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The Efficacy of Antidepressants as a Treatment for Bulimia Nervosa
Bulimia nervosa is an eating disorder, which affects many people in the world today. Those who are afflicted by bulimia nervosa have recurrent “powerful and intractable urge[s] to overeat” known as binges, as well as a great fear of becoming fat (Zwaan, 2003). One who suffers from bulimia nervosa will engage in some sort of behavior to prevent weight gain. In the purging type of bulimia nervosa the methods of weight gain prevention used are vomiting, over-use of laxatives, diuretics or enemas. In the non-purging type of bulimia one only uses fasting or exercise to counteract previous or anticipated future binges. In order to meet the DSM-IV criteria for bulimia nervosa one must engage in these behaviors twice a week for three months.
There are many methods used to treat bulimia nervosa, one of which is the use of pharmaceuticals. There is a significant amount of research on antidepressants in particular as a treatment for bulimia nervosa. Bulimia nervosa is a very serious condition, and the question of how effective antidepressants are as a treatment for bulimia nervosa begs to be asked.
What are Antidepressants?
Antidepressant is a broad category of pharmaceuticals that includes several different drugs that are used to cure depression. These drugs act on depression by altering brain chemistry. The main types of antidepressants are selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and (TCAs) monoamine oxidase inhibitors (MAOIs). SSRIs are the most prescribed type of antidepressant. SSRIs they affect the levels of a chemical in the brain called serotonin. This chemical “helps regulate mood” as well as playing a role in “digestion, pain, sleep, mental clarity, and other bodily functions” (Smith, 2010). While antidepressants can have many helpful effects, antidepressants can also in some cases increase depression, and increase suicide risk. Antidepressants can also be very difficult to come off of, causing painful withdrawal symptoms such as depression, anxiety, and even brain zaps.
Antidepressants were initially tested as a treatment for bulimia nervosa because of the “association of bulimia nervosa with depressive illness” (Zwaan, 2003). It is believed that antidepressants could be helpful in treating bulimia because they have “a direct effect on ingestive behavior” such as appetite and how full one feels after a meal (Zwaan, 2003). Since antidepressants are not understood completely, it is possible that antidepressants may have other properties that help change bulimic behavior.
The department of Psychiatry at the Universidade Federal de São Paulo conducted a meta-analysis that tested the efficacy of antidepressants versus the efficacy of placebos for treating people with bulimia nervosa. In this analysis, a variety of different studies were compared, many of them testing fluoxetine which is the active ingredient in the popular antidepressants Prozac and Sarafem. This analysis ignored any data relating to dosages of fluoxetine less than 60 mg because dosages lower than 60 mg do not seem to have any effect on bulimia nervosa whatsoever. The study concluded that there is “statistical evidence” that using a single antidepressant has some efficacy in treating bulimia nervosa, however the analysis also states that “the effect is modest” (Bacaltchuk, 2009). While the study did analyze TCAs, SSRIs, and MAOIs, it did not find a difference in the efficacies of the three different types of antidepressants. The analysis commented on the fact that the dropout rate of the studies examined was high. It blamed this on the “side effects” of the drugs, as well as the “patients’ negative attitudes towards medication use” (Bacaltchuk, 2009). This analysis concluded that antidepressants could be beneficial to those who suffer from bulimia nervosa; however, the analysis stated that antidepressants should be used in conjunction with another form of therapy. Antidepressants should not be used alone in treatment, but the use of antidepressants could facilitate another form of bulimia nervosa therapy.
Another meta-analysis, conducted by R Sysko, focused on early responses to antidepressant treatment of bulimia nervosa. This study focused on the use of fluoxetine because it is “the only antidepressant medication approved by the US Food and Drug Administration (FDA) for the treatment of BN” (Sysko, 2010). This analysis also focused on doses of 60mg as this “produced significantly greater reductions in bulimic symptoms when compared to fluoxetine 20mg/day”(Sysko, 2010). This analysis used data from two simple studies of the effectiveness of fluoxetine as a treatment for bulimia nervosa as compared to placeboes. In this analysis, data was graphed and analyzed in order to find a way to predict whether fluoxetine would be effective based on an early response. This analysis concluded that by the third week it could be predicted whether one would respond to fluoxetine or not. If a patient showed less than a 60% decrease in vomiting by this time, it was 72% likely that this user would not respond to the fluoxetine. This study also had a fairly high dropout rate due to peoples’ unwillingness to drug themselves.
