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Norris ML, Spettigue W, Obeid N. Pragmatic clinical trials to advance research in children and adolescents with eating disorders. Int J Eat Disord 2024; 57:1350-1356. [PMID: 38578194 DOI: 10.1002/eat.24209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/22/2024] [Accepted: 03/22/2024] [Indexed: 04/06/2024]
Abstract
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.
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Affiliation(s)
- Mark L Norris
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Wendy Spettigue
- Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicole Obeid
- CHEO Research Institute, Ottawa, Ontario, Canada
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
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Said O, Sengun Filiz E, Stringer D, Applewhite B, Kellermann V, Mutwalli H, Bektas S, Akkese MN, Kumar A, Carter B, Simic M, Sually D, Bentley J, Young AH, Madden S, Byford S, Landau S, Lawrence V, Treasure J, Schmidt U, Nicholls D, Himmerich H. Olanzapine for young PEople with aNorexia nervosa (OPEN): A protocol for an open-label feasibility study. EUROPEAN EATING DISORDERS REVIEW 2024; 32:532-546. [PMID: 38299859 DOI: 10.1002/erv.3060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 12/13/2023] [Accepted: 12/30/2023] [Indexed: 02/02/2024]
Abstract
INTRODUCTION Antipsychotics are routinely prescribed off-label for anorexia nervosa (AN) despite limited evidence. This article presents a protocol of a study aiming to assess the feasibility of a future definitive trial on olanzapine in young people with AN. METHODS AND ANALYSIS In an open-label, one-armed feasibility study, 55 patients with AN or atypical AN, aged 12-24, receiving outpatient, inpatient or day-care treatment who are considered for olanzapine treatment will be recruited from NHS sites based in England. Assessments will be conducted at screening, baseline and at 8-, 16 weeks, 6- and 12 months. Primary feasibility parameters will be proportions of patients who agree to take olanzapine and who adhere to treatment and complete study assessments. Qualitative methods will be used to explore acceptability of the intervention and study design. Secondary feasibility parameters will be changes in body mass index, psychopathology, side effects, health-related quality of life, carer burden and proportion of participants who would enrol in a future randomised controlled trial. The study is funded by the National Institute for Health Research via Health Technology Assessment programme. DISCUSSION Olanzapine for young PEople with aNorexia nervosa will inform a future randomised controlled trial on the efficacy and safety of prescribing olanzapine in young people with AN.
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Affiliation(s)
- Olena Said
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Ece Sengun Filiz
- Division of Psychiatry, Department of Brain Sciences, Imperial College London, London, UK
| | - Dominic Stringer
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Briana Applewhite
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Vanessa Kellermann
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Hiba Mutwalli
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Clinical Nutrition, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Sevgi Bektas
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Melahat Nur Akkese
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Ashish Kumar
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Mersey Care NHS Foundation Trust, Merseyside, UK
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Mima Simic
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Dilveer Sually
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Jessica Bentley
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Sloane Madden
- University of Sydney, Sydney, New South Wales, Australia
| | - Sarah Byford
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Sabine Landau
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Vanessa Lawrence
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Janet Treasure
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Ulrike Schmidt
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Dasha Nicholls
- Division of Psychiatry, Department of Brain Sciences, Imperial College London, London, UK
| | - Hubertus Himmerich
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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Lewis YD, Bergner L, Steinberg H, Bentley J, Himmerich H. Pharmacological Studies in Eating Disorders: A Historical Review. Nutrients 2024; 16:594. [PMID: 38474723 PMCID: PMC11154472 DOI: 10.3390/nu16050594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/14/2024] Open
Abstract
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.
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Affiliation(s)
- Yael D. Lewis
- Hadarim Eating Disorders Unit, Shalvata Mental Health Centre, Hod Hasharon 4534708, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Lukas Bergner
- Forschungsstelle für die Geschichte der Psychiatrie, Klinik und Poliklinik Psychiatrie und Psychotherapie, Medizinische Fakultät der Universität Leipzig, 04103 Leipzig, Germany; (L.B.); (H.S.)
| | - Holger Steinberg
- Forschungsstelle für die Geschichte der Psychiatrie, Klinik und Poliklinik Psychiatrie und Psychotherapie, Medizinische Fakultät der Universität Leipzig, 04103 Leipzig, Germany; (L.B.); (H.S.)
| | - Jessica Bentley
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AF, UK; (J.B.); (H.H.)
| | - Hubertus Himmerich
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London SE5 8AF, UK; (J.B.); (H.H.)
- South London and Maudsley NHS Foundation Trust, London BR3 3BX, UK
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Fornaro M, Mondin AM, Billeci M, Fusco A, De Prisco M, Caiazza C, Micanti F, Calati R, Carvalho AF, de Bartolomeis A. Psychopharmacology of eating disorders: Systematic review and meta-analysis of randomized controlled trials. J Affect Disord 2023; 338:526-545. [PMID: 37393954 DOI: 10.1016/j.jad.2023.06.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 06/17/2023] [Accepted: 06/28/2023] [Indexed: 07/04/2023]
Abstract
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.
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Affiliation(s)
- Michele Fornaro
- Section of Psychiatry - Department of Neuroscience, Reproductive Sciences, and Dentistry, University School of Medicine Federico II, Naples, Italy.
| | - Anna Maria Mondin
- Section of Psychiatry - Department of Neuroscience, Reproductive Sciences, and Dentistry, University School of Medicine Federico II, Naples, Italy
| | - Martina Billeci
- Section of Psychiatry - Department of Neuroscience, Reproductive Sciences, and Dentistry, University School of Medicine Federico II, Naples, Italy
| | | | - Michele De Prisco
- Section of Psychiatry - Department of Neuroscience, Reproductive Sciences, and Dentistry, University School of Medicine Federico II, Naples, Italy; Bipolar and Depressive Disorders Unit, IDIBAPS CIBERSAM, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Claudio Caiazza
- Section of Psychiatry - Department of Neuroscience, Reproductive Sciences, and Dentistry, University School of Medicine Federico II, Naples, Italy
| | - Fausta Micanti
- Section of Psychiatry - Department of Neuroscience, Reproductive Sciences, and Dentistry, University School of Medicine Federico II, Naples, Italy
| | - Raffaella Calati
- Department of Psychology, University of Milan-Bicocca, Piazza dell'Ateneo Nuovo, 1, 20126 Milan, Italy; Department of Adult Psychiatry, Nîmes University Hospital, 4 Rue du Professeur Robert Debré, 30029 Nimes, France.
| | - André Férrer Carvalho
- Deakin University, IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Florey Institute for Neuroscience and Mental Health, the Department of Psychiatry, The University of Melbourne, Melbourne, Australia; St Vincent's Mental Health Unit, Department of Psychiatry, University of Melbourne, Parkville, Melbourne, Australia
| | - Andrea de Bartolomeis
- Section of Psychiatry - Department of Neuroscience, Reproductive Sciences, and Dentistry, University School of Medicine Federico II, Naples, Italy; Chair Staff for Health Education and Sustainable Development, UNESCO, Naples, Italy.
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Frank B, Arnold S, Jaite C, Correll CU. Antipsychotic effects on anthropometric outcomes in anorexia nervosa: a retrospective chart review of hospitalized children and adolescents. J Eat Disord 2023; 11:151. [PMID: 37674209 PMCID: PMC10481458 DOI: 10.1186/s40337-023-00862-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/07/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Off-label antipsychotic use is not uncommon in youth with anorexia nervosa (AN), aiming to enhance suboptimal weight restoration, yet its efficacy remains debated, especially in youth. METHODS Retrospective chart review of consecutively admitted inpatients (ages 8-18 years) with restricting/binge-purge AN, comparing youth with versus without antipsychotic treatment regarding baseline factors, treatment, and anthropometric outcome characteristics including all patients and matched subgroups. Matched subsamples were also compared regarding faster versus slower weight change (median split). Furthermore, within-subject analyses compared weight gain trajectories before versus after antipsychotic use in antipsychotic-treated youth. These results were then compared in a pre-/post design with the matched control group without antipsychotic treatment, using the mean duration until antipsychotic use in the antipsychotic-treated group as the dividing timeline, controlling for a potential order effect, in that later rather than earlier antipsychotic treatment for AN may be more successful. RESULTS Of 294 youth with AN (median age = 15.2 (interquartile range = 14.0, 16.6) years, females = 96.6%, restricting subtype = 81.0%, hospitalization duration = 98.2 ± 43.2 days), 44 (15.0%) underwent 52 antipsychotic trials (olanzapine = 63.5%). In multivariable analyses, antipsychotic use was independently associated with younger age, childhood physical abuse history, comorbid borderline personality traits, and lower pre-antipsychotic weight gain (p < 0.0001). In unmatched groups, antipsychotic-treated versus non-treated youth had significantly lower discharge anthropometric parameters, longer inpatient treatment, and lower weight change/week (p < 0.001-p = 0.005), without significant differences between olanzapine and non-olanzapine antipsychotics (p = 0.27-0.44). Non-significant antipsychotic effects on weight outcomes were confirmed in (1) matched subgroups of antipsychotic-treated versus non-treated youth (n = 43 each), (2) youth with faster versus slower weight gain (n = 21 vs. n = 22), and (3) antipsychotic-treated youth when comparing weight change before versus after antipsychotic use (n = 31). Moreover, in antipsychotic-treated youth, weight change/week remained significantly lower versus matched non-antipsychotic-treated youth (n = 31) both before (p = 0.053) and after (p = 0.006) the median time (5 weeks) until antipsychotic use. CONCLUSIONS In this naturalistic study, clinician's antipsychotic choice, given to a more severely ill subgroup of adolescents with AN, did not significantly improve overall worse weight change trajectories during inpatient treatment, even in matched subgroups. Randomized trials in individuals reflecting real-world samples are needed to evaluate the utility of antipsychotic treatment in youth with AN.
