Eating Disorders and the Challenge of Treatment: An Expert Interview With Nancy D. Berkman, PhD
Eating disorders are very difficult to treat, and anorexia nervosa can be lethal. Are there any advances on this front? In order to get a better grasp of our current knowledge of treatment options and outcomes for patients with eating disorders, Alisa Gutman, a Medscape writer, interviewed Nancy D. Berkman, PhD, MLIR, Health Policy Analyst, RTI International, after the release of a systematic review of the eating disorder literature conducted by RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC). The American Psychiatric Association and Laureate Psychiatric Hospital proposed a list of important questions in the field to the Agency for Healthcare Research and Quality (AHRQ). The RTI-UNC EPC evaluated published studies from 1980 through the present with relevance to treatment of eating disorders in patients 10 years of age and older. The authors focused on anorexia nervosa, bulimia nervosa, and binge eating disorder. This report is intended to disseminate information to practitioners, patients, and the general population about the clinical management of eating disorders and to generate questions for future studies to treat these serious conditions.
This report is particularly important in conveying current gaps in our armamentarium for treating eating disorders. The authors found that for anorexia in particular, there are still few effective treatment interventions available.
Medscape: Which treatments have been used for the management of anorexic patients?
Nancy D. Berkman, PhD: Numerous therapies have been tried with anorexic patients, including pharmacologic and behavioral interventions. Medications that have been used include selective serotonin reuptake inhibitors (SSRIs), fluoxetine, tricyclic antidepressants, hormones (including testosterone and growth hormones), and nutritional supplements such as zinc. None of these medications has been efficacious for weight gain, which is the primary outcome of interest in this population.
Medscape: Can you describe the type of therapy that is most efficacious in this patient population?
Dr. Berkman: Behavioral therapies that have been tried for anorexic patients include cognitive behavioral therapy (CBT), nonspecific supportive clinical management, family therapy, and cognitive-analytic therapy (CAT). There is some evidence that CBT may reduce relapse risk after weight restoration in adults. There is insufficient evidence in the literature to determine efficacy during the acute phase of disease intervention (prior to weight restoration). While we know that it is common in the field to combine medication and psychotherapy, there were no published trials that combined these treatments and, therefore, we have no information about this type of combination treatment.
Medscape: Which treatments work best for younger patients with anorexia nervosa? Are there any treatments that have efficacy on older or chronic patient groups?
Dr. Berkman: Among adolescents only, family therapy, based on principles of parental control of initial refeeding, leads to clinically meaningful weight gain and psychological change. As noted above, CBT may reduce relapse in adults following weight restoration. On the basis of our analysis of disease outcomes, recovery is more likely among those who have had a shorter duration of illness. Anorexia is a very serious disease that is often chronic in nature, lingering for 5-10 years or even longer in some patients, and it is associated with a heightened risk of death, including death from suicide.
Medscape: I understand that bulimia nervosa patients are more responsive to pharmacologic intervention than anorexia nervosa patients. Which medications have shown utility for the treatment of bulimia nervosa?
Dr. Berkman: Fluoxetine (60 mg/day) administered for 6-18 weeks was shown to reduce core bulimic symptoms of binge eating and purging and associated psychological features of the disorder in the short term. There is preliminary evidence that it is also associated with prevention of relapse at 1 year. No studies of other drugs have sufficiently replicated positive findings, or dropouts from treatment were too large for the studies to be conclusive. A reasonably large number of studies found that CBT is efficacious in reducing binge eating and purging and psychological features of the disease in both the short and long term.
Medscape: Which medications have yielded symptom improvement in patients with binge-eating disorder?
Dr. Berkman: We looked at decreases in binge eating and decreases in weight in overweight individuals. Some preliminary data indicate that SSRIs, tricyclic antidepressants, and anticonvulsants are efficacious in reducing bingeing episodes and weight. CBT was also found to be efficacious in this patient population. Dialectical behavioral therapy and self-help may also be efficacious but affect binge-eating symptoms only.
Medscape: Are there any novel drug classes being studied for use in treating any of these eating disorders?
Dr. Berkman: Good question. No trials using novel pharmacotherapy have been published or released yet. Small trials of fluoxetine and olanzapine are being conducted for treating anorexia nervosa, but no large-scale clinical trials are currently under way.
Medscape: Your report has provided a lot of information regarding the current status of our knowledge of several different types of eating disorders. On the basis of your results, what are the most important questions in the eating disorder field now?
Dr. Berkman: There is still a serious gap in treatment options for people with anorexia nervosa. While some therapies and treatments have proven useful for bulimia nervosa patients, far fewer promising options are available for individuals with anorexia nervosa. Another gap in the literature is in the evaluation of individuals with chronic eating disorders whose disease state is below the threshold for a diagnosis of either anorexia nervosa or bulimia nervosa. Also, more longitudinal studies are necessary to get a better understanding of the relapsing and remitting nature of these disorders.
The report, The Management of Eating Disorders, can be found online at: http://www.ahrq.gov/downloads/pub/evide