Pharmacotherapy

What is pharmacotherapy?

It is the branch of psychiatry that deals specifically with medication.  The medication used is “psychoactive”, which means that it has effects on the brain and other parts of the nervous system.

How is it incorporated into other forms of treatment?

Medication is often one component of a treatment plan that might include cognitive behavior therapy, relaxation training, nutrition counseling, family therapy, and even rehabilitation counseling, aimed at helping people get back into optimal function.  Although there are a few conditions that lend themselves to treatment that is purely psychopharmacological, most disorders are treated with an integrated, multi-disciplinary and coordinated approach.  Even when someone is receiving “only medication”, they are working with a clinician, and meeting regularly with that clinician, who is prescribing and monitoring side effects, etc.  The regular meetings may serve as supportive therapy, and even include aspects of cognitive behavioral, or more dynamic therapies.

Are there certain medications that are more effective than others for anorexia?  for bulimia?

There is no pharmacological treatment approved for anorexia in its acute phase.  However, fluoxetine (Prozac), a serotonin-reuptake inhibitor, has been found to be effective for people who have recovered normal weight after a bout with acute anorexia.  The fluoxetine helps to prevent relapse and is approved for this use by the FDA.  Some people find that anti-anxiety medications (benzodiazepines such as clonazepam or lorazepam) or other serotonin-reuptake inhibitors (which are anti-anxiety as well as anti-depressant) can help to reduce the anxiety and tension surrounding eating.  For people with especially severe anxiety or distortions in body image, an “atypical antipsychotic” such as olanzapine (Zyprexa), risperidone (Risperdal) or quetiapine (Seroquel) may be used.  However, due to significant weight gain as a side effect, most people with anorexia are not willing to try this class of medication.

For bulimia, the serotonin-reuptake inhibitors have been shown to be effective (fluoxetine or Prozac, sertraline or Zoloft, citalopram or Celexa, escitalopram or Lexapro).  Before these medications were in regular usage (pre-1980’s), the older tricyclic antidepressants (imipramine or Tofranil) were used, but they have more serious and dangerous side effects and are now very rarely prescribed.

When depression accompanies eating disorders, many antidepressants may prove effective.  These include (brand names) the serotonin-reuptake inhibitors (Prozac, Zoloft, Celexa, Lexapro), the serotonin-norepinephrine reuptake inhibitors (Effexor, Cymbalta), and older tricyclic antidepressants (Tofranil, Pamelor).  Buproprion (Wellbutrin) is NOT recommended for people with eating disorders because of the risk of seizures.

Are there any risks associated with these medications?

All medications have some side effects and some risk, but the medications used for eating disorders in this day and age are reasonably safe.  The serotonin-reuptake inhibitors have the following RARE serious side effects:  increased suicidal thinking and mania.  The COMMON side effects include decreased sexual interest (libido) and more trouble having an orgasm, increased vivid dreaming, blunting of emotions, weight gain, difficulty sleeping or increased sedation, stomach upset, headaches, enhanced effects of alcohol, and “discontinuation symptoms” such as dizziness and flu-like symptoms.  The side effects are generally considered more “nuisance” side effects, except for the two serious ones mentioned.  Of course, anyone can be allergic to a medication and this can always cause serious problems.  Also, some people on other medications can experience drug-drug interactions that can be problematic.  One should always check with the pharmacist when starting a new medication, to get a sense of what to expect.

The older, tricyclic antidepressants are much more serious, and include cardiac arrhythmias.  As previously stated, Wellbutrin should not be used in eating disorder patients due to the risk of seizures.

How long do I have to be on these medications?

There is no hard and fast rule to how long people stay on medications.  Specifically referring to the serotonin-reuptake inhibitors, it is usually recommended that one stay on them for at least 6 months, if they are to be effective.  However, this is based on data related to depression, and may not be relevant to people taking them to help with eating disorders.  The important thing is to remember to work closely with your clinician when considering discontinuing, and to taper off of the medications slowly.  Following a slow taper will not only minimize the likelihood of “discontinuation symptoms” such as dizziness and flu-like symptoms, which are uncomfortable but not dangerous, but it also will decrease the likelihood of relapse.  Some people find that they really feel better, with fewer cravings and less urge to binge or purge on medication, and they prefer to stay on them.  There is no documentation of problems with long-term medication usage.

 

Margaret S. Ross, MD
Director, Behavioral Medicine
Student Health Services, Boston University

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