Dronabinol in severe, enduring anorexia nervosa: a randomized controlled trial

Treatment escalation for people with anorexia nervosa: setting, therapies and nutritional interventions

PURPOSE OF REVIEW

Adult patients with severe anorexia nervosa often receive the same unsuccessful treatment without changes regarding the setting, the therapies, or nutritional interventions.

RECENT FINDINGS

Settings where people with anorexia nervosa are treated include their general practitioner, an independent psychiatric practice, a community mental health team (CMHT), a specialized eating disorder outpatient service, eating disorder early intervention services, a highly intensive eating disorder outpatient or home treatment programme, eating disorder daycare, an inpatient eating disorder service, a general hospital or a general psychiatric hospital, or residential treatment. At a specialized eating disorder service, patients should be offered evidence-based psychotherapy for anorexia nervosa, dietary advice and physical health monitoring as a first step. Additionally, they may be allocated to a specific treatment pathway, family interventions and creative therapies. As a second step, clinicians may consider integrating interventions targeting psychiatric or physical comorbidities, medication for anorexia nervosa or noninvasive neurostimulation. After several years of futile treatment, deep brain stimulation (DBS) should be considered to prevent a chronic course of anorexia nervosa. Nutritional interventions can be escalated from nutritional counselling to nasogastric tube feeding. Patients who rely on nasogastric tube feeding might benefit from percutaneous endoscopic gastrostomy (PEG). Patients who vomit despite a nasogastric tube, might need nasojejunal tube feeding.

SUMMARY

Treatment for people with anorexia nervosa should be regularly reviewed and, if necessary, escalated to avoid a chronic and longstanding disease course.

Clinical and scientific review of severe and enduring anorexia nervosa in intensive care settings: introducing an innovative treatment paradigm

BACKGROUND

Anorexia nervosa is a serious and potentially lethal psychiatric disorder. Furthermore, there is significant evidence that some individuals develop a very long-standing form of the illness that requires a variety of different treatment interventions over time.

OBJECTIVE

The primary goal of this paper was to provide a review of treatment strategies for severe and enduring anorexia nervosa (SE-AN) with the particular focus on treatments involving hospital care. Additionally, we wish to highlight a contemporary approach to such care and provide qualitative reactions to this model from both staff and patients.

METHODS

A selective and strategic review of the treatment literature for SE-AN was conducted for the current paper. Emphasis was placed on clinical or scientific papers related to hospital-based care. Additionally, staff who work on a specific inpatient eating disorder unit with a substantial treatment program for SE-AN, along with a number of SE-AN patients were surveyed regarding their experiences working on, or receiving treatment on the unit. Importantly, the staff of this unit created a specific treatment protocol for individuals receiving hospital care. The results of the highlight both advantages and challenges of a hospital-based protocol oriented toward emphasizing quality of life, medical stability, and a health-promoting meal plan.

DISCUSSION

While there is general inconsistency with the type of treatment that is best suited to individuals with SE-AN, this is particularly true for higher levels of care that rely on inpatient hospital units or residential treatment settings. This is a highly significant clinical topic in need of further clinical and scientific examination.

Does hypoleptinemia trigger entrapment in anorexia nervosa? Etiological and clinical considerations

Based on the recent observation that human recombinant leptin (r-Met-hu-leptin; metreleptin) may induce a profound alleviation of the complex symptomatology of patients with anorexia nervosa (AN), we examine the implications for our conceptualisation of this eating disorder. Hypoleptinemia as a core endocrine feature of AN serves as a central and peripheral trigger of tissue-specific adaptations to starvation. In this narrative review, we argue that leptin deficiency may explain many of the puzzling features of this eating disorder. Weight loss can be viewed as a two-step process, with only the second step entailing hypoleptinemia and thereby the entrapment characteristic of AN. We discuss the central and peripheral distribution of leptin receptors and consider possible functional implications of hypoleptinemia. We contrast the slow psychological recovery of patients with AN and of people who experienced starvation upon weight recovery with the rapid onset of improvements upon off-label metreleptin treatment. Characteristics of the sex and age dependent secretion of leptin may contribute to the elevated vulnerability of young females to develop AN.

Severe enduring anorexia nervosa (SE-AN) treatment options and their effectiveness: a review of literature

INTRODUCTION

 For nearly 20% of patients diagnosed with Anorexia Nervosa (AN), the eating disorder (ED) is prolonged and becomes long-lasting. It has been reported that patients diagnosed with Severe Enduring Anorexia Nervosa (SE-AN) have worse ED symptoms, higher rates of lifetime hospitalization, and lower psychosocial well-being compared to patients with shorter disease duration.

OBJECTIVES

 This review aims to describe the treatments proposed to date and their effectiveness on SE-AN-related outcomes.

METHODS

 We conducted a PubMed search for studies addressing the issue of treatment approach to SE-AN adults, that were published between 2003 and 2023, peer-reviewed, written in the English language, and available in full-text. Next, we inductively created relevant macro-themes by synthesizing the data from the included articles.

RESULTS

 Of 251 PubMed studies, 25 articles were considered for data extraction, all published between 2003 and 2022. We identified three macro-themes. The first macro-theme, "Psychotherapy", mostly takes into consideration treatment effectiveness of cognitive behavioral therapy (CBT). Various reports determined its greater effectiveness compared to Specialist Supportive Clinical Management (SSCM), and one study proved that outpatient CBT is a valid alternative to hospitalization. The second one involves "Pharmacological Treatments". Research on dronabinol, a synthetic orexigenic cannabinoid, antipsychotics (in particular, olanzapine and haloperidol), and ketamine showed some mixed results regarding the often-complementary areas of weight gain and improvement in ED-related symptoms. Regarding the third macro-theme, "Brain Stimulation Therapies," such as Repetitive Transcranial Magnetic Stimulation (rTMS) and Deep Brain Stimulation (DBS), we found promising results in improving ED-related psychological traits (such as mood and anxiety), affective regulation, and quality of life. However, we have observed divergent results regarding outcome measures such as BMI and weight gain.

CONCLUSIONS

 SE-AN patients are predicted to encounter both medical complications and psychological distress of increasing severity that will inevitably affect their quality of life; to our knowledge, research evidence on treatment options for SE-AN remains limited, and the methodological quality of studies is generally low. These findings denote the need to focus future research efforts on effective treatment strategies specific to long-lasting EDs.

Pharmacological Studies in Eating Disorders: A Historical Review

Eating disorders (EDs) are serious mental health conditions characterised by impaired eating behaviours and nutrition as well as disturbed body image, entailing considerable mortality and morbidity. Psychopharmacological medication is an important component in the treatment of EDs. In this review, we performed a historic analysis of pharmacotherapeutic research in EDs based on the scientific studies included in the recently published World Federation of Societies for Biological Psychiatry (WFSBP) guidelines for ED treatment. This analysis focuses on early approaches and trends in the methods of clinical pharmacological research in EDs, for example, the sample sizes of randomised controlled trials (RCTs). We found the development of psychopharmacological treatments for EDs followed advancements in psychiatric pharmacotherapy. However, the application of RCTs to the study of pharmacotherapy for EDs may be an impediment as limited participant numbers and inadequate research funding impede generalisability and statistical power. Moreover, current medication usage often deviates from guideline recommendations. In conclusion, the RCT model may not effectively capture the complexities of ED treatment, and funding limitations hinder research activity. Novel genetically/biologically based treatments are warranted. A more comprehensive understanding of EDs and individualised approaches should guide research and drug development for improved treatment outcomes.

Astrocytic Dagla Deletion Decreases Hedonic Feeding in Female Mice

Introduction: Endocannabinoids and exogenous cannabinoids are potent regulators of feeding behavior and energy metabolism. Stimulating cannabinoid receptor signaling enhances appetite, particularly for energy-dense palatable foods, and promotes energy storage. To elucidate the underlying cellular mechanisms, we investigate here the potential role of astrocytic endocannabinoid 2-arachidonoylglycerol (2-AG). Astrocytes provide metabolic support for neurons and contribute to feeding regulation but the effect of astrocytic 2-AG on feeding is unknown. Materials and Methods: We generated mice lacking the 2-AG synthesizing enzyme diacylglycerol lipase alpha (Dagla) in astrocytes (GLAST-Dagla KO) and investigated hedonic feeding behavior in male and female mice. Body weight and baseline water and food intake was characterized; additionally, the mice went through milk, saccharine, and sucrose preference tests in fed and fasted states. In female mice, the estrous cycle stages were identified and plasma levels of female sex hormones were measured. Results: We found that the effects of the inducible astrocytic Dagla deletion were sex-specific. Acute milk preference was decreased in female, but not in male mice and the effect was most evident in the estrus stage of the cycle. This prompted us to investigate sex hormone profiles, which were found to be altered in GLAST-Dagla KO females. Specifically, follicle-stimulating hormone was elevated in the estrus stage, luteinizing hormone in the proestrus, and progesterone was increased in both proestrus and estrus stages of the cycle compared with controls. Conclusions: Astrocytic Dagla regulates acute hedonic appetite for palatable food in females and not in males, possibly owing to a deregulated female sex hormone profile. It is plausible that endocannabinoid production by astrocytes at least partly contributes to the greater susceptibility to overeating in females. This finding may also be important for understanding the effects of exogenous cannabinoids on sex hormone profiles.

