Medication in treatment of adolescent eating disorders
An Interview with Dr. James Lock,
Stanford University Eating Disorders Program
Dr. Lock is Professor of Child Psychiatry and Pediatrics in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine where he also serves as Director of the Eating Disorder Program for Children and Adolescents. He is the co-author of Treatment Manual for Anorexia Nervosa: A Family-Based Approach, Help Your Teenager Beat an Eating Disorder and Treating Bulimia in Adolescents: A Family-Based Approach. He has lectured widely in the US, Canada, South America, Europe, and Australia. He has been funded by the NIH to conduct treatment research in eating disorders continuously since 1997. Dr. Lock also serves as Clinical Advisor to Maudsley Parents. We talked with him about the role of medication in treating eating disorders.
Dr. Lock, thank you so much for talking with us. Can you give us an overview of what the research tells us about medication in the treatment of children and adolescents with eating disorders?
The research is very limited in medication treatments for eating disorders in general and in children and adolescents even less has been done. No medication has been shown to be effective for the core symptoms of anorexia nervosa in adults or children. There are conflicting studies about the effectiveness of SSRIs (like Prozac) to prevent weight loss after hospitalization (Kaye et al., 2001; Walsh et al., 2006). However, the largest and better controlled study did not find benefit of adding Prozac even with psychotherapy (cognitive-behavioral therapy) (Walsh et al., 2006).
The newer atypical antipsychotics (risperidone, olanzapine) have been used in one randomized controlled trial (RCT) in adults, but patients tended to refuse to take the medication, so although some patients gained weight, results of the study were inconclusive. In children and adolescents, a number of small studies suggest these are helpful for anxiety and perhaps obsessive features, but do not appear as useful for weight gain or the thought processes associated with anorexia (Barbarich et al., 2004; Bissada, Tasca, Barber, & Bradwejn, 2008; Boachie, Goldfield, & Spettigue, 2003; Brambilla et al., 2007; Mehler et al., 2001) At this point, the use of these medications should be considered only in highly refractory cases and for short term treatment addressing severe behavioral or psychological resistance to weight restoration.
We often hear from parents of teens with anorexia nervosa (AN) who are very concerned about signs of depression and obsessive behavior they see. What advice would you give them?
As both depressed feelings and obsessive behaviors are associated with AN itself, unless there is a definite history of depression or OCD PRIOR to the onset of AN, I would suggest waiting until weight is restored to about 90% of expected before starting a medication for these co-morbid condition. I would also suggest that a child and adolescent psychiatrist with expertise in eating disorders be involved in prescribing and monitoring any medications for this population and age group as they would have the necessary expertise to make sure that the medication was prescribed and monitored safely and appropriately.
What about bulimia nervosa? Is there are role for medication in treatment?
For bulimia nervosa, all classes of antidepressants seem to be useful in adults, though the SSRIs are considered the safest and likely the best tolerated (Walsh et al., 2000; Walsh et al., 1997). However, psychological therapies, particularly cognitive-behavioral therapy and interpersonal therapy (IPT) appear to be more useful. In some cases, adding an SSRI to psychotherapy may help boost the effects.(Fichter et al., 1991; Walsh et al., 2000). In adolescents, there is only one small study of a case series of adolescents treated with fluoxetine (Prozac). This study suggested fluoxetine was well tolerated and possibly beneficial in the context of a range of other psychotherapies. At this point, the recommendation for use of fluoxetine would be similar to that for adults with bulimia nervosa: use when psychotherapy cannot be used and as an adjunct to therapy when needed.
Can you give parents some advice about how to find appropriate help and how they can best work with their child’s psychiatrist?
This can be a challenge. I would suggest contacting the nearest treatment center for eating disorders and ask them for referrals. One can also review the child psychiatrists that are member of the Academy of Eating Disorders to identify possible local providers.
Barbarich, N., McConaha, C., Gaskill, J., LaVia, M., Frank, G., Brooks, S., et al. (2004). An open trial of olanzapine in anorexia nervosa. Journal of Clinical Psychiatry, 65, 1480-1482.
Bissada, H., Tasca, G., Barber, A., & Bradwejn, J. (2008). Olanzapine in the treatment of low body weight and obsessive thinking in women with anorexia nervosa: a randomized, double-blind, placebo controlled trial. Am J Psychiatry, 165, 1281-1288.
Boachie, A., Goldfield, G., & Spettigue, W. (2003). Olanzapine use as an adjuctive treatment for hospitalized children with anorexia nerovsa: case reports. Int J Eat Disord, 33, 98-103.
Brambilla, F., Garcia, C., Fassino, S., Daga, G., Favaro, A., Santonastaso, P., et al. (2007). Olanzapine therapy in anorexia nervosa: psychobiological effects. Int Clin Psychopharmacol, 22, 197-204.
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Kaye, W. H., Nagata, T., Weltzin, T., Hsu, B., Sokol, M., McConaha, C., et al. (2001). Double-blind placebo controlled administration of fluoxetine in restricting and restricting-purging type anorexia nervosa. Biological Psychiatry, 49, 644-652.
Mehler, C., Wewetzer, C., Schulze, U., Warnke, A., Theisen, F., & Dittman, R. (2001). Olanzapine in children and adolescents with chronic anorexia nervosa: A study of five cases. European Child and Adolescent Psychiatry, 10, 151-157.
Walsh, B. T., Agras, W. S., Devlin, M. J., Fairburn, C. G., Wilson, G. T., Kahn, C., et al. (2000). Fluoxetine for bulimia nervosa following poor response to psychotherapy. Am J Psychiatry, 157(8), 1332-1334.
Walsh, B. T., Kaplan, A. S., Attia, E., Olmsted, M., Parides, M., Carter, J., et al. (2006). Fluoxetine after weight restoration in anorexia nervosa: a randomized clinical trial. JAMA, 295, 2605-2612.
Walsh, B. T., Wilson, G. T., Loeb, K. L., Devlin, M. J., Pike, K. M., Roose, S. P., et al. (1997). Medication and psychotherapy in the treatment of bulimia nervosa. American Journal of Psychiatry, 154(4), 523-531.
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