Psychopharmacological advances in eating disorders

Editorial: Biological Therapies and Eating Disorders

OBJECTIVE

Blood-based biomarkers and neuroimaging techniques have improved our understanding of the underlying biology of eating disorders (EDs) and have increased our diagnostic portfolio.

METHOD

This editorial accompanies an article collection on novel biological approaches to treat EDs.

RESULTS

The collection covers intermittent theta burst stimulation, therapeutic drug monitoring, pharmacological treatments (olanzapine, metreleptin, psychedelics, and anti-inflammatory medications), microbiome-based treatments such as pro- and prebiotics, as well as individually tailored treatment approaches for EDs.

DISCUSSION

Research of brain areas and bodily systems that are related to memory, emotions and immune function will hopefully expand the biological treatment options for people with EDs.

Eating- and Weight-Related Disorders in the Armed Forces

BACKGROUND/OBJECTIVES

Like in the general population, the prevalences of eating- and weight-related health issues in the armed forces are increasing. Relevant medical conditions include the eating disorders (EDs) anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant restrictive food intake disorder (ARFID), as well as body dysmorphic disorder, muscle dysmorphia, and the relative energy deficiency in sport (RED-S) syndrome.

METHODS

We performed a narrative literature review on eating- and weight-related disorders in the armed forces.

RESULTS

Entry standards might exclude people with obesity, with EDs, or at high risk for EDs from entering the armed forces for military reasons and to protect the individual's health. Relevant potential risk factors of eating- and weight-related disorders in the military are the emphasis on appearance and fitness in the military, high levels of stress, military sexual trauma, post-traumatic stress disorder, deployment, relocation, long commutes, consumption of ultra-processed foods and beverages, limitations on food selection and physical exercise, and intensive combat training and field exercises. Eating- and weight-related disorders negatively impact professional military appearance and lead to problems with cardiorespiratory and neuromuscular fitness; daytime sleepiness; and a higher risk of musculoskeletal injuries, and other physical and mental health problems. Current and potential future therapeutic options include occupational health measures, psychosocial therapies, neuromodulation, and drug treatments.

CONCLUSIONS

Even though randomized controlled trials (RCTs) have been performed to test treatments for obesity in the armed forces, RCTs for the treatment of EDs, body dysmorphic disorder, muscle dysmorphia, and RED-S syndrome are lacking in the military context.

Olanzapine for young PEople with aNorexia nervosa (OPEN): results of a feasibility study

BACKGROUND

Despite the availability of evidence-based treatments for anorexia nervosa (AN), remission rates are moderate, and mortality is high. Olanzapine is used as adjunct therapy for AN in case of insufficient response to first-line treatments, even though the evidence is limited. Its effect on eating disorder (ED) psychopathology, its efficacy and tolerability, and its acceptability and adherence rate are unclear.

METHODS

We assessed the feasibility of a future definitive trial on olanzapine in young people with AN in an open-label, one-armed feasibility study that aimed to include 55 patients with AN or atypical AN aged 12-24 who gained < 2 kg within at least one month of treatment as usual (TAU) during outpatient, inpatient, or day-care treatment. Time points for assessments were at baseline, 8 weeks, 16 weeks, and 6 or 12 months. We estimated the following planning parameters: Recruitment rate (number of patients who agreed to take olanzapine/number eligible), adherence rate (number adhering to treatment/number recruited) and attrition rate (number completing study assessments/number recruited). In addition, two exploratory effect size parameters were estimated: Mean change in body mass index (BMI) and mean change in ED psychopathology.

RESULTS

Fifty-two people were pre-screened (June 2022 to May 2023; 10 study sites in England). 13 were ineligible at pre-screening . Of the 39  approached, 4 were found ineligible at screening. Of the remaining 35 eligible, 10 declined and 5 did not take part for other reasons. Thus, 20 participants were recruited and started olanzapine (recruitment rate: 20/35 = 57%). 15 out of 20 (75%) continued olanzapine for ≥ 16 weeks, and 13 participants (65%) remained in the trial until follow-up (either 6 or 12 months). Participants experienced, on average, a decrease over time in their Eating Disorder Examination Questionnaire (EDE-Q) Global scores (0.07 per week, N = 20) and an increase in BMI (0.08 kg/m2 per week, N = 20) during treatment with olanzapine plus TAU.

CONCLUSIONS

Possible reasons for the recruitment difficulties and low adherence rate include the high clinical workload of ED services during the COVID-19 pandemic and the reluctance of patients to agree to take olanzapine under the relatively restricted conditions of a clinical study.

TRIAL REGISTRATION

International standard randomised controlled trial register number: ISRCTN80075010. Registration date: 27/04/2022.

Sustained insulin treatment restoring metabolic status, body weight, and cognition in an anorexia nervosa-like animal model in mice

INTRODUCTION

Anorexia Nervosa (AN) is a psycho-socio-biological disease characterized by severe weight loss as result of dieting and hyperactivity. Effective treatments are scarce, despite its significant prevalence and mortality. AN patients show lower basal insulin levels and increased metabolic clearance, leading to weight loss, cognitive deficits, and hormonal imbalances. Low-dose polymer insulin could potentially reverse these effects by restoring brain function, reducing fear of weight gain, encouraging food intake, and restoring fat depots. This study evaluates an insulin delivery system designed for sustained release and AN treatment.

METHODS

AN-like model was established through dietary restriction (DR). On days 1-25, mice were on DR, and on days 26-31 they were on ad libitum regimen. An insulin-loaded delivery system was administered subcutaneously (1% w/w insulin). The impact of insulin treatment on gene expression in the hippocampus (cognition, regulation of stress, neurogenesis) and hypothalamus (eating behavior, mood) was assessed. Behavioral assays were conducted to evaluate motor activity and cognitive function.

RESULTS

The delivery system demonstrated sustained insulin release, maintaining therapeutic plasma levels. Diet restriction mice treated with the insulin delivery system showed body weight restoration. Gene expression analysis revealed enhanced expression of CB1 and CB2 genes associated with improved eating behavior and cognition, while POMC expression was reduced. Insulin-polymer treatment restored cognitive function and decreased hyperactivity in the AN-like model.

CONCLUSION

The PSA-RA-based insulin delivery system effectively restores metabolic balance, body weight, and cognitive function in the AN model. Its ability to steadily release insulin makes it a promising candidate for AN treatment."

Pharmacological Studies in Eating Disorders: A Historical Review

Eating disorders (EDs) are serious mental health conditions characterised by impaired eating behaviours and nutrition as well as disturbed body image, entailing considerable mortality and morbidity. Psychopharmacological medication is an important component in the treatment of EDs. In this review, we performed a historic analysis of pharmacotherapeutic research in EDs based on the scientific studies included in the recently published World Federation of Societies for Biological Psychiatry (WFSBP) guidelines for ED treatment. This analysis focuses on early approaches and trends in the methods of clinical pharmacological research in EDs, for example, the sample sizes of randomised controlled trials (RCTs). We found the development of psychopharmacological treatments for EDs followed advancements in psychiatric pharmacotherapy. However, the application of RCTs to the study of pharmacotherapy for EDs may be an impediment as limited participant numbers and inadequate research funding impede generalisability and statistical power. Moreover, current medication usage often deviates from guideline recommendations. In conclusion, the RCT model may not effectively capture the complexities of ED treatment, and funding limitations hinder research activity. Novel genetically/biologically based treatments are warranted. A more comprehensive understanding of EDs and individualised approaches should guide research and drug development for improved treatment outcomes.

