For individuals with bulimia nervosa, the choice is generally a type of antidepressant called a selective serotonin re-uptake inhibitor (SSRI). Often prescribed in combination with psychotherapy, SSRIs are better tolerated and generate fewer side effects than the “older” antidepressants (tricyclic antidepressants and MAOI inhibitors). Prozac (fluoxetine), the only medication approved by the U.S. Food and Drug Administration for the treatment of bulimia nervosa, is an SSRI. So are Lexapro (escitalopram), Luvox (fluvoxamine), Paxil (paroxetine) and Zoloft (sertraline). Patients start on a low dose, which is increased gradually, as tolerated. SSRIs generally take up to 6 weeks to become effective, so individuals should not expect improvement immediately.

SSRIs are valuable not only for their potentially positive effects on the mood problems and anxiety that often accompany bulimia nervosa but also because they tend to help relieve the urge to binge eat. Complex and not well understood, the mechanisms through which SSRIs reduce binge eating are a topic of ongoing research. Located near the pituitary gland toward the base of the brain, the hypothalamus is a structure that regulates a number of functions, including appetite and weight. Key to this regulatory activity are neurotransmitters, so named because they transmit information from one neuron (brain cell) to another. The chemicals norepinephrine and dopamine are neurotransmitters; another is serotonin, which manages mood, anxiety and satiety (the sense that one has eaten enough) and is probably dysregulated in eating disorder sufferers.

The last decade has seen the development of new antidepressants that can be helpful in the treatment of eating disorders. One of these is Effexor (venlafaxine), which blocks the reuptake of serotonin and norepinephrine. Others include tetracyclic compounds such as Ludiomil (maprotiline-blocks norepinephrine re-uptake) and Remeron (mirtazapine-may enhance noradrenergic and specific serotonergic activity). Sometimes it is necessary for a patient to try several antidepressants or dosages before finding one that is therapeutic.

In 2004, amid concerns that antidepressants increase the risk of suicide in children and adolescents, the U.S. Food and Drug Administration issued a “black box warning” advising clinicians that young patients on these medications needed close monitoring. Subsequently, a major review of many studies revealed that the risk of suicidal thoughts and behaviors among children and adolescents on antidepressants is much lower than originally thought. The prescribing physician provides education about the safety and potential benefits of antidepressants so that young patients and their parents can make thoughtful, informed decisions.

For the treatment of binge eating disorder (BED), antidepressants often improve mood and help with binge suppression, but don’t necessarily lead to weight loss. Several other medications are now under study for use with this disorder, and early results sound promising. One is Meridia (sibutramine), an appetite suppressant belonging to a new family of medications approved by the U.S. Food and Drug Administration for the treatment of obesity. Testing of sibutramine as a possible medication for BED has demonstrated decreases in binge eating, body weight and depression. Also under investigation is the specific norepinephrine reuptake inhibitor Strattera (atomoxetine), which is used for the treatment of attention-deficit hyperactivity disorder. A short-term trial of Strattera in patients with BED resulted in lower body weight and less binge eating. A third potential medication for BED is the anticonvulsant drug Topamax (topiramate), which can reduce the frequency of binge eating and promote weight loss and may also be useful for patients with bulimia nervosa. Some patients with BED need to try a series of medications in order to determine what is most effective.

Many individuals with anorexia nervosa are treated with antidepressants and seem to tolerate them well. Although SSRIs tend to ease the anxiety, low mood and obsessive-compulsive thinking that go along with this illness, they do not lead to weight gain or keep patients who have gained weight in the hospital from relapsing post-discharge.

For those with severe anorexia nervosa who continue to deny that they have a problem, medications such as Zyprexa (olanzapine) can be helpful. Originally formulated for the treatment of schizophrenia, these atypical antipsychotic drugs are likely to allay the relentless obsessions, compulsions and agitation that often occur in anorexia nervosa and may permit some weight gain.

Benzodiazepines such as Ativan (lorazepam) or Klonopin (clonazepam) can help quell the anxiety that is frequently experienced in eating disorders. A number of patients benefit from the combined use of a benzodiazepine and an SSRI. Ativan is short-acting compared to some SSRIs and can be useful right before meals to increase an individual’s ability to take in food.

Buspar (buspirone) is an anti-anxiety medication that differs chemically from the benzodiazepines and tends to be less sedating. It takes about two to four weeks for this medication to become effective. Buspar can be therapeutic to individuals with eating disorders who struggle not only with anxiety but also with depression. Sometimes Buspar is prescribed in combination with an SSRI.

For eating disorder sufferers who do not find antidepressants helpful there is the anticonvulsive medication Neurontin (gabapectin), which exerts a therapeutic effect on anxiety and mood. Neurontin can be taken in conjunction with an SSRI.

Continued research into the genetics of eating disorders and into the biology of neurotransmitters is paving the way for the development of new medications for the treatment of these illnesses. Building on current knowledge, further studies are likely to enhance the ability of clinicians to predict which patients will respond to (which) antidepressants. In addition, research is underway to determine how to best use medication in conjunction with psychotherapy.

For side effects and other information about the drugs introduced above, please consult:
National Institute of Mental Health Medication Booklet
Drugs.com


References
Pharmacological approaches in the treatment of binge eating disorder
Appolinario, J.C., McElroy, S.L. Pharmacological approaches in the treatment of binge eating disorder. Current Drug Targets 2004; 5 (3): 301-307.

Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials
Bridge, J.A., Iyengar, S., Salary, C.B., Barbe, R.P., Birmaher, B., Pincus, H.A., Ren, L., Brent, A. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. Journal of the American Medical Association 2007; 297 (15):1683-96.

Pharmacological treatment of binge eating disorder
Carter, W.P., Hudson, J.I., Lalonde, J.K., Pindyck, L., McElroy, S.L., Pope, H.G. Jr. Pharmacological treatment of binge eating disorder. International Journal of Eating Disorders 2003; 34 Suppl: S74-88.

An open trial of fluoxetine for adolescents with bulimia nervosa
Kotler, L.A., Devlin, M.J., Davies, M., & Walsh, B.T. An open trial of fluoxetine for adolescents with bulimia nervosa. Journal of Child and Adolescent Psychopharmacology 2003; 13 (3): 329–335.

Atomoxetine in the treatment of binge-eating disorder: a randomized placebo-controlled trial
McElroy, S.L., Guerdjikova, A., Kotwal, R., Welge, J.A., Nelson, E.B., Lake, K.A., Keck, P.E., Jr., Hudson, J.I. Atomoxetine in the treatment of binge-eating disorder: a randomized placebo-controlled trial. Journal of Clinical Psychiatry 2007; 68 (3): 390-398.

Topiramate treatment in bulimia nervosa patients: a randomized, double-blind, placebo-controlled trial
Nickel, C., Tritt, K., Muehlbacher, M., Pedrosa, Gil F., Mitterlehner, F.O., Kaplan, P., Lahmann, C., Leiberich, P.K., Krawczyk, J., Kettler, C., Rother, W.K., Lowe, T.H., Nickel, M.K. Topiramate treatment in bulimia nervosa patients: a randomized, double-blind, placebo-controlled trial. International Journal of Eating Disorders 2005; 38 (4):295-300.

Fluoxetine after weight restoration in anorexia nervosa
Walsh, T., Kaplan, A., Attia, E., Olmstead, M., Parides, M., Carter, J., Pike, M., Devlin, M., Woodside, B., Roberto, C., Rockert, W. Fluoxetine after weight restoration in anorexia nervosa. Journal of the American Medical Association 2006; 295 (22): 2605-12.


This page was last updated on October 10, 2007.