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

Subanesthetic Ketamine Ameliorates Activity-Based Anorexia of Adult Mice

OBJECTIVE

Anorexia nervosa (AN) is an eating disorder with the second highest mortality of all mental illnesses and high relapse rate, especially among adult females, yet with no accepted pharmacotherapy. A small number of studies have reported that adult females who struggled with severe and relapsing AN experienced sustained remission of the illness following ketamine infusions. Two other reports showed that 30 mg/kg IP ketamine can reduce vulnerability of adolescent mice to activity-based anorexia (ABA), an animal model of AN. However, no study has tested the efficacy of ketamine on adult ABA mice. This study aimed to fill this gap in knowledge.

METHODS

Forty-one female mice underwent three cycles of ABA (ABA1, ABA2, and ABA3) to assess relapse vulnerability in adulthood. Of them, 13 received ketamine injections (30 mg/kg, 3 doses) during ABA2 (KET) in adulthood to assess ketamine's acute effects during ABA2 and ketamine's potential for sustained efficacy during ABA3, 10-13 days later. The remaining 28 received vehicle or no injections during ABA2 (CON).

RESULTS

Severe weight loss (>20% of baseline) during ABA3 was observed for 89% of CON but only 69% of KET. Overall wheel running per day was significantly less for KET than CON (p < 0.01) throughout ABA2, including hours of food availability, and these reductions were sustained through ABA3. Food consumption was not altered significantly by ketamine.

DISCUSSION

These findings suggest that ketamine may reduce adult females' vulnerability to ABA and may protect women from AN relapse by reducing hyperactivity.

Can we effectively manage binge eating disorder with pharmacotherapy?

INTRODUCTION

Pharmacological and other treatments for binge eating disorder (BED) predate its inclusion as the third main eating disorder in the 2013 DSM-5. Currently, second in line to psychological therapy are psychotropics such as antidepressants, anticonvulsants and stimulants.

AREAS COVERED

This review summarizes the evidence and emerging evidence on the pharmacotherapies for BED and their potential for wider use.

EXPERT OPINION

Pharmacotherapy has utility as an alternative or adjunctive treatment for those exhibiting insufficient response to, or not preferencing, psychological interventions. Medications may also benefit individuals with BED and other co-occurring mental health conditions, such as depression and attention deficit hyperactivity disorder. In addition, there are several agents (e.g. glucagon like peptide-1 receptor agonists and the combination of naltrexone-bupropion) displaying promise for weight and binge eating reduction in people with BED and high BMI. Future research should extend the understanding of the role of medication in BED, focusing on their sustained effects over time, when and if they may be ceased, their effectiveness in people with adequate weight, and the risks associated with weight loss in those with BED and high weight.

Ketogenic Food Ameliorates Activity-Based Anorexia of Adult Female Mice

OBJECTIVE

Genome-wide association studies implicate metabo-psychiatric origins for anorexia nervosa (AN). There are two case reports totaling six adult females who experienced complete remission of AN following a treatment comprised of ketogenic diet (targeting metabolism) with ketamine infusions (targeting psychiatric origins), but no study has determined the efficacy of ketogenic diet, alone. We addressed this gap in knowledge, with exploration of potential molecular mechanisms, using an animal model.

METHOD

Adult C57BL6 female mice underwent 2 or 3 cycles of activity-based anorexia (ABA1, ABA2, ABA3), an animal model of AN relapse, in which AN-like maladaptive behaviors of hyperactivity and voluntary food restriction are elicited when wheel access is combined with food restriction. ABA was categorized as severe, based on weight loss ≥ 20%, food restriction-evoked increase in wheel counts > 10,000/6 h, and crouching/grimace, and compared across two groups: (1) KG, fed ketogenic food continuously (N = 25); and (2) CON, fed standard diet (N = 28).

RESULTS

86% of CON versus none of the KG were crouching with grimace during ABA1. 93% of CON versus 11% of KG lost weight severely during ABA2 (p < 0.001, 8% difference of group mean weights). Severe hyperactivity was prevalent among CON (86%) and rare for KG (4%) during ABA2 (p < 0.001 on all food-restricted days). ABA up-regulated BDNF (brain-derived neurotrophic factor) in the hippocampus of both groups but ketone body, β-hydroxybutyrate, in urine was increased only among KG.