An Update on Eating Disorders

Abstract:

It is no surprise that eating disorders (EDs) are increasing all over the planet. With the emergence of global westernization, development in technology, and societal changes, nearly all regions of the globe have been influenced by the concept of a perfect body image and height. EDs are a considerable public concern, a bewilderment for psychologists and a challenge for physicians. The primary EDs include anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). AN is an ED that is psychological and possibly life-threatening. Usually, people with AN experience an exceedingly low body weight due to their height and body shape. The highest rate of occurrence is between 14 and 17 years of age. BN is an extreme, lifethreatening, neurological ED in which you have binge eating cycles. You may not have any sense of balance in your diet throughout these binges. The weight-control engagement of patients with AN and BN results in various physiological shifts. EDs can control your lives and can be quite hard to cope with. Yet you will develop a better understanding of who you are by therapy, return to healthy eating and exercise, and undo any of the severe complications of AN. Investigation into EDs has yielded valuable new information over the past few decades, notably involving the psychological features and care of patients. The purpose of this study/review is to expand the knowledge of the people about these EDs, their global burden, diagnostic criteria, risk factors, medical complications, management, and the newly added avoidant/restrictive food intake disorder.

Pharmacotherapy, alternative and adjunctive therapies for eating disorders: findings from a rapid review

BACKGROUND

The current review broadly summarises the evidence base for pharmacotherapies and adjunctive and alternative therapies in the treatment of eating disorders and disordered eating.

METHODS

This paper forms part of a Rapid Review series examining the evidence base in the field of eating disorders. This was conducted to inform the Australian National Eating Disorder Research and Translation Strategy 2021-2030. ScienceDirect, PubMed and Ovid/Medline were searched for included studies published between 2009 and 2021 in English. High-level evidence such as meta-analyses, large population studies and randomised control trials were prioritised, and grey literature excluded. Data from included studies relating to pharmacotherapy, and to adjunctive and alternative therapies in eating disorders, were synthesised and disseminated in the current review.

RESULTS

A total of 121 studies were identified, relating to pharmacotherapy (n = 90), adjunctive therapies (n = 21) and alternative therapies (n = 22). Some of the identified studies involved combinations of the above (e.g. adjunctive pharmacotherapy). Evidence of efficacy of interventions across all three categories was very limited with few relevant high quality clinical trials. There was a particular scarcity of evidence around effective treatments for anorexia nervosa (AN). With treatment of bulimia nervosa (BN), fluoxetine has exhibited some efficacy leading to regulatory approval in some countries. With binge eating disorder (BED), recent evidence supports the use of lisdexamfetamine. Neurostimulation interventions show some emerging efficacy in the treatment of AN, BN and BED but some, such as deep brain stimulation can be highly invasive.

CONCLUSION

Despite widespread use of medications, this Rapid Review has identified a lack of effective medications and adjunctive and alternative therapies in the treatment of EDs. An intensification of high-quality clinical trial activity and drug discovery innovation are required to better assist patients suffering from EDs.

The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines

Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a "silo effect," in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive-compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines update 2023 on the pharmacological treatment of eating disorders

OBJECTIVES

This 2023 update of the WFSBP guidelines for the pharmacological treatment of eating disorders (EDs) reflects the latest diagnostic and psychopharmacological progress and the improved WFSBP recommendations for the assessment of the level of evidence (LoE) and the grade of recommendation (GoR).

METHODS

The WFSBP Task Force EDs reviewed the relevant literature and provided a timely grading of the LoE and the GoR.

RESULTS

In anorexia nervosa (AN), only a limited recommendation (LoE: A; GoR: 2) for olanzapine can be given, because the available evidence is restricted to weight gain, and its effect on psychopathology is less clear. In bulimia nervosa (BN), the current literature prompts a recommendation for fluoxetine (LoE: A; GoR: 1) or topiramate (LoE: A; GoR: 1). In binge-eating disorder (BED), lisdexamfetamine (LDX; LoE: A; GoR: 1) or topiramate (LoE: A; GoR: 1) can be recommended. There is only sparse evidence for the drug treatment of avoidant restrictive food intake disorder (ARFID), pica, and rumination disorder (RD).

CONCLUSION

In BN, fluoxetine, and topiramate, and in BED, LDX and topiramate can be recommended. Despite the published evidence, olanzapine and topiramate have not received marketing authorisation for use in EDs from any medicine regulatory agency.

Novel ketamine and zinc treatment for anorexia nervosa and the potential beneficial interactions with the gut microbiome

Anorexia nervosa (AN) is a severe illness with diverse aetiological and maintaining contributors including neurobiological, metabolic, psychological, and social determining factors. In addition to nutritional recovery, multiple psychological and pharmacological therapies and brain-based stimulations have been explored; however, existing treatments have limited efficacy. This paper outlines a neurobiological model of glutamatergic and γ-aminobutyric acid (GABA)-ergic dysfunction, exacerbated by chronic gut microbiome dysbiosis and zinc depletion at a brain and gut level. The gut microbiome is established early in development, and early exposure to stress and adversity contribute to gut microbial disturbance in AN, early dysregulation to glutamatergic and GABAergic networks, interoceptive impairment, and inhibited caloric harvest from food (e.g., zinc malabsorption, competition for zinc ions between gut bacteria and host). Zinc is a key part of glutamatergic and GABAergic networks, and also affects leptin and gut microbial function; systems dysregulated in AN. Low doses of ketamine in conjunction with zinc, could provide an efficacious combination to act on NMDA receptors and normalise glutamatergic, GABAergic and gut function in AN.

The intersection between eating disorders and gastrointestinal disorders: a narrative review and practical guide

Eating disorders include a spectrum of disordered thinking patterns and behaviours around eating. There is increasing recognition of the bi-directional relationship between eating disorders and gastrointestinal disease. Gastrointestinal symptoms and structural issues might arise from eating disorders, and gastrointestinal disease might be a risk factor for eating disorder development. Cross-sectional research suggests that individuals with eating disorders are disproportionately represented among people seeking care for gastrointestinal symptoms, with avoidant-restrictive food intake disorder in particular garnering attention for high rates among individuals with functional gastrointestinal disorders. This Review aims to describe the research to date on the relationship between gastrointestinal disorders and eating disorders, highlight research gaps, and provide brief, practical guidance for the gastroenterology provider in detecting, potentially preventing, and treating gastrointestinal symptoms in eating disorders.

