BULIMIA NERVOSA AND THE EFFECT OF ANTIDEPRESSANT DRUGS

Brooke Altenau

WHAT IS BULIMIA NERVOSA?

Bulimia nervosa afflicts mostly women (about 6% of adolescent girls, and 5% of college women). Most individuals with bulimia engage in compensatory activities such as vomiting, laxative abuse, strict dieting, and vigorous exercise (Alexander).

PRIMARY SYMPTOMS OF BULIMIA

The primary symptoms of bulimia are recurrent episodes of binge eating and compensatory measures to purge the calories. There is an excessive influence of the importance of the body and weight on one's self-evaluation (Negri).

Symptoms of bulimia can be quite invisible because the bulimic can maintain normal weight. Occasionally, patterns of behavior may signal a problem: Do they restrict certain food? Do they eat in a ritualistic way? Are they overly concerned with diet? Do they weigh themselves every day? Do large quantities of food disappear from the refrigerator? Do they visit the bathroom soon after meals or frequently? (Negri).

Some bulimics have a telltale scar on the first two knuckles of their hand from inducing vomiting. Some purge themselves up to several times a day. This can lead to serious medical consequences: dental cavities, electrolyte imbalances, disturbances in heart rhythm and dangerously low blood pressure (Negri).

ANTIDEPRESSANTS AND THE TREATMENT OF BULIMIA

Psychiatrist Linda Gochfield, who teaches brief psychotherapies to mental-health professionals, maintains that if people have a problem that responds to medication, that can be the briefest and most effective therapy of all (Davis).

While bulimia often occurs with comorbid mood disturbances, the treatment benefit found for antidepressants in bulimia may not be merely alleviation of depressive symptoms; the increased serotonin levels also help reduce food intake. Looking at results of 14 studies of treatment of bulimia with antidepressants, it has been noted that administration to bulimics agents that increase the availability of serotonin virtually always produces better results than placebo, regardless of the presence or absence of depression (Alexander).

There is now compelling evidence from double-blind, placebo-controlled studies that antidepressant medication is useful in the treatment of bulimia nervosa. What is less clear is which patients are most likely to benefit from antidepressant medications and how to best sequence the various therapeutic interventions available. The utility of antidepressant medications in bulimia nervosa has led to their evaluation in binge eating disorder. The limited information currently available suggests that antidepressant treatment may be associated with a reduction in binge frequency in obese patients with binge eating disorder, but does not lead to weight reduction. Additional studies of the use of medication in the treatment of binge eating disorder and of the role of pharmacotherapy in the treatment of bulimia nervosa are needed (Devlin).

The results of psychopharmacological treatment studies of patients with bulimia nervosa have overall been more favorable than those of anorexic patients. Statistically significant effects concerning the reduction of bulimic or depressive symptoms in bulimia nervosa has been demonstrated for tricyclic antidepressants, serotonergic agents (Prozac), non-selective monoamine-oxydase-inhibitors, and trazodone. The antibulimic effect appears not to be associated with the antidepressant effect (Fichter).

The FDA recently approved the first drug, fluoxetine or Prozac, for bulimia. Other medications have been found to be helpful for bulimia and bingeing. Treatment for these disorders tends to be multi-modal. A treatment team would include an internist or pediatrician, a psychotherapist, a nutritionist, and possibly a psychopharmacolist and family therapist (Negri).

PROZAC AND THE TREATMENT OF BULIMIA

Fluoxetine HCI (Prozac) is the first drug in this country to receive an indication for treatment of bulimia nervosa. The selective serotonin reuptake inhibitor (SSRI) is also used in treatment of depression and obsessive-compulsive disorder. The recommended dosage is 60 mg/day. About 3 of American women will have bulimia at some time in their lives; up to half of all bulimic patients have another psychiatric disorder such as depression or obsessive-compulsive disorder (Rx Pad).

