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.

Choosing a Therapist

The relationship between therapist and patient is the foundation of any successful eating disorder treatment.  All of the anxiety, fear, anger and hope reside in that relationship. No treatment can move forward without a therapeutic bond that works. There is so much weight on the choice of the therapist but how does a patient know she has found the right one?  There are no directions, there is no checklist, no magic wand that confirms this is the one. The only guide is the almost mystical idea of a good "fit" between therapist and patient.  To make it even harder, an eating disorder makes someone doubt everything about herself, yet choosing the right therapist is based on trusting oneself. So the best advice is to ignore the eating disorder and trust your instincts.

No wonder this decision is so daunting.

Here are five important clues a patient can identify even after one session. These clues will help guide a patient in the right direction and are closely related to traits important in an eating disorder therapist.

The best place to start is to ask a few questions right after the  first session.  Did the therapist really listen and try to understand? Did the therapist think she knew everything already? Did the session feel like an awkward and forced exchange or a real conversation between two people?  In other words, the patient should feel like she just had a good conversation, not a psychological evaluation.

The next question to ask is how knowledgeable and experienced the therapist seems to be.  It is worth asking about the therapist's training and experience treating people with eating disorders. This information is important but far from enough. The best gauge is to ask for a treatment plan. Both the answer and the way the answer is given are important. The treatment needs to be specific and include members of the treatment team, goals for how to handle food, reduction in symptoms and the expected time frame to see results. The answer should come easily and naturally: the patient needs to feel the therapist can handle the treatment and has successfully treated patients before.

Eating disorder treatment demands flexibility. As a patient starts to get better, the therapy will need to change considerably by providing different types of support through different stages of treatment. There are many small but critical variables in an initial session such as where to sit, how to pay and how often to meet. Negotiating each seemingly minor issue is a clue. The easier each step felt, the more likely the therapist is flexible.  Using this flexibility will indicate if the therapy can become a true collaboration. The therapist knows how to treat people with eating disorders and the patient knows herself. This foundation of mutual respect and a flexible relationship starts right in the first session. If it is not there, it is very unlikely to develop.

This relationship will be a very important part of a patient's life. She will spend a lot of time with the therapist and invest time, energy and money so it is important to assess the therapist as a person too. Did you like the therapist?  Is this someone you want to get to know?  Could you trust this person?  A first appointment can be so stressful that a patient might ignore her own instincts. It's okay to put these thoughts together later and not know right away.

Invariably during a first session, a patient asks me if I think she can really get better. Struggling with an eating disorder day after day leads to feeling trapped and hopeless. After all, people who don't understand often say no one should feel so confounded by food! Eating disorders are much more complex, but our society floods us with simple ways of handling food and only makes someone with an eating disorder feel more hopeless. Coming out of a first session, a patient needs to feel hope again. She needs to believe her life can really change.

These five attributes--a therapist who is real, knowledgeable, flexible, likeable and hopeful--are a place to start in choosing the right person. It is better to plan to pay attention ahead of time: write these questions down and check the list right afterwards. Once the therapist is in place, often the next big question is treatment with  psychiatric medications: whether to use them, what they do and will they work.  Look for the next post.

Outpatient Treatment Teams

Putting together a treatment team is the most important part of outpatient recovery.  There are too many components for one clinician to address: psychological health, medication management, meal plans, medical status, social interactions and family support.  The primary clinician needs to assess each patient and then assemble a cohesive group of people which can treat the patient AND work together.  However, this critical fact is not always evident to therapists.  Many assume individual therapy is enough. Residential treatment centers acknowledge the need for coordinated outpatient care but rarely follow through.  It can take a long time for even the most educated families to understand how critical a cohesive team is to recovery.  Sadly, the burden usually falls on the patient.  

In order to create a workable team, there are a few things to bear in mind: what are the benefits of having a team? What are the possible components of a team? What is each member's role? How do you find a team?  How do you monitor communication and assess progress?

Ideally, a treatment team is composed of clinicians who know each other, have a similar treatment philosophy and have worked together previously.  The team can constantly assess progress, quickly make any needed changes and express clear and consistent strategies for recovery.  Since each clinician is free to focus attention on one aspect of the patient's care, the team can address all of her needs in recovery.  Once the patient learns she can rely on her treatment providers, she can focus her energy on getting better, not questioning her treatment.