Assessment and management of disorders of gut-brain interaction in patients with eating disorders

Disorders of gut-brain interaction (DBGI), also known as functional gastrointestinal disorders, are common in individuals with eating disorders, and may precede or perpetuate disordered eating. Understanding the pathophysiology of common gastrointestinal symptoms in DGBI can be important for the care of many patients with eating disorders. In this review, we summarize the literature to date on the complex relationship between DBGI and eating disorders and provide guidance on the assessment and management of the most common symptoms of DBGI by anatomic region: esophageal symptoms (globus and functional dysphagia), gastroduodenal symptoms (functional dyspepsia and nausea), and bowel symptoms (abdominal pain, bloating and constipation).

Pharmacotherapy in anorexia nervosa: A Danish nation-wide register-based study

OBJECTIVE

No medications have been indicated for the treatment of anorexia nervosa (AN). Nonetheless, individuals with AN are frequently treated pharmacologically. The present study maps nationwide pharmacotherapy two years before to five years after first AN diagnosis.

METHODS

We identified all medication prescriptions in a national register-based study of patients with a first diagnosis of AN between 1998 and 2011, and age and gender matched controls (1:10). Medication classes were compared using odds ratios (OR) between patients and controls; between patients below and above 15 years; between patients with and without comorbidity; and between those diagnosed before or after 2005.

RESULTS

The odds of pharmacotherapy were increased in patients for all classes of medication except a small residual class. Highest odds were found for alimentary (OR 2.8, p < 0.001) and psychopharmacological (OR 5.5, p < 0.001) medication. The former peaked one year prior to first diagnosis and the latter one year after. Older patients had increased risk of almost all medication classes with cardiovascular medication showing a fivefold OR (p < 0.001). Patients with psychiatric comorbidity had a threefold OR for psychopharmacological medication (p < 0.001) compared to patients without psychiatric comorbidity. Calendar year showed few and small differences.

CONCLUSION

The extended use of all medication classes both prior to and after first diagnosis of AN highlights the severe cause and complexity of AN. The results encourage clinical caution of pharmacotherapy, highlight the need for pharmacotherapy guidelines for AN, and emphasize the urgency of research in pharmacotherapy in AN.

Eating Disorders and Disordered Eating in Competitive Cycling: A Scoping Review

This article reports on the findings from a scoping review on eating disorders and disordered eating in competitive cycling. The review was informed by a scoping review methodological framework as well as the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR) reporting guidelines. PubMed, SPORTDiscus and Web of Science were used to identify relevant literature for review. Fourteen studies met the eligibility criteria and were included in the full review. A narrative synthesis was used to summarise the main findings and themes across the included literature. Findings from the review are presented under the following themes: cycling as an 'at-risk' discipline; power to weight ratio; energy requirements and risk of low energy availability; the social environment of cycling; nutrition support provision; relationship between eating disorders/disordered eating and exercise addiction; and recommendations made in identified literature. Overall, the literature suggests competitive cycling is a sport with a high prevalence of disordered eating and/or eating disorders and a sport with unique risk factors that contribute to this. Crucially, more research is needed in this area. The article concludes with the gaps in the literature highlighted, implications for future research, and applications to policy and practice suggested.

Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span

BACKGROUND

Multiple published sources from around the world have confirmed an association between an array of adverse childhood experiences (ACEs) and other traumatic events with eating disorders (EDs) and related adverse outcomes, including higher morbidity and mortality.

METHODS

In keeping with this Special Issue's goals, this narrative review focuses on the ACEs pyramid and its purported mechanisms through which child maltreatment and other forms of violence toward human beings influence the health and well-being of individuals who develop EDs throughout the life span. Relevant literature on posttraumatic stress disorder (PTSD) is highlighted when applicable.

RESULTS

At every level of the pyramid, it is shown that EDs interact with each of these proclaimed escalating mechanisms in a bidirectional manner that contributes to the predisposition, precipitation and perpetuation of EDs and related medical and psychiatric comorbidities, which then predispose to early death. The levels and their interactions that are discussed include the contribution of generational embodiment (genetics) and historical trauma (epigenetics), social conditions and local context, the ACEs and other traumas themselves, the resultant disrupted neurodevelopment, subsequent social, emotional and cognitive impairment, the adoption of health risk behaviors, and the development of disease, disability and social problems, all resulting in premature mortality by means of fatal complications and/or suicide.

CONCLUSIONS

The implications of these cascading, evolving, and intertwined perspectives have important implications for the assessment and treatment of EDs using trauma-informed care and trauma-focused integrated treatment approaches. This overview offers multiple opportunities at every level for the palliation and prevention of EDs and other associated trauma-related conditions, including PTSD.

Psychiatric medication use by Canadian adults prior to entering an outpatient eating disorders program: Types and combinations of medications, predictors of being on a medication, and clinical considerations

This study examined the proportion of Canadian adults who were on psychiatric medication prior to entering specialized outpatient care for an eating disorder, the types and combinations of medications taken, and predictors of being on a medication. A retrospective chart review of 223 adults with an eating disorder was conducted. A large proportion of the adults (61%) had been prescribed a psychiatric medication prior to entering specialized outpatient care. Of these adults, 74.6% were prescribed one medication and 24.3% were on a combination of two or more. Antidepressant and anti-anxiety medications were the most commonly prescribed (78%), while stimulant medications (2.1%), benzodiazepines (13.7%), and antipsychotics (10.7%) were also reported. Being at a higher weight status was a significant predictor of being on a psychiatric medication at intake assessment. Adults with comorbid depression were 2.68 times more likely to be on a psychiatric medication. Although the number of Canadian adults on psychiatric medication may well exceed the documented efficacy of these medications for eating disorders, psychopharmacological intervention could have been aimed at targeting comorbid conditions. Clinicians specializing in pharmacology and eating disorders may have an important role to provide psychoeducation to all providers.

Headache, eating disorders, PTSD, and comorbidity: implications for assessment and treatment

PURPOSE

Severe headaches (HAs) have been associated with eating disorders (ED) as well as with trauma, posttraumatic stress disorder (PTSD), major depression and anxiety. However, data addressing all of these factors in the same subjects are limited.

METHODS

In a large sample of patients (n = 1461, 93% female) admitted to residential treatment (RT) for an ED, we assessed within 48-72 h of admission subjective reports of frequent HAs and their associations with severity of ED, PTSD, major depressive and state-trait anxiety symptoms, as well as quality of life measures. HA ratings were significantly correlated to the number of lifetime trauma types as well as to symptoms of PTSD, major depression, and state-trait anxiety.

RESULTS

Results indicated that 39% of patients endorsed that frequent HAs occurred "often" or "always" (HA+) in association with their eating or weight issues. This HA-positive (HA+) group had statistically significant higher numbers of lifetime trauma types, higher scores on measures of ED, PTSD, major depressive, and state-trait anxiety symptoms, and worse quality of life measures (p ≤ 0.001) in comparison to the HA-negative (HA-) group, who endorsed that frequent HAs occurred "never," "rarely," or "sometimes" in association with their eating or weight issues. The HA + group also had a significantly higher rate of a provisional PTSD diagnosis (64%) than the HA- group (35%) (p ≤ .001). Following comprehensive RT, HA frequency significantly improved (p ≤ .001).