Integration of Endogenous Opioid System Research in the Interprofessional Diagnosis and Treatment of Obesity and Eating Disorders

This third and final chapter in our trilogy introduces the clinical distinctions and phenotypical similarities between obesity and eating disorders. Research elaborating on the shared neurobiological substrates for obesity and eating disorders is discussed. We present an interprofessional model of treatment for both disordered eating and for obesity. Additionally, this chapter establishes the translational importance of research connecting endogenous opioid activity with both obesity and eating disorders, with an emphasis on clinical interventions. We conclude with a discussion of future directions for research.

[Cannabis use in adolescents : Narrative Review and Position paper of the "Addiction Disorders in Adolescents" task force of the Austrian Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (ÖGKJP)]

BACKGROUND

Cannabis is the illegal drug most frequently used by Minors in Austria. Due to the gradual decriminalization and legalization that has taken place in many European countries in recent years, the ÖGKJP would like to take a balanced and scientifically based stand on the complex issue of cannabis use and abuse among young people.

METHODS

The authors searched the medline for current studies using searches tailored to each specific subtopic. Furthermore, recognized compendiums were quoted.

RESULTS

While occasional recreational use of cannabis in adults with completed brain maturation and no risk profile for mental disorders is likely to be relatively harmless, early initiation of use with regular use and the increasingly available, highly potent cannabis varieties can lead to explicit and sometimes irreversible neurocognitive brain dysfunction.

CONCLUSION

Legalisation of cannabis consumption for minors needs to be objected to due to the risks of the expected damage in the area of brain development. At the same time, however, it is important to establish sensible legal regulations in order to be able to adequately counteract the fact that over 30% of all European young people occasionally consume cannabis. We are also clearly recommending to not criminalize cannabis users and provide necessary support to vulnerable and addicted cannabis users.

Cancer-Cachexia-Induced Human Skeletal Muscle Myotube Degeneration Is Prevented via Cannabinoid Receptor 2 Agonism In Vitro

Cachexia syndrome, leading to reduced skeletal muscle and fat mass, is highly prevalent in cancer patients, resulting in further negative implications for these patients. To date, there is no approved therapy for cachexia syndrome. The objective of this study was to establish an in vitro model of cancer cachexia in mature human skeletal muscle myotubes, with the intention of exploiting the cell model to assess potential cachexia therapeutics, specifically cannabinoid related drugs. Having cultured and differentiated primary human muscle myoblasts to mature myotubes, we successfully established two cancer cachexia models using conditioned media (CM) from human colon adenocarcinoma (SW480) and from non-small-cell lung carcinoma (H1299) cultured cells. The cancer-CM-induced extensive myotube degeneration, demonstrated by a significant reduction in mature myotube diameter, which progressed over the period studied. Myotube degeneration is a characteristic feature of cancer cachexia and was used in this study as an index of cachexia. Expression of cannabinoid 1 and 2 receptors (CB1R and CB2R) was confirmed in the mature human skeletal muscle myotubes. Subsequently, the effect of cannabinoid compounds on this myotube degeneration were assessed. Tetrahydrocannabinol (THC), a partial CB1R/CB2R agonist, and JWH133, a selective CB2R agonist, proved efficacious in protecting mature human myotubes from the deleterious effects of both (SW480 and H1299) cancer cachexia conditions. ART27.13, a full, peripherally selective CB1R/CB2R agonist, currently being trialled in cancer cachexia (IRAS ID 278450, REC 20/NE/0198), was also significantly protective against myotube degeneration in both (SW480 and H1299) cancer cachexia conditions. Furthermore, the addition of the CB2R antagonist AM630, but not the CB1R antagonist Rimonabant, abolished the protective effect of ART27.13. In short, we have established a convenient and robust in vitro model of cancer-induced human skeletal muscle cachexia. The data obtained using the model demonstrate the therapeutic potential of ART27.13 in cancer-induced cachexia prevention and provides evidence indicating that this effect is via CB2R, and not CB1R.

The relationship between cannabis and anorexia nervosa: a scoping review

BACKGROUND

Relapse rates in Anorexia Nervosa (AN) remain high, warranting exploration of further treatments. Cannabinoid agonists are of interest as they have shown successful outcomes in the treatment of associated conditions, such as post-traumatic stress disorder. This scoping review explores the endocannabinoid system (ECS), benefits/harms/null effects of cannabinoid treatment, and harms of cannabis use in AN.

METHODS

PubMed, PsycINFO, Cochrane, and Web of Science were searched for studies published between 2010 and August 2023, with human participants that explored the ECS, cannabinoid treatment, or cannabis use, and included 1 or more keywords for both cannabis and AN in the title and or abstract. Reports describing secondary anorexia, reports not available in English, grey literature, reports combining data from AN with other conditions, and reports only reporting the prevalence of cannabis abuse/dependence were excluded. Data were extracted from 17 reports (n = 15 studies). For the ECS, outcomes included genetics such as allele expression related to the ECS, cannabinoid receptor availability, and circulating levels of endocannabinoids. For benefits/harms/null effects of cannabinoid treatment, outcomes included changes in weight, eating disorder (ED) symptoms, physical activity (PA), and hormones. For harms of cannabis use, outcomes included genetics related to cannabis use disorder and associations between cannabis use and ED symptoms.

RESULTS

Eight studies (n = 8 reports) found abnormalities in the ECS in AN including expression of related alleles, genotypes, and haplotypes, availability of cannabinoid receptors, and levels of endocannabinoids. Three studies (n = 5 reports) found benefits/harms/null effects of cannabinoid treatment. Benefits included weight gain, improved ED symptoms and reduced PA, while null effects included no changes in weight or ED symptoms, and harms included increased PA and lowered adipose hormones. Four studies (n = 4 reports) expanded upon harms of cannabis use, including genetic predispositions to cannabis use disorder, and compensatory behaviors related to cannabis use.

CONCLUSION

Limited evidence suggests that abnormalities in the ECS in AN may render cannabis a potential treatment for weight restoration and associated symptoms. Future research may wish to investigate individualized dosing approaches to maximize beneficial effects while minimizing harms. Level II Evidence: Scoping Review.

Psychopharmacology of eating disorders: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The concurrent assessment of weight and affective psychopathology outcomes relevant to the psychopharmacology of major eating disorders (EDs), namely anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), warrants systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

PubMed, Scopus, and ClinicalTrials.gov were inquired from inception through August 31st, 2022, for RCTs documenting any psychopharmacological intervention for EDs diagnosed according to validated criteria and reporting weight and psychopathology changes. Adopted keywords were: "anorexia nervosa," "bulimia nervosa," "binge eating disorder," "antidepressant," "antipsychotic," and "mood stabilizer." No language restriction applied.

RESULTS

5122 records were identified, and 203 full-texts were reviewed. Sixty-two studies entered the qualitative synthesis (AN = 22, BN = 23, BED = 17), of which 22 entered the meta-analysis (AN = 9, BN = 10, BED = 3). Concerning BMI increase in AN, olanzapine outperformed placebo (Hedges'g = 0.283, 95%C·I. = 0.051-0.515, I2 = 0 %; p = .017), whereas fluoxetine failed (Hedges'g = 0.351, 95%C.I. = -0.248 to 0.95, I2 = 63.37 %; p = .251). Fluoxetine not significantly changed weight (Hedges'g = 0.147, 95%C.I. = -0.157-0.451, I2 = 0 %; p = .343), reducing binging (Hedges'g = 0.203, 95%C.I. = 0.007-0.399, I2 = 0 %; p = .042), and purging episodes (Hedges'g = 0.328, 95%C.I. = -0.061-0.717, I2 = 58.97 %; p = .099) in BN. Lisdexamfetamine reduced weight (Hedges'g = 0.259, 95%C.I. = 0.071-0.446, I2 = 0 %; p = .007) and binging (Hedges'g = 0.571, 95%C.I. = 0.282-0.860, I2 = 53.84 %; p < .001) in BED.