The Food and Drug Administration has approved Prozac for a new indication: the treatment of bulimia nervosa. Bulimia is characterized by recurrent episodes of binge eating, feelings of being out of control, and an obsession with food and weight (Alexander).

"The great advantage of Prozac is its tolerability as compared to the other classes of antidepressants--the tricyclics and the monoamine oxidase inhibitors (MAOIs). Other selective serotonin reuptake inhibitors (SSRIs) are presumed to work but have not been studied-nor have doing studies been done for them," concluded B. Timothy Walsh, M.D., professor of clinical psychiatry, College of Physicians and Surgeons, Columbia University (Alexander).

ZOLOFT AND TREATMENT

The FDA has ordered Pfizer Inc. to stop distributing sales brochures to doctors and health-care institutions that the agency says were unapproved, and in some cases possibly unsafe, uses of the drug Zoloft, its popular antidepressant. A letter from the FDA to Pfizer CEO William Steere Jr. cites the company for marketing Zoloft for treating premenstrual depression, chronic low-grade depression, obsessive-compulsive disorder and postpartum depression, uses not approved by the FDA (Langreth).

STUDY #1

Turnbull and others examined pretreatment variables to predict outcome in two treatments for bulimia nervosa. Those with more frequent bingeing may require a more intense intervention, and those who have been ill longer may be more motivated to respond to treatment (Turnbull).

STUDY #2

The drug's approval as a therapy for bulimia was based on three double-blind, placebo-controlled clinical trials. In the first two trials 387 women received either 60 mg or 20 mg of fluoxetine or placebo. Patients were typical of those requiring treatment, and all met DSM-III-R criteria for bulimia nervosa. Median reductions in binge-eating episodes for the two eight week studies were 67% for 60 mg fluoxetine, 45% for 20 mg fluoxetine, and 33% for placebo. Vomiting episodes were reduced 56%, 29%, and 5%, respectively (Alexander).

Patient responses were divided into three levels according to reductions in episodes: complete (100%), marked (75%-99%), and moderate (50%-74%). For binge-eating episodes among women receiving the 60 mg dose, slightly more than 20% were complete responders, slightly more than 15% were marked, and slightly fewer than 15% were moderate. For vomiting, 16% showed complete response; 12% and 22% showed marked and moderate responses respectively (Alexander).

Evaluation through the Eating Disorder Inventory or EDI also showed a significant treatment benefit indicating a reduction in concern with an extreme pursuit of thinness. Evaluations both by physicians and by patients revealed significant improvement. Also, it was pointed out that the 60 mg dose is triple the recommended fluoxetine dose for depression (20 mg) (Alexander).

STUDY #3

Pamela K. Keel and James E. Mitchell sought to synthesize existing data on outcome for individuals diagnosed with bulimia nervosa in order to better understand long-term outcome and prognostic factors.

Method: They reviewed 88 studies that conducted follow-up assessments with bulimic subjects at least 6 months after presentation. Findings are summarized for the areas of mortality, recovery, relapse, crossover, and prognostic variables.

Results: The crude mortality rate due to all causes of death for subjects with bulimia nervosa in these studies was 0.3 or seven deaths among 2,194 subjects; however, ascertainment rates and follow-up periods were small and likely to produce underestimation. Five to 10 years following presentation, approximately 50 of women initially diagnosed with bulimia nervosa had fully recovered from their disorder, while nearly 20 continued to meet full criteria for bulimia nervosa. Approximately 30 of the women experienced relapse into bulimic symptoms, and risk of relapse appeared to decline 4 years after presentation. Few prognostic factors have been consistently identified, but personality traits, such as impulsivity, may contribute to poorer outcome. In addition, participation in a treatment outcome study was associated with improved outcome for follow-up periods less than 5 years.

Conclusions: Treatment interventions may speed eventual recovery but do not appear to alter outcome more than 5 years following presentation. Long-term outcome for women diagnosed with bulimia nervosa remains unclear. However, this disorder may be chronic for at least a subset of women (Keel).