CONCLUSION

These findings have important implications for the assessment and treatment of HAs in the context of ED, PTSD and related psychiatric comorbidities, especially at higher levels of care. In addition, the importance of identifying traumatic histories and treating comorbid PTSD and related psychopathology in individuals presenting with severe HAs is emphasized.

LEVEL OF EVIDENCE

III Evidence obtained from well-designed cohort or case-control analytic studies.

Music therapy interventions for eating disorders: Lack of robust evidence and recommendations for future research

Music therapy (MT) has been used to support people with a variety of eating disorders (EDs), but it is unclear whether there is sufficient and robust evidence from controlled experimental studies. In this article, we report the results of a systematic review that summarises the evidence from published controlled studies where MT has been used to treat people diagnosed with any type of ED. Our results demonstrate that robust evidence concerning the effectiveness of MT for the treatment of EDs is severely lacking. Nonetheless, the evidence described in this paper warrants further investigation especially given that new treatment strategies for EDs are urgently needed. To this end, we offer a set of recommendations for future high-quality experimental studies that can inform the development of effective MT interventions and support for people with EDs.

Psychopharmacologic Management of Eating Disorders

PURPOSE OF REVIEW

Identifying medications that may be used as therapeutic agents for eating disorders is a longstanding focus of research, with varying degrees of success. The present review consolidates the most recent findings on pharmacological treatment of three eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED).

RECENT FINDINGS

Recent research suggests that olanzapine demonstrates positive effects on weight gain among outpatients with AN. There are fewer recent advances in psychopharmacological treatment for BN and BED, likely due to the relative success of prior medication trials. Olanzapine is the first medication to safely promote weight gain among individuals with AN. Fluoxetine is FDA-approved for BN treatment, and lisdexamfetamine is FDA-approved for BED treatment. BN and BED also generally respond well to SSRIs prescribed off-label. Research on psychopharmacological treatments for other eating disorders, such as avoidant-restrictive food intake disorder and other specified feeding and eating disorders, are sorely needed.

Efficacy and safety of antipsychotics and antidepressants in the treatment of anorexia nervosa: a systematic review

INTRODUCTION

The recommendations of the current guidelines are based on low quality evidence. Periodic updating is required, taking recent evidence into consideration.

OBJECTIVE

To synthesise the best available clinical evidence on the efficacy and safety of second-generation antidepressants and antipsychotics in patients with anorexia nervosa.

METHODS

Systematic review (CRD42020150577). We searched PubMed, SCOPUS, Ovid(Cochrane), EMBASE and LILACS for randomised clinical trials performed in patients with anorexia nervosa that evaluated the use of second-generation antipsychotics or oral antidepressants, at any dose and for any length of time, in outpatient and/or hospital treatment, taking weight (body mass index), psychopathological entities and safety as results.

RESULTS

Five studies were included, with four assessed as having a high risk of bias. The evidence indicates that patients receiving treatment with olanzapine or fluoxetine tend to stay in treatment programmes for longer. Olanzapine showed favourable results (one study) in terms of weight gain, but did not show the same results in psychopathology, where the evidence is contradictory.

CONCLUSIONS

In accordance with previous reviews, our work allows us to conclude that there is contradictory information on the efficacy of psychotropic drugs in the treatment of anorexia nervosa. Future work should focus on developing clinical trials of high methodological quality.

Management of anorexia nervosa in pregnancy: a systematic and state-of-the-art review

Anorexia nervosa is a potentially severe, chronic, and relapsing mental disorder that is more common in women and girls during the reproductive years (usually defined as those aged 12-51 years). It is associated with suicide and mortality linked with the physical consequences of starvation. Although anorexia nervosa is a disorder of low prevalence, and even lower prevalence in pregnancy, it is associated with substantial risks for the mother and infant when under-recognised and undermanaged. Despite the complexity and risk of managing anorexia nervosa in pregnancy, few studies are available to guide care. We conducted a systematic review, identifying only eight studies that addressed the management of anorexia nervosa in pregnancy. These studies were case studies or case reports examining narrow aspects of management. Subsequently, we conducted a state-of-the-art review across research in relevant disciplines and areas of expertise for managing anorexia nervosa in pregnancy and synthesised the findings into recommendations and principles for multidisciplinary management of anorexia nervosa in pregnancy. These recommendations included a focus on the specialist mental health, obstetric, medical, and nutritional care required to ensure optimal outcomes for women and their infants. Despite the complexity and risks, a gap exists in the comprehensive guidelines and recommendations for managing anorexia nervosa in pregnancy. This Review provides multidisciplinary recommendations for clinical care in this area. Managing anorexia nervosa in pregnancy is an area of clinical care that requires a multidisciplinary approach and includes those experienced in managing high-risk pregnancies.

Novel Approaches to Tackling Emotional Loss of Control of Eating Across the Weight Spectrum

Emotional overeating is a process that is particularly relevant to people within the binge spectrum of eating disorders. Approximately a third of people with overweight share this phenotype. In addition, this behaviour may occur in neurodevelopmental disorders (attention-deficit hyperactivity disorder (ADHD)) and other psychiatric disorders. The biopsychosocial underpinnings of emotional eating include a genetic vulnerability to a higher weight and various cognitive and emotional traits. The environment also plays a key role. For example, the commodification of food and beauty and exposure to weight stigma, unpleasant eating experiences and general adversity can set the scene. The majority of people with binge-eating disorder do not seek treatment (perhaps related to internalised stigma and shame). Hence opportunities for early intervention and secondary prevention are lost. Most guidelines for binge-eating disorder (based on the limited available research) recommend forms of cognitive psychotherapies and antidepressants. However, novel treatments that target underlying mechanisms are in development. These include interventions to improve emotional regulation and inhibitory control using neuromodulation and/or brain training. New technologies have been applied to talking therapies, including apps which can offer ‘just-in-time interventions’ or virtual reality or avatar work which can deliver more personalised interventions using complex scenarios. Drugs used for the treatment of ADHD, psychiatric and metabolic disorders may have the potential to be repurposed for binge-eating disorder. Thus, this is an area of rapid change with novel solutions being applied to this problem.

Insulin normalized brain metabolic status on a Model of Anorexia Nervosa in Mice

INTRODUCTION

Anorexia nervosa is a psycho-socio-biological disease, characterized by self-starvation and distorted perception of body weight. Patients often over-exercise. Insulin is an anabolic hormone that increases food intake and restores body fat and is present in low levels in anorexia nervosa patients: thus may have therapeutic potential in treating anorexia nervosa.

AIMS

to explore whether low levels insulin administration may result in recovery of cerebral function and restoration of metabolic disorder providing a treatment option for anorexia nervosa.

METHODS

Female Sabra mice maintained on DR of 2.0 hours per day for 32 days, in cages with or without wheel attached to an electronic counter (activity wheel). They were then permitted to eat ad libitum for additional 15 days. On the second week, mice were injected ip with 0.5U/kg long acting Insulin(Lantus) or saline and cognitive function was evaluated. Insulin administered three times a week during days 8-32. Mice euthanized on day 48 and cerebral levels of monoamines, 2-AG and expression of genes associated with metabolic status were evaluated.