LIMITATIONS

Small sample size, short duration, and lack of reliable operational definitions affect most of the included sponsored RCTs.

CONCLUSIONS

The efficacy of different drugs varies across different EDs, warranting additional primary studies recording broad psychopathological and cardiometabolic outcomes besides weight, especially against established psychotherapy interventions.

Pharmacotherapy, alternative and adjunctive therapies for eating disorders: findings from a rapid review

BACKGROUND

The current review broadly summarises the evidence base for pharmacotherapies and adjunctive and alternative therapies in the treatment of eating disorders and disordered eating.

METHODS

This paper forms part of a Rapid Review series examining the evidence base in the field of eating disorders. This was conducted to inform the Australian National Eating Disorder Research and Translation Strategy 2021-2030. ScienceDirect, PubMed and Ovid/Medline were searched for included studies published between 2009 and 2021 in English. High-level evidence such as meta-analyses, large population studies and randomised control trials were prioritised, and grey literature excluded. Data from included studies relating to pharmacotherapy, and to adjunctive and alternative therapies in eating disorders, were synthesised and disseminated in the current review.

RESULTS

A total of 121 studies were identified, relating to pharmacotherapy (n = 90), adjunctive therapies (n = 21) and alternative therapies (n = 22). Some of the identified studies involved combinations of the above (e.g. adjunctive pharmacotherapy). Evidence of efficacy of interventions across all three categories was very limited with few relevant high quality clinical trials. There was a particular scarcity of evidence around effective treatments for anorexia nervosa (AN). With treatment of bulimia nervosa (BN), fluoxetine has exhibited some efficacy leading to regulatory approval in some countries. With binge eating disorder (BED), recent evidence supports the use of lisdexamfetamine. Neurostimulation interventions show some emerging efficacy in the treatment of AN, BN and BED but some, such as deep brain stimulation can be highly invasive.

CONCLUSION

Despite widespread use of medications, this Rapid Review has identified a lack of effective medications and adjunctive and alternative therapies in the treatment of EDs. An intensification of high-quality clinical trial activity and drug discovery innovation are required to better assist patients suffering from EDs.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines update 2023 on the pharmacological treatment of eating disorders

OBJECTIVES

This 2023 update of the WFSBP guidelines for the pharmacological treatment of eating disorders (EDs) reflects the latest diagnostic and psychopharmacological progress and the improved WFSBP recommendations for the assessment of the level of evidence (LoE) and the grade of recommendation (GoR).

METHODS

The WFSBP Task Force EDs reviewed the relevant literature and provided a timely grading of the LoE and the GoR.

RESULTS

In anorexia nervosa (AN), only a limited recommendation (LoE: A; GoR: 2) for olanzapine can be given, because the available evidence is restricted to weight gain, and its effect on psychopathology is less clear. In bulimia nervosa (BN), the current literature prompts a recommendation for fluoxetine (LoE: A; GoR: 1) or topiramate (LoE: A; GoR: 1). In binge-eating disorder (BED), lisdexamfetamine (LDX; LoE: A; GoR: 1) or topiramate (LoE: A; GoR: 1) can be recommended. There is only sparse evidence for the drug treatment of avoidant restrictive food intake disorder (ARFID), pica, and rumination disorder (RD).

CONCLUSION

In BN, fluoxetine, and topiramate, and in BED, LDX and topiramate can be recommended. Despite the published evidence, olanzapine and topiramate have not received marketing authorisation for use in EDs from any medicine regulatory agency.

Emerging therapeutic targets for anorexia nervosa

INTRODUCTION

Anorexia nervosa is a frequent eating disorder that affects predominantly young women and may take a severe and chronically worsening course of disease contributing to its high mortality rate. Although a multitude of treatment options exist, this disease still bears a high relapse rate. In light of these facts, an improvement of existing and development of new treatment targets and options is warranted.

AREAS COVERED

The present review article covers recent developments in psychotherapy associated with the respective neuropsychological and brain alterations as well as highlights current and future pharmacotherapeutic options.

EXPERT OPINION

Several encouraging developments in the field of psychotherapy such as interventions targeting neurocognitive profiles or addressing reward processing, brain stimulation as well as pharmacological modulation of hormones, namely leptin, oxytocin, ghrelin and nesfatin-1 signaling might be - most likely as part of a multimodal treatment approach - efficacious in order to improve treatment of patients with anorexia nervosa, especially those with a severe course of disease as well as comorbidities. As anorexia nervosa represents a complex and severe mental disorder, it seems most likely that a combination and integration of different evidence-based treatment approaches and settings will contribute to an improved prognosis of this eating disorder. This should be further explored in future studies.

Beyond monoamines: II. Novel applications for PET imaging in psychiatric disorders

Early applications of positron emission tomography (PET) in psychiatry sought to identify derangements of cerebral blood flow and metabolism. The need for more specific neurochemical imaging probes was soon evident, and these probes initially targeted the sites of action of neuroleptic (dopamine D₂ receptors) and psychoactive (serotonin receptors) drugs. For nearly 30 years, the centrality of monoamine dysfunction in psychiatric disorders drove the development of an armamentarium of monoaminergic PET radiopharmaceuticals and imaging methodologies. However, continued investments in monoamine-enhancing drug development realized only modest gains in efficacy and tolerability. As patent protection for many widely prescribed and profitable psychiatric drugs lapsed, drug development pipelines shifted away from monoamines in search of novel targets with the promises of improved efficacy, or abandoned altogether. Over this period, PET radiopharmaceutical development activities closely parallelled drug development priorities, resulting in the development of new PET imaging agents for non-monoamine targets. In part two of this review, we survey clinical research studies using the novel targets and radiotracers described in part one across major psychiatric application areas such as substance use disorders, anxiety disorders, eating disorders, personality disorders, mood disorders, and schizophrenia. Important limitations of the studies described are discussed, as well as key methodologic issues, challenges to the field, and the status of clinical trials seeking to exploit these targets for novel therapeutics.

Cannabis and adverse cardiovascular events: A systematic review and meta-analysis of observational studies

Background

Cannabis is the most used illicit drug in the world. Global trends of decriminalization and legalization of cannabis lead to various forms of cannabis use and bring great concerns over adverse events, particularly in the cardiovascular (CV) system. To date, the association between cannabis and adverse CV events is still controversial.

Purpose

We aim to conduct a systematic review and meta-analysis to assess the adverse CV events from cannabis use.

Patients and methods

A systematic search for publications describing the adverse CV events of cannabis use, including acute myocardial infarction (MI) and stroke, was performed via PubMed, Scopus, and Cochrane Library databases. Data on effect estimates in individual studies were extracted and combined via random-effects meta-analysis using the DerSimonian and Laird method, a generic inverse-variance strategy.

Results

Twenty studies with a total of 183,410,651 patients were included. The proportion of males was 23.7%. The median age and follow-up time were 42.4 years old (IQR: 37.4, 50.0) and 6.2 years (IQR: 1.7, 27.7), respectively. The prevalence of cannabis use was 1.9%. Cannabis use was not significantly associated with acute MI (pooled odds ratio (OR): 1.29; 95%CI: 0.80, 2.08), stroke (pooled OR 1.35; 95%CI: 0.74, 2.47), and adverse CV events (pooled OR: 1.47; 95%CI: 0.98, 2.20).

Conclusion

The risk of adverse CV events including acute MI and stroke does not exhibit a significant increase with cannabis exposure. However, caution should be exercised when interpreting the findings due to the heterogeneity of the studies.

Therapeutic uses of psychedelics for eating disorders and body dysmorphic disorder

BACKGROUND

Clinical use of psychedelics has gained considerable attention, with promising benefits across a range of mental disorders. Current pharmacological and psychotherapeutic treatments for body dysmorphic disorder (BDD) and eating disorders (EDs) have limited efficacy. As such, other treatment options such as psychedelic-assisted therapies are being explored in these clinical groups.

AIMS

This systematic review evaluates evidence related to the therapeutic potential of psychedelics in individuals diagnosed with BDD and EDs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of all study designs published to the end of February 2022 that identified changes in ED/BDD symptom severity from psychedelics using validated measures to assess symptom changes.

RESULTS

Our search detected a total of 372 studies, of which five met inclusion criteria (two exploratory studies, two case reports, and one prospective study). These were included in the data evaluation. Effects of psychedelics on BDD and various ED symptoms were identified mostly through thematic analyses and self-reports.

CONCLUSIONS

Our findings highlight that more research is needed to determine the safety and efficacy of psychedelics in BDD and EDs and we suggest avenues for future exploration.