STUDY #4

This study used L. Benjamin's structural analysis of social behavior (1974) rating scales to assess how perceptions of parental relationships relate to self-concept. The results indicate that female patients with bulimia perceive both parents as hostility disengaged. Furthermore, the self-concepts of patients with bulimia were significantly associated with perceptions of paternal attack or friendliness, which differentiated them from control participants. The results were discussed in terms of the possible relations between family factors and self-concept in bulimia (Klein).

STUDY #5

This study presents data which suggests that fluoxetine is effective in the treatment of bulimia nervosa. Two trials of unprecedented size (n=387 and 398, respectively) have recently been reported. These two studies show that fluoxetine, 60 mg/day, has a clear beneficial effect on behavioral and other (attitudinal) measures of bulimic symptomatology, and that this dose of fluoxetine is well tolerated in patients with bulimia nervosa (Wood).

PREDISPOSING FACTORS

Predisposing factors for bulimia nervosa, according to B. Timothy Walsh, M.D., professor of clinical psychiatry, College of Physicians and Surgeons, Columbia University, New York City, include female gender, living in a culture that emphasizes thinness, and familial obesity. A consistent precipitating factor in bulimia is dieting. "Bulimia almost always first develops in the course of a diet or right after," Walsh observed. Typically, individuals have lost some weight and, after bingeing in response to hunger, induce vomiting or one of the other compensatory mechanisms. "By the time they come to a clinic, through a complex interaction of behavior, psychology, and biology, they are caught in a cycle of bingeing and vomiting," he said (Alexander).

BULIMIC CYCLE

Once the cycle is established, enlarged gastric capacity--along with other factors that may contribute to disturbed saiety, such as 5-HT receptor changes, slowed gastric emptying, decreased cholecystokinin release, and altered vagal activity--many reinforce the pattern. Foremost among physiologic consequences are esophageal inflammation or tears, stomach emptying disorders, and colon ruptures or dysfunction. Phychological effects include guilt, isolation, impaired relationships, mood disturbances, and possible suicide. The condition is often chronic, intractable, or relapsing (Alexander).

Works Cited

Alexander, Walter. "Prozac Wins New Indication: For Bulimia Nervosa." Drug Topics 141 6 Jan. 1997.

Council, JR, MH Klein, and S. Wonerlich. "Relationship of Social Perceptions and Self-Concept in Bulimia Nervosa." Journal of Consulting & Clinical Psychology. 64(6): 1231-7, 1996 Dec.

Davis, Flora. "Medications: The Briefest Therapy?" Working Woman 21 Feb. 1996.

Devlin, MJ and BT Walsh. "Pharmacotherapy of Bulimia Nervosa and Binge Eating Disorder." Addictive Behaviors. 20(6): 757-64, 1995 Nov.-Dec.

Fichter, MM. "Drug Treatment of Anorexia Nervosa and Bulimia Nervosa." [ Review]. Nervenarzt. 64(1): 21-35, 1993 Jan.

Keel, Pamela K. and James E. Mitchell. "Outcome in Bulimia Nervosa." The American Journal of Psychiatry 154. Washington: March 1997.

Langreth, Robert. "Pfizer Ordered to Alter Claims for Zoloft Uses." Wall Street Journal 7 Aug. 1996.

Negri, Gloria. "Q. & A. With Anne E. Becker, M.D., Eating Disorder Specialist." Boston Globe: Boston, Mass. Feb. 2, 1997.

"Rx Pad: New Drugs, New Indications." Patient Care 31: Feb. 28, 1997.

Turnbull, Susan J. "Predictors of Outcome for Two Treatments for Bulimia Nervosa: Short and Long Term." International Journal of Eating Disorders 21: Jan. 1997.

Wood, A. " Pharmacotherapy of Bulimia Nervosa--Experience with Fluoxetine." International Clinical Psychopharmacology. 8(4): 295-9, 1993 Winter.