RESULTS

Activity wheel mice decreased body weight, 2-AG, dopamine levels and 5-HT1A and increased Camkk2 and SIRT1 gene expression compared to mice without it. Insulin increased body weight, decreased revolutions, enhanced NPY and normalized Camkk2, SIRT-1, BDNF, elevated 2-AG and improved cognition in the wheel group.

CONCLUSION

low dose insulin administration to animal model of anorexia associated with exercise, led to alterations and normalization in brain metabolic status and improved cognition. Insulin should be further explored as potential novel treatment for anorexia nervosa.

Change of hypothalamic adult neurogenesis in mice by chronic treatment of fluoxetine

OBJECTIVE

More than half of patients with depression display eating disorders, such as bulimia nervosa and anorexia nervosa. Feeding centers are located in the hypothalamus, and hypothalamic adult neurogenesis has an important role in feeding and energy balance. Antidepressants, which can regulate adult neurogenesis in the hippocampus, olfactory bulb, and neocortex, are used for eating disorders, but it is unclear whether antidepressants change hypothalamic adult neurogenesis. In this study, we used immunohistological analysis to assess effects of the antidepressant fluoxetine (FLX) on hypothalamic adult neurogenesis of adult mice.

RESULTS

Expressions of the proliferating cell marker, Ki67, and the neural stem cell marker, nestin, were significantly decreased in the hypothalamus by FLX. As regard to postmitotic cells, the number of the neural marker, NeuN, positive cells was significantly upregulated by FLX, but that of the astrocytic marker, S100B, positive cells was significantly reduced by FLX. The number of the oligodendrocyte marker, Olig2, positive cells was not changed by FLX. Interestingly, FLX treatment did not affect the total number of newly generated cells in the hypothalamus, comparing that in controls. These results suggest that FLX treatment influence hypothalamic adult neurogenesis and shift the balance between the numbers of neurons and astrocytes under studied conditions.

The Microbiota/Microbiome and the Gut-Brain Axis: How Much Do They Matter in Psychiatry?

The functioning of the central nervous system (CNS) is the result of the constant integration of bidirectional messages between the brain and peripheral organs, together with their connections with the environment. Despite the anatomical separation, gut microbiota, i.e., the microorganisms colonising the gastrointestinal tract, is highly related to the CNS through the so-called "gut-brain axis". The aim of this paper was to review and comment on the current literature on the role of the intestinal microbiota and the gut-brain axis in some common neuropsychiatric conditions. The recent literature indicates that the gut microbiota may affect brain functions through endocrine and metabolic pathways, antibody production and the enteric network while supporting its possible role in the onset and maintenance of several neuropsychiatric disorders, neurodevelopment and neurodegenerative disorders. Alterations in the gut microbiota composition were observed in mood disorders and autism spectrum disorders and, apparently to a lesser extent, even in obsessive-compulsive disorder (OCD) and related conditions, as well as in schizophrenia. Therefore, gut microbiota might represent an interesting field of research for a better understanding of the pathophysiology of common neuropsychiatric disorders and possibly as a target for the development of innovative treatments that some authors have already labelled "psychobiotics".

Therapeutic Potentials of Ketamine and Esketamine in Obsessive-Compulsive Disorder (OCD), Substance Use Disorders (SUD) and Eating Disorders (ED): A Review of the Current Literature

The obsessive-compulsive spectrum refers to disorders drawn from several diagnostic categories that share core features related to obsessive-compulsive disorder (OCD), such as obsessive thoughts, compulsive behaviors and anxiety. Disorders that include these features can be grouped according to the focus of the symptoms, e.g., bodily preoccupation (i.e., eating disorders, ED) or impulse control (i.e., substance use disorders, SUD), and they exhibit intriguing similarities in phenomenology, etiology, pathophysiology, patient characteristics and clinical outcomes. The non-competitive N-methyl-D-aspartate receptor (NMDAr) antagonist ketamine has been indicated to produce remarkable results in patients with treatment-resistant depression, post-traumatic stress disorder and OCD in dozens of small studies accrued over the past decade, and it appears to be promising in the treatment of SUD and ED. However, despite many small studies, solid evidence for the benefits of its use in the treatment of OCD spectrum and addiction is still lacking. Thus, the aim of this perspective article is to examine the potential for ketamine and esketamine in treating OCD, ED and SUD, which all involve recurring and intrusive thoughts and generate associated compulsive behavior. A comprehensive and updated overview of the literature regarding the pharmacological mechanisms of action of both ketamine and esketamine, as well as their therapeutic advantages over current treatments, are provided in this paper. An electronic search was performed, including all papers published up to April 2021, using the following keywords ("ketamine" or "esketamine") AND ("obsessive" OR "compulsive" OR "OCD" OR "SUD" OR "substance use disorder" OR "addiction" OR "craving" OR "eating" OR "anorexia") NOT review NOT animal NOT "in vitro", on the PubMed, Cochrane Library and Web of Science online databases. The review was conducted in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The use and efficacy of ketamine in SUD, ED and OCD is supported by glutamatergic neurotransmission dysregulation, which plays an important role in these conditions. Ketamine's use is increasing, and preliminary data are optimistic. Further studies are needed in order to better clarify the many unknowns related to the use of both ketamine and esketamine in SUD, ED and OCD, and to understand their long-term effectiveness.

Possible use of fermented foods in rehabilitation of anorexia nervosa: the gut microbiota as a modulator

Anorexia nervosa is a serious psychiatric disorder with high morbidity and mortality rate. Evidence for the optimal psychopharmacological approach to managing the disorder remains limited, with nutritional treatment, focused on weight restoration through the consumption of high energy diet, regarded as one of the fundamental steps in treatment. The human gut microbiome is increasingly recognised for its proposed role in gastrointestinal, metabolic, immune and mental health, all of which may be compromised in individuals with anorexia nervosa. Dietary intake plays an important role in shaping gut microbiota composition, whilst the use of fermented foods, foods with potential psychobiotic properties that deliver live bacteria, bacterial metabolites, prebiotics and energy, have been discussed to a lesser extent. However, fermented foods are of increasing interest due to their potential capacity to affect gut microbiota composition, provide beneficial bacterial metabolites, and confer beneficial outcomes to host health. This review provides an overview of the role of the gut microbiota in relation to the disease pathology in anorexia nervosa and especially focuses on the therapeutic potential of fermented foods, proposed here as a recommended addition to the current nutritional treatment protocols warranting further investigation.

Efficacy and Safety of Antipsychotics and Antidepressants in the Treatment of Anorexia Nervosa: a Systematic Review

INTRODUCTION

The recommendations of the current guidelines are based on low quality evidence. Periodic updating is required, taking recent evidence into consideration.

OBJECTIVE

To synthesise the best available clinical evidence on the efficacy and safety of second-generation antidepressants and antipsychotics in patients with anorexia nervosa.

METHODS

Systematic review (CRD42020150577). We searched PubMed, SCOPUS, Ovid(Cochrane), EMBASE and LILACS for randomised clinical trials performed in patients with anorexia nervosa that evaluated the use of second-generation antipsychotics or oral antidepressants, at any dose and for any length of time, in outpatient and/or hospital treatment, taking weight (body mass index), psychopathological entities and safety as results.