Medical cannabinoids: a pharmacology-based systematic review and meta-analysis for all relevant medical indications

BACKGROUND

Medical cannabinoids differ in their pharmacology and may have different treatment effects. We aimed to conduct a pharmacology-based systematic review (SR) and meta-analyses of medical cannabinoids for efficacy, retention and adverse events.

METHODS

We systematically reviewed (registered at PROSPERO: CRD42021229932) eight databases for randomized controlled trials (RCTs) of dronabinol, nabilone, cannabidiol and nabiximols for chronic pain, spasticity, nausea /vomiting, appetite, ALS, irritable bowel syndrome, MS, Chorea Huntington, epilepsy, dystonia, Parkinsonism, glaucoma, ADHD, anorexia nervosa, anxiety, dementia, depression, schizophrenia, PTSD, sleeping disorders, SUD and Tourette. Main outcomes and measures included patient-relevant/disease-specific outcomes, retention and adverse events. Data were calculated as standardized mean difference (SMD) and ORs with confidence intervals (CI) via random effects. Evidence quality was assessed by the Cochrane Risk of Bias and GRADE tools.

RESULTS

In total, 152 RCTs (12,123 participants) were analysed according to the type of the cannabinoid, outcome and comparator used, resulting in 84 comparisons. Significant therapeutic effects of medical cannabinoids show a large variability in the grade of evidence that depends on the type of cannabinoid. CBD has a significant therapeutic effect for epilepsy (SMD - 0.5[CI - 0.62, - 0.38] high grade) and Parkinsonism (- 0.41[CI - 0.75, - 0.08] moderate grade). There is moderate evidence for dronabinol for chronic pain (- 0.31[CI - 0.46, - 0.15]), appetite (- 0.51[CI - 0.87, - 0.15]) and Tourette (- 1.01[CI - 1.58, - 0.44]) and moderate evidence for nabiximols on chronic pain (- 0.25[- 0.37, - 0.14]), spasticity (- 0.36[CI - 0.54, - 0.19]), sleep (- 0.24[CI - 0.35, - 0.14]) and SUDs (- 0.48[CI - 0.92, - 0.04]). All other significant therapeutic effects have either low, very low, or even no grade of evidence. Cannabinoids produce different adverse events, and there is low to moderate grade of evidence for this conclusion depending on the type of cannabinoid.

CONCLUSIONS

Cannabinoids are effective therapeutics for several medical indications if their specific pharmacological properties are considered. We suggest that future systematic studies in the cannabinoid field should be based upon their specific pharmacology.

Polygenic association with severity and long-term outcome in eating disorder cases

About 20% of individuals with anorexia nervosa (AN) remain chronically ill. Therefore, early identification of poor outcome could improve care. Genetic research has identified regions of the genome associated with AN. Patients with anorexia nervosa were identified via the Swedish eating disorder quality registers Stepwise and Riksät and invited to participate in the Anorexia Nervosa Genetics Initiative. First, we associated genetic information longitudinally with eating disorder severity indexed by scores on the Clinical Impairment Assessment (CIA) in 2843 patients with lifetime AN with or without diagnostic migration to other forms of eating disorders followed for up to 16 years (mean = 5.3 years). Second, we indexed the development of a severe and enduring eating disorder (SEED) by a high CIA score plus a follow-up time ≥5 years. We associated individual polygenic scores (PGSs) indexing polygenic liability for AN, schizophrenia, and body mass index (BMI) with severity and SEED. After multiple testing correction, only the BMI PGS when calculated with traditional clumping and p value thresholding was robustly associated with disorder severity (β_PGS = 1.30; 95% CI: 0.72, 1.88; p = 1.2 × 10^-5) across all p value thresholds at which we generated the PGS. However, using the alternative PGS calculation method PRS-CS yielded inconsistent results for all PGS. The positive association stands in contrast to the negative genetic correlation between BMI and AN. Larger discovery GWASs to calculate PGS will increase power, and it is essential to increase sample sizes of the AN GWASs to generate clinically meaningful PGS as adjunct risk prediction variables. Nevertheless, this study provides the first evidence of potential clinical utility of PGSs for eating disorders.

Cannabinoids for Symptom Management in Patients with Kidney Failure

People with kidney failure can experience a range of symptoms that lead to suffering and poor quality of life. Available therapies are limited, and evidence for new treatment options is sparse, often resulting in incomplete relief of symptoms. There is growing interest in the potential for cannabinoids, including cannabidiol and tetrahydrocannabinol, to treat symptoms across a wide range of chronic diseases. As legal prohibitions are withdrawn or minimized in many jurisdictions, patients are increasingly able to access these agents. Cannabinoid receptors, CB1 and CB2, are widely expressed in the body, including within the nervous and immune systems, and exogenous cannabinoids can have anxiolytic, anti-emetic, analgesic and anti-inflammatory effects. Considering their known physiological actions and successful studies in other patient populations, cannabinoids may be viewed as potential therapies for a variety of common symptoms affecting those with kidney failure, including pruritus, nausea, insomnia, chronic neuropathic pain, anorexia, and restless legs syndrome. In this review, we summarize the pharmacology and pharmacokinetics of cannabinoids, along with what is known about the use of cannabinoids for symptom relief in those with kidney disease, and the evidence available concerning their role in management of common symptoms. Presently, while these agents show varying efficacy with a reasonable safety profile in other patient populations, evidence-based prescribing of cannabinoids for people with symptomatic kidney failure is not possible. Given the symptom burden experienced by individuals with kidney failure, there is an urgent need to understand the tolerability and safety of these agents in this population, which must ultimately be followed by robust, randomized controlled trials to determine if they are effective for symptom relief.

Cortisol, Depression, and Anxiety Levels Before and After Short-Term Intensive Nutritional Stabilization in Patients With Severe Anorexia Nervosa

INTRODUCTION

Depression and anxiety are well-known comorbid conditions in patients with anorexia nervosa (AN). Hypercortisolemia in patients with AN may be pathogenic and contribute to depression and anxiety symptomatology.

OBJECTIVE

The aim of this study was to investigate short-term changes in cortisol levels and depression and anxiety symptomatology following intensive re-nutrition in patients with severe AN and hospitalized in a specialized unit. Furthermore, we investigated the potential association between cortisol levels and psychometric parameters.

METHODS

A total of 36 patients with AN were enrolled in the study. Nine dropped out before follow-up. Patients underwent paraclinical and psychometric examinations at admission and discharge. Measurements included plasma cortisol, cortisol binding globulin (CBG), 24-h urine cortisol, and self-report questionnaires regarding eating disorder, depression, anxiety, and stress symptoms. Patients were hospitalized in the unit for somatic stabilization and intensive re-nutrition. Mean admission length was 41 days. The study was registered at ClinicalTrials.gov (NCT02502617).

RESULTS

Cortisol levels in blood and urine did not change from admission to discharge in patients with severe AN. Symptoms of depression, anxiety, stress, and eating disorder remained elevated at discharge. There were no associations between changes in cortisol levels and changes in psychometrics.

DISCUSSION

Our results suggest that short-term intensive re-nutrition did not alter hypothalamic-pituitary-adrenal axis activity or mental health in patients with severe AN. Long-term stabilization and longer follow-up after hospital discharge may be needed to detect changes in cortisol levels and whether these changes are associated with depression and anxiety symptomatology. Greater knowledge about cortisol levels and mental health in patients with severe AN may help in the development of new treatment choices for the chronically ill patients. Future studies could investigate whether cortisol-lowering drugs have a therapeutic effect on mental health in AN.

The Peripheral Cannabinoid Receptor Type 1 (CB1) as a Molecular Target for Modulating Body Weight in Man

The cannabinoid 1 (CB₁) receptor regulates appetite and body weight; however, unwanted central side effects of both agonists (in wasting disorders) or antagonists (in obesity and diabetes) have limited their therapeutic utility. At the peripheral level, CB₁ receptor activation impacts the energy balance of mammals in a number of different ways: inhibiting satiety and emesis, increasing food intake, altering adipokine and satiety hormone levels, altering taste sensation, decreasing lipolysis (fat break down), and increasing lipogenesis (fat generation). The CB₁ receptor also plays an important role in the gut–brain axis control of appetite and satiety. The combined effect of peripheral CB₁ activation is to promote appetite, energy storage, and energy preservation (and the opposite is true for CB₁ antagonists). Therefore, the next generation of CB₁ receptor medicines (agonists and antagonists, and indirect modulators of the endocannabinoid system) have been peripherally restricted to mitigate these issues, and some of these are already in clinical stage development. These compounds also have demonstrated potential in other conditions such as alcoholic steatohepatitis and diabetic nephropathy (peripherally restricted CB₁ antagonists) and pain conditions (peripherally restricted CB₁ agonists and FAAH inhibitors). This review will discuss the mechanisms by which peripheral CB₁ receptors regulate body weight, and the therapeutic utility of peripherally restricted drugs in the management of body weight and beyond.