  

A team can involve a therapist, psychiatrist (to prescribe medications but who can also be the therapist), nutritionist (who hopefully specializes in treating eating disorders), primary medical doctor, group therapist and family therapist.  The therapist's role is to coordinate the team by communicating regularly with all of its members and to establish goals of recovery.  The nutritionist focuses primarily on meal plans and adequate nutrition but also plays a significant role in managing the anxiety and fear around eating.  If the nutritionist addresses these feelings, the therapist can focus on the psychological and emotional aspects of recovery.  Since these two members see the patient most often, they set the tone for communication.  Other members of the team play a more peripheral role but address key components of treatment.  The psychiatrist manages symptoms related to the eating disorder, mostly depression and anxiety, with medications; the primary care doctor treats medical conditions secondary to the eating disorder; the family therapist stabilizes the family unit struggling with the effects of the illness; and the group therapist teaches how to establish relationships without the eating disorder as a barrier.

Every patient does not need each component so the primary therapist should spell out what the treatment team should look like during an initial evaluation.  It is the therapist's job to have network of referrals who communicate regularly.  It can be such hard work to find a good fit with a therapist--someone trustworthy, knowledgeable and approachable--and team building is a way to appraise the therapeutic relationship.  It is a good idea to ask what each member would contribute to the team and what are the therapist's expectations of that team member.  Hopefully, these questions can lead to a dialogue, not an argument, and start the kind of collaboration needed for recovery.

The hardest and most important issue is monitoring communication and assessing progress.  The therapist and patient need to establish that reassessment is a regular part of treatment.  In fact, it is better to set aside time every few months to reflect on the current state of the treatment.  The more concrete the better: goals that have been met, goals that are being addressed, goals without an adequate treatment strategy and new goals to discuss.  Then the therapist needs to have a clear plan to communicate any changes to the team.  This process makes treatment more transparent to the patient and directly tests the team's integration.  If the communication is slow or unclear, the patient and therapist need to address these lapses immediately.  The next step might mean changing communication methods or even replacing a team member.  Unfortunately, a crisis often exposes a poorly functioning team.  At that point, the patient and therapist need to handle the crisis and then immediately make changes in the team.  Those critical moments often happen in recovery and either galvanize the team towards progress or mire the patient in ineffective treatment.

Now it is clear that successful recovery is not possible without a team of clinicians.  That team needs a leader: the therapist!  Which begs the question, how do you find a therapist?  Look out for the next post.

Residential Treatment

The most distressed call always comes from someone who wants to discuss residential treatment. The questions abound: what's the best program? where do you send people? how do I figure out what I need? will it help me get better? do any of them take insurance? what do I do afterwards? I usually take a deep breath and try to steer the conversation away from the sense of panic. That starts with a few basics about inpatient treatment. There are good programs, but they don't cure anyone. A real treatment plan involves an informed decision about inpatient treatment, if it is necessary, followed by a reasonable, flexible and long-term plan for aftercare. Residential treatment won't speed anything up, but it can help a very sick person get well enough to function and to think, and that is a big step towards really being able to start treatment.

The first thing to know is that there are a lot of treatment programs. The second thing is that most of them are new and have almost no proven track record. After a little research, the process starts to feel like choosing between spa vacations, not eating disorder recovery. There appears to be treatment alongside the yoga and horseback riding, but each new center only helps further glamorize eating disorders as it promises a quick and longlasting recovery. In truth, there is a lot of money to be made from these programs. They start at $30,000 per month and only increase from there. Without any clearly proven treatment, each program can promote its own mix of nutrition advice, philosophy, and mindful activity with a promise of full recovery. Naturally, this kind of business plan can lure people into the residential treatment world. Yes, these programs only need to jump through the legal hoops but pass no clinical muster. I always find this a terrifying thought and shudder at what passes for treatment and recovery.

Inpatient treatment exists in a bubble. Outside the walls of the program, a patient has to learn how to handle relationships, work and family and how to avoid triggers for the eating disorder behaviors. You can teach coping strategies in a program, but you cannot truly test them. It is very hard work to live in a program and not engage in the eating disorder, but there is no choice. So residential treatment is just a stepping stone, but real recovery happens in real life. This may seem obvious, but then why don't most treatment programs recognize how critical a discharge plan truly is?

Any time a patient of mine chooses to be in a residential treatment center, I believe the most important and immediate decision is what will happen when she returns home. Too many people leave residential treatment and then slowly lose the gains from all of their hard work without ever having established a complete outpatient treatment program. Setting up that team needs to be among the first steps of an initial inpatient treatment plan. In effect, programs set patients up to fail. How can a program offer recovery and then have no plan for aftercare? Do people need multiple hospitalizations to get better or is the system organized that way? Even more concerning, is it all just about the profit?