DISCUSSION

Ketogenic diet may reduce severity of AN relapse through reduction of compulsive exercise, via mechanisms that are in addition to BDNF up-regulation and involve β-hydroxybutyrate.

Emotional processing in binge drinking, tobacco use disorder and their comorbidity in youth: A preregistered PRISMA scoping review

BACKGROUND

Binge drinking (BD) and tobacco use disorder (TUD) are prevalent among youth, with significant social and health implications. However, research into the emotional impairments associated with BD and TUD during adolescence is sparse and lacks integration within a comprehensive model of emotional processes. Moreover, the impact of comorbid BD and TUD on emotional deficits remains largely unexplored. We propose the first review focused on the variation of emotional deficits in BD, TUD, or their comorbidity among adolescents and we systematically explore differences across various emotional abilities.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines (PRISMA-ScR), we conducted a preregistered review of existing literature on emotional processing impairments in BD and/or TUD among adolescents. From 481 papers initially identified, 7 were included in this review. Additionally, we proposed experimental avenues for future research based on identified shortcomings in current literature.

RESULTS

Our scoping review indicates that emotional deficits are likely prevalent in both BD and TUD populations, affecting emotional appraisal/identification, response, and regulation. However, further investigation is necessary to ascertain the magnitude and scope of these deficits in adolescents and adults, as well as to delineate the distinct or combined influence of BD and TUD on emotional disturbances.

CONCLUSION

While some emotional deficits are apparent, we contend that examining emotional deficits in BD and TUD separately, as well as together, would offer a more comprehensive understanding of their nature and inform the development of novel treatment strategies.

Binge, Purge, and Wander: Navigating Bulimia and Attention Deficit Hyperactivity Disorder (ADHD)

A 32-year-old woman with no prior medical conditions, but a history of anorexia nervosa (AN) diagnosed in adolescence, was referred for evaluation by an eating disorders (ED) specialist due to worsening bingeing and purging behaviors. Her clinical presentation was characterized by a body mass index (BMI) approaching the underweight range and frequent bingeing and purging episodes occurring twice daily, consistent with a diagnosis of BN. No other medical or psychiatric comorbidities were diagnosed, including mood, anxiety, and substance use disorders, which are often comorbid with ED. However, the patient reported significant difficulties in managing both personal and professional activities, attributing these challenges to impaired concentration. She had difficulty staying focused on tasks and was easily distracted by unrelated thoughts or stimuli. As a result, she often procrastinated on household and self-care tasks. She also reported problems with time management, frequently arriving late to work, struggling to complete assignments on time, and underestimating how long tasks would take. Initial treatment with fluoxetine and cognitive behavioral therapy (CBT) yielded no substantial improvement. Given the presence of symptoms suggestive of attention deficit hyperactivity disorder (ADHD), a one-month trial of lisdexamfetamine (LDX) was initiated. This intervention resulted in a marked reduction in bingeing and purging episodes and a notable improvement in the patient's concentration, thereby enhancing her overall quality of life. The importance of ADHD screening is underscored, particularly for high-functioning adult women who may not present typical symptoms. In this case, a thorough clinical assessment and detailed anamnesis raised suspicion of previously unrecognized ADHD, that may have been present since childhood. Although the literature on the comorbidity of ADHD and BN is limited, this case highlights a potential link between the two conditions. The significant improvement observed following the introduction of psychostimulants supports the hypothesis that untreated ADHD may contribute to the exacerbation of BN symptoms. Further research is essential to clarify the underlying mechanisms and establish a solid scientific basis for future clinical interventions and therapeutic strategies.