Potential therapeutic benefits of cannabinoid products in adult psychiatric disorders: A systematic review and meta-analysis of randomised controlled trials

The utility of cannabinoids and cannabinoid-based products (CBPs) as a pharmacological aid to treat psychiatric disorders in adulthood is still poorly understood despite a number of comprehensive general reviews discussing the topic. With a focus on randomized controlled trial (RCT) data, this review and meta-analysis aimed to aggregate and evaluate all current high-quality (Level-1) research that specifically assessed the effectiveness of a CBP on a diagnosed adult psychiatric disorder. The following databases, from their inception to September 2020, were included in the search: Academic Search Premier, PubMed, Ovid MEDLINE®, Web of Science™, PsycARTICLES, PsycINFO, CINAHL (Nursing and Allied Health), and Scopus. Risk of bias for each study was individually assessed using the revised Cochrane tool. Of the 2397 papers identified, thirty-one RCTs met criteria for inclusion: ten trials focused on treating cannabis use disorder, six on schizophrenia, five on opioid/tobacco use disorder, three on anxiety disorders, two on Tourette's disorder, two on anorexia nervosa, and one trial each for attention-deficit/hyperactivity disorder, posttraumatic stress disorder, and obsessive compulsive disorder. This review finds limited evidence for the effectiveness of CBPs to acutely treat a narrow range of psychiatric symptoms. We report no evidence supporting the mid- to long-range effectiveness of any currently available CBP. In general, quality of the evidence was assessed as low- to moderate. Importantly, none of the studies discussed in this review presently endorse the use of cannabis flower as a method of treatment for any recognized psychiatric disorder. Larger, hypothesis driven RCTs are required prior to making further therapeutic recommendations.

Inpatients with severe-enduring anorexia nervosa: Understanding the "enduringness" specifier

BACKGROUND

Despite the need for a common definition of severe and enduring anorexia nervosa (SE-AN) with the overarching goal to optimize treatments, this definition still is being debated. Therefore, in this study we conducted an in-depth investigation of the history of AN and its clinical outcomes on inpatients with AN to ascertain the eventual "profiles" for individuals with varying durations of the illness (DOI).

METHODS

We recruited 169 inpatients with AN, grouping them according to DOI: <3 years (short duration, SD-AN); 3-6.99 years (medium duration, MD-AN); and ≥7 years (long duration, LD-AN). We then performed a self-report and interview-based investigation of AN history, clinical data, eating, and general psychopathology, including personality, premorbid traits, stage of change, and quality of life. We measured the clinical outcomes for hospitalization as well.

RESULTS

The majority of the measures did not differ across groups. Those with LD-AN were older and diagnosed mostly with the binge-purging AN subtype, failed more previous AN-related treatments, reported a lower lifetime body mass index, and trended toward a younger age at onset when compared to the other groups. All patients responded equally well to hospitalization, but patients with SD-AN improved less in drive for thinness and body-related concerns.

CONCLUSIONS

We did not find the "enduringness" of AN to be a specifier of severity. Hospitalization was effective for those with LD-AN and MD-AN, while interventions for the core cognitive aspects of over-evaluation of body shape should be offered to patients with SD-AN.

Hair endocannabinoid concentrations in individuals with acute and weight-recovered anorexia nervosa

BACKGROUND

The endocannabinoid system has been suggested to modulate energy metabolism and stress response and could be an important factor in the pathophysiology of anorexia nervosa (AN). In the context of AN, excessive physical activity may influence endocannabinoid concentrations. The objective of this study was to investigate hair endocannabinoid concentrations at different stages of the disorder. Measurement in hair allows for a cumulative assessment of endocannabinoid concentrations independent of circadian rhythms.

METHODS

In a combined cross-sectional and longitudinal design, we measured hair concentrations of the endocannabinoids anandamide and 2-arachidonoylglycerol and the endocannabinoid-related compounds palmitoylethanolamide, oleoylethanolamide, and stearoylethanolamide in female underweight patients with acute AN (n = 67, reassessment of n = 47 after short-term weight restoration with a body mass index increase of at least 14%), individuals long-term recovered from AN (n = 27), and healthy control participants (n = 84).

RESULTS

Hair concentrations of anandamide and all endocannabinoid-related compounds were elevated in acute AN and decreased over the course of short-term weight restoration. Anandamide concentrations remained elevated in long-term recovered AN patients. In long-term recovered patients, physical activity correlated positively with the concentrations of all endocannabinoid-related compounds.

CONCLUSION

The current study provides evidence for a significant alteration of the endocannabinoid system in acute AN, which may partly persist into long-term recovery. The endocannabinoid system may be a possible target for pharmaceutical interventions in AN, which should be explored in further preclinical and subsequently clinical randomized controlled trials.

Treatment studies with cannabinoids in anorexia nervosa: a systematic review

INTRODUCTION

Anorexia nervosa (AN) is a psychiatric disorder with a high mortality and unknown etiology, and effective treatment is lacking. For decades, cannabis has been known to cause physical effects on the human body, including increasing appetite, which may be beneficial in the treatment of AN.

OBJECTIVE

To systematically review the literature for evidence of an effect of cannabinoids on (1) weight gain, and (2) other outcomes, in AN.

METHOD

A systematic review was done using three databases Embase, PubMed and Psychinfo. The review was registered in PROSPERO with ID number CRD42019141293 and was done according to PRISMA guidelines.

RESULTS

There were 1288 studies identified and after thorough review and exclusion of copies, 4 studies met the inclusion criteria. Three studies used the same AN population and utilized data from one original study, leaving only two original studies. Both of these were Randomized Controlled Trials that explored the effects of delta-9-tetrahydrocannabinol (Δ9-THC) or dronabinol in AN, whereof one study was properly designed and powered and showed a weight increase of an added 1 kg over 4 weeks over placebo.

DISCUSSION AND CONCLUSION

There are few studies and the level of evidence is low. The only properly designed, low bias and highly powered study found a weight increasing effect of dronabinol in AN, while the other, using Δ9-THC at a high dose, found no effect and where the dose may have counteracted the weight gaining effects due to adverse events. More research on cannabinoids in anorexia nervosa is warranted, especially its effects on psychopathology.

LEVEL OF EVIDENCE

Level I, systematic review.

Are There Therapeutic Benefits of Cannabinoid Products in Adult Mental Illness?

A position statement developed by the Canadian Psychiatric Association's (CPA) Research Committee and approved by the CPA's Board of Directors on May 13, 2020.

A Perspective on Chronic and Long-Lasting Anorexia Nervosa

Anorexia Nervosa (AN) is a severe eating disorder which typically develops in younger females. Many studies focus on this specific population, a majority of which will eventually partially or fully recover. A minority will become chronic despite extensive treatment. These patients are treatment-resistant and may not necessarily benefit from usual treatment. In this article we will reflect on possible mechanisms which may explain the maintenance of disease, and especially on the possible role of affective and anxiety disturbances. We will use, due to the lack of large-scale studies, data from risk and prognostic factors, treatment options and neurobiological correlates in chronic AN patients. Lastly, we will propose how these elements may advise further research and treatments.

Relationship between eating disorder duration and treatment outcome: Systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis examine the contribution of duration to treatment outcome for eating disorders.

METHOD

Studies (n = 31) were identified that examined associations (r) between duration and 45 different outcomes. We were unable to extract r for seven studies (9 outcomes) and extracted r for 36 outcomes across 24 studies (2,349 participants). Indicators of treatment outcome were heterogeneous and thus a series of different meta-analyses, aimed at increasing homogeneity, were conducted.

RESULTS

First, we examined the average effect size for one primary eating disorder related outcome from each of the 24 studies. There was no association between duration and treatment outcome (r = .05, 95% CI: -.03:.13), with high heterogeneity. Second, we conducted three sub-group analyses to explore possible sources of heterogeneity (diagnosis: anorexia nervosa versus bulimia nervosa; nature of the outcome: binary versus continuous; or type of outcome: binary indicator of recovery, eating disorder psychopathology, weight gain). There was no significant moderation or associations between duration and outcome (ranging from .02-.08), with low to medium heterogeneity. Third, two stand-alone analyses examined outcomes related to weight gain (n = 8) and eating disorder psychopathology (n = 5), with nonsignificant rs of .23/-.06, respectively. High levels of heterogeneity were present.

