Citalopram versus fluoxetine for the treatment of patients with bulimia nervosa: a single-blind randomized controlled trial

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.

Psychedelics in the treatment of eating disorders: Rationale and potential mechanisms

Eating disorders are serious illnesses showing high rates of mortality and comorbidity with other mental health problems. Psychedelic-assisted therapy has recently shown potential in the treatment of several common comorbidities of eating disorders, including mood disorders, post-traumatic stress disorder, and substance use disorders. The theorized therapeutic mechanisms of psychedelic-assisted therapy suggest that it could be beneficial in the treatment of eating disorders as well. In this review, we summarize preliminary data on the efficacy of psychedelic-assisted therapy in people with anorexia nervosa, bulimia nervosa, and binge eating disorder, which include studies and case reports of psychedelic-assisted therapy with ketamine, MDMA, psilocybin, and ayahuasca. We then discuss the potential therapeutic mechanisms of psychedelic-assisted therapy in these three eating disorders, including both general therapeutic mechanisms and those which are relatively specific to eating disorders. We find preliminary evidence that psychedelic-assisted therapy may be effective in the treatment of anorexia nervosa and bulimia nervosa, with very little data available on binge eating disorder. Regarding mechanisms, psychedelic-assisted therapy may be able to improve beliefs about body image, normalize reward processing, promote cognitive flexibility, and facilitate trauma processing. Just as importantly, it appears to promote general therapeutic factors relevant to both eating disorders and many of their common comorbidities. Lastly, we discuss potential safety concerns which may be associated with these treatments and present recommendations for future research.

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.

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.

DRIMC: an improved drug repositioning approach using Bayesian inductive matrix completion

Motivation

One of the most important problems in drug discovery research is to precisely predict a new indication for an existing drug, i.e. drug repositioning. Recent recommendation system-based methods have tackled this problem using matrix completion models. The models identify latent factors contributing to known drug-disease associations, and then infer novel drug-disease associations by the correlations between latent factors. However, these models have not fully considered the various drug data sources and the sparsity of the drug-disease association matrix. In addition, using the global structure of the drug-disease association data may introduce noise, and consequently limit the prediction power.

Results

In this work, we propose a novel drug repositioning approach by using Bayesian inductive matrix completion (DRIMC). First, we embed four drug data sources into a drug similarity matrix and two disease data sources in a disease similarity matrix. Then, for each drug or disease, its feature is described by similarity values between it and its nearest neighbors, and these features for drugs and diseases are mapped onto a shared latent space. We model the association probability for each drug-disease pair by inductive matrix completion, where the properties of drugs and diseases are represented by projections of drugs and diseases, respectively. As the known drug-disease associations have been manually verified, they are more trustworthy and important than the unknown pairs. We assign higher confidence levels to known association pairs compared with unknown pairs. We perform comprehensive experiments on three benchmark datasets, and DRIMC improves prediction accuracy compared with six stat-of-the-art approaches.

Availability and implementation

Source code and datasets are available at https://github.com/linwang1982/DRIMC.

Supplementary information

Supplementary data are available at Bioinformatics online.

Recent advances in therapies for eating disorders

Eating disorders are serious psychiatric illnesses with high rates of morbidity and mortality. Effective treatments have traditionally included behaviorally focused therapies as well as several medication strategies. Recent years have seen promising developments in these treatments, including additional support for family-based approaches for children and adolescents, new evidence for "third-wave" behavioral therapies, and new support for the use of lisdexamfetamine for binge eating disorder and olanzapine for anorexia nervosa. Case study and pilot data are beginning to show limited support for neuromodulatory interventions targeting brain regions thought to be involved in eating disorders. This review summarizes treatment developments over the last several years and points towards future directions for the field.

Pharmacotherapy of eating disorders

PURPOSE OF REVIEW

Medications are commonly prescribed in the treatment of eating disorders. In this review, we discuss relevant medications used for the treatment of bulimia nervosa, binge eating disorder (BED), and anorexia nervosa. We focus on recent research developments, where applicable, in addition to discussing important findings from older studies to provide a complete synopsis of the current evidence base for eating disorder treatment using pharmacologic agents.

RECENT FINDINGS

Medications are generally useful for patients with bulimia nervosa and BED. For bulimia nervosa, antidepressant medications are the primary pharmacologic treatment and limited new research has been completed. For BED, lisdexamfetamine is reported to be generally well tolerated and effective, and is the first medication to be indicated by the US Food and Drug Administration for treatment of BED. For anorexia nervosa, there is limited evidence supporting benefits of medications. Second-generation antipsychotics, particularly olanzapine, appear to demonstrate some benefit for weight gain in anorexia nervosa, although are not advised as a stand-alone treatment. Transdermal administration of hormonal agents is also being explored for improving bone health in anorexia nervosa.