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Affiliation(s)
- Bettina Frank
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité-Universitaetsmedizin Berlin, Campus Virchow, Corporate Member of Freie Universitaet Berlin, Humboldt Universitaet zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sabine Arnold
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité-Universitaetsmedizin Berlin, Campus Virchow, Corporate Member of Freie Universitaet Berlin, Humboldt Universitaet zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Charlotte Jaite
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité-Universitaetsmedizin Berlin, Campus Virchow, Corporate Member of Freie Universitaet Berlin, Humboldt Universitaet zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Department of Clinical Psychology and Psychotherapy in Childhood and Adolescence, University of Hildesheim, Hildesheim, Germany
| | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité-Universitaetsmedizin Berlin, Campus Virchow, Corporate Member of Freie Universitaet Berlin, Humboldt Universitaet zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
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Sandhya L, Ganesan P. Reply to H. Onishi et al. J Clin Oncol 2023; 41:4185-4186. [PMID: 37352487 DOI: 10.1200/jco.23.01090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 06/25/2023] Open
Affiliation(s)
- Lakshmi Sandhya
- Lakshmi Sandhya, MD and Prasanth Ganesan, MD, Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Lakshmi Sandhya, MD and Prasanth Ganesan, MD, Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Himmerich H, Lewis YD, Conti C, Mutwalli H, Karwautz A, Sjögren JM, Uribe Isaza MM, Tyszkiewicz-Nwafor M, Aigner M, McElroy SL, Treasure J, Kasper S. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines update 2023 on the pharmacological treatment of eating disorders. World J Biol Psychiatry 2023:1-64. [PMID: 37350265 DOI: 10.1080/15622975.2023.2179663] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 06/24/2023]
Abstract
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.
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Affiliation(s)
- Hubertus Himmerich
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, UK
| | - Yael Doreen Lewis
- Hadarim Eating Disorders Unit, Shalvata Mental Health Center, Hod HaSharon, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chiara Conti
- Department of Psychological, Health, and Territorial Sciences, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Hiba Mutwalli
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Clinical Nutrition, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Andreas Karwautz
- Eating Disorders Care & Research Unit, Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | | | | | - Marta Tyszkiewicz-Nwafor
- Department of Child and Adolescent Psychiatry, Poznan University of Medical Sciences, Poznań, Poland
| | - Martin Aigner
- Universitätsklinikum Tulln, Tulln an der Donau, Austria
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Janet Treasure
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, UK
| | - Siegfried Kasper
- Center for Brain Research, Medical University of Vienna, Vienna, Austria
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Kooij KL, Luijendijk MCM, Drost L, Platenburg G, van Elburg A, Adan RAH. Intranasal administration of olanzapine has beneficial outcome in a rat activity-based anorexia model. Eur Neuropsychopharmacol 2023; 71:65-74. [PMID: 37031523 DOI: 10.1016/j.euroneuro.2023.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 02/15/2023] [Accepted: 03/10/2023] [Indexed: 04/11/2023]
Abstract
The atypical antipsychotic drug olanzapine is prescribed despite clinical studies on olanzapine treatment showing mixed results on treatment efficacy in anorexia nervosa. We investigated the effect of systemic and intranasal administration of olanzapine in the activity-based anorexia (ABA) model. Rats were habituated to a running wheel and exposed to the ABA model while treated with olanzapine. During ABA rats had 1.5 h of daily access to food and ad libitum access to a running wheel for seven consecutive days. Olanzapine was administered via an osmotic minipump (1, 2.75, and 7.5 mg/kg) or intranasally 2 h before dark onset (1 and 2.75 mg/kg). We monitored body weight, food intake, wheel revolutions, body temperature, and adipose tissue. We found 2.75 and 7.5 mg/kg systemic olanzapine decreased wheel revolutions during ABA. Relative adipose tissue mass was increased in the 7.5 mg/kg olanzapine-treated group while body weight, food intake, and body temperature were unaltered by the systemic olanzapine. 1 and 2.75 mg/kg intranasal olanzapine diminished wheel revolutions and body temperature during the first 2 h after administration. The intranasal olanzapine-treated rats had a higher body weight at the end of ABA. We find that olanzapine has beneficial outcomes in the ABA via two administration routes by acting mainly on running wheel activity. Intranasal olanzapine showed a rapid effect in the first hours after administration in reducing locomotor activity. We recommend further exploring intranasal administration of olanzapine in anorectic patients to assist them in coping with restlessness.
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Affiliation(s)
- Karlijn L Kooij
- Department of Translational Neuroscience, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; Altrecht Eating Disorders Rintveld, Zeist, the Netherlands.
| | - Mieneke C M Luijendijk
- Department of Translational Neuroscience, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
| | - Lisa Drost
- Department of Translational Neuroscience, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands
| | | | - Annemarie van Elburg
- Altrecht Eating Disorders Rintveld, Zeist, the Netherlands; Department of Clinical Psychology, Utrecht University, the Netherlands.
| | - Roger A H Adan
- Department of Translational Neuroscience, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; Altrecht Eating Disorders Rintveld, Zeist, the Netherlands; Dept of Neuroscience and Physiology, Sahlgrenska academy, Univ of Gothenborg, Sweden.
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9
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Zagami M, Klepper E, Wienecke E, Andrzejewski M, Sikder A, Ahmed A, Robinson H. A review of psychocutaneous disorders from a psychotherapeutic perspective—Toolkit for the dermatologist. SKIN HEALTH AND DISEASE 2023. [PMID: 37538328 PMCID: PMC10395638 DOI: 10.1002/ski2.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction The study of psychocutaneous disorders requires a multidisciplinary approach. It is of paramount importance that dermatologists understand the psychiatric premise for these disorders. Mental health professionals can also benefit from a better understanding of the dermatologic manifestations of psychiatric disorders they may encounter in their practice. Aim The aim of this study is to elevate the level of understanding regarding psychotherapeutic treatment of psychocutaneous disorders. Methods We performed a literature review using the major databases. Four researchers reviewed English, full text, peer-reviewed articles that were published after 2000 using our specific search terms and inclusion/exclusion criteria. Results The majority of psychocutaneous disorders seem to be clustered among three DSM-5 disorders: depressive disorders, anxiety disorders, and obsessive-compulsive related disorders. Conclusions Better recognition of the underlying psychiatric comorbidities may lead to improved patient outcomes.
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Affiliation(s)
- Mary Zagami
- Robinson & Max Dermatology PA Lutherville‐ Timonium Maryland USA
| | - Edward Klepper
- Robinson & Max Dermatology PA Lutherville‐ Timonium Maryland USA
| | - Eric Wienecke
- Robinson & Max Dermatology PA Lutherville‐ Timonium Maryland USA
| | | | - Ahmed Sikder
- Robinson & Max Dermatology PA Lutherville‐ Timonium Maryland USA
| | - Ali Ahmed
- Robinson & Max Dermatology PA Lutherville‐ Timonium Maryland USA
| | - Howard Robinson
- Robinson & Max Dermatology PA Lutherville‐ Timonium Maryland USA
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10
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Thorey S, Blanchet C, Guessoum SB, Moro MR, Ludot M, Carretier E. Efficacy and tolerance of second-generation antipsychotics in anorexia nervosa: A systematic scoping review. PLoS One 2023; 18:e0278189. [PMID: 36928656 PMCID: PMC10019643 DOI: 10.1371/journal.pone.0278189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/03/2023] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION Second-generation antipsychotics (SGAs) are frequently prescribed for the treatment of resistant anorexia nervosa. However, few clinical trials have been conducted so far and no pharmacological treatment has yet been approved by the Food and Drug Administration. The aim of this paper is to conduct a systematic scoping review exploring the effectiveness and safety of atypical antipsychotics in anorexia nervosa (AN). METHOD We conducted a systematic scoping review of the effectiveness and tolerability of SGAs in the management of AN. We included articles published from January 1, 2000, through September 12, 2022 from the PubMed and PsycInfo databases and a complementary manual search. We selected articles about adolescents and adults treated for AN by four SGAs (risperidone, quetiapine, aripiprazole or olanzapine). This work complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRIMA-ScR) and was registered in the Open Science Framework (OSF) repository. RESULTS This review included 55 articles: 48 assessing the effectiveness of SGAs in AN and 7 focusing only on their tolerability and safety. Olanzapine is the treatment most frequently prescribed and studied with 7 randomized double-blind controlled trials. Other atypical antipsychotics have been evaluated much less often, such as aripiprazole (no randomized trials), quetiapine (two randomized controlled trials), and risperidone (one randomized controlled trial). These treatments are well tolerated with mild and transient adverse effects in this population at particular somatic risk. DISCUSSION Limitations prevent the studies both from reaching conclusive, reliable, robust, and reproducible results and from concluding whether or not SGAs are effective in anorexia nervosa. Nonetheless, they continue to be regularly prescribed in clinical practice. International guidelines suggest that olanzapine and aripiprazole can be interesting in severe or first-line resistant clinical situations.
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Affiliation(s)
- Solène Thorey
- APHP, Cochin Hospital, Maison de Solenn, Paris, France
- Versailles Saint-Quentin-en-Yvelines University, Versailles, France
| | - Corinne Blanchet
- APHP, Cochin Hospital, Maison de Solenn, Paris, France
- UVSQ, Inserm, CESP, Team DevPsy, Paris-Saclay University, Villejuif, France
| | - Sélim Benjamin Guessoum
- APHP, Cochin Hospital, Maison de Solenn, Paris, France
- UVSQ, Inserm, CESP, Team DevPsy, Paris-Saclay University, Villejuif, France
- Laboratoire de Psychologie Clinique, Psychopathologie et Psychanalyse, Paris Cité University, Boulogne-Billancourt, France
| | - Marie Rose Moro
- APHP, Cochin Hospital, Maison de Solenn, Paris, France
- UVSQ, Inserm, CESP, Team DevPsy, Paris-Saclay University, Villejuif, France
- Laboratoire de Psychologie Clinique, Psychopathologie et Psychanalyse, Paris Cité University, Boulogne-Billancourt, France
| | - Maude Ludot
- APHP, Cochin Hospital, Maison de Solenn, Paris, France
- UVSQ, Inserm, CESP, Team DevPsy, Paris-Saclay University, Villejuif, France
- Laboratoire de Psychologie Clinique, Psychopathologie et Psychanalyse, Paris Cité University, Boulogne-Billancourt, France
| | - Emilie Carretier
- APHP, Cochin Hospital, Maison de Solenn, Paris, France
- UVSQ, Inserm, CESP, Team DevPsy, Paris-Saclay University, Villejuif, France
- Laboratoire de Psychologie Clinique, Psychopathologie et Psychanalyse, Paris Cité University, Boulogne-Billancourt, France
- * E-mail:
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Antipsychotics in the Treatment of Children and Adolescents with Anorexia Nervosa: A Systematic Review. Biomedicines 2022; 10:biomedicines10123167. [PMID: 36551922 PMCID: PMC9775317 DOI: 10.3390/biomedicines10123167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/20/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
Evidence about the use of pharmacologic agents in the treatment of Anorexia Nervosa (AN) is lacking, especially in childhood and adolescence. A systematic scoping review was conducted to outline current literature evidence about the use of antipsychotics in this population. A total of 499 studies were identified with the initial search, and 28 of these studies were selected regarding the use of olanzapine (n = 13), risperidone (n = 4), aripiprazole (n = 3), chlorpromazine (n = 3), pimozide (n = 1) clotiapine (n = 1) and multiple antipsychotics (n = 3) in these patients. Overall, major side effects were reported infrequently; improvements in psychopathology and weight measures have been suggested in the majority of the considered studies. Nonetheless, the lack of RCT or good-quality studies strongly limits the generalizability of results in clinical practice.