DISCUSSION

Duration did not influence treatment outcome across any of our meta-analyses. Increasing homogeneity and power will allow more stable estimates of the impact of duration on outcome to be calculated; to this end, future treatment studies should include outcome related to weight gain (anorexia nervosa) and improvements in eating disorder psychopathology.

Adverse effects of cannabidiol: a systematic review and meta-analysis of randomized clinical trials

Cannabidiol (CBD) is being investigated as a treatment for several medical disorders but there is uncertainty about its safety. We conducted the first systematic review and meta-analysis of the adverse effects of CBD across all medical indications. Double-blind randomized placebo-controlled clinical trials lasting ≥7 days were included. Twelve trials contributed data from 803 participants to the meta-analysis. Compared with placebo, CBD was associated with an increased likelihood of withdrawal for any reason (OR 2.61, 95% CI: 1.38-4.96) or due to adverse events (OR 2.65, 95% CI: 1.04-6.80), any serious adverse event (OR 2.30, 95% CI: 1.18-4.48), serious adverse events related to abnormal liver function tests (OR 11.19, 95% CI: 2.09-60.02) or pneumonia (OR 5.37, 95% CI: 1.17-24.65), any adverse event (OR 1.55, 95% CI: 1.03-2.33), adverse events due to decreased appetite (OR 3.56, 95% CI: 1.94-6.53), diarrhoea (OR 2.61, 95% CI: 1.46-4.67), somnolence (OR 2.23, 95% CI: 1.07-4.64) and sedation (OR 4.21, 95% CI: 1.18-15.01). Associations with abnormal liver function tests, somnolence, sedation and pneumonia were limited to childhood epilepsy studies, where CBD may have interacted with other medications such as clobazam and/or sodium valproate. After excluding studies in childhood epilepsy, the only adverse outcome associated with CBD treatment was diarrhoea (OR 5.03, 95% CI: 1.44-17.61). In summary, the available data from clinical trials suggest that CBD is well tolerated and has relatively few serious adverse effects, however interactions with other medications should be monitored carefully. Additional safety data from clinical trials outside of childhood epilepsy syndromes and from studies of over-the-counter CBD products are needed to assess whether the conclusions drawn from clinical trials can be applied more broadly.

Pharmacological treatment of eating disorders, comorbid mental health problems, malnutrition and physical health consequences

The pharmacological treatment of patients with an eating disorder (ED) often includes medications to treat their ED, comorbid mental health problems, malnutrition and the physical health problems resulting from it. The currently approved pharmacological treatment options for EDs are limited to fluoxetine for bulimia nervosa (BN) and - in some countries - lisdexamfetamine for binge eating disorder (BED). Thus, there are no approved pharmacological options for anorexia nervosa (AN), even though study results for olanzapine and dronabinol are promising. Topiramate might be an additional future option for the treatment of BN and BED. Selective serotonin reuptake inhibitors (SSRI), mirtazapine and bupropion could be considered for the treatment of comorbid unipolar depression. However, AN and BN are contraindications for bupropion. For ED patients with a manic episode, we recommend olanzapine in AN and risperidone in BN and BED; whereas for bipolar depression, olanzapine (plus fluoxetine) seems appropriate in AN and lamotrigine in BN and BED. Acute anxiety or suicidality may warrant benzodiazepine treatment with lorazepam. Proton-pump inhibitors, gastroprokinetic drugs, laxatives and hormones can alleviate certain physical health problems caused by EDs. Therapeutic drug monitoring, pharmacogenomic testing, a more restrictive use of "pro re nata" (PRN) medication, an interdisciplinary treatment approach, shared decision making (SDM) and the formulation of common treatment goals by the patients, their family or carers and clinicians could improve treatment success and safety. Novel genetic, immunological, microbiome and brain imaging research as well as new pharmacological developments like the use of psychedelics, stimulants, novel monoaminergic drugs, hormone analogues and drugs which enhance the effects of psychotherapy may extend our therapeutic options in the near future.

Severe and enduring anorexia nervosa: Update and observations about the current clinical reality

Several objectives underlie the current article. First, to review historical diagnostic issues and clinical strategies for treating SE-AN. Second, to provide an overview of recent evidence informed strategies and clinical innovations for the treatment of SE-AN. Third, based on the authors' collective clinical and research experience, we offer eight observations that we believe capture the current clinical experience of patients with SE-AN. Some of these observations represent empirically testable hypotheses, but all are designed to generate a meaningful discussion about the treatment of this group of individuals with eating disorders. Finally, we hope to call clinicians, scientists, professional organizations, advocates, and policy makers to action to attend to critical issues related to the care of individuals with SE-AN. We believe that an international discussion could clarify areas of need for these patients and identify opportunities for clinical innovation that would enhance the lives of individuals with SE-AN and their families.

A multicenter audit of outpatient care for adult anorexia nervosa: Symptom trajectory, service use, and evidence in support of "early stage" versus "severe and enduring" classification

BACKGROUND

We explored the utility of "staging" anorexia nervosa (AN) by duration of illness and psychological wellbeing. We also investigated 12-month symptom trajectories and service usage in a large cohort of patients with AN assessed for outpatient treatment.

METHOD

We conducted secondary analyses on data from a multisite clinical trial of adults with AN (n = 187) recruited from 22 NHS England specialist eating disorder (ED) services into a digital treatment augmentation study. Clinical outcomes and service use were measured at postintervention (six weeks), 6 and 12 months. We grouped patients into two categories: "early stage" (illness duration <3 years; n = 60) and "severe and enduring" stage (SE-AN; n = 41) indicated by distress (Depression Anxiety and Stress Scales, DASS ≥60) and illness duration (≥7 years).

RESULTS

At 12 months, patients reported large improvements in body mass index, small to moderate improvements in ED symptoms, mood, and work/social adjustment, and 23.6% met criteria for recovery. However, patients classified as SE-AN reported higher rates of accessing intensive services, higher ED symptomatology, and poorer work/social adjustment at baseline, and lower rates of improvement in work/social adjustment at 12 months compared to "early stage" respondents.

DISCUSSION

Although present findings suggest overall symptomatic improvements, exploratory results highlight marked differences in course and service use between people at different stages of AN, suggesting a need to consider staging for clinical decision-making. Further research differentiating between clinical subtypes of AN and adoption of a more personalized approach may ensure that services and care pathways better fit patient needs.

Treatment interventions for Severe and Enduring Eating Disorders: Systematic review

OBJECTIVE

Approximately 20% of people with Anorexia Nervosa (AN) and 10% with Bulimia Nervosa (BN) will eventually develop a long-standing illness. Although there is no set definition for Severe and Enduring eating Disorder (SE-ED), the common criteria relate to a long duration of the disorder and a number of unsuccessful treatment attempts. Research evidence for treatment of SE-ED remains limited, thus the objective of this systematic review was to describe different treatment interventions and their effects on SE-ED-related outcomes.

METHOD

A systematic search for quantitative treatment studies of adult participants with SE-ED was conducted in June 2019 (PROSPERO, CRD42018115802) with no restriction on eating disorder type. Altogether, 2,938 studies were included for title and abstract screening.

RESULTS

After systematic searches and article screening, 23 studies (3 randomized controlled trials, 3 open-label studies, 8 naturalistic follow-up studies, 8 case series and case studies, and 1 partially blinded pilot study) were included in the analysis and data extraction. Methodological quality of the included studies was generally low. Inpatient treatment programs (n = 5) were effective in short-term symptom reduction, but long-term results were inconsistent. Outpatient and day-hospital treatment programs (n = 5) seemed promising for symptom reduction. Drug interventions (n = 5) showed some benefits, especially as adjuvant therapies. Brain stimulation (n = 6) led to improvements in depressive symptoms. Other treatments (n = 2) produced mixed results.

DISCUSSION

This is the first systematic review to examine all of the different treatment interventions that have been studied in SE-ED. The results will inform future interventions in research and clinical practice.

Possible therapeutic applications of cannabis in the neuropsychopharmacology field

Cannabis use induces a plethora of actions on the CNS via its active chemical ingredients, the so-called phytocannabinoids. These compounds have been frequently associated with the intoxicating properties of cannabis preparations. However, not all phytocannabinoids are psychotropic, and, irrespective of whether they are psychotropic or not, they have also shown numerous therapeutic properties. These properties are mostly associated with their ability to modulate the activity of an intercellular communication system, the so-called endocannabinoid system, which is highly active in the CNS and has been found altered in many neurological disorders. Specifically, this includes the neuropsychopharmacology field, with diseases such as schizophrenia and related psychoses, anxiety-related disorders, mood disorders, addiction, sleep disorders, post-traumatic stress disorder, anorexia nervosa and other feeding-related disorders, dementia, epileptic syndromes, as well as autism, fragile X syndrome and other neurodevelopment-related disorders. Here, we gather, from a pharmacological and biochemical standpoint, the recent advances in the study of the therapeutic relevance of the endocannabinoid system in the CNS, with especial emphasis on the neuropsychopharmacology field. We also illustrate the efforts that are currently being made to investigate at the clinical level the potential therapeutic benefits derived from elevating or inhibiting endocannabinoid signaling in animal models of neuropsychiatric disorders.