RESULTS

Five studies were included, with four assessed as having a high risk of bias. The evidence indicates that patients receiving treatment with olanzapine or fluoxetine tend to stay in treatment programmes for longer. Olanzapine showed favourable results (one study) in terms of weight gain, but did not show the same results in psychopathology, where the evidence is contradictory.

CONCLUSIONS

In accordance with previous reviews, our work allows us to conclude that there is contradictory information on the efficacy of psychotropic drugs in the treatment of anorexia nervosa. Future work should focus on developing clinical trials of high methodological quality.

Descriptions of Disordered Eating in German Psychiatric Textbooks, 1803-2017

The most common eating disorders (EDs) according to DSM-5 are anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED). These disorders have received increasing attention in psychiatry due to rising prevalence and high morbidity and mortality. The diagnostic category "anorexia nervosa," introduced by Ernest-Charles Lasègue and William Gull in 1873, first appears a century later in a German textbook of psychiatry, authored by Gerd Huber in 1974. However, disordered eating behavior has been described and discussed in German psychiatric textbooks throughout the past 200 years. We reviewed content regarding eating disorder diagnoses but also descriptions of disordered eating behavior in general. As material, we carefully selected eighteen German-language textbooks of psychiatry across the period 1803-2017. Previously, in German psychiatry, disordered eating behaviors were seen as symptoms of depressive disorders, bipolar disorder or schizophrenia, or as manifestations of historical diagnoses no longer used by the majority of psychiatrists such as neurasthenia, hypochondria and hysteria. Interestingly, 19th and early 20th century psychiatrists like Kraepelin, Bumke, Hoff, Bleuler, and Jaspers reported symptom clusters such as food refusal and vomiting under these outdated diagnostic categories, whereas nowadays they are listed as core criteria for specific eating disorder subtypes. A wide range of medical conditions such as endocrinopathies, intestinal or brain lesions were also cited as causes of abnormal food intake and body weight. An additional consideration in the delayed adoption of eating disorder diagnoses in German psychiatry is that people with EDs are commonly treated in the specialty discipline of psychosomatic medicine, introduced in Germany after World War II, rather than in psychiatry. Viewed from today's perspective, the classification of disorders associated with disordered eating is continuously evolving. Major depressive disorder, schizophrenia and physical diseases have been enduringly associated with abnormal eating behavior and are listed as important differential diagnoses of EDs in DSM-5. Moreover, there are overlaps regarding the neurobiological basis and psychological and psychopharmacological therapies applied to all of these disorders.

Medical management of eating disorders: an update

PURPOSE OF REVIEW

Eating disorders are associated with numerous medical complications. The aim of this study was to review recent progress in improving the medical management of patients with eating disorders.

RECENT FINDINGS

With close medical monitoring and electrolyte supplementation, accelerated refeeding protocols improve weight restoration without increasing the risk of refeeding syndrome. Olanzapine improves weight restoration better than placebo, without leading to adverse metabolic effects seen in individuals not in starvation. Alterations of the gut microbiome in anorexia nervosa have been demonstrated, but their clinical relevance remains unclear.

SUMMARY

Medical complications of eating disorders may facilitate the first contact with health professionals and treatment initiation. Medical complications of anorexia nervosa generally occur due to starvation, malnutrition and their associated physiological effects, whereas medical complications of bulimia nervosa are generally due to purging behaviors. Most medical complications in patients with binge eating disorder are secondary to obesity. Most medical complications of eating disorders can be effectively treated with nutritional management, weight normalization and the termination of purging behaviors. In summary, eating disorders are associated with many medical complications that have to be carefully assessed and managed as early as possible to improve long-term outcomes.

Reduced Environmental Stimulation in Anorexia Nervosa: An Early-Phase Clinical Trial

Reduced Environmental Stimulation Therapy (REST) alters the balance of sensory input to the nervous system by systematically attenuating sensory signals from visual, auditory, thermal, tactile, vestibular, and proprioceptive channels. Previous research from our group has shown that REST via floatation acutely reduces anxiety and blood pressure (BP) while simultaneously heightening interoceptive awareness in clinically anxious populations. Anorexia nervosa (AN) is an eating disorder characterized by elevated anxiety, distorted body representation, and abnormal interoception, raising the question of whether REST might positively impact these symptoms. However, this approach has never been studied in eating disorders, and it is unknown whether exposure to floatation REST might worsen AN symptoms. To examine these possibilities, we conducted an open-label study to investigate the safety and tolerability of REST in AN. We also explored the acute impact of REST on BP, affective symptoms, body image disturbance, and interoception. Twenty-one partially weight-restored AN outpatients completed a protocol involving four sequential sessions of REST: reclining in a zero-gravity chair, floating in an open pool, and two sessions of floating in an enclosed pool. All sessions were 90 min, approximately 1 week apart. We measured orthostatic BP before and immediately after each session (primary outcome), in addition to collecting BP readings every 10 min during the session using a wireless waterproof system as a secondary outcome measure. Each participant's affective state, awareness of interoceptive sensations, and body image were assessed before and after every session (exploratory outcomes). There was no evidence of orthostatic hypotension following floating, and no adverse events (primary outcome). Secondary analyses revealed that REST induced statistically significant reductions in BP (p < 0.001; Cohen's d, 0.2-0.5), anxiety (p < 0.001; Cohen's d, >1) and negative affect (p < 0.01; Cohen's d, >0.5), heightened awareness of cardiorespiratory (p < 0.01; Cohen's d, 0.2-0.5) but not gastrointestinal sensations, and reduced body image dissatisfaction (p < 0.001; Cohen's d, >0.5). The findings from this initial trial suggest that individuals with AN can safely tolerate the physical effects of REST via floatation. Future randomized controlled trials will need to investigate whether these initial observations of improved anxiety, interoception, and body image disturbance occur in acutely ill AN populations.

Clinical Trial Registration

ClinicalTrials.gov; Identifier: NCT02801084 (April 01, 2016).

Effects of IL-6 Signaling Pathway Inhibition on Weight and BMI: A Systematic Review and Meta-Analysis

Inhibitors of the IL-6 signaling pathway, such as tocilizumab, are frequently administered for the treatment of immune diseases, e.g., rheumatoid arthritis and multicentric Castleman's disease. The aim of this systematic review and meta-analysis was to ascertain the effects of IL-6 pathway inhibitors on weight and body mass index (BMI). Using PRISMA guidelines, we systematically reviewed relevant articles from three databases (PubMed, OVID, EMBASE). A random effects model was used to estimate standardized mean change (SMCC). Ten studies with a total of 1531 patients were included in the meta-analysis for weight and ten studies with a total of 1537 patients were included in the BMI meta-analysis. The most commonly administered IL-6 pathway inhibitor was tocilizumab. IL-6 pathway inhibitors were associated with increases in weight (SMCC = 0.09, p = 0.016, 95% CI [0.03, 0.14]) and BMI (SMCC = 0.10, p = 0.0001, 95% CI [0.05, 0.15]). These findings suggest that the IL-6 pathway is involved in weight regulation. Modulating IL-6 signaling may be a potential future therapeutic avenue used as an adjunct for the treatment of disorders associated with weight changes, such as cancer cachexia and anorexia nervosa.