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12
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Pruccoli J, Pettenuzzo I, Parmeggiani A. Low-Dose Olanzapine in the Treatment of Adolescents with Anorexia Nervosa: An Observational Naturalistic Case-Control Study. J Child Adolesc Psychopharmacol 2022; 32:304-310. [PMID: 35612433 DOI: 10.1089/cap.2022.0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Although recent articles have investigated the use of low-dose olanzapine in different psychiatric conditions, only one study so far has assessed this treatment in 13 girls with anorexia nervosa (AN). Methods: Observational naturalistic case-control study aimed at reporting the use and tolerability of low-dose olanzapine in the context of a multidisciplinary hospital intervention for adolescents with AN. Three groups with AN were compared: group 1 was treated with low-dose olanzapine (≤5 mg/day), group 2 with full-dose olanzapine (>5 mg/day), and group 3 (control group) was treated without antipsychotics. Psychopathology was assessed at admission (T0) and discharge (T1) with Eating Disorders Inventory-3 Eating Disorders Risk, Body Uneasiness Test Global Severity Index (BUT-GSI), Beck's Depression Inventory-II (BDI-II), and Self-administered Psychiatric Scales for Children and Adolescents, Depression subtest (SAFA-D). Possible differences among the three groups, concerning clinical and treatment variables, were screened. Then, potential differences of T0-T1 modifications in psychopathological variables among the three treatment groups were assessed with analyses of covariance, corrected for baseline psychopathology and potential confounders, including possible concurrent antidepressants. Results: A total of 118 patients were enrolled (F = 94.1%; mean age = 15.4 ± 1.7 years), including 52 controls, 37 treated with low-dose olanzapine, and 29 with full-dose olanzapine. Low-dose olanzapine was well tolerated and used for a mean of 132.1 (±98.6) days, starting with a dosage of 3.4 (±1.2) mg/day and increasing to a maximum dose of 4.4 (±1.1) mg/day. The multidisciplinary intervention resulted in an improvement of BUT-GSI (p < 0.001), BDI-II (p < 0.001), and SAFA-D (p < 0.001) for the entire sample. Individuals treated with full-dose olanzapine experienced a significantly lower improvement in depressive measures: BDI-II (F[2,61] = 12.653, p < 0.001, η2 = 0.269) and SAFA-D (F[2,57] = 7.413, p = 0.001, η2 = 0.170), than the other groups. Discussion: This naturalistic controlled study expands the existing evidence on the use and tolerability of low-dose olanzapine in adolescents with AN. These results should be assessed in wider and prospective samples.
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Affiliation(s)
- Jacopo Pruccoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Regional Center for Feeding and Eating Disorders in Children and Adolescents, Child Neurology and Psychiatry Unit, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Ilaria Pettenuzzo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Regional Center for Feeding and Eating Disorders in Children and Adolescents, Child Neurology and Psychiatry Unit, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Antonia Parmeggiani
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Regional Center for Feeding and Eating Disorders in Children and Adolescents, Child Neurology and Psychiatry Unit, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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13
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Han R, Bian Q, Chen H. Effectiveness of olanzapine in the treatment of anorexia nervosa: A systematic review and meta-analysis. Brain Behav 2022; 12:e2498. [PMID: 35020271 PMCID: PMC8865148 DOI: 10.1002/brb3.2498] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/22/2021] [Accepted: 01/02/2022] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Anorexia nervosa (AN) is a severe psychiatric disorder characterized by starvation and malnutrition, a high incidence of coexisting psychiatric conditions, and treatment resistance. The effect of pharmacotherapy has been controversial. METHOD A systematic review was conducted for evidence of an effect of olanzapine versus placebo in adults or its effect as adjuvant treatment of AN in adolescents. RESULTS A total of seven articles (304 patients with AN) were identified. There were four double-blind, randomized studies examining the effect of olanzapine in the treatment of AN. The mean difference in body mass index (BMI) at the end of treatment between olanzapine and placebo was 0.67 kg/m2 (95% confidence interval (CI) 0.15-1.18 kg/m2 ; p = 0.01; I2 = 0%, p for heterogeneity < 0.79). The olanzapine groups showed a significant increase in BMI of 0.68 kg/m2 (95% CI 0.22-1.13 kg/m2 ; p < 0.001; I2 = 0%, p for heterogeneity = 0.74) compared to the placebo groups. Only two studies examined the effect of olanzapine as adjuvant treatment in adolescents and showed an increase in BMI of 0.66 kg/m2 (95% CI -0.36 to 1.67 kg/m2 ; p = 0.21; I2 = 11%, p for heterogeneity = 0.32). DISCUSSION Olanzapine showed efficacy in the treatment of AN with an increased BMI at the end of treatment in adults. The effect of olanzapine as adjuvant treatment in adolescents remains unclear.
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Affiliation(s)
- Ruijun Han
- Department of Psychiatry, Beijing Huilongguan Hospital, Beijing, China
| | - Qingtao Bian
- Department of Psychiatry, Beijing Huilongguan Hospital, Beijing, China
| | - Hao Chen
- Department of Internal Medicine, Teikyo University Hospital, Tokyo, Japan
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14
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Timing of Psychopharmacological and Nutritional Interventions in the Inpatient Treatment of Anorexia Nervosa: An Observational Study. Brain Sci 2021; 11:brainsci11091242. [PMID: 34573262 PMCID: PMC8472646 DOI: 10.3390/brainsci11091242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 09/03/2021] [Accepted: 09/18/2021] [Indexed: 11/20/2022] Open
Abstract
This study aims to investigate possible different outcomes in the inpatient treatment of anorexia nervosa (AN) related to different timings of psychopharmacological and nutritional interventions. A retrospective observational study was conducted, involving young patients hospitalized for AN, treated with naso-gastric tube feeding (NGT). Participants were divided into five groups according to early (0–7 days) or late (8+ days) introduction of atypical antipsychotics (AAP) and NGT: early AAP-early NGT (EE), early AAP-late NGT (EL), late AAP-early NGT (LE), late AAP-late NGT (LL) and a control group treated with NGT only (NGT). Concurrent clinical and treatment variables were analyzed. AN psychopathology was measured with the Eating Disorder Inventory-3 (EDI-3) EDRC score. Outcomes were assessed as admission-discharge body-mass index (BMI) improvement and length of hospital stay (LOS). Contributions of variables related to outcomes were assessed with multifactorial-analyses of variance (MANOVA). Seventy-nine patients were enrolled in the study. LOS was different among treatment groups (F (4, 75) = 5.993, p < 0.001), and EE patients showed lower LOS than LE (p < 0.001) and LL (p = 0.025) patients. BMI improvement was not significantly different among treatment groups but correlated negatively with age (F (1, 72) = 10.130, p = 0.002), and admission BMI (F (1, 72) = 14.681, p < 0.001). In conclusion, patients treated with early AAP and early NGT showed lower LOS than those treated with late AAP. Prognostic treatment variables should be investigated in wider samples.
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15
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Short-Term Outcome of Inpatient Treatment for Adolescents with Anorexia Nervosa Using DSM-5 Remission Criteria. J Clin Med 2021; 10:jcm10143190. [PMID: 34300355 PMCID: PMC8307185 DOI: 10.3390/jcm10143190] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/13/2021] [Accepted: 07/18/2021] [Indexed: 12/12/2022] Open
Abstract
This study evaluated the short-term outcome of a multimodal inpatient treatment concept for adolescents with anorexia nervosa (AN). In this prospective observational study, a cohort of 126 female adolescents with AN (age range: 11–17, mean age: 14.83) was longitudinally followed from admission to discharge (average duration of stay: 77 days). We used gold-standard clinical interviews and self-report data, as well as DSM-5 remission criteria, to evaluate the treatment outcome. From admission to discharge, body-mass-index (BMI) significantly improved by 2.6 kg/m2. Data from clinical interviews and self-reports yielded similar improvements in restraint eating and eating concerns (large effects). Lower effects were observed for variables assessing weight/shape concerns and drive for thinness. At discharge, 23.2% of patients showed full remission of AN, 31.3% partial remission, and 45.5% no remission according to DSM-5 criteria. Differences in remission groups were found regarding AN severity, age at admission, and use of antidepressant medication. Living with both parents, longer duration of inpatient treatment and the use of antipsychotic medication were significantly associated with higher BMI change. The findings provide evidence for the short-term effectiveness of our inpatient treatment concept. We recommend using DSM-5 based remission criteria to evaluate the treatment outcome to improve the comparability of studies.
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16
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Brynes N, Tarchichi T, McCormick AA, Downey A. Restrictive Eating Disorders: Accelerating Treatment Outcomes in the Medical Hospital. Hosp Pediatr 2021; 11:751-759. [PMID: 34103401 DOI: 10.1542/hpeds.2020-005389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Pediatric patients with anorexia nervosa and atypical anorexia nervosa may present to hospitals with significant vital sign instability or serum laboratory abnormalities necessitating inpatient medical hospitalization. These patients require specialized care, numerous resources, and interdisciplinary collaboration during what can be a protracted admission. Recent evidence informs areas in which care can be accelerated, and published protocols from major children's hospitals are helpful roadmaps to creating a streamlined hospitalization. In our narrative review, we focused on 3 key areas: (1) implementation of a rapid nutritional rehabilitation program; (2) assessment and management of the refeeding syndrome; and (3) early integration of psychoeducation and therapeutic interventions during inpatient hospitalization. A practical review of the literature in these 3 areas will give concrete, actionable information to pediatric hospitalists as they care for young people with restrictive eating disorders.