Olanzapine in the treatment of anorexia nervosa: a systematic review

Anorexia nervosa, with the highest mortality rate among psychiatric diseases, is characterized by low body mass index, fear of weight gain, and disturbed body image. Even though multiple drugs have been proposed for the treatment of anorexia nervosa, current treatment modalities include nutritional support and psychotherapy. In this study, our aim is to analyze the efficiency and possible adverse effects of olanzapine, an atypical anti-psychotic drug, in the treatment of anorexia nervosa. The studies investigating the efficiency and possible adverse effects of olanzapine in anorexia nervosa have been searched by using 3 databases (Embase, PubMed, and Cochrane Library). DerSimonian-Laird random effects meta-analyses have been used in the statistical analysis. Effect of olanzapine treatment in accordance with the duration and dosage of drug have been analyzed by the determination of 95% confidence intervals (p value < 0.05 is considered as statistically significant). Despite the presence of some contradictory studies, olanzapine treatment has been found beneficial in anorexia nervosa. In addition, analysis reveals that statistically significant beneficial effect of olanzapine treatment is used at high doses and for short duration. Possible side effects include neuroleptic malignant syndrome, hypoglycemia, and heart block in patients suffering from anorexia nervosa. Even though there is obvious need for more comprehensive further studies, current literature favors olanzapine treatment. The efficiency of olanzapine is considered to be related to changes in dopaminergic and serotonergic system in anorexic patients both in terms of neurotransmitter levels and receptor activity.

Targeting the Endocannabinoid CB1 Receptor to Treat Body Weight Disorders: A Preclinical and Clinical Review of the Therapeutic Potential of Past and Present CB1 Drugs

Obesity rates are increasing worldwide and there is a need for novel therapeutic treatment options. The endocannabinoid system has been linked to homeostatic processes, including metabolism, food intake, and the regulation of body weight. Rimonabant, an inverse agonist for the cannabinoid CB1 receptor, was effective at producing weight loss in obese subjects. However, due to adverse psychiatric side effects, rimonabant was removed from the market. More recently, we reported an inverse relationship between cannabis use and BMI, which has now been duplicated by several groups. As those results may appear contradictory, we review here preclinical and clinical studies that have studied the impact on body weight of various cannabinoid CB1 drugs. Notably, we will review the impact of CB1 inverse agonists, agonists, partial agonists, and neutral antagonists. Those findings clearly point out the cannabinoid CB1 as a potential effective target for the treatment of obesity. Recent preclinical studies suggest that ligands targeting the CB1 may retain the therapeutic potential of rimonabant without the negative side effect profile. Such approaches should be tested in clinical trials for validation.

The effect of underweight on female and male reproduction

Chronic energy deficiency can impair the hypothalamic-pituitary-gonadal (HPG) axis and lead to hypothalamic anovulation in underweight women. This review presents the syndromes related to underweight status that are associated with infertility, summarizes the underlying mechanisms, and reviews the available treatment options. Eating disorders, such as anorexia nervosa (AN), constitute the most common cause of infertility in underweight women, who, in addition, experience miscarriages, and sexual dysfunction. The relative energy deficiency in sports (RED-S; former terminology: athlete's triad) involves menstrual dysfunction due to low energy availability, which results in anovulation. Moreover, lipodystrophies, malnutrition, starvation, systematic illnesses (malignancies, endocrinopathies, infectious diseases, advanced chronic diseases, neurologic illnesses), and the utilization of drugs can cause excessive weight loss. They may result in fertility problems due to the loss of adipose tissue and the subsequent hormonal disturbances. Each of these conditions requires multidisciplinary management. Nutritional counseling should target the restoration of energy balance by increasing intake and reducing output. Medical treatment, recommended only for patients who did not respond to standard treatment, may include antipsychotics, antidepressants, or leptin administration. Finally, psychiatric treatment is considered an integral part of the standard treatment.

Pharmacotherapeutic strategies for the treatment of anorexia nervosa - too much for one drug?

INTRODUCTION

Anorexia nervosa is a severe psychiatric illness and no medication has been approved for its treatment. This lack of biological treatments requires the development of new directions for pharmacological research.

AREAS COVERED

There is modest but emerging evidence that dopamine D2 and serotonin 1A and 2A receptor agonistic and antagonist medication might be beneficial for weight gain, although the underlying mechanisms are uncertain. Improving quality of life including treating comorbid conditions is an additional important outcome measure, but this has not been well researched. Biological and psychological risk factors together with neurobiological alterations during the illness maintain the disorder 's pathophysiology. Neuroscience research can be used to understand those interactions and advance the research agenda. The authors discuss the above as well as give perspectives on future research.

EXPERT OPINION

If a multidisciplinary approach that includes evidence-based psychotherapy shows unsatisfactory success in weight normalization and cognitive-emotional recovery, then more experimental treatments that are safe and have indicated treatment effectiveness should be tried to augment treatment. Identification and treatment of comorbid conditions to improve quality of life of the patient should also be part of the treatment regimen, even if the effect on weight gain is uncertain.

Psychological Treatments for People With Severe and Enduring Anorexia Nervosa: A Mini Review

This Mini-Review presents recent research into evidence for psychological treatments for people with severe and enduring anorexia nervosa (SEAN). Two psychological therapies, specialist supportive clinical management (SSCM), and cognitive behavior therapy for anorexia nervosa (CBT-AN) have limited (one randomized controlled study) evidence of efficacy. Both have had adaptations for SEAN, notably with revision of the primary treatment goal of improved quality of life and full weight recovery a secondary goal. A major issue with existing studies is poor definition of SEAN, and the large deficit in research that has used an agreed definition of SEAN. In particular, it may be problematic to extrapolate from studies of people with either severe and/or enduring but not intractable or "resistant" illness. People with longstanding AN who have not received evidence based care should be offered this with an expectation of recovery. Similarly, people with SEAN may be offered care with judicious mitigation of expectations. In the future, trials should include people with SEAN clearly defined. Trials with a subsample of participants likely to have SEAN, if identified at randomisation, are an opportunity for secondary analyses of such participants. This would widen the evidence base for psychological treatments providing hope for people with this devastating illness. Finally, there is an urgent need not only to strengthen our existing knowledge with studies of sufficient power, but also, fundamentally, to derive novel conceptualizations of what "treatment" involves.

Enantioselective Total Synthesis of Potent 9β-11-Hydroxyhexahydrocannabinol

The first total synthesis of potent cannabinoid, 9β-11-hydroxyhexahydrocannabinol, is achieved through a proline-catalyzed inverse-electron-demand Diels-Alder reaction. Using this asymmetric catalysis, the cyclohexane ring is constructed with two chiral centers as a single diastereomer with 97% ee. The creation of the third chiral center and benzopyran ring is demonstrated with the elegant synthetic strategies. This mild and efficient synthetic methodology provides a new route for the asymmetric synthesis of the other potent hexahydrocannabinols.

Eating disorder animal model

PURPOSE OF REVIEW

The aim of this review is to describe animal models that simulate the features of eating disorders. The literature pertaining to animal models that are of relevance for clinical eating disorders and the possible underpinning mechanisms was reviewed using PubMed, Ovid database and Google Scholar.

RECENT FINDINGS

New refinements of the circuits regulated by neurotransmitters and neuropeptides which instigate eating behaviours and the various feedback pathways which monitor acute and chronic nutrient status continue to be discovered. Moreover, work with the animal models that simulate the behavioural features and risk factors related to eating disorders is flourishing and providing new insights into possible causal mechanisms. For example, rodents develop binge-eating behaviours if they are intermittently exposed to processed, palatable foods and/or sugar adulterated drinks. This led to the controversial conceptualization of binge eating as a form of food addiction. Self-starvation taken to a fatal consequence such as occurs in anorexia nervosa can emerge in rodents exposed to triggers like social exclusion and/or the opportunity to exercise.

SUMMARY

There are plausible animal models for both anorexia nervosa and binge-eating disorders. These can be used to elaborate the theoretical models to explain the mechanisms underpinning eating disorders.

Randomized Placebo-Controlled Trial of Nabilone for Agitation in Alzheimer's Disease

OBJECTIVE

To investigate the efficacy and safety of nabilone for agitation in patients with moderate-to-severe Alzheimer's disease (AD).

