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.