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Affiliation(s)
- Nicole Brynes
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tony Tarchichi
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew A McCormick
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amanda Downey
- Departments of Pediatrics and Psychiatry and Behavioral Sciences, University of California, San Francisco, California
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17
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Hornberger LL, Lane MA. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics 2021; 147:peds.2020-040279. [PMID: 33386343 DOI: 10.1542/peds.2020-040279] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Eating disorders are serious, potentially life-threatening illnesses afflicting individuals through the life span, with a particular impact on both the physical and psychological development of children and adolescents. Because care for children and adolescents with eating disorders can be complex and resources for the treatment of eating disorders are often limited, pediatricians may be called on to not only provide medical supervision for their patients with diagnosed eating disorders but also coordinate care and advocate for appropriate services. This clinical report includes a review of common eating disorders diagnosed in children and adolescents, outlines the medical evaluation of patients suspected of having an eating disorder, presents an overview of treatment strategies, and highlights opportunities for advocacy.
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Affiliation(s)
- Laurie L Hornberger
- Division of Adolescent Medicine, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; and
| | - Margo A Lane
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba
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18
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Muratore AF, Attia E. Current Therapeutic Approaches to Anorexia Nervosa: State of the Art. Clin Ther 2020; 43:85-94. [PMID: 33293054 DOI: 10.1016/j.clinthera.2020.11.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/15/2022]
Abstract
Anorexia nervosa (AN) is a devastating psychiatric disorder characterized by extreme restriction of food intake and low body weight, both associated with significant medical and psychological morbidity. The clinical severity of AN has prompted the consideration and study of behavioral and pharmacological treatments in efforts to establish empirically based methods to reduce the burden of the disorder. Among adolescents, family-based treatment is considered a first-line behavioral treatment. Research continues to explore the efficacy of family-based treatment and predictors of treatment response to further improve outcomes. Several behavioral treatments for adults also exist, including cognitive-behavioral therapy, exposure and response prevention, third-wave acceptance-based treatments, and supportive psychotherapy, all of which help to improve symptoms and promote modest weight gain. Despite this, no one treatment is considered superior, and all existing behavioral approaches leave a proportion of adults symptomatic or at a high risk of relapse. As such, among adults, there is continued need for development of novel, mechanism-based approaches to better target the core symptoms of AN. Although antidepressants impart little benefit on weight or symptoms, the second-generation antipsychotic olanzapine has shown ability to promote modest weight gain in outpatients with AN. Most recently, the field's evolving conceptualization of AN as a biologically based disorder coupled with technological advancements has led to consideration of varying neuromodulation strategies as a potential therapeutic approach that remains under investigation.
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Affiliation(s)
- Alexandra F Muratore
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA; New York State Psychiatric Institute, New York, NY, USA.
| | - Evelyn Attia
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA; New York State Psychiatric Institute, New York, NY, USA
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Tahıllıoğlu A, Özcan T, Yüksel G, Majroh N, Köse S, Özbaran B. Is aripiprazole a key to unlock anorexia nervosa?: A case series. Clin Case Rep 2020; 8:2827-2834. [PMID: 33363831 PMCID: PMC7752603 DOI: 10.1002/ccr3.3271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022] Open
Abstract
Aripiprazole contributes an increase in body mass index and attenuation in anorexia nervosa (AN) symptoms, leading clinical improvements with lower side-effect profile; but it is not enough to cure comorbid depressive symptoms in AN.
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Affiliation(s)
- Akın Tahıllıoğlu
- Department of Child and Adolescent PsychiatryFaculty of MedicineEge UniversityIzmirTurkey
| | - Tuğçe Özcan
- Department of Child and Adolescent PsychiatryFaculty of MedicineEge UniversityIzmirTurkey
| | - Gamze Yüksel
- Department of Child and Adolescent PsychiatryFaculty of MedicineEge UniversityIzmirTurkey
| | - Noorjahan Majroh
- Department of Child and Adolescent PsychiatryFaculty of MedicineEge UniversityIzmirTurkey
| | - Sezen Köse
- Department of Child and Adolescent PsychiatryFaculty of MedicineEge UniversityIzmirTurkey
| | - Burcu Özbaran
- Department of Child and Adolescent PsychiatryFaculty of MedicineEge UniversityIzmirTurkey
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20
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Dalle Grave R, Sartirana M, Sermattei S, Calugi S. Treatment of Eating Disorders in Adults Versus Adolescents: Similarities and Differences. Clin Ther 2020; 43:70-84. [PMID: 33223229 DOI: 10.1016/j.clinthera.2020.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 10/22/2020] [Indexed: 12/16/2022]
Abstract
FINDINGS Although several individual psychotherapies for adults with eating disorders are empirically supported, with family-based treatment (FBT) being the leading recommended empiric treatment in adolescents, patients with eating disorders are still difficult to treat, and outcomes are often poor. In some countries, the clinical services for adolescents and adults are separate, and it is common for patients to receive treatments that differ in terms of both theory and content when they are switched from adolescent to adult services. Changes in the nature of treatment also often occur when patients move from less intensive types of care to more intensive treatment, and vice versa. These transitions may create a discontinuity in the care pathway and disorient patients and their significant others about the strategies and procedures used for addressing eating problems. However, the observation that younger and older patients essentially share the same eating-disorder psychopathology has led to evidence-based enhanced cognitive-behavioral therapy (CBT-E) being adapted for use in adolescents. Originally an evidence-based treatment for adults with eating disorders, CBT-E has yielded promising results in trials in cohorts of adolescent outpatients and inpatients, and is recommended as an alternative to FBT in adolescent patients. IMPLICATIONS With a unified treatment such as CBT-E, several issues that plague conventional eating-disorder services could be partially overcome, as patients can move seamlessly from adolescence to adulthood and through different levels of care, with no change in the nature of the treatment itself. Future randomized, controlled trials should compare FBT to CBT-E to better clarify the specific therapeutic needs of subgroups of adolescents and adult patients with eating disorders.
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Affiliation(s)
| | | | - Selvaggia Sermattei
- Department of Eating and Weight Disorders, Villa Garda Hospital, Garda, Italy.
| | - Simona Calugi
- Department of Eating and Weight Disorders, Villa Garda Hospital, Garda, Italy.
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21
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Gorrell S, Lebow J, Kinasz K, Mitchell JE, Goldschmidt AB, Le Grange D, Accurso EC. Psychotropic medication use in treatment-seeking youth with eating disorders. EUROPEAN EATING DISORDERS REVIEW 2020; 28:739-749. [PMID: 32926514 DOI: 10.1002/erv.2788] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/07/2020] [Accepted: 08/10/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Psychotropic medication use in youth with eating disorders (EDs) is poorly understood despite high co-occurrence of psychiatric disorders. This study examined characteristics associated with medication use in treatment-seeking youth with EDs. METHOD Youth up to age 18 reported on medication use when presenting to an academic medical center outpatient ED service in the United States. Data presented were collected between 1998-2015. RESULTS The sample (N = 604) was predominantly female (90.6%) with a mean age of 15.3 years (SD = 2.3). Approximately one-third (30%, n = 173) were taking psychotropic medications (40%, n = 70, were taking multiple medications). Antidepressant use was most common (26%, n = 152), followed by atypical antipsychotics (8%, n = 43). Adjusting for co-occurring psychiatric disorders, non-Hispanic Whites who had received prior treatment (psychotherapy, hospitalization) were significantly more likely to be using medication. Longer illness duration and prior treatment were associated with greater antidepressant use. For atypical antipsychotics, prior hospitalization was associated with greater use. CONCLUSIONS Findings confirm moderate psychotropic medication use among young patients with EDs despite a lack of clarity regarding optimally effective pharmacologic interventions in this population. Pharmacological trials examining the efficacy of medications for young patients with EDs are warranted to inform future prescribing practice.
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Affiliation(s)
- Sasha Gorrell
- Department of Psychiatry, University of California, San Francisco, California, USA
| | - Jocelyn Lebow
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathryn Kinasz
- Department of Psychiatry, University of California, San Francisco, California, USA
| | - James E Mitchell
- Sanford Biobehavioral Research Institute, Fargo, North Dakota, USA.,School of Medicine and Health Sciences, University of North Dakota, Fargo, North Dakota, USA
| | - Andrea B Goldschmidt
- Weight Control and Diabetes Research Center, The Miriam Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Daniel Le Grange
- Department of Psychiatry, University of California, San Francisco, California, USA.,Department of Psychiatry & Behavioral Neuroscience, The University of Chicago, Chicago, Illinois, USA
| | - Erin C Accurso
- Department of Psychiatry, University of California, San Francisco, California, USA
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22
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Cassioli E, Sensi C, Mannucci E, Ricca V, Rotella F. Pharmacological treatment of acute-phase anorexia nervosa: Evidence from randomized controlled trials. J Psychopharmacol 2020; 34:864-873. [PMID: 32448045 DOI: 10.1177/0269881120920453] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Anorexia nervosa (AN) is the psychiatric disorder with the highest mortality rate, with a standard mortality ratio of 5.86. Despite the large use of psychotropic drugs in the clinical setting, Food and Drug Administration has not approved any psychoactive treatment for AN. AIMS The aim of this study was to perform an updated systematic review and meta-analysis of published randomized controlled trials (RCTs) investigating psychopharmacological treatment in acute-phase AN. METHODS The present paper follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. An extensive literature search was performed. All RCTs enrolling patients with acute-phase AN, comparing at least one psychotropic drug with another drug, placebo, treatment-as-usual or no treatment were included. The main outcome was the effect of psychoactive drugs on body mass index (BMI); data on psychopathological outcomes were also collected when available. RESULTS A total of 19 RCTs met all specified criteria. Of these, 11 were excluded from quantitative analyses. Of the eight studies included in the meta-analyses, five reported data on BMI, showing no significant difference between olanzapine and placebo for weight recovery. No significant result was found for AN psychopathology, depressive and anxious symptoms for any of the molecules studied. CONCLUSIONS RCTs published in this field display methodological biases, low sample sizes and short follow-up periods. Further research efforts are needed in this field as no evidence has been demonstrated for the use of any psychotropic drug in acute-phase AN neither for weight recovery, nor for comorbid psychiatric symptoms.
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Affiliation(s)
- Emanuele Cassioli
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Carolina Sensi
- Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Valdo Ricca
- Department of Health Sciences, University of Florence, Florence, Italy
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Çöpür S, Çöpür M. Olanzapine in the treatment of anorexia nervosa: a systematic review. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00195-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractAnorexia 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.