Antidepressants compared to placebo for people with binge eating disorder: A systematic review and meta-analysis

Binge eating disorder (BED) is the most prevalent eating disorder. Treatment options include pharmacotherapy as well as psychotherapy, with the latter recommended as a first-line option. However, the use of psychotherapeutic interventions poses several challenges. Antidepressants are easily accessible, but they lack robust evidence-base. This systematic review aims to comprehensively examine the efficacy and safety of antidepressants for the treatment of BED. Five databases were searched for randomized controlled trials (RCTs) comparing antidepressants vs. placebo in BED until 23/11/2023. Pairwise meta-analytic evaluations were performed. The primary outcomes were remission and binge eating frequency. Secondary outcomes were response to treatment, eating psychopathology, depression, anxiety, body weight, Body Mass Index (BMI), all-cause discontinuation, discontinuation due to adverse effects and total adverse events. Sixteen RCTs with a total of 984 participants were meta-analysed. Antidepressants were more effective than placebo in achieving remission (RR: 1.39, 95 % CI: 1.04 to 1.86) and in reducing binge eating episodes (SMD: -0.29, 95 % CI: -0.51 to -0.06). Similarly, in the secondary outcomes of response and depression, antidepressants demonstrated superiority over placebo. Antidepressants appear to be effective in reducing symptoms of BED. Small samples and effect sizes hinder the generalizability and clinical utility of these results. There is a lack of follow-up findings regarding the maintenance of effects. There is a pressing need for more RCTs examining antidepressants and other types of pharmacotherapy. Future research should include larger number of participants and increase the duration of follow-up.

Pragmatic clinical trials to advance research in children and adolescents with eating disorders

OBJECTIVE

To discuss the utility of pragmatic clinical trials (PCTs) to help advance research in eating disorders (EDs).

METHODS

We describe challenges associated with traditional explanatory research trials and examine PCTs as an alternative, including a review of the PRECIS-2 tool.

RESULTS

There are many challenges associated with the design and completion of traditional RCTs within the field of EDs. Pragmatic clinical trials are studies that closely align with conditions available in everyday practice and focus on outcomes that are relevant to patients and clinicians. Results of PCTS maximize applicability and generalizability to clinical settings.

DISCUSSION

Available therapies established for the treatment of EDs provide remission rates that rarely exceed 50%, implying a need for additional research on new or adjunctive treatments. In addition to a general overview of PCTs, we draw upon published literature and our own experiences involving adjunctive olanzapine for the treatment of children and youth with anorexia nervosa to help highlight challenges associated with randomized controlled trial (RCT) design and implementation, and offer pragmatic suggestions that would allow patients greater choice in treatment trials, while at the same time capturing outcomes that are most likely to advance treatment efforts.

CONCLUSIONS

Pragmatic clinical trials provide alternatives to RCT design that can help bolster research in EDs that aims to explore real-world effects of interventions.

PUBLIC SIGNIFICANCE

Available therapies established for the treatment of eating disorders (EDs) in children and adolescents provide remission rates that rarely exceed 50%, implying a need for additional research on new or adjunctive treatments. In this article, we discuss the utility of pragmatic trials to help promote research that can help advance knowledge that is relevant to clinical care settings.

Overweight during development dysregulates cellular metabolism and critical genes that control food intake in the prefrontal cortex

BACKGROUNDS AND AIMS

Childhood obesity is increasing substantially across the world. The World Obesity Federation (WOF) and World Health Organization (WHO) predicted that in 2030 > 1 billion people will be obese, and by 2035 over 4 billion will reach obesity worldwide. According to WHO, the world soon cannot afford the economic cost of obesity, and we need to act to stop obesity acceleration now. Data in the literature supports that the first 1000 days of life are essential in preventing obesity and related adversities. Therefore, using basic research, the present a study that focuses on the immediate effect of overnutrition and serotonin modulation during the lactation period.

METHODS

Using a neonatal overfeeding model, male Wistar rats were divided into four groups based on nutrition or serotonin modulation by pharmacological treatment up to 22 days of life. Cellular and mitochondrial function markers, oxidative stress biomarkers and mRNA levels of hedonic and homeostatic genes were evaluated.

RESULTS

Our data showed that overfeeding during lactation decrease NAD/NADH ratio, citrate synthase activity, and increase ROS production. Lipid and protein oxidation were increased in overfed animals, with a decrease in antioxidant defenses, we also observe a differential expression of mRNA levels of homeostatic and hedonic genes. On the contrary, serotonin modulation with selective serotonin reuptake inhibitors treatment reduces harmful effects caused by overnutrition.