The role of residential treatment is for short-term stabilization of symptoms. Look for programs with a long track record. Also, the philosophy of the director reflects heavily on the program, so do some research on that person. Their training, experience and availability mean a lot. Also--to hammer a point home--ask about discharge planning immediately.

I do believe residential treatment can make a difference. Some people need a safe environment with almost constant attention to get healthy enough to work in an outpatient setting. But many others would benefit from a cohesive, experienced, outpatient treatment team. What comprises an effective team? What should you look for and how will you know when you've found it? Look for the next post.

Let's Start with a Question: Taking the Plunge

Several years ago, when I was in the process of moving back to New York, a patient sat me down at the end of a session and said she knew best how to start a practice working with people with eating disorders. She suggested I create a website and let patients find me online. This is somewhat unorthodox for a psychiatrist so I thought long and hard about the ramifications of this decision. But after several lengthy discussions, I thought I understood what an online presence would mean for my practice. For many reasons, people with eating disorders feel much more comfortable finding treatment on their own, but I think it boils down to two central ones: anonymity and the difficulty in finding experienced providers. Hopefully, I could provide an online contact to help lead people to the right treatment, either with me or with another resource. I have since received emails and calls from patients, mothers, fathers, siblings and other treatment providers all looking for help in one way or another. They are almost universally surprised at how hard it is to find adequate care and appreciative of any useful leads or guidance.

Despite our country's fascination with eating disorders both in celebrities and in our own communities, there is so much confusion about eating disorder diagnosis and treatment. Anorexia and Bulimia are the only disorders recognized in the field of psychiatry: every other set of symptoms is filed away under Eating Disorder Not Otherwise Specified. In my experience, almost anyone sick more than a few years has EDNOS, which means that even the classification system is woefully inadequate. In addition, there appear to be few practitioners trained to handle the complexities and struggle involved in eating disorder treatment and recovery. Here in New York City, where it often feels like there are more therapists per capita than anywhere in the world, it can be hard to find people able and willing to help patients with eating disorders. After insurance is taken into account, the process of finding treatment exhausts even the most persistent. I have had countless conversations with patients and family members desperate to find someone willing to help them navigate the system to find the right treatment.

But those were the calls I had anticipated.

The other kind of calls caught me off guard. One morning, a few months after I put up my website, a father called in a huff of anger, apparently right after an argument with his wife at the breakfast table. He wanted me to settle the debate, and I quickly realized that my availability online might mean something very different. He was calling about how to feed their six year old daughter. "She never eats," he said. "We keep putting food in front of her, and she just doesn't like anything." Understandably, they were at their wits end. He insisted they should just let her eat when she wants to, and she said they should force her to eat her meals. She insisted their daughter needed to eat healthy food no matter what, and he wasn't so sure it was worth the prolonged battle every day. Apparently, my answer was going to resolve the debate. Did I belong here? Was this where my training led me: all the way back to the formative years of eating? I had my own internal debate at that very moment: stay focused on the treatment of people with eating disorders or consider my role more widely as a source of knowledge in the muddle of addressing food and weight in our society. I felt this was a turning point: remain the neutral psychiatrist focused on his work or take the plunge. Plunge into what? That I had not figured out yet.

"Just let her eat what she wants and give her a range of choices. She knows how to eat and will remain healthy. Nothing to worry about," I said. He was palpably relieved.

I, on the other hand, remain hesitant and confused, but I have not looked back. Even more deeply rooted in our society than the fascination with eating disorders is a disorientation and confusion about food: what to eat? what not to eat? when to eat it? what is healthy food? what should I feed my children? The questions are endless, and people apparently have no reputable source to go to for answers other than doctors. Since I talk to people about food all day and think about what is normal and abnormal eating, perhaps I was a reputable source.

I thought I could start to answer some of the more universal and pressing questions I receive by writing about them. Some of the topics may relate primarily to eating disorder treatment, but many questions relate to the reality of struggling with food and weight in our society. I know I often have sound advice and useful guidance about treatment for an eating disorder. However, I also believe that talking and thinking about food and weight has put me in a position to offer insight and guidance as to how to handle these issues for the curious, not just the sick.

With all of this in mind, I have decided to take the plunge.