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Boutari C, Pappas PD, Mintziori G, Nigdelis MP, Athanasiadis L, Goulis DG, Mantzoros CS. The effect of underweight on female and male reproduction. Metabolism 2020; 107:154229. [PMID: 32289345 DOI: 10.1016/j.metabol.2020.154229] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Chrysoula Boutari
- Department of Medicine, Boston VA Healthcare System and Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Panagiotis D Pappas
- Unit of Reproductive Endocrinology, 1(st) Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
| | - Gesthimani Mintziori
- Unit of Reproductive Endocrinology, 1(st) Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
| | - Meletios P Nigdelis
- Unit of Reproductive Endocrinology, 1(st) Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
| | - Loukas Athanasiadis
- 3(rd) Department of Psychiatry, Medical School, Aristotle University of Thessaloniki, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1(st) Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
| | - Christos S Mantzoros
- Department of Medicine, Boston VA Healthcare System and Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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25
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Huang J, Hei GR, Yang Y, Liu CC, Xiao JM, Long YJ, Peng XJ, Yang Y, Zhao JP, Wu RR. Increased Appetite Plays a Key Role in Olanzapine-Induced Weight Gain in First-Episode Schizophrenia Patients. Front Pharmacol 2020; 11:739. [PMID: 32528286 PMCID: PMC7256453 DOI: 10.3389/fphar.2020.00739] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/04/2020] [Indexed: 01/10/2023] Open
Abstract
Weight gain and metabolic disturbances, potentially influenced by increased appetite, are common effects of olanzapine treatment in patients with schizophrenia. In this study, we explored the association between olanzapine-induced weight gain and metabolic effects with increased appetite. Drug-naïve, first-episode schizophrenia patients were treated with olanzapine for 12 weeks. Assessments included time to increased appetite, body weight, body mass index, biochemical indicators of blood glucose and lipids, proportion of patients who gained more than 7% or 10% of their baseline weight upon treatment conclusion, patients who developed dyslipidemia, and Positive and Negative Syndrome Scale scores. In total, 33 patients with schizophrenia receiving olanzapine were enrolled and 31 completed the study. During the 12-week olanzapine treatment, 77.4% (24/31) patients had increased appetite with 58.1% (18/31) patients having increased appetite within the first 4 weeks. The mean time for increased appetite was 20.3 days. More patients in the increased appetite group increased their initial body weight by more than 7% after 12 weeks when compared to patients with unchanged appetite (22/24 [91.7%] vs. 3/7 [42.9%], p = 0.004). Earlier increased appetite led to more weight gain during the following month. Overall, 50% of patients in the increased appetite group had dyslipidemia after 12 weeks. Our results demonstrated that olanzapine induced significantly appetite increase in first-episode patients with schizophrenia and appetite increase played a key role in olanzapine-induced weight gain and dyslipidemia. Clinical Trial Registration NCT03451734. Registered March 2, 2018 (retrospectively registered).
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Affiliation(s)
- Jing Huang
- Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.,China National Clinical Research Center on Mental Disorders, Changsha, China.,China National Technology Institute on Mental Disorders, Hunan Key Laboratory of Psychiatry and Mental Health, Changsha, China
| | - Gang-Rui Hei
- Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.,China National Clinical Research Center on Mental Disorders, Changsha, China.,China National Technology Institute on Mental Disorders, Hunan Key Laboratory of Psychiatry and Mental Health, Changsha, China
| | - Ye Yang
- Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.,China National Clinical Research Center on Mental Disorders, Changsha, China.,China National Technology Institute on Mental Disorders, Hunan Key Laboratory of Psychiatry and Mental Health, Changsha, China
| | - Chen-Chen Liu
- Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.,China National Clinical Research Center on Mental Disorders, Changsha, China.,China National Technology Institute on Mental Disorders, Hunan Key Laboratory of Psychiatry and Mental Health, Changsha, China
| | - Jing-Mei Xiao
- Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.,China National Clinical Research Center on Mental Disorders, Changsha, China.,China National Technology Institute on Mental Disorders, Hunan Key Laboratory of Psychiatry and Mental Health, Changsha, China
| | - Yu-Jun Long
- Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.,China National Clinical Research Center on Mental Disorders, Changsha, China.,China National Technology Institute on Mental Disorders, Hunan Key Laboratory of Psychiatry and Mental Health, Changsha, China
| | - Xing-Jie Peng
- Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.,China National Clinical Research Center on Mental Disorders, Changsha, China.,China National Technology Institute on Mental Disorders, Hunan Key Laboratory of Psychiatry and Mental Health, Changsha, China
| | - Yi Yang
- Mental Health Institute, Wenzhou Kangning Hospital, Wenzhou Medical University, Wenzhou, China
| | - Jing-Ping Zhao
- Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.,China National Clinical Research Center on Mental Disorders, Changsha, China.,China National Technology Institute on Mental Disorders, Hunan Key Laboratory of Psychiatry and Mental Health, Changsha, China
| | - Ren-Rong Wu
- Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, China.,China National Clinical Research Center on Mental Disorders, Changsha, China.,China National Technology Institute on Mental Disorders, Hunan Key Laboratory of Psychiatry and Mental Health, Changsha, China.,Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China
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26
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Frank GKW. Pharmacotherapeutic strategies for the treatment of anorexia nervosa - too much for one drug? Expert Opin Pharmacother 2020; 21:1045-1058. [PMID: 32281881 DOI: 10.1080/14656566.2020.1748600] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Guido K W Frank
- UCSD Eating Disorder Center for Treatment and Research, University of California San Diego , San Diego, CA, USA
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27
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Kan C, Eid L, Treasure J, Himmerich H. A Meta-Analysis of Dropout and Metabolic Effects of Antipsychotics in Anorexia Nervosa. Front Psychiatry 2020; 11:208. [PMID: 32256415 PMCID: PMC7090227 DOI: 10.3389/fpsyt.2020.00208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/03/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Second-generation antipsychotics are often used off-label in the treatment of anorexia nervosa (AN) across the clinical spectrum. Patients with anorexia nervosa often cite concerns about metabolic effects, such as weight gain, as reasons for their reluctance to start or continue second-generation antipsychotics. Improving our understanding of the metabolic effect patients experience and reasons underlying their disinclination will enable us to build rapport and guide our clinical decisions. We therefore aimed to conduct a comprehensive review of dropouts, metabolic effects, and patient-reported outcomes associated with second-generation antipsychotic in people with AN. METHOD EMBASE, Medline, and PsycINFO were searched for all relevant studies published until 2019, and retrieved studies were assessed for eligibility as per predefined inclusion criteria. A random-effects meta-analysis was conducted to assess overall dropout rates. RESULTS Of 983 citations retrieved, 21 studies met the inclusion criteria for the systematic review and 10 studies had appropriate data for meta-analysis. Using the random effects model, the pooled dropout rate in the intervention arm (95% confidence interval) from psychopharmacological trials was 28% (19 to 38%) in people with AN. Personal reasons or factors associated with study were commonest reason for dropout, not adverse events or metabolic effects as hypothesized. CONCLUSION Compared to personal reasons, drug-related factors such as side effects seem to play a lesser role for the discontinuation of antipsychotic treatment under trial conditions. This suggests an urgent need to consider and fully examine potential individual and patient-related factors that influence dropout rates in psychopharmacological trials and treatment compliance in clinical settings.
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Affiliation(s)
- Carol Kan
- Psychological Medicine, King's College London, London, United Kingdom
| | - Laura Eid
- Psychological Medicine, King's College London, London, United Kingdom
| | - Janet Treasure
- Psychological Medicine, King's College London, London, United Kingdom
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28
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Couturier J, Isserlin L, Norris M, Spettigue W, Brouwers M, Kimber M, McVey G, Webb C, Findlay S, Bhatnagar N, Snelgrove N, Ritsma A, Preskow W, Miller C, Coelho J, Boachie A, Steinegger C, Loewen R, Loewen T, Waite E, Ford C, Bourret K, Gusella J, Geller J, LaFrance A, LeClerc A, Scarborough J, Grewal S, Jericho M, Dimitropoulos G, Pilon D. Canadian practice guidelines for the treatment of children and adolescents with eating disorders. J Eat Disord 2020; 8:4. [PMID: 32021688 PMCID: PMC6995106 DOI: 10.1186/s40337-020-0277-8] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 01/06/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline. METHODS Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders. RESULTS Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed. CONCLUSIONS Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Wendy Preskow
- National Initiative for Eating Disorders, Toronto, Canada
| | - Catherine Miller
- Canadian Mental Health Association - Waterloo, Wellington, Dufferin, Kitchener, Canada
| | | | | | | | | | | | | | - Catherine Ford
- 9Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - Kerry Bourret
- 10St. Joseph's Care Group - Thunder Bay, Thunder Bay, Canada
| | | | - Josie Geller
- 6The Univeristy of British Columbia, Vancouver, Canada
| | | | | | - Jennifer Scarborough
- Canadian Mental Health Association - Waterloo, Wellington, Dufferin, Kitchener, Canada
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29
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Couturier J, Isserlin L, Spettigue W, Norris M. Psychotropic Medication for Children and Adolescents with Eating Disorders. Child Adolesc Psychiatr Clin N Am 2019; 28:583-592. [PMID: 31443877 DOI: 10.1016/j.chc.2019.05.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Psychotropic medications are commonly used in the treatment of eating disorders in children and adolescents. This article reviews the evidence base on psychotropic medications, including all randomized trials, uncontrolled trials, and case reports for the treatment of anorexia nervosa, bulimia nervosa, other specified feeding and eating disorders, binge-eating disorder, and avoidant/restrictive food intake disorder. Despite advances in the number of medication-based studies completed in young patients with eating disorders over the last 2 decades, significantly more work needs to be done in terms of identifying what role, if any, psychotropic medications can have on treatment outcomes.
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Affiliation(s)
- Jennifer Couturier
- McMaster University, McMaster Children's Hospital, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
| | - Leanna Isserlin
- University of Ottawa, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada
| | - Wendy Spettigue
- University of Ottawa, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada
| | - Mark Norris
- University of Ottawa, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada
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30
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Abstract
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.