CONCLUSION

Early effects of overnutrition significantly affect the prefrontal cortex at molecular and cellular level, which could mediate obesity-related neurodegenerative dysfunction.

The impact of the COVID-19 pandemic on rates of adolescents receiving psychopharmacological medication in Austria

BACKGROUND

The COVID-19 pandemic has impacted many aspects of everyday life, including the (mental) healthcare system. An increase in depression and anxiety symptoms has been reported worldwide, and is particularly pronounced in females and young people. We aimed to evaluate changes in prescription rates for psychopharmacological medication, which is often used to treat depression and anxiety.

METHOD

Based on data from the Austrian public health insurance institutions, we conducted an interrupted time series analysis of antidepressants and antipsychotics, comparing prescription rate developments before and throughout the COVID-19 pandemic (2013 to 2021), with a special focus on adolescents (10-19 years) in comparison to the general population. Data were based on all public prescriptions in the outpatient sector nationwide. Age- and sex-stratified time-series models were fitted to the pre-COVID period (first quarter (Q1) of 2013 to second quarter (Q2) of 2020). These were used to generate forecasts for the period from the third quarter (Q3) of 2020 to the fourth quarter (Q4) of 2021, which were subsequently compared to observed developments in order to assess significant deviations from the forecasted development paths.

RESULTS

For the majority of the evaluated period, we found a significant excess of antidepressant prescriptions among both male and female adolescents (10-14 and 15-19 years) compared to the forecasted development path, while the general population was mostly within 97.5% confidence intervals of the forecasts. Regarding antipsychotics, the interrupted time series analysis revealed a significant excess in the group of female adolescents in almost all quarters, which was especially pronounced in the 15-19 age group. Prescription rates of antipsychotics in the general population only showed a significant excess in two quarters.

CONCLUSION

Increased rates of adolescents receiving psychopharmacological treatment echo the epidemiological trends of an increase in depression and anxiety symptoms reported in the literature. This increase is especially pronounced in female adolescents.

Efficacy of pharmacotherapies for bulimia nervosa: a systematic review and meta-analysis

OBJECTIVE

The main purpose was to evaluate the efficacy and tolerability of different medications used to treat bulimia nervosa (BN).

METHODS

Randomized controlled trials (RCTs) were identified from published sources through searches in PubMed, Cochrane Library, Web of Science, and Embase from inception to November 2022. Primary outcomes were changes in the frequency of binge eating episodes and vomiting episodes from baseline to endpoint. Secondary outcomes were differences in the improvement of scores in depressive symptoms, tolerability (dropout due to adverse events) and weight change.

RESULTS

The literature search ultimately included 11 drugs, 33 studies and 6 types of drugs, 8 trials with TCAs (imipramine, desipramine), 14 with SSRIs (fluoxetine, citalopram and fluvoxamine), 6 with MAOIs (phenelzine, moclobemide and brofaromine), 3 with antiepileptic drugs (topiramate), 1 with mood stabilizers (lithium), and 1 with amphetamine-type appetite suppressant (fenfluramine). The reduction in binge eating episodes was more likely due to these drugs than the placebo, and the SMD was -0.4 (95% CI -0.61 ~ -0.19); the changes in the frequency of vomiting episodes (SMD = -0.16, 95% CI -0.3 ~ -0.03); weight (WMD = -3.05, 95% CI -5.97 ~ -0.13); and depressive symptoms (SMD = -0.32, 95% CI -0.51 ~ -0.13). However, no significant difference was found in dropout due to adverse events (RR = 1.66, 95% CI 1.14 ~ 2.41).

CONCLUSIONS

This meta-analysis indicates that most pharmacotherapies decreased the frequency of binge-eating and vomiting episodes, body weight, and depressive symptoms in BN patients, but the efficacy was not significant. In each drug the efficacy is different, treating different aspects, different symptoms to improve the clinical performance of bulimia nervosa.