New aspects of diagnosis and pharmacotherapy of eating disorders

Mirtazapine in the treatment of adolescent anorexia nervosa. Case-control study

OBJECTIVE

Anorexia nervosa (AN) is a serious and potentially life-threatening psychiatric disorder. Pharmacotherapeutic possibilities still remain limited. We sought to determine if there was a positive effect on body weight and body mass index (BMI) in AN patients being treated for depression or anxiety with mirtazapine.

METHODS

Using a case-control design, we found nine female patients with AN who had been treated with mirtazapine for depression or anxiety during hospitalization in our department. We also found nine female controls with AN, who had not received any pharmacotherapy. The two groups of patients were matched according to age and BMI. Case and control groups did not differ significantly in age (15.2 +/- 1.9 Vs. 14.7 +/- 1.7 years; P = 0.549), or in BMI (15.6 +/- 2.3 Vs. 15.6 +/- 2.1; P = 0.946) at baseline. Weight and BMI were evaluated at baseline and again after the patients had completed 1, 2, 3 and 4 weeks of treatment.

RESULTS

The mean dose of mirtazapine was 21.7 +/- 1.8 mg at the end of week 4. Using ANOVA Repeated Measures, we found no significant differences between cases and controls with regard to weight (P = 0.981) or BMI (P = 0.576). However, there was a non-significant trend in patients which had been treated with mirtazapine which showed slightly more improvement, in the measured parameters, at the end of weeks 1, 2 and 3, compared to controls.

CONCLUSION

Results are limited by small sample size. However, the use of mirtazapine could be useful in the treatment of AN in adolescence.

Milnacipran in the treatment of bulimia nervosa: a report of 16 cases

Controlled trials in patients with bulimia nervosa have demonstrated efficacy of antidepressant medications with serotonergic function (e.g. fluoxetine) as well as noradrenergic function (e.g. desipramine). Sixteen out-patients with bulimia nervosa according to DSM-IV criteria were treated in a drug surveillance with 100 mg of milnacipran, a specific serotonin and noradrenaline reuptake inhibitor (SNRI). Ten patients completed the 8-week observation period. The reasons for premature attrition were improvement in one patient (no. 12), a generalized exanthema in one patient (no. 7), severe nausea in one patient (no. 8) and non-compliance due to non-drug-related reasons in three patients (no. 1, 2, and 16). An intent-to-treat analysis exhibited a significant reduction in weekly binge eating and vomiting frequency from baseline to the end of treatment. Three patients stopped binge eating and purging completely during the last week of treatment. Furthermore, there was a concomitant decrease of depression ratings (HAMD, BDI). Our preliminary data give rise to the notion that milnacipran may be promising in the treatment of bulimia nervosa.

Receptor and transporter imaging studies in schizophrenia, depression, bulimia and Tourette's disorder--implications for psychopharmacology

Considerable progress has been achieved over the past 15 years in uncovering the biological basis of major psychiatric disorders. To determine patterns of brain dysfunction and to uncover the mechanism of action of centrally active compounds we used single photon emission computerized tomography (SPECT) as well as positron emission tomography (PET) in patients diagnosed with schizophrenia, depression, bulimia and Tourette's disorder. Striatal D2 and 5-HT1A receptors were studied in schizophrenia and 5-HT transporters (5-HTT) in depression and bulimia. Patients were either drug-naïve or drug free, or we studied the influence of specifically acting compounds on receptor/transporter occupancy. We could demonstrate that atypical antipsychotics have a dose-dependent (with the exception of clozapine and quetiapine) lower striatal D2 receptor occupancy rate compared with typical neuroleptics, paralleling the more favourable extrapyramidal side effects of atypical antipsychotics. However, no association between striatal D2 receptor occupancy rates and antipsychotic efficacy has been found. The measurement of 5-HT1A receptors in drug-naïve schizophrenic patients using the in vivo PET methodology revealed an increase of cortical 5-HT1A receptor binding potential in schizophrenia. beta-CIT as a ligand for measurement of 5-HT transporter densities (5-HTT) revealed lower rates in depression compared to age- and sex-matching healthy controls, a measurement that has also been obtained for bulimia. We also documented seasonal variations in brain serotonergic function by our finding of reduced brain 5-HTT availability in winter (compared to summer) in healthy controls. Furthermore, displaceable [123I] beta-CIT binding in the area corresponding to the left striatum (representing predominantly the density of dopamine transporters) was significantly reduced in SAD patients compared to healthy controls. In depression as well as in bulimia, selective serotonin reuptake inhibitors significantly decreased the beta-CIT binding potential, however, no significant dose relationship has been obtained in depression. Genotyping depressed patients for the serotonin transporter promoter gene region (5-HTTLPR) did not provide evidence for in vivo functional regulation of 5-HTT availability by 5-HTTLPR in the thalamus-hypothalamus and mesencephalon-pons of healthy subjects. In patients suffering from Tourette's disorder (TD) we were unable to detect differences of dopamine transporter densities between psychotropic drug-naïve TD patients and controls. Furthermore, no difference could be found between currently treated (with antipsychotics) and psychotropic drug-naïve TD patients. Our data provide insight into the pathophysiology of neuropsychiatric disorders and may guide future psychopharmacological drug developments.

Do drugs have a place in the treatment of eating disorders in adolescence?

This paper reviews the literature on drug treatment of eating disorders in adolescence. No well-controlled psychopharmacological studies specifically of adolescent patients with eating disorders have been performed. Therefore, the evidence for rational treatment guidelines is extremely limited. More psychopharmacological studies - especially SSRI trials - of adolescents with eating disorders are needed before general clinical recommendations can be issued. Cyproheptadine appears to be a safe and interesting drug that should be explored further, particularly in severely restricting patients with anorexia nervosa (AN). The use of zinc supplement in the treatment of AN also requires further study.