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Affiliation(s)
- Lauren E. Davis
- New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, USA
| | - Evelyn Attia
- New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, USA
- Weill Cornell Medical Center, New York, USA
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31
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Y Beykloo M, Nicholls D, Simic M, Brauer R, Mills E, Wong ICK. Survey on self-reported psychotropic drug prescribing practices of eating disorder psychiatrists for the treatment of young people with anorexia nervosa. BMJ Open 2019; 9:e031707. [PMID: 31542765 PMCID: PMC6756572 DOI: 10.1136/bmjopen-2019-031707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/01/2019] [Accepted: 08/14/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To survey current prescribing practices of psychotropic drugs by child and adolescent eating disorder (CAED) psychiatrists in the treatment of anorexia nervosa (AN). DESIGN Cross-sectional self-administered survey. SETTING All children and young people eating disorder services (CYP EDS) in England during a national training programme. PARTICIPANTS 44 CAED psychiatrists practising in CYP EDS in England. PRIMARY AND SECONDARY OUTCOME MEASURES CAED psychiatrists completed a questionnaire regarding the pattern of psychopharmacological care in AN that they provide and the medication treatment pattern at their CYP EDS. Secondary outcome measures included the process of continuing pharmacotherapy from secondary care to primary care. RESULTS Of the 77 CYP EDS representing every team in England, 44 teams represented by a CAED psychiatrist responded, despite 13 having no psychiatrists in post at the time of the study (response rate 69%). Most (40%) respondents estimated that <10% of patients with AN were prescribed psychotropic medications. Olanzapine was reported as the most commonly prescribed medication for AN by 38% of the respondents, followed by fluoxetine (29%) and sertraline (10%). The most common minimum olanzapine initiation dose in this study was at 2.5 mg/day for a duration of 2-4 weeks, reaching a maximum dose of 5 mg/day. Most (68%) reviewed medications every week (30%) or every 2 weeks (38%). Over 50% of the respondents reported continuation of olanzapine prescribing within the CYP EDS teams. CONCLUSIONS This nationally representative survey showed that despite a lack of evidence, psychotropic medications are commonly prescribed to a minority of patients, most frequently, olanzapine. Further evidence is needed on which patients may potentially benefit from pharmacotherapy as an adjunct to psychological interventions.
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Affiliation(s)
- Maedeh Y Beykloo
- Research Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Dasha Nicholls
- Faculty of Medicine, Department of Brain Sciences, Imperial College London, London, UK
| | - Mima Simic
- Michael Rutter Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Ruth Brauer
- Research Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Elizabeth Mills
- Research Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Ian C K Wong
- Research Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
- Department of Pharmacology and Pharmacy, University of Hong Kong, Hong Kong, Hong Kong
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32
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Herpertz-Dahlmann B, Dahmen B. Children in Need-Diagnostics, Epidemiology, Treatment and Outcome of Early Onset Anorexia Nervosa. Nutrients 2019; 11:E1932. [PMID: 31426409 PMCID: PMC6722835 DOI: 10.3390/nu11081932] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 11/20/2022] Open
Abstract
Knowledge of anorexia nervosa (AN) in childhood is scarce. This review gives a state-of-the-art overview on the definition, classification, epidemiology and etiology of this serious disorder. The typical features of childhood AN in comparison to adolescent AN and avoidant restrictive eating disorder (ARFID) are described. Other important issues discussed in this article are somatic and psychiatric comorbidity, differential diagnoses and medical and psychological assessment of young patients with AN. Special problems in the medical and psychological treatment of AN in children are listed, although very few studies have investigated age-specific treatment strategies. The physical and mental outcomes of childhood AN appear to be worse than those of adolescent AN, although the causes for these outcomes are unclear. There is an urgent need for ongoing intensive research to reduce the consequences of this debilitating disorder of childhood and to help patients recover.
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Affiliation(s)
- Beate Herpertz-Dahlmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH, Neuenhofer Weg 21, D-52074 Aachen, Germany.
| | - Brigitte Dahmen
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH, Neuenhofer Weg 21, D-52074 Aachen, Germany
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Himmerich H, Bentley J, Lichtblau N, Brennan C, Au K. Facets of shared decision-making on drug treatment for adults with an eating disorder. Int Rev Psychiatry 2019; 31:332-346. [PMID: 30870048 DOI: 10.1080/09540261.2019.1571995] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Hubertus Himmerich
- a South London and Maudsley NHS Foundation Trust , Bethlem Royal Hospital , London , UK.,b Department of Psychological Medicine , IoPPN, King's College London , London , UK
| | - Jessica Bentley
- b Department of Psychological Medicine , IoPPN, King's College London , London , UK
| | | | - Clare Brennan
- a South London and Maudsley NHS Foundation Trust , Bethlem Royal Hospital , London , UK
| | - Katie Au
- a South London and Maudsley NHS Foundation Trust , Bethlem Royal Hospital , London , UK
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34
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Attia E, Steinglass JE, Walsh BT, Wang Y, Wu P, Schreyer C, Wildes J, Yilmaz Z, Guarda A, Kaplan A, Marcus MD. Olanzapine Versus Placebo in Adult Outpatients With Anorexia Nervosa: A Randomized Clinical Trial. Am J Psychiatry 2019; 176:449-456. [PMID: 30654643 PMCID: PMC7015155 DOI: 10.1176/appi.ajp.2018.18101125] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study evaluated the benefits of olanzapine compared with placebo for adult outpatients with anorexia nervosa. METHODS This randomized double-blind placebo-controlled trial of adult outpatients with anorexia nervosa (N=152, 96% of whom were women; the sample's mean body mass index [BMI] was 16.7) was conducted at five sites in North America. Participants were randomly assigned in a 1:1 ratio to receive olanzapine or placebo and were seen weekly for 16 weeks. The primary outcome measures were rate of change in body weight and rate of change in obsessionality, assessed with the Yale-Brown Obsessive Compulsive Scale (YBOCS). RESULTS Seventy-five participants were assigned to receive olanzapine and 77 to receive placebo. A statistically significant treatment-by-time interaction was observed, indicating that the increase in BMI over time was greater in the olanzapine group (0.259 [SD=0.051] compared with 0.095 [SD=0.053] per month). There was no significant difference between treatment groups in change in the YBOCS obsessions subscale score over time (-0.325 compared with -0.017 points per month) and there were no significant differences between groups in the frequency of abnormalities on blood tests assessing potential metabolic disturbances. CONCLUSIONS This study documented a modest therapeutic effect of olanzapine compared with placebo on weight in adult outpatients with anorexia nervosa, but no significant benefit for psychological symptoms. Nevertheless, the finding on weight is notable, as achieving change in weight is notoriously challenging in this disorder.
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Affiliation(s)
- Evelyn Attia
- Columbia University Irving Medical Center;,New York State Psychiatric Institute;,Weill Cornell Medical College
| | - Joanna E. Steinglass
- Columbia University Irving Medical Center;,New York State Psychiatric Institute
| | - B Timothy Walsh
- Columbia University Irving Medical Center;,New York State Psychiatric Institute
| | | | - Peng Wu
- Columbia University Irving Medical Center
| | | | - Jennifer Wildes
- University of Pittsburgh Medical Center;,University of Chicago
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35
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Medication in AN: A Multidisciplinary Overview of Meta-Analyses and Systematic Reviews. J Clin Med 2019; 8:jcm8020278. [PMID: 30823566 PMCID: PMC6406645 DOI: 10.3390/jcm8020278] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 12/12/2022] Open
Abstract
Drugs are widely prescribed for anorexia nervosa in the nutritional, somatic, and psychiatric fields. There is no systematic overview in the literature, which simultaneously covers all these types of medication. The main aims of this paper are (1) to offer clinicians an overview of the evidence-based data in the literature concerning the medication (psychotropic drugs and medication for somatic and nutritional complications) in the field of anorexia nervosa since the 1960s, (2) to draw practical conclusions for everyday practise and future research. Searches were performed on three online databases, namely MEDLINE, Epistemonikos and Web of Science. Papers published between September 2011 and January 2019 were considered. Evidence-based data were identified from meta-analyses, if there were none, from systematic reviews, and otherwise from trials (randomized or if not open-label studies). Evidence-based results are scarce. No psychotropic medication has proved efficacious in terms of weight gain, and there is only weak data suggesting it can alleviate certain psychiatric symptoms. Concerning nutritional and somatic conditions, while there is no specific, approved medication, it seems essential not to neglect the interest of innovative therapeutic strategies to treat multi-organic comorbidities. In the final section we discuss how to use these medications in the overall approach to the treatment of anorexia nervosa.
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Pillay J, Boylan K, Newton A, Hartling L, Vandermeer B, Nuspl M, MacGregor T, Featherstone R, Carrey N. Harms of Antipsychotics in Children and Young Adults: A Systematic Review Update. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:661-678. [PMID: 29865900 PMCID: PMC6187435 DOI: 10.1177/0706743718779950] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To update and extend our previous systematic review on first- (FGAs) and second-generation antipsychotics (SGAs) for treatment of psychiatric and behavioral conditions in children, adolescents, and young adults (aged ≤24 years). This article focuses on the evidence for harms. METHOD We searched (to April 2016) 8 databases, gray literature, trial registries, Food and Drug Administration reports, and reference lists. Two reviewers conducted study screening and selection independently, with consensus for selection. One reviewer extracted and another verified all data; 2 reviewers independently assessed risk of bias. We conducted meta-analyses when appropriate and network meta-analysis across conditions for changes in body composition. Two reviewers reached consensus for ratings on the strength of evidence for prespecified outcomes. RESULTS A total of 135 studies (95 trials and 40 observational) were included, and 126 reported on harms. FGAs caused slightly less weight gain and more extrapyramidal symptoms than SGAs. SGAs as a class caused adverse effects, including weight gain, high triglyceride levels, extrapyramidal symptoms, sedation, and somnolence. They appeared to increase the risk for high cholesterol levels and type 2 diabetes. Many outcomes for individual drug comparisons were of low or insufficient strength of evidence. Olanzapine caused more short-term gains in weight and body mass index than several other SGAs. The dose of SGAs may not make a difference over the short term for some outcomes. CONCLUSIONS Clinicians need to weigh carefully the benefit-to-harm ratio when using antipsychotics, especially when treatment alternatives exist. More evidence is needed on the comparative harms between antipsychotics over the longer term.
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Affiliation(s)
- Jennifer Pillay
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada
| | - Khrista Boylan
- 2 Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Amanda Newton
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada.,3 Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Hartling
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada.,3 Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ben Vandermeer
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada
| | - Megan Nuspl
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada
| | - Tara MacGregor
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada
| | - Robin Featherstone
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada
| | - Normand Carrey
- 4 Douglas Research Institute and IWK Health Centre, Halifax, Nova Scotia, Canada.,5 Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
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Non-invasive brain stimulation for food cravings, consumption, and disorders of eating: A review of methods, findings and controversies. Appetite 2018; 124:78-88. [DOI: 10.1016/j.appet.2017.03.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 11/23/2022]
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Abstract
SummaryThis article provides an overview of classification and outcome of eating disorders, before focusing on current evidence-based treatment for the two main disorders of anorexia nervosa and bulimia nervosa.