A review of antidepressants compared to psychological treatments for bulimia nervosa was also conducted. This review was designed to investigate the effectiveness of antidepressants when compared to psychological treatment of bulimia nervosa. It also investigated the effects of combining psychological treatments for bulimia nervosa. This review drew upon data from numerous studies which were hand picked and chosen based on quality. This meta-analysis drew data from antidepressant studies that tested TCAs, SSRIs, and MAOIs. It also drew upon data from cognitive-behavior therapy, psychodynamic therapy, interpersonal therapy, and several other types of psychological treatments in order to test the efficacy of these methods. This review concluded that cognitive behavior therapy designed specifically for bulimia nervosa is the best way to treat bulimia nervosa. The review also states that if cognitive behavior therapy alone is not working “augmentation with antidepressants can be recommended” (Hay, 2010). This review stated that there was not a large amount of data on cognitive behavior therapy used in conjunction with antidepressants and that more data is necessary for future discussions and studies on this topic.
The study conducted by the department of Psychiatry at the Universidade Federal de São Paulo seems to be a valid study. Before it analyzes each of the studies it checks for possible bias and analyzes only studies that are unbiased. It used a large number of studies in its analysis in order to increase its accuracy. The second study, conducted by R Sysko, shows that if the use of antidepressants does not yield a fast, positive response in bulimia nervosa patients, then it is likely not to work as a method of controlling bulimia nervosa at all. While this is interesting information is not terribly useful, as there is still over a 25% chance that antidepressants may be helpful in the treatment of bulimia nervosa even if they do not begin helping in a matter of three weeks. The review of antidepressants compared to psychological treatments of bulimia nervosa used the same method of assessing the validity of the studies it cited as the analysis that the Universidade Federal de São Paulo conducted. This method seems to assess the quality of the studies it uses very thoroughly before using them; therefore this study is most likely valid.
The three studies all point to the conclusion that antidepressants can help in reducing behaviors associated with bulimia nervosa, however, the three studies also all give the disclaimer that antidepressant therapy may not always be completely effective. In addition, two of the three studies suggest that a combination of psychological treatment of bulimia nervosa as well as antidepressant treatment is more likely to succeed than either of the two alone. One of the main reasons that antidepressants are not used as widely is because many people are afraid of the possible effects of antidepressants, and do not want to alter their brain chemistry. This is also the reason that the dropout rate was fairly high for some of the studies.
Fluoxetine seems to be the drug that is tested most as a treatment for bulimia nervosa simply because it is the only drug that is currently approved by the FDA as a treatment for bulimia nervosa. It seems that most antidepressant drugs have more or less the same effect on bulimia nervosa as fluoxetine despite the fact that fluoxetine is the only one that is approved for as a treatment of bulimia nervosa currently.
Summary and Conclusion
Antidepressants can and should be used to treat bulimia nervosa if the patient is open to using antidepressants. While antidepressants do not have a high level of efficacy in treating bulimia nervosa, antidepressants can certainly help its treatment especially when combined with psychological therapy. In the end antidepressants are simply drugs that will alter one’s brain chemistry, the only way to truly treat an eating disorder like bulimia nervosa is to treat the underlying psychological problems that lead one to bulimic behavior in the first place. People are usually much more open to psychological therapy over taking a brain altering drug. A mix of cognitive behavior therapy as well as a dosage of 60 mg of fluoxetine appears to be an effective method of treating the eating disorder.
There may be some negative withdrawal symptoms associated with coming off of an antidepressant such as “headache, nausea, pins and needles, dizziness and anxiety,” however the withdrawal symptoms associated with coming off of fluoxetine are usually very mild (Prozac, 2007). Using other antidepressants could result in other more painful withdrawal symptoms; therefore fluoxetine is likely the best antidepressant to take as a treatment for bulimia nervosa.
In the future more studies should be conducted on the effects of cognitive behavior therapy in conjunction with antidepressants compared to the use of cognitive behavior therapy alone. While there was one study that focused on this topic, that study admitted that it could have been improved if it had had more data on the subject. Although it is fairly clear that antidepressants can be useful in the treatment of bulimia nervosa, the question of how useful they actually are becomes more pertinent as their usefulness becomes apparent.
Bacaltchuk, J., & Hay, P. P. (2009). Antidepressants versus placebo for people with bulimia nervosa. The Cochrane Library, (1). doi:10.1002/14651858.CD003391.
Hay, P. P., Claudino, A. M., & Kaio, M. H. (2010). Antidepressants versus psychological treatments and their combination for bulimia nervosa. The Cochrane Library.
Prozac (fluoxetine) . (2007, December 9). Retrieved December 8, 2010, from NetDoctor website: http://www.netdoctor.co.uk/medicines/100002193.html
Smith, M., Robinson, L., & Segal, J., Ph.D. (2010, November). Antidepressants. Retrieved December 8, 2010, from Helpguide.org website: http://helpguide.org/mental/medications_depression.htm
Sysko, R., Sha, N., Duan, N., & Walsh, B. T. (2010, June). Early response to antidepressant treatment in bulimia nervosa. Psychological Medicine , 40(6). doi:10.1017/S0033291709991218
Zwaan, M. D., & Roerig, J. (2003). Pharmacological Treatment of Eating Disorders: A Review. In Eating Disorders (pp. 223-286). West Sussex, England: John Wiley & Sons Ltd.
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