Psychiatric Medications

Psychiatric medications have become a national obsession. Everyone seems to believe there is a pill to cure all of our woes. That is no different when it comes to treating eating disorders. Often patients come to treatment looking for the pill that will make their eating disorder disappear. They go away terribly disappointed.

Psychiatric medications do have a role in eating disorder treatment, but a limited one. Although the majority of patients end up taking medications, the patient is rarely aware of what the goal of treatment really is. I wonder if the prescription is almost a reflex response--thoughtless and automatic--because the psychiatrist doesn't know what else to do.

Let me be clear. Medications do not cure eating disorders and rarely even treat them directly. Instead they can treat the secondary symptoms of anxiety and depression and sometimes reduce the eating behaviors. Before a prescription is written, every patient needs to understand that medications play a secondary role in treating eating disorders. If a patient is considering taking a medication, she needs to know the goal of treatment, target symptoms and the time frame to assess the effectiveness.  To get more specific, it makes the most sense to break eating disorders down by behavior categories: restricting, binging, overeating and obesity.

Restricting behaviors--controlled starvation--usually fall under the diagnosis of Anorexia Nervosa but can also encompass a wider range of symptoms such as purging, chew-spitting, diet pills and laxative abuse. The psychological effects of starvation are very powerful and include depression, anxiety and obsessive-compulsive symptoms. Medications will not change the desire to restrict or change the desire to be thin, but antidepressants are often prescribed to treat the depression and anxiety. The obvious point is that food will work much better than any medication. Although starvation reinforces the obsessive thoughts, obsessive-compulsive symptoms often predate the eating disorder. High doses of antidepressants--usually SSRIs--can lessen the intensity of these thoughts and make it easier for a patient to eat. Since the medications take two to three months to work, it is critical to start all components of treatment right away and not wait for the  medication to take effect.

Binging disorders can include Bulimia Nervosa, binge eating disorder or other binging syndromes such as night eating disorder. These disorders can also lead to secondary depression and anxiety symptoms and are often treated with antidepressants. Once again the eating disorder symptoms are the primary cause of depression and anxiety. Eliminating the behaviors will be much more effective than any medication. There are two critical differences between binging and restricting disorders. First, there are medications proven to cut down binging: once again high dose SSRIs. Most of the research studies have shown that frequent binging can be cut in half after about eight weeks of treatment. The patients in these studies typically binged several times daily. Less is known about medications for people with more mild symptoms. Topamax--a medication mainly used to treat seizures--has more limited evidence to treat binging. Patients request it because weight loss is a common side effect and frequently cannot tolerate it because slowed and confused thinking is another common one. Neither of these medications are particularly effective without a complete treatment plan. The second difference is that a handful of patients with binging disorders actually have primary depression. This group usually has a strong history of depression in their family and longstanding depressive symptoms that don't fluctuate with the ebb and flow of the eating disorder. In these cases, the eating disorder will get much better when the depression is treated.

The mental health world has only just begun to try to treat compulsive overeating and obesity. Only binge eating disorder is even being considered as a psychiatric diagnosis for now, but I have gotten more calls about overeating than anything else over the past year. Most of the patients who come for an evaluation have a long history of overeating and have made multiple attempts at weight loss including diets, nutritionists, obesity specialists and exercise. This is often the last stop before bariatric surgery, and many of these patients hope there is a magic pill which will rescue them from their long struggle. Unfortunately, that pill does not exist.

Overeating can sometimes mask depression, bipolar disorder or anxiety, and treatment with the right medications can open the door to success with food as well. But those are the rare cases. The only other psychiatric medications used are appetite suppressants that are uniformly addictive so that the immediate success only leads to many more complications in the long run.

These medications, primarily Adderall and Ritalin, are the most challenging aspect of psychopharmacogical treatment of all eating disorders, not just overeating or obesity. Stimulants are usually used to treat Attention Deficit Disorder but are also used as a secondary treatment for depression. Patients often start these medications for one of these diagnoses but are lured by the side effect of powerful appetite suppression. All of a sudden, patients feel like they have found the magic pill which helps them not eat and not think about eating. This is not a cure but can feel like a huge weight has been lifted. For the doctor, this seemingly miraculous effect gives one immediate satisfaction. It is too easy to imagine a patient  truly cured and even to forgo the long, but necessary, real treatment. The biggest problem with stimulants is they are very addictive. Physically, a patient will have withdrawal if she stops the medication but will also become tolerant: you need more to get the same effect. As a patient needs a higher dose, the side effects get worse and scarier such as severe heart problems. Psychologically, a patient will feel like she cannot function without the medication. Rather than learn how to face the eating disorder, the pill becomes the only tool to combat the illness. Then she will continue the medication, at any cost. The final take home message is use stimulants with caution to treat an eating disorder.

Clearly, psychiatric medications are of limited benefit in treating eating disorders, but this discussion also highlighted another messy topic: the different diagnoses of eating disorders. Stay tuned for the next post.

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