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Abstract
INTRODUCTION Anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED) are the primary eating disorders (EDs). The only psychopharmacological treatment options for EDs with approval in some countries include fluoxetine for BN and lisdexamfetamine for BED. Given the high comorbidity and genetic correlations with other psychiatric disorders, it seems possible that novel medications for these conditions might also be effective in EDs. Areas covered: The current scientific literature has increased our understanding of how medication could be beneficial for patients with EDs on a molecular, functional and behavioral level. On the basis of theoretical considerations about neurotransmitters, hormones and neural circuits, possible drug targets for the treatment of EDs may include signal molecules and receptors of the self-regulatory system such as serotonin, norepinephrine and glutamate, the hedonic system including opioids, cannabinoids and dopamine and the hypothalamic homeostatic system including histamine, ghrelin, leptin, insulin, and glucagon-like peptide-1. Expert commentary: The latest research points to an involvement of both the immune and the metabolic systems in the pathophysiology of EDs and highlights the importance of the microbiome. Therefore, the next few years may unveil drug targets for EDs not just inside and outside of the brain, but possibly even outside of the human body.
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Affiliation(s)
- Hubertus Himmerich
- a Department of Psychological Medicine , King's College London , London , UK
| | - Janet Treasure
- a Department of Psychological Medicine , King's College London , London , UK
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Mairs R, Nicholls D. Assessment and treatment of eating disorders in children and adolescents. Arch Dis Child 2016; 101:1168-1175. [PMID: 27381185 DOI: 10.1136/archdischild-2015-309481] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 05/24/2016] [Accepted: 05/25/2016] [Indexed: 01/13/2023]
Abstract
Feeding and eating disorders (FEDs) are serious mental health disorders that cause impairments in physical health, development, cognition and psychosocial function and can go undetected for months or years. They are characterised by disturbed eating behaviour associated with concerns about weight and shape or by disinterest in food, phobic avoidance or avoidance due to sensory aspects of food. Restrictive forms of FEDs lead to significant weight loss requiring intervention. Without specific knowledge of these conditions, they can evade detection, delaying time to diagnosis and treatment and potentially influencing outcome. This review article focuses on the key factors involved in the psychiatric assessment and treatment of four feeding or eating disorders (EDs): anorexia nervosa, avoidant-restrictive food intake disorder, bulimia nervosa and binge eating disorder. They have been chosen for discussion as they are most likely to be encountered in both a psychiatric and paediatric setting. It emphasises the importance of a family-focused, developmentally appropriate and multidisciplinary approach to care. It does not address aspects of medical assessment and treatment. Other feeding or EDs not included in this article are pica, rumination disorder, other specified feeding and eating disorder and unspecified feeding and eating disorder.
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Affiliation(s)
- Rebecca Mairs
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Dasha Nicholls
- Department of Child and Adolescent Mental Health, Great Ormond Street Hospital, London, UK.,UCL Institute of Child Health, London, UK
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The Role of Psychotropic Medications in the Management of Anorexia Nervosa: Rationale, Evidence and Future Prospects. CNS Drugs 2016; 30:419-42. [PMID: 27106297 PMCID: PMC4873415 DOI: 10.1007/s40263-016-0335-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Anorexia nervosa (AN) is a severe psychiatric disorder without approved medication intervention. Every class of psychoactive medication has been tried to improve treatment outcome; however, randomized controlled trials have been ambiguous at best and across studies have not shown robust improvements in weight gain and recovery. Here we review the available literature on pharmacological interventions since AN came to greater public recognition in the 1960s, including a critical review of why those trials may not have been successful. We further provide a neurobiological background for the disorder and discuss how cognition, learning, and emotion-regulating circuits could become treatment targets in the future. Making every effort to develop effective pharmacological treatment options for AN is imperative as it continues to be a complex psychiatric disorder with high disease burden and mortality.
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Treasure J, Zipfel S, Micali N, Wade T, Stice E, Claudino A, Schmidt U, Frank GK, Bulik CM, Wentz E. Anorexia nervosa. Nat Rev Dis Primers 2015; 1:15074. [PMID: 27189821 DOI: 10.1038/nrdp.2015.74] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Anorexia nervosa (AN) is a psychiatric condition characterized by severe weight loss and secondary problems associated with malnutrition. AN predominantly develops in adolescence in the peripubertal period. Without early effective treatment, the course is protracted with physical, psychological and social morbidity and high mortality. Despite these effects, patients are noted to value the beliefs and behaviours that contribute to their illness rather than regarding them as problematic, which interferes with screening, prevention and early intervention. Involving the family to support interventions early in the course of the illness can produce sustained changes; however, those with a severe and/or protracted illness might require inpatient nursing support and/or outpatient psychotherapy. Prevention programmes aim to moderate the overvaluation of 'thinness' and body dissatisfaction as one of the proximal risk factors. The low prevalence of AN limits the ability to identify risk factors and to study the timing and sex distribution of the condition. However, genetic profiles, premorbid features, and brain structures and functions of patients with AN show similarities with other psychiatric disorders and contrast with obesity and metabolic disorders. Such studies are informing approaches to address the neuroadaptation to starvation and the other various physical and psychosocial deficits associated with AN. This Primer describes the epidemiology, diagnosis, screening and prevention, aetiology, treatment and quality of life of patients with AN.
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Affiliation(s)
- Janet Treasure
- King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London SE5 8AF, UK
| | - Stephan Zipfel
- Department of Psychosomatic Medicine, University of Tuebingen, Tuebingen, Germany
| | - Nadia Micali
- University College London, Institute of Child Health, Behavioural and Brain Sciences Unit, London, UK.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tracey Wade
- School of Psychology, Flinders University, Adelaide, Australia
| | - Eric Stice
- Oregon Research Institute, Eugene, Oregon, USA
| | - Angélica Claudino
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Ulrike Schmidt
- King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London SE5 8AF, UK
| | - Guido K Frank
- Eating Disorder Centre of Denver, University of Colorado, Denver, Colorado, USA
| | - Cynthia M Bulik
- University of North Carolina at Chapel Hill, North Carolina, USA.,Karolinska Institutet, Stockholm, Sweden
| | - Elisabet Wentz
- Gillberg Neuropsychiatry Centre, University of Gothenburg, Gothenburg Sweden
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Herpertz-Dahlmann B, van Elburg A, Castro-Fornieles J, Schmidt U. ESCAP Expert Paper: New developments in the diagnosis and treatment of adolescent anorexia nervosa--a European perspective. Eur Child Adolesc Psychiatry 2015; 24:1153-67. [PMID: 26226918 PMCID: PMC4592492 DOI: 10.1007/s00787-015-0748-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 07/15/2015] [Indexed: 01/20/2023]
Abstract
Anorexia nervosa is a potentially life-threatening disorder with a typical onset in adolescence and high rates of medical complications and psychiatric comorbidity. This article summarizes issues relating to classification in DSM-5 and presents a narrative review of key evidence-based medical and behavioral interventions for adolescent AN and subthreshold restricting eating disorders, mainly, but not exclusively published between 2012 and 2014. In addition, it systematically compares the clinical guidelines of four European countries (Germany, Spain, The Netherlands, and United Kingdom) and outlines common clinical practice, in relation to treatment settings, nutritional rehabilitation, family-oriented and individual psychotherapy, and psychopharmacological treatment. With the exception of family-based treatment, which is mainly evaluated and practiced in Anglo-American countries, the evidence base is weak, especially for medical interventions such as refeeding and pharmacological intervention. There is a need for common European research efforts, to improve the available evidence base and resulting clinical guidance.
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Affiliation(s)
- Beate Herpertz-Dahlmann
- Department of Child & Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Clinics, RWTH Aachen, Neuenhofer Weg 21, 52074, Aachen, Germany.
| | - Annemarie van Elburg
- Department of Social Sciences, Rintveld, Center for Eating Disorders, Altrecht Mental Health Institute, Utrecht University, Utrecht, The Netherlands
| | - Josefina Castro-Fornieles
- Department of Child & Adolescent Psychiatry, Neurosciences Institute, Hospital Clinic of Barcelona, CIBERSAM, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ulrike Schmidt
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Klenotich SJ, Ho EV, McMurray MS, Server CH, Dulawa SC. Dopamine D2/3 receptor antagonism reduces activity-based anorexia. Transl Psychiatry 2015; 5:e613. [PMID: 26241351 PMCID: PMC4564564 DOI: 10.1038/tp.2015.109] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 05/18/2015] [Accepted: 06/14/2015] [Indexed: 01/04/2023] Open
Abstract
Anorexia nervosa (AN) is an eating disorder characterized by severe hypophagia and weight loss, and an intense fear of weight gain. Activity-based anorexia (ABA) refers to the weight loss, hypophagia and paradoxical hyperactivity that develops in rodents exposed to running wheels and restricted food access, and provides a model for aspects of AN. The atypical antipsychotic olanzapine was recently shown to reduce both AN symptoms and ABA. We examined which component of the complex pharmacological profile of olanzapine reduces ABA. Mice received 5-HT(2A/2C), 5-HT3, dopamine D1-like, D2, D3 or D2/3 antagonist treatment, and were assessed for food intake, body weight, wheel running and survival in ABA. D2/3 receptor antagonists eticlopride and amisulpride reduced weight loss and hypophagia, and increased survival during ABA. Furthermore, amisulpride produced larger reductions in weight loss and hypophagia than olanzapine. Treatment with either D3 receptor antagonist SB277011A or D2 receptor antagonist L-741,626 also increased survival. All the other treatments either had no effect or worsened ABA. Overall, selective antagonism of D2 and/or D3 receptors robustly reduces ABA. Studies investigating the mechanisms by which D2 and/or D3 receptors regulate ABA, and the efficacy for D2/3 and/or D3 antagonists to treat AN, are warranted.
