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The treatment of an eating disorder is never medication alone, but certain antidepressants support the long-term changes that lead to recovery. Here is what you need to know about the most commonly used antidepressants for treating eating disorders.

People who have eating disorders often have to deal with shame and anxiety. They may be in denial about the realities of their disease. They make lack insight and self-awareness of how they came to be in their current state. None of the personal growth that is needed to overcome an eating disorder comes from taking a pill, but antidepressant therapy can sometimes help support changes in the brain that over the long term support changes in attitudes, behaviors, and quality of life. Here are some important facts about antidepressant therapy for the most common eating disorders.

When antidepressant medications help you lose weight, it's not because they magically speed up the rate at which your body burns calories (although there are banned medications like ephedrine and pseudoephedrine that actually do help your body burn calories faster, with significant risk to heart health). When an antidepressant helps you lose weight, it is because it made it easier to stick to your diet.

Antidepressants for anorexia nervosa

Antidepressants aren't generally regarded as particularly helpful in anorexia. They are not first-line treatment for this eating disorder. However, once a patient has recovered weight to 85 percent of normal, then a selective serotonin reuptake inhibitor (SSRI) like Prozac (fluoxetine) may help some patients achieve a stable path to gaining even more weight. It's important that the prescribing physician monitor anorexia patients for signs of potential overdose. Serotonin syndrome, a combination of symptoms that may include intense headaches and manic behavior, is a risk for people with anorexia who take SSRIs.

Antidepressant therapy is never the sole treatment for anorexia. They are only used when the patient is also engaged in psychotherapy, usually cognitive behavioral therapy.

Olanzapine (Zyprexa) is often mentioned with antidepressants for treating anorexia, but olanzapine isn't an antidepressant. Olanzapine is an antipsychotic drug more commonly used in the treatment of schizophrenia. It may be offered to people who live with anorexia when they are in hospital care to help control anxiety, excessive thinking about food ("rumination"), and withdrawal from day to day responsibilities ("failure to engage").

Antidepressants for bulimia nervosa

Unlike anorexia, bulimia is usually treated with antidepressant therapy. When people who are hospitalized for severe bulimia do not respond to talk therapy, they often respond to antidepressant therapy. Antidepressants are especially helpful for bulimics who have issues with anxiety, depression, obsessions, and impulse control. 

Fluoxetine (Prozac) is an FDA-approved medication for treatment of bulimia nervosa. Of all the SSRI antidepressants, it gets the best results with the fewest side effects. Usually bulimia patients are started on a low dose of Prozac, for instance, 20 mg a day, and gradually brought up to a full dose of 80 mg a day if they don't suffer too many side effects. 

There have been clinical trials that have found benefit in other SSRI antidepressants not specifically approved for treating bulimia that may be used off-label to treat people who have bulimia who also have depression. Clinical studies have found benefits in giving bulimics sertraline (Zoloft), fluvoxamine (Luvox), and citalopram (Celexa). The problem with Celexa is that even when it can be used off-label to treat people who have bulimia who are also depressed, the FDA does not permit prescribing more than 40 mg a day, which usually is not enough to make a difference for symptoms of bulimia.

Antidepressants for binge eating disorders

Selective serotonin reuptake inhibitors such as citalopram (Celexa), fluoxetine (Prozac), fluvoxamine (Luvox), and sertraline (Zoloft) usually aren't very helpful for reducing the number of binge eating episodes. Clinical trials find them no more effective than placebo. Worse, clinical studies found that SSRI medications were not any better than a sugar pill for treating depression in people who have binge eating disorder, either. So what does work?

Until about 2010, many doctors got much better results for reducing the frequency of binge eating with a drug called sibutramine (Meridia). The problem with sibutramine is that an unacceptably large number of patients using it developed cardiovascular complications. 

So what works for reducing the number of episodes of binge eating? The general answer is psychotherapy, but the scientific jury is still out on which form of psychotherapy is the most helpful. One study found that cognitive behavioral therapy (CBT) produced greater reductions in the number of binge eating episodes, a lower relapse rate, and greater reductions in hunger than behavioral weight loss treatment (BWL). However, other studies have found that cognitive behavior therapy is no more effective than interpersonal therapy (IPT), and one study even found that simply giving binge eaters a book to read worked just as well as giving binge eaters a book to read plus two sessions a week with a therapist or just sending them to the therapist twice a week. Moreover, cognitive behavioral therapy reduced the number of binge eating sessions but didn't result in greater weight loss. 

Four new drugs, Belviq, Contrave, Qsymia, and Saxenda interrupt or interfere with neurological connections between the digestive tract and the brain that power appetite. All of these drugs are expensive, about $1,000 per month, and Saxenda, which has a slightly different mode of action, is usually not covered by insurance.

What's the bottom line for antidepressants for treating eating disorders?

Antidepressants are never the entire answer for eating disorders. They don't help people make major changes to gain or lose weight. Sometimes antidepressants at least relieve depression, although even that effect is unreliable. But they may be part of feeling better while working through these extremely challenging conditions.

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  • Photo courtesy of SteadyHealth

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