Pharmacological treatment of eating disorders, comorbid mental health problems, malnutrition and physical health consequences

The pharmacological treatment of patients with an eating disorder (ED) often includes medications to treat their ED, comorbid mental health problems, malnutrition and the physical health problems resulting from it. The currently approved pharmacological treatment options for EDs are limited to fluoxetine for bulimia nervosa (BN) and - in some countries - lisdexamfetamine for binge eating disorder (BED). Thus, there are no approved pharmacological options for anorexia nervosa (AN), even though study results for olanzapine and dronabinol are promising. Topiramate might be an additional future option for the treatment of BN and BED. Selective serotonin reuptake inhibitors (SSRI), mirtazapine and bupropion could be considered for the treatment of comorbid unipolar depression. However, AN and BN are contraindications for bupropion. For ED patients with a manic episode, we recommend olanzapine in AN and risperidone in BN and BED; whereas for bipolar depression, olanzapine (plus fluoxetine) seems appropriate in AN and lamotrigine in BN and BED. Acute anxiety or suicidality may warrant benzodiazepine treatment with lorazepam. Proton-pump inhibitors, gastroprokinetic drugs, laxatives and hormones can alleviate certain physical health problems caused by EDs. Therapeutic drug monitoring, pharmacogenomic testing, a more restrictive use of "pro re nata" (PRN) medication, an interdisciplinary treatment approach, shared decision making (SDM) and the formulation of common treatment goals by the patients, their family or carers and clinicians could improve treatment success and safety. Novel genetic, immunological, microbiome and brain imaging research as well as new pharmacological developments like the use of psychedelics, stimulants, novel monoaminergic drugs, hormone analogues and drugs which enhance the effects of psychotherapy may extend our therapeutic options in the near future.

Severe and enduring anorexia nervosa: Update and observations about the current clinical reality

Several objectives underlie the current article. First, to review historical diagnostic issues and clinical strategies for treating SE-AN. Second, to provide an overview of recent evidence informed strategies and clinical innovations for the treatment of SE-AN. Third, based on the authors' collective clinical and research experience, we offer eight observations that we believe capture the current clinical experience of patients with SE-AN. Some of these observations represent empirically testable hypotheses, but all are designed to generate a meaningful discussion about the treatment of this group of individuals with eating disorders. Finally, we hope to call clinicians, scientists, professional organizations, advocates, and policy makers to action to attend to critical issues related to the care of individuals with SE-AN. We believe that an international discussion could clarify areas of need for these patients and identify opportunities for clinical innovation that would enhance the lives of individuals with SE-AN and their families.

Impact of TNF-α Inhibitors on Body Weight and BMI: A Systematic Review and Meta-Analysis

Objective

The aim of this systematic review and meta-analysis of longitudinal studies was to ascertain to effects of TNF-α inhibitor therapy on body weight and BMI.

Methods

Three databases (PubMed, OVID, and EMBASE) were systematically searched from inception to August 2018. We identified prospective, retrospective, and randomized controlled studies in adults with immune-mediated inflammatory diseases treated with TNF-α inhibitors based on pre-specified inclusion criteria. A random-effects model was used to estimate standardised mean change (SMCC).

Results

Twenty-six longitudinal studies with a total of 1,245 participants were included in the meta-analysis. We found evidence for a small increase in body weight (SMCC = 0.24, p = .0006, 95% CI [0.10, 0.37]) and in BMI (SMCC = 0.26, p < .0001, 95% CI [0.13, 0.39]). On average, patients gained 0.90kg (SD = 5.13) under infliximab, 2.34kg (D = 5.65) under etanercept and 2.27kg (SD = 4.69) during treatment with adalimumab within the duration of the respective studies (4–104 weeks).

Conclusion

Our results yield further support the for the view that TNF-α inhibitors increase body weight and BMI as a potential side effect. Modulating cytokine signaling could be a future therapeutic mechanism to treat disorders associated with weight changes such as anorexia nervosa.

Cognitive Interpersonal Model for Anorexia Nervosa Revisited: The Perpetuating Factors that Contribute to the Development of the Severe and Enduring Illness

The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.

Polaprezinc (Zinc-L-Carnosine Complex) as an Add-on Therapy for Binge Eating Disorder and Bulimia Nervosa, and the Possible Involvement of Zinc Deficiency in These Conditions: A Pilot Study

BACKGROUND

Zinc plays an important role in appetite regulation. L-Carnosine, an endogenous dipeptide, may also regulate eating behavior via its histaminergic and antiglutamatergic properties. Polaprezinc (zinc-L-carnosine complex) is a medication for gastric ulcers. A small case series reported successful treatment of binge eating with add-on polaprezinc.

METHODS

This was an open trial of add-on polaprezinc in patients with binge eating disorder (BED; n = 22) or bulimia nervosa (BN; n = 7) receiving antidepressants. A 4-week baseline period was followed by a 16-week polaprezinc treatment at 150 mg/d (containing 34 mg zinc and 116 mg L-carnosine) in addition to ongoing psychotropic medications. We also assessed their zinc status via a laboratory index and zinc deficiency-related symptoms.

RESULTS

At the study end, both conditions showed a significant reduction in the 4-week frequency of combined objective and subjective binge eating episodes, the 4-week frequency of days when at least 1 such episode occurred (only in BED), several aspects of eating disorder psychopathology (rated by the Eating Disorder Examination-Questionnaire), and comorbid depressive symptoms (rated by the 16-item Quick Inventory of Depressive Symptomatology [Self-Report]). Serum copper/zinc ratio decreased from 1.4 to 1.1 on average in both conditions. All patients had multiple zinc deficiency-related symptoms at baseline that substantially improved after polaprezinc treatment. Overall, the effectiveness of polaprezinc was greater in BED patients than in BN patients, with minor adverse effects.

CONCLUSIONS

These findings offer preliminary evidence for the effectiveness of polaprezinc in treating BED and BN and suggest the involvement of zinc deficiency in these conditions.

Eating disorder animal model

PURPOSE OF REVIEW

The aim of this review is to describe animal models that simulate the features of eating disorders. The literature pertaining to animal models that are of relevance for clinical eating disorders and the possible underpinning mechanisms was reviewed using PubMed, Ovid database and Google Scholar.

RECENT FINDINGS

New refinements of the circuits regulated by neurotransmitters and neuropeptides which instigate eating behaviours and the various feedback pathways which monitor acute and chronic nutrient status continue to be discovered. Moreover, work with the animal models that simulate the behavioural features and risk factors related to eating disorders is flourishing and providing new insights into possible causal mechanisms. For example, rodents develop binge-eating behaviours if they are intermittently exposed to processed, palatable foods and/or sugar adulterated drinks. This led to the controversial conceptualization of binge eating as a form of food addiction. Self-starvation taken to a fatal consequence such as occurs in anorexia nervosa can emerge in rodents exposed to triggers like social exclusion and/or the opportunity to exercise.