DESIGN

This 14-week randomized double-blind crossover trial compared nabilone to placebo (6 weeks each) with a 1-week washout between phases.

SETTING

Patients were recruited from a long-term care facility and geriatric psychiatry clinics.

PARTICIPANTS

Patients had AD (standardized Mini-Mental State Examination [sMMSE ≤24]) and agitation (Neuropsychiatric Inventory-Nursing Home version [NPI-NH]-agitation/aggression subscore ≥3).

INTERVENTION

Nabilone (target 1-2 mg) versus placebo.

MEASUREMENTS

The primary outcome was agitation (Cohen Mansfield Agitation Inventory [CMAI]). Secondary outcomes included NPI-NH total, NPI-NH caregiver distress, cognition (sMMSE and Severe Impairment Battery [SIB] or Alzheimer's Disease Assessment Scale of Cognition), global impression (Clinician's Global Impression of Change [CGIC]), and adverse events.

RESULTS

Thirty-nine patients (mean ± SD age = 87 ± 10, sMMSE = 6.5 ± 6.8, CMAI = 67.9 ± 17.6, NPI-NH total = 34.3 ± 15.8, 77% male, nabilone dose = 1.6 ± 0.5 mg) were randomized. There were no crossover or treatment-order effects. Using a linear mixed model, treatment differences (95% CI) in CMAI (b = -4.0 [-6.5 to -1.5], t(30.2) = -3.3, p = 0.003), NPI-NH total (b = -4.6 [-7.5 to -1.6], t(32.9) = -3.1, p = 0.004), NPI-NH caregiver distress (b = -1.7 [-3.4 to -0.07, t(33.7) = -2.1, p = 0.041), and sMMSE (b = 1.1 [0.1-2.0], t(22.6) = 2.4, p = 0.026) all favored nabilone. However, in those who completed the SIB (n = 25) treatment differences favored placebo (b = -4.6 [-7.3 to -1.8], t(20.7) = -4.8, p = 0.003). CGIC improvement during nabilone (47%) and placebo (23%) was not significantly different (McNemar's test, exact p = 0.09). There was more sedation during nabilone (45%) compared to placebo (16%) phases (McNemar's test, exact p = 0.02), but treatment-limiting sedation was not significantly different (McNemar's test, exact p = 0.22).

CONCLUSIONS

Nabilone may be an effective treatment for agitation. However, sedation and cognition should be closely monitored.

Impaired brain endocannabinoid tone in the activity-based model of anorexia nervosa

OBJECTIVE

Despite the growing knowledge on the functional relationship between an altered endocannabinoid (eCB) system and development of anorexia nervosa (AN), to date no studies have investigated the central eCB tone in the activity-based anorexia (ABA) model that reproduces key aspects of human AN.

METHOD

We measured levels of two major eCBs, anandamide (AEA) and 2-arachidonoylglycerol (2-AG), those of two eCB-related lipids, oleoylethanolamide (OEA) and palmitoylethanolamide (PEA), and the cannabinoid type-1 receptor (CB1R) density in the brain of female ABA rats, focusing on areas involved in homeostatic and rewarding-related regulation of feeding behavior (i.e., prefrontal cortex, nucleus accumbens, caudato putamen, amygdala, hippocampus and hypothalamus). Analysis was carried out also at the end of recovery from the ABA condition.

RESULTS

At the end of the ABA induction phase, 2-AG was significantly decreased in ABA rats in different brain areas but not in the caudato putamen. No changes were detected in AEA levels in any region, whereas the levels of OEA and PEA were decreased exclusively in the hippocampus and hypothalamus. Furthermore, CB1R density was decreased in the dentate gyrus of hippocampus and in the lateral hypothalamus. After recovery, both 2-AG levels and CB1R density were partially normalized in some areas. In contrast, AEA levels became markedly reduced in all the analyzed areas.

DISCUSSION

These data demonstrate an altered brain eCB tone in ABA rats, further supporting the involvement of an impaired eCB system in AN pathophysiology that may contribute to the maintenance of some symptomatic aspects of the disease.

The novel cannabinoid CB1 receptor agonist AM11101 increases food intake in female rats

BACKGROUND AND PURPOSE

Δ⁹ -tetrahydrocannabinol (THC) acts via cannabinoid CB₁ receptors to increase feeding. Here, we assessed the orexigenic effect of AM11101, a novel CB₁ receptor agonist designed to have a more favourable pharmacodynamic profile than THC.

EXPERIMENTAL APPROACH

The acute, orexigenic effects of AM11101 and THC were compared in female rats. Food intake and meal patterns were also examined following once daily treatment with AM11101 and THC for 7 days.

KEY RESULTS

AM11101 (0.01-0.1 mg·kg^-1 ) increased food intake during the first hour following both acute and chronic treatments in pre-fed and freely feeding animals. This orexigenic effect persisted for up to 4 hr, with no compensatory decrease in feeding during the subsequent 4-22 hr. THC (1 mg·kg^-1 ) increased 1-hr food intake in pre-fed animals, but was less reliable than AM11101 in increasing 1-hr food intake in freely feeding animals following both acute and chronic administration. The orexigenic effect of both compounds was due to an increase in meal size, not meal number.

CONCLUSIONS AND IMPLICATIONS

Our study provides the first demonstration that AM11101 increases short-term food intake via a selective increase in meal size. AM11101 promotes a more reliable orexigenic effect than THC in freely feeding animals, with no subsequent compensatory decrease in feeding. AM11101 may offer a greater efficacy than THC and its congeners in stimulating food intake in underweight clinical populations.

Medicinal Properties of Cannabinoids, Terpenes, and Flavonoids in Cannabis, and Benefits in Migraine, Headache, and Pain: An Update on Current Evidence and Cannabis Science

BACKGROUND

Comprehensive literature reviews of historical perspectives and evidence supporting cannabis/cannabinoids in the treatment of pain, including migraine and headache, with associated neurobiological mechanisms of pain modulation have been well described. Most of the existing literature reports on the cannabinoids Δ⁹ -tetrahydrocannabinol (THC) and cannabidiol (CBD), or cannabis in general. There are many cannabis strains that vary widely in the composition of cannabinoids, terpenes, flavonoids, and other compounds. These components work synergistically to produce wide variations in benefits, side effects, and strain characteristics. Knowledge of the individual medicinal properties of the cannabinoids, terpenes, and flavonoids is necessary to cross-breed strains to obtain optimal standardized synergistic compositions. This will enable targeting individual symptoms and/or diseases, including migraine, headache, and pain.

OBJECTIVE

Review the medical literature for the use of cannabis/cannabinoids in the treatment of migraine, headache, facial pain, and other chronic pain syndromes, and for supporting evidence of a potential role in combatting the opioid epidemic. Review the medical literature involving major and minor cannabinoids, primary and secondary terpenes, and flavonoids that underlie the synergistic entourage effects of cannabis. Summarize the individual medicinal benefits of these substances, including analgesic and anti-inflammatory properties.

CONCLUSION

There is accumulating evidence for various therapeutic benefits of cannabis/cannabinoids, especially in the treatment of pain, which may also apply to the treatment of migraine and headache. There is also supporting evidence that cannabis may assist in opioid detoxification and weaning, thus making it a potential weapon in battling the opioid epidemic. Cannabis science is a rapidly evolving medical sector and industry with increasingly regulated production standards. Further research is anticipated to optimize breeding of strain-specific synergistic ratios of cannabinoids, terpenes, and other phytochemicals for predictable user effects, characteristics, and improved symptom and disease-targeted therapies.

Facets of shared decision-making on drug treatment for adults with an eating disorder

Shared decision-making (SDM) means that clinicians and the patient make decisions about the treatment together. Regarding drug treatment in eating disorders (EDs), such decisions may include psychopharmacological treatment for the ED itself, medications for potential co-morbid psychiatric disorders, pharmacological strategies to alleviate the health consequences of an ED, or 'pro re nata' (PRN) medication which is given in acute care when required. Decisions regarding drug treatment in EDs should be specific in terms of the active pharmacological substance, its dose, its route of administration, and the duration of treatment. Decisions should be made with regard to the specific health risks of patients with EDs and the entire treatment approach, and should take alternative measures, additional therapies, and specific combinations of therapies into account. The differences in the expectations of patients, carers, and clinicians towards drug treatment, the lack of specific suggestions in clinical practice guidelines, and the lack of approved psychopharmacological treatment options make SDM necessary, but also a challenge. However, SDM may be limited due to the patient's impaired insight or limited capacity due to the ED. Thus, the legal framework must be taken into consideration.