SUMMARY

Although pharmacotherapy has established utility in bulimia nervosa and BED, further research on medications for the treatment of eating disorders, particularly anorexia nervosa, is necessary.

2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management

Eating disorders, such as anorexia nervosa and bulimia nervosa, can have devastating effects on both the health and performance of athletes. Compared to non-athletes, both female and male athletes are at higher risk of developing an eating disorder. This is especially true for athletes participating in sports where low body weight or leanness confers a competitive advantage. Screening for disordered eating behaviours, eating disorders and for related health consequences should be a standard component of preparticipation examinations, and team physicians should be knowledgeable of the updated diagnostic criteria for eating disorders in the Diagnostic and Statistical Manual-V. Athletes with eating disorders should undergo thorough evaluation and treatment by an experienced multidisciplinary team. Team physicians play a critical role in decision-making on clearance for participation and return to play. Using evidence-based guidelines for clearance and return to play encourages transparency and accountability between the sports medicine care team and the athlete. Efforts to prevent eating disorders should be aimed at athletes, coaches, parents and athletic administrators, and focused on expanding knowledge of healthy nutrition in support of sport performance and health.

A 3-month at-home tube feeding in 118 bulimia nervosa patients: a one-year prospective survey in adult patients

BACKGROUND & AIMS

To study the 1-yr follow-up of 118 bulimia nervosa (BN) patients after a 3-month at-home tube feeding (TF) in a prospective study.

METHODS

At-home TF lasted 3 months, including one month of exclusive TF (no food). All patients fulfilled 4 questionnaires (score of binge/purging episodes (BP), eating disorder inventory, anxiety, depression), before, at the 3-month TF point, and 6 and 12 months latter.

RESULTS

The score of BP episodes dramatically decreased from 28.8 ± 15 (before TF) to 7.3 ± 5.4 at 3 months, as well as at 1 yr (15.1 ± 6.2). We also obtained a 50% decrease in Beck score (depression) and Hamilton score (anxiety). Curiously, there was no difference between the BP scores of the patients following psychotherapy and those who did not, despite lower scores for anxiety and depression.

CONCLUSION

In conclusion, in bulimia nervosa patients having normal BMI and purging behavior, home-TF allow to obtain total withdrawal from bingeing/purging in at least 75% of the cases at short term (3 months) and in 25% of the patients at one year, whatever the patients have or have not psychotherapy.

Does anger mediate between personality and eating symptoms in bulimia nervosa?

The goals of the study were to explore anger correlation with bulimic symptoms and to test the mediation power of anger between personality and eating psychopathology. A total of 242 bulimia nervosa (BN) outpatients and 121 healthy controls were recruited. Assessment was performed using Temperament and Character Inventory (TCI); State-Trait Anger Expression Inventory 2 (STAXI-2); Eating Disorder Inventory-2 (EDI-2); Body Shape Questionnaire (BSQ); Binge Eating Scale (BES); and Beck Depression Inventory (BDI). Mediation was tested on the whole BN group, on controls and on two BN subgroups based on a previous history of anorexia nervosa. Self-Directedness and Cooperativeness extensively relate to anger and psychopathology in bulimic group. Bulimic symptoms are related to Trait Reactive Anger. Trait Anger and Anger Expression fully mediate Cooperativeness effects on binge eating and Impulsiveness in the BN subjects. Anger Expression-In partially mediates between Harm Avoidance and Social Insecurity/Interpersonal Distrust in BN subjects. The comparison with controls and the analysis of subgroups underlines that these patterns are specific for BN. Anger mediation between Cooperativeness, and binge eating and impulsive behaviours confirm the relevance of relational dynamics in the expression of these core eating symptoms. Relational skills may represent a relevant target for the treatment of BN.

Clinical psychopharmacology of eating disorders: a research update

The paper presents a critical review (with search date 2010) of the major psychotropic medications assessed in eating disorders, namely antipsychotics, antidepressants, mood-stabilizing medications, anxiolytic and other agents. The evidence of efficacy of drug treatments is mostly weak or moderate. In addition, attrition rates are usually higher than for psychotherapies. However, there is support for use of antidepressants, particularly high-dose fluoxetine in bulimia nervosa, and anticonvulsants (topiramate) for binge-eating disorder. Low-dose antipsychotic medication may be clinically useful as adjunct treatment in acute anorexia, particularly where there is high anxiety and obsessive eating-related ruminations and failure to engage, but more trials are needed. Drug therapies such as topiramate and anti-obesity medication may aid weight loss in obese or overweight patients with binge-eating disorder; however, common or potentially serious adverse effects limit their use.