SUMMARY

There are plausible animal models for both anorexia nervosa and binge-eating disorders. These can be used to elaborate the theoretical models to explain the mechanisms underpinning eating disorders.

Fish as models for understanding the vertebrate endocrine regulation of feeding and weight

The frequencies of eating disorders and obesity have increased worldwide in recent years. Their pathophysiologies are still unclear, but recent evidence suggests that they might be related to changes in endocrine and neural factors that regulate feeding and energy homeostasis. In order to develop efficient therapeutic drugs, a more thorough knowledge of the neuronal circuits and mechanisms involved is needed. Although to date, rodents have mostly been used models in the area of neuroscience and neuroendocrinology, an increasing number of studies use non-mammalian vertebrates, in particular fish, as model systems. Fish present several advantages over mammalian models and they share genetic and physiological homology to mammals with close similarities in the mechanisms involved in the neural and endocrine regulation of appetite. This review briefly describes the regulation of feeding in two model species, goldfish and zebrafish, how this regulation compares to that in mammals, and how these fish could be used for studies on endocrine regulation of eating and weight and its dysregulations.

Off-label uses of drugs for depression

The prescription of drugs for depression is rising rapidly. One of the reasons for this trend is their many off-label uses. Up to one third of all prescriptions are for non-indicated use, which in addition to drug repurposing includes different dosing or duration than those recommended. In this review, we elaborate on what antidepressants can treat besides depression. The five classes of drugs for depression are introduced, and their mechanisms of action and serious side effects are described. The most common off-label uses of antidepressants are discussed, with a special focus on treating eating disorders, sleep problems, smoking cessation and managing chronic pain. Depression is often a comorbidity when antidepressants are chosen as therapy, but good therapeutic effects have been observed for other conditions also when depression is not involved. Finally, a new type of antidepressant developed from the hallucinogenic "party drug" ketamine is briefly introduced. This recent development suggests that antidepressants will keep playing a central role in medicine for years to come.

Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults

Attention deficit with or without hyperactivity disorder (ADHD) is one of the most frequent neuropsychiatric disorders, and affects 2-4% of adults. In contrast with many European countries, the identification and management of adult ADHD remains underdeveloped in France, and a subject of controversy. This review provides a practical update on current knowledge about ADHD in adults for French-speaking professionals who have to detect or manage adult patients with ADHD. ADHD is classified as a neurodevelopmental disorder in the recent update of the international diagnostic classification. While symptoms and impairment due to ADHD are frequently severe during childhood, they often evolve as children grow older, with frequent persistent disabilities in adulthood. In adulthood, the clinical presentation, as in childhood, involves the symptom triad of inattention, hyperactivity and impulsivity. However, differences are noted: hyperactivity is more often internalized, symptoms of inattention may be masked by anxiety symptoms or obsessive-like compensation strategies. ADHD is often diagnosed during childhood, but it is not rare for the diagnosis to be made later. Failure to recognise symptoms resulting in misdiagnosis, or alternatively well-developed compensation factors could be two underlying reasons for the long delay until diagnosis. Other symptoms, such as emotional deregulation or executive function-related symptoms are also usually observed in adults. In addition, in adults, ADHD is often associated with other psychiatric disorders (in 80% of cases); this makes the diagnosis even more difficult. These disorders encompass a broad spectrum, from mood disorders (unipolar or bipolar), to anxiety disorders, and other neurodevelopmental disorders and personality disorders, especially borderline and antisocial personality disorder. Substance-use disorders are very common, either as a consequence of impulsivity and emotional dysregulation or as an attempt at self-treatment. Sleep disorders, especially restless leg syndrome and hypersomnolence, could share common pathophysiological mechanisms with ADHD. ADHD and comorbidity-related symptoms are responsible for serious functional impairment, in various domains, leading to academic, social, vocational, and familial consequences. The impact on other psychiatric disorders as an aggravating factor should also be considered. The considerable disability and the poorer quality of life among adults with ADHD warrant optimal evaluation and management. The diagnostic procedure for ADHD among adults should be systematic. Once the positive diagnosis is made, the evaluation enables characterisation of the levels of severity and impairment at individual level. A full examination should also assess medical conditions associated with ADHD, to provide personalized care. In recent years, a growing number of assessment tools have been translated and validated in French providing a wide range of structured interviews and standardized self-report questionnaires for the evaluation of core and associated ADHD symptoms, comorbidities and functional impairment. The treatment of ADHD in adults is multimodal, and aims to relieve the symptoms, limit the burden of the disease, and manage comorbidities. The most relevant and validated psychological approaches are psycho-education, cognitive-behavioural therapy and "third wave therapies" with a specific focus on emotional regulation. Cognitive remediation and neurofeedback are promising strategies still under evaluation. Medications, especially psychostimulants, are effective for alleviating ADHD symptoms with a large effect size. Their safety and tolerance are satisfactory, although their long-term clinical benefit is still under discussion. In France, methylphenidate is the only stimulant available for the treatment of ADHD. Unfortunately, there is no authorization for its use among adults except in continuation after adolescence. Hence the prescription, which is subject to the regulations on narcotics, is off-label in France. This article aims to provide practical considerations for the management of ADHD and associated disorders in adults, in this particular French context.

Stationäre Behandlung von Kindern und Jugendlichen mit Anorexia nervosa und Bulimia nervosa

Zusammenfassung. Anorexia nervosa und Bulimia nervosa betreffen vor allem Jugendliche sowie junge Erwachsene, wobei das Ersterkrankungsalter sinkt, und bei Anorexia nervosa bereits 8-Jährige betroffen sein können. Häufig ist der Verlauf chronisch und kann sowohl schwere körperliche als auch psychische Komorbiditäten nach sich ziehen. Schlimmstenfalls enden Essstörungen tödlich (je nach Schweregrad der Erkrankung Mortalitätsraten bis zu 15 % bei Anorexia nervosa). Ein frühzeitiger Therapiebeginn geht mit einer verbesserten Prognose einher, weshalb die rasche Diagnosestellung von großer Bedeutung ist. Wesentlich hierfür ist die sichere Kenntnis der Diagnosekriterien sowie der essstörungstypischen Folgen. Es werden Aspekte der Symptomatik, Diagnostik, Differentialdiagnostik, Epidemiologie, Pathogenese, Funktionalität, sowie Therapiemöglichkeiten und eigene sowie internationale Studienergebnisse mit Schwerpunkt auf der stationären Therapie von Jugendlichen mit Anorexia nervosa und Bulimia nervosa ausgeführt.

Facets of shared decision-making on drug treatment for adults with an eating disorder

Shared decision-making (SDM) means that clinicians and the patient make decisions about the treatment together. Regarding drug treatment in eating disorders (EDs), such decisions may include psychopharmacological treatment for the ED itself, medications for potential co-morbid psychiatric disorders, pharmacological strategies to alleviate the health consequences of an ED, or 'pro re nata' (PRN) medication which is given in acute care when required. Decisions regarding drug treatment in EDs should be specific in