugs are currently being investigated.

The delusion of possession in chronically psychotic patients.

Sixty-one chronically psychotic outpatients were grouped according to the presence or absence of a history of delusional possession. Compared with patients without a history of delusional possession (N = 36), possessed patients (N = 25) had significantly more self-reported childhood sexual abuse, higher dissociation scores, more cannabis abuse, more experiences of thought control, and more voices heard inside their heads. These findings support the hypothesis that in some psychotic patients, possession beliefs may reflect childhood trauma and dissociation.

An open trial of buspirone added to neuroleptics in schizophrenic patients.

Twenty chronic schizophrenic patients completed at least 2 weeks of a 6-week trial of buspirone (mean dose 23.8 mg/day) added to a stable dose of neuroleptic. At week 6, mean scores were significantly improved (p less than 0.01) on the Brief Psychiatric Rating Scale, the Simpson Angus Scale for Extrapyramidal Symptoms and the Global Assessment Scale. Overall measures of akathisia and tardive dyskinesia were not significantly changed at week 6. In the 7 patients taking oral haloperidol, mean plasma concentrations of haloperidol were significantly increased (p less than 0.05) by 26% 6 weeks after adding buspirone.

Elevation of plasma concentrations of haloperidol after the addition of fluoxetine.

Fluoxetine (20 mg/day) was added for 7-10 days to stable doses of haloperidol given to eight psychotic patients. Mean plasma concentrations of haloperidol were elevated by 20% (p less than 0.05), but extrapyramidal side effects did not increase appreciably, indicating a relatively minor interaction between these agents.

Self-reports of childhood abuse in chronically psychotic patients.

A heterogeneous sample of 61 chronically psychotic patients were subgrouped according to the presence or absence of a self-reported history of childhood abuse. Patients reporting childhood abuse (n = 27) had an earlier age of onset, scored higher on the Dissociative Experiences Scale, reported more amnesia, and relapsed more frequently than patients not reporting abuse histories. Histories of childhood abuse and of past stimulant abuse predicted the score on the Dissociative Experiences Scale. A history of childhood abuse may thus contribute to the symptomatology and course of illness in some chronically psychotic patients.

Reversal of fluoxetine-induced anorgasmia by cyproheptadine in two patients.

The authors report two cases of ejaculatory dysfunction induced by fluoxetine. Cyproheptadine, an antihistaminic and antiserotonergic drug, restored sexual function in each case. Possible mechanisms of fluoxetine-induced anorgasmia are presented and treatment options are reviewed.

Clovoxamine in the treatment of depressed outpatients: a double-blind, parallel-group comparison against amitriptyline and placebo.

In a double-blind, random-assignment, parallel-group trial, outpatients with major depression received either the new antidepressant clovoxamine, the tricyclic amitriptyline, or placebo for 6 weeks. By an "improvement" criterion of 50% or greater improvement in the Hamilton Depression Scale (HAM-D) total score, 88% of clovoxamine completers improved versus 75% with amitriptyline and 43% with placebo; however, due to small numbers, the differences failed to reach statistical significance. Diminished salivary flow was significantly greater with amitriptyline, as were complaints of dry mouth, somnolence, dizziness, and headache. Nausea and vomiting were more common in the clovoxamine-treated group. With amitriptyline, but not with clovoxamine, memory performance declined over a month. However, psychomotor performance was not affected.

A crossover study of lecithin treatment of tardive dyskinesia.

The authors enrolled 21 patients in a random-order, crossover, double-blind trial of phosphatidylcholine (lecithin) 20 g/day and placebo. Fourteen patients completed at least 6 weeks of the second 8-week trial and were used for efficacy analyses. Side effects were minimal. The lecithin treatment effect--about one half of an Abnormal Involuntary Movement Scale point--was seen as a statistical effect of treatment order, based on differences between patients who took the active compound before or after they took the placebo. Clinically, however, the lecithin effect was negligible.

Trial of fluoxetine added to neuroleptics for treatment-resistant schizophrenic patients.

Mean ratings of positive and negative symptoms and depression significantly improved in nine treatment-resistant schizophrenic patients who completed a 6-week open trial of fluoxetine added to their neuroleptics. The authors identify differences between responders and nonresponders and recommend controlled trials.

A role for high-dose antipsychotics.

The authors present a series of cases demonstrating that some chronically psychotic patients require higher doses of antipsychotic medication (greater than 15 mg/day of haloperidol equivalents) than are currently in vogue as a result of research on low-dose treatment. In a random sample of 100 patients treated with psychotropic medication, 64 were treated with antipsychotics. Of these, 8 (12.5%) appeared to require high doses. The literature on low-dose treatment is reviewed, and the role of higher-dose therapy is placed in perspective.

The therapist as representative payee.

The effects of the therapist's assuming control of the patient's finances through representative payeeship is discussed. The authors use case examples from an urban outpatient community mental health center to illustrate administrative issues, ethical conflicts, and transference and countertransference manifestations of payeeship. They favor an approach whereby the institution is formally the payee and a clinician is designated to manage a patient's account. For most patients for whom a clinician assumed payeeship, compliance with treatment increased, the number and length of hospitalizations decreased, and housing arrangements improved. Although designating the therapist as payee has a significant impact on the therapeutic relationship, in most cases the patient is so impaired that the benefits outweight the liabilities.

Fluoxetine-induced sexual dysfunction.

Of the first 60 patients treated at our clinic with the antidepressant fluoxetine, 5 (8.3%) developed treatment-emergent sexual dysfunction (anorgasmia and/or delayed orgasm). Three of those 5 patients had a history of treatment-emergent sexual dysfunction while receiving other antidepressant agents. Clinicians should be aware of this side effect of fluoxetine.