Review: Antidepressants increase remission and clinical improvement in bulimia nervosaPDF
ACP J Club. 2002 May-June;136:106. doi:10.7326/ACPJC-2002-136-3-106
Related Content in this Issue
• Companion Abstract and Commentary: Review: Psychological treatment is as effective as antidepressants for bulimia nervosa, but a combination is best
Bacaltchuk J, Hay P. Antidepressants versus placebo for people with bulimia nervosa. Cochrane Database Syst Rev. 2001;(4):CD003931 (latest version 19 Aug 2001). [PubMed ID: 11687198]
In patients with bulimia nervosa (BN), are antidepressants effective for increasing remission and clinical improvement?
Studies were identified by searching MEDLINE; EMBASE/Excerpta Medica; LILACS; PsycLIT; SCISEARCH; the Cochrane Depression, Anxiety, and Neurosis Group Database of Trials; the Cochrane Controlled Trials Register; Clinical Evidence; and reference lists. The International Journal of Eating Disorders was also hand searched, and authors and pharmaceutical companies were contacted.
Studies were selected if they were randomized controlled trials (RCTs) that compared any antidepressant with placebo for ≥ 4 weeks in patients with BN. RCTs were excluded if patients had binge-eating or purging-type anorexia nervosa or binge-eating disorder.
2 reviewers assessed the quality of RCTs and extracted data on patients, study characteristics, drug regimens, and outcomes (including remission [100% reduction in binge or purge episodes], clinical improvement ≥ 50% reduction in binge or purge episodes], and dropouts).
16 RCTs (1300 patients) met the selection criteria. Any antidepressant was better than placebo for increasing remission at a mean follow-up of 8 weeks (8 RCTs) and clinical improvement at a mean follow-up of 9 weeks (8 RCTs) (Table). Groups did not differ for dropout rates (14 RCTs) (Table).
In patients with bulimia nervosa, antidepressants are effective in the short term for increasing remission and clinical improvement rates.
Source of funding: Not stated.
For correspondence: Dr. J. Bacaltchuk, Universidade Federal de São Paulo, São Paulo—SP, Brazil. E-mail firstname.lastname@example.org.
Table. Antidepressants vs placebo for bulimia nervosa at 6 to 16 weeks*
|Outcomes||Antidepressant type||Weighted event rates||RBI (95% CI)||NNT (CI)|
|Remission||All types||20% vs 7.9%||105% (32 to 219)||9 (6 to 16)|
|TCAs||14% vs 9.1%||136% (−4 to 476)||Not significant|
|MAOIs||25% vs 6.3%||229% (−22 to 1289)||Not significant|
|Other antidepressants||15% vs 0%||664% (−1 to 5773)||7 (4 to 27)|
|Clinical improvement||All types||64% vs 33%||84% (38 to 145)||4 (3 to 5)|
|TCAs||77% vs 17%||294% (59 to 872)||2 (2 to 3)|
|SSRIs||58% vs 38%||51% (26 to 81)||5 (4 to 9)|
|Other antidepressants||44% vs 8.2%||321% (74 to 919)||3 (3 to 5)|
|Dropouts||SSRIs||34% vs 40%||18% (1 to 32)||Not significant|
|Other antidepressants||30% vs 32%||6% (−83 to 52)||Not significant|
|All types||34% vs 31%||3% (−20 to 32)||Not significant|
|TCAs||26% vs 11%||93% (15 to 225)||Not significant|
|MAOIs||34% vs 29%||20% (−33 to 113)||Not significant|
*MAOIs = monoamine oxidase inhibitors; SSRIs = selective serotonin reuptake inhibitors; TCAs = tricyclic antidepressants. Other abbreviations defined in Glossary; RBI, RRR, RRI, NNT, NNH, and CI calculated from data in article.
The reviews by Bacaltchuk and colleagues are laudable for the rigor of the data analyses, but they rightly generate more questions than answers. Bacaltchuk and Hay have comprehensively reviewed 16 published RCTs of antidepressant treatments for BN. Although modest effectiveness is shown, high dropout rates among patients limit the clinical application of these data, and the authors comment on the need for more studies of tolerability and cost-effectiveness. The studies included were generally of short duration in young adult women who did not have any substantial psychiatric comorbid conditions. The results therefore cannot be generalized to the substantial minority of bulimic patients with comorbid “multi-impulsive” personality characteristics (1) or substance abuse or to adolescents.
Pharmacologic treatment trials of BN are dominated by the reported reduction in bulimic symptoms, but clinicians and their patients are more interested in remission of symptoms. The emphasis of this review on remission is therefore of greater clinical application than the emphasis of its sources. The review discusses the limitations of outcome measures and is right to conclude that the use of antidepressants as sole therapy “does not seem sufficient to effectively treat these patients.”
Bacaltchuk and colleagues review a scant number of studies comparing combined antidepressant medication and psychotherapy with each treatment alone. In clinical practice, cognitive behavioral therapy (CBT), which is limited by its availability, is generally regarded as the treatment of choice for BN, with antidepressant medication as an adjunct. This review supports that approach by using restricted data from fairly small studies. However, the clinical risk associated with a pharmacologic approach to BN seems to be a higher dropout rate than with CBT, and again, the results cannot necessarily be generalized beyond young adult women who have no substantial comorbid illness.
The U.K. Department of Health’s National Service Framework for Mental Health has stressed the importance of managing such eating disorders as BN in primary care (2), noting that “antidepressants can reduce purging and bingeing whether or not the person is also depressed.” Although this statement is true in the short term, it would seem an optimistic reading of the literature. Prescription of antidepressants may appear to be the easiest route in a primary care setting, but the clinical implication of Bacaltchuk and colleagues’ review is that the easiest route may not be the most effective, cost-effective, or acceptable for clinicians and their patients.
However, in the busy world of primary care, the treatment of BN will continue to be driven by available resources. CBT for BN is generally preferred by the family doctor when specialists with such training are available. But the Royal College of Psychiatrists, in collaboration with the Consumers’ Association, has recently reported the dearth of specialist eating-disorder services beyond southeastern England (3). Thus, in the more likely scenario of limited eating-disorder services, use of antidepressant medication may seem more attractive. These 2 reviews agree with that approach and suggest that antidepressant medication will produce positive short-term results. BN, however, is not a short-term illness. Relapse prevention deserves greater scrutiny for patients with BN and anorexia nervosa, and longer-term follow-up studies should drive the next generation of treatment intervention studies.
Regarding treatment of BN in particular, a pressing need exists for longer-term studies examining relapse rates, health economics, and comparisons of classes of antidepressants for treatment concordance.
John F. Morgan, MD, MA
St. George’s Hospital Medical School, University of London
London, England, UK
3. Eating Disorders in the UK: Policies for Service Development and Training. London: Royal College of Psychiatrists; August 2001. www.rcpsych.ac.uk/publications/cr/council/cr87.pdf.