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Affiliation(s)
- S J Klenotich
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - E V Ho
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - M S McMurray
- Department of Psychology, University of Illinois at Chicago, Chicago, IL, USA
| | - C H Server
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - S C Dulawa
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA,Department of Psychiatry and Behavioral Neuroscience, University of Chicago, 924 E. 57th Street Room R022, MC3077, Chicago, IL 60637, USA. E-mail:
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45
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Monge MC, Forman SF, McKenzie NM, Rosen DS, Mammel KA, Callahan ST, Hehn R, Rome ES, Kapphahn CJ, Carlson JL, Romano ME, Malizio JB, Bravender TD, Sigel EJ, Rouse MR, Graham DA, Jay MS, Hergenroeder AC, Fisher MM, Golden NH, Woods ER. Use of Psychopharmacologic Medications in Adolescents With Restrictive Eating Disorders: Analysis of Data From the National Eating Disorder Quality Improvement Collaborative. J Adolesc Health 2015; 57:66-72. [PMID: 26095410 DOI: 10.1016/j.jadohealth.2015.03.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/23/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Psychopharmacologic medications are often prescribed to patients with restrictive eating disorders (EDs), and little is known about the frequency of use in adolescents. We examined the use of psychopharmacologic medications in adolescents referred for treatment of restrictive ED, potential factors associated with their use, and reported psychiatric comorbidities. METHODS Retrospective data from the initial and 1-year visits were collected for patients referred for evaluation of restrictive ED at 12 adolescent-based ED programs during 2010 (Group 1), including diagnosis, demographic information, body mass index, prior treatment modalities, and psychopharmacologic medications. Additional data regarding patients' comorbid psychiatric conditions and classes of psychopharmacologic medications were obtained from six sites (Group 2). RESULTS Overall, 635 patients met inclusion criteria and 359 had 1-year follow-up (Group 1). At intake, 20.4% of Group 1 was taking psychopharmacologic medication and 58.7% at 1 year (p ≤ .0001). White, non-Hispanic race (p = .020), and prior higher level of care (p < .0001) were positively associated with medication use at 1 year. Among Group 2 (n = 256), serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors use was most common, and 62.6% had a reported psychiatric comorbidity. Presence of any psychiatric comorbidity was highly associated with medication use; odds ratio, 10.0 (5.6, 18.0). CONCLUSIONS Adolescents with restrictive ED treated at referral centers have high rates of reported psychopharmacologic medication use and psychiatric comorbidity. As more than half of this referral population were reported to be taking medication, continued investigation is warranted to ensure the desired outcomes of the medications are being met.
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Affiliation(s)
- Maria C Monge
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts.
| | - Sara F Forman
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole M McKenzie
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - David S Rosen
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kathleen A Mammel
- Division of Adolescent Pediatrics, Beaumont Children's Hospital, Royal Oak, Michigan
| | - S Todd Callahan
- Division of Adolescent Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rebecca Hehn
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, Massachusetts
| | - Ellen S Rome
- Section of Adolescent Medicine, Department of General Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Cynthia J Kapphahn
- Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California
| | - Jennifer L Carlson
- Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California
| | - Mary E Romano
- Division of Adolescent Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joan B Malizio
- Division of Adolescent Medicine, Steven and Alexandra Cohen Children's Medical Center, North Shore-Long Island Jewish Health System, New Hyde Park, New York
| | - Terrill D Bravender
- Department of Pediatrics, The Ohio State University, Columbus, Ohio; Nationwide Children's Hospital, Columbus, Ohio
| | - Eric J Sigel
- Children's Hospital of Colorado, Section of Adolescent Medicine, University of Colorado, Aurora, Colorado
| | - Mary R Rouse
- Department of Pediatrics, Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana
| | - Dionne A Graham
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - M Susan Jay
- Division of Adolescent Medicine, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Albert C Hergenroeder
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Martin M Fisher
- Division of Adolescent Medicine, Steven and Alexandra Cohen Children's Medical Center, North Shore-Long Island Jewish Health System, New Hyde Park, New York; Department of Pediatrics, Hofstra North Shore-Long Island Jewish School of Medicine, Hempstead, New York
| | - Neville H Golden
- Division of Adolescent Medicine, Stanford University School of Medicine, Stanford, California
| | - Elizabeth R Woods
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
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van den Heuvel LL, Jordaan GP. The psychopharmacological management of eating disorders in children and adolescents. J Child Adolesc Ment Health 2015; 26:125-37. [PMID: 25391711 DOI: 10.2989/17280583.2014.909816] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In this review we synthesised current literature on the psychopharmacological management of eating disorders (EDs) in children and adolescents (C&As). We focus specifically on anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED). The treatment of EDs is determined by physical and psycho-social factors and needs. Pharmacological management should therefore be viewed and incorporated as one component of a multi-disciplinary comprehensive treatment plan for specific requirements of a patient depending on the stage of the disorder. As there is a dearth of studies evaluating the use of psychopharmacology for EDs in C&As we first review the findings from studies performed in adults and then discuss specific studies performed in C&As. We include information from reviews and treatment guidelines to assist the clinician with an approach to the use of psychopharmacological agents in the treatment of EDs in C&As.
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Affiliation(s)
- Leigh L van den Heuvel
- a Department of Psychiatry, Faculty of Medicine and Health Sciences , Stellenbosch University PO Box 19063, Tygerberg 7505 , South Africa
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Abstract
Psychopharmacologic treatment is playing a greater role in the management of patients with eating disorders. In this paper, we review randomized, placebo-controlled trials (RCTs) conducted in anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and other eating disorders over the past 3 years. Fluoxetine remains the only medication approved for an eating disorder, that being BN. RCTs of antipsychotics in AN have had mixed results; the only agent with some evidence of efficacy is olanzapine. One study suggests dronabinol may induce weight gain in AN. Preliminary studies suggest lack of efficacy of alprazolam, dehydroepiandrosterone, or physiologic estrogen replacement in AN; erythromycin in BN; and the opioid antagonist ALKS-33 in BED. In BED with obesity or overweight, bupropion may cause mild weight loss without seizures, and chromium may improve glucose regulation. Also in BED, three RCTs suggest the stimulant prodrug lisdexamfetamine may reduce binge eating episodes, and another RCT suggests intranasal naloxone may decrease time spent binge eating. There remains a disconnection between the size of eating disorders as a public health problem and the lack of pharmacotherapy research of these conditions.
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48
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Lock J, La Via MC. Practice parameter for the assessment and treatment of children and adolescents with eating disorders. J Am Acad Child Adolesc Psychiatry 2015; 54:412-25. [PMID: 25901778 DOI: 10.1016/j.jaac.2015.01.018] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 01/31/2015] [Indexed: 10/23/2022]
Abstract
This Practice Parameter reviews evidence-based practices for the evaluation and treatment of eating disorders in children and adolescents. Where empirical support is limited, clinical consensus opinion is used to supplement systematic data review. The Parameter focuses on the phenomenology of eating disorders, comorbidity of eating disorders with other psychiatric and medical disorders, and treatment in children and adolescents. Because the database related to eating disorders in younger patients is limited, relevant literature drawn from adult studies is included in the discussion.
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Dold M, Aigner M, Klabunde M, Treasure J, Kasper S. Second-Generation Antipsychotic Drugs in Anorexia Nervosa: A Meta-Analysis of Randomized Controlled Trials. PSYCHOTHERAPY AND PSYCHOSOMATICS 2015; 84:110-116. [PMID: 25722106 DOI: 10.1159/000369978] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 11/05/2014] [Indexed: 11/19/2022]
Abstract
Background: Second-generation antipsychotic drugs (SGAs) are increasingly administered to achieve weight gain in anorexia nervosa. In this meta-analysis, we aimed to determine if any evidence for this treatment option can be derived from randomized controlled trials (RCTs). Methods: Based on the 'World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Eating Disorders', a systematic update literature search was applied to identify all RCTs investigating the efficacy, acceptability, and tolerability of SGAs in anorexia nervosa in comparison to placebo/no treatment. The primary outcome was weight gain measured by mean change in body mass index (BMI). Secondary outcomes were mean changes in Yale-Brown-Cornell Eating Disorders Scale (YBC-EDS) total score and Eating Disorders Inventory (EDI) total score and premature discontinuation of treatment. Employing a random-effects model standardized mean differences based on Hedges's g and Mantel-Haenszel risk ratios were calculated. Results: Seven RCTs (n = 201) investigating olanzapine (N = 4), quetiapine (N = 2), and risperidone (N = 1) were included. We found no statistically significant between-group differences for mean BMI change when pooling the SGAs (N = 7, n = 161; Hedges's g = 0.13, 95% CI: -0.17 to 0.43; p = 0.4) and when examining the individual drugs. Furthermore, the SGAs failed to differentiate statistically significantly from placebo/no treatment for all secondary outcomes. Conclusions: Based on the current evidence, pharmacological treatment of anorexia nervosa with SGAs cannot be generally recommended although some individuals or subgroups of patients might benefit from an antipsychotic medication. Further research is required to identify which patients will likely benefit from such a treatment option. © 2015 S. Karger AG, Basel.
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Affiliation(s)
- Markus Dold
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
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Abstract
BACKGROUND Anorexia nervosa (AN) is a serious psychiatric disease. Choice of acute inpatient care for AN is driven by the severity of symptoms and the level of risk to the patient. Inpatient hospitalization of patients with AN typically includes a behavioral weight gain protocol that is designed to address the core features of the disorder: weight, appetite, and distorted thoughts and behavior. Some add-on treatments may also be included in the inpatient treatment model and may have potential benefits, including faster or greater weight gain; such treatments include psychotherapy, psychoeducation, pharmacological treatment, and nutritional replacement. OBJECTIVE The goal of this study was to systematically review randomized clinical trials (RCTs) that have compared the efficacy of different forms of add-on treatment delivered during admission to a 24-hour hospital and to summarize the existing data regarding weight gain associated with such pharmacological, medical, and psychological interventions. METHODS Systematic electronic and manual searches were conducted to identify published RCTs concerning inpatient treatment of AN. Weight gain was used as the main outcome variable. RESULTS Overall, no significant increase in weight recovery was reported with atypical antipsychotics compared to placebo or therapy as usual. Only one study showed slight benefits in young patients during hospitalization (d=0.77; 95% confidence interval [CI] -0.09-1.64). No significant effects on weight recovery were found for antidepressants (d=-0.10; 95% CI=-0.63-0.42). In addition, none of the add-on psychotherapy techniques that were evaluated demonstrated superiority compared with control interventions in the inpatient setting. Cyclic enteral nutrition was studied in one RCT in which it demonstrated superiority compared to oral refeeding only (d=0.97; 95% CI=0.51-1.47). Other less common treatments such as bright light therapy and lithium carbonate were not found to produce additional significant weight improvement compared with placebo. CONCLUSION Most add-on treatments during the acute inpatient phase of AN treatment are not effective in increasing weight recovery. Long-term follow-up studies after the acute treatment phase are needed to make evidence-based recommendations.
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