Efficacy of tube feeding in binge-eating/vomiting patients: a 2-month randomized trial with 1-year follow-up

BACKGROUND

In many binge-eating/vomiting patients, abstinence could not be obtained from classical treatments. Since the authors showed that tube feeding (TF) reduced such episodes in anorexia nervosa (AN)-hospitalized patients, they carried out a randomized trial on the efficacy of TF plus cognitive behavioral therapy (CBT) vs CBT alone in AN and bulimia nervosa adult outpatients.

METHODS

The authors randomly assigned 103 ambulatory patients to receive 16 sessions of CBT alone (n = 51) or CBT plus 2 months of TF (n = 52). The main goal was abstinence of binge-eating/vomiting episodes. Other criteria were gains in fat-free mass and muscle mass improvements in nutrition markers, and quality of life (SF-36 Health Survey), depression (Beck Depression Inventory), and anxiety (Hamilton Anxiety Rating Scale) scores. Evaluations were performed at 1, 2 (end of treatment), 5, 8, and 14 months (analysis of variance).

RESULTS

TF patients were rapidly and more frequently abstinent at the end of treatment (2 months) than the CBT patients: 81% vs 29% (P < .001). Fat-free mass, biological markers, depressive state (-58% vs -26%), anxiety (-48% vs -15%), and quality of life (+42% vs +13%) were more improved in the TF group than in the CBT group (P < .05). One year later, more TF patients remained abstinent (68% vs 27%, P = .02); they were less anxious, were less depressed, and had better quality of life than the CBT patients (P < .05).

CONCLUSION

TF combined with CBT offered better results than CBT alone.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of eating disorders

OBJECTIVES

The treatment of eating disorders is a complex process that relies not only on the use of psychotropic drugs but should include also nutritional counselling, psychotherapy and the treatment of the medical complications, where they are present. In this review recommendations for the pharmacological treatment of eating disorders (anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED)) are presented, based on the available literature.

METHODS

The guidelines for the pharmacological treatment of eating disorders are based on studies published between 1977 and 2010. A search of the literature included: anorexia nervosa bulimia nervosa, eating disorder and binge eating disorder. Many compounds have been studied in the therapy of eating disorders (AN: antidepressants (TCA, SSRIs), antipsychotics, antihistaminics, prokinetic agents, zinc, Lithium, naltrexone, human growth hormone, cannabis, clonidine and tube feeding; BN: antidepressants (TCA, SSRIs, RIMA, NRI, other AD), antiepileptics, odansetron, d-fenfluramine Lithium, naltrexone, methylphenidate and light therapy; BED: antidepressants (TCA, SSRIs, SNRIs, NRI), antiepileptics, baclofen, orlistat, d-fenfluramine, naltrexone).

RESULTS

In AN 20 randomized controlled trials (RCT) could be identified. For zinc supplementation there is a grade B evidence for AN. For olanzapine there is a category grade B evidence for weight gain. For the other atypical antipsychotics there is grade C evidence. In BN 36 RCT could be identified. For tricyclic antidepressants a grade A evidence exists with a moderate-risk-benefit ratio. For fluoxetine a category grade A evidence exists with a good risk-benefit ratio. For topiramate a grade 2 recommendation can be made. In BED 26 RCT could be identified. For the SSRI sertraline and the antiepileptic topiramate a grade A evidence exists, with different recommendation grades.

CONCLUSIONS

Additional research is needed for the improvement of the treatment of eating disorders. Especially for anorexia nervosa there is a need for further pharmacological treatment strategies.

A randomized, double-blind trial comparing sertraline and fluoxetine 6-month treatment in obese patients with Binge Eating Disorder

Previous studies support the use of selective serotonin reuptake inhibitors (SSRIs), in overweight patients with Binge Eating Disorder (BED), but results are far from conclusive. Sertraline has been studied less extensively, and there have been a few studies concerning SSRIs that report follow-up data at more than 12 weeks of follow-up. The present study assesses the effectiveness of sertraline and fluoxetine over a period of 24 weeks in obese patients with BED (DSM-IV-TR). Forty-two obese outpatients were randomized and assigned to one of two different drug treatments: 22 were treated with sertraline (dose range: 100-200 mg/day) and 20 with fluoxetine (dose range: 40-80 mg/day). Subjects were assessed at baseline and at 8, 12, and 24 weeks of treatment for binge frequency, weight loss, and severity of psychopathology. No significant differences were found between the two treatments. After 8 weeks of treatment a significant improvement in the Binge Eating Scale score and a significant weight loss emerged. These results were maintained by responders (weigh loss of at least 5% of baseline weight) over 24 weeks. The results suggest that a 6-month treatment with SSRI may be an effective option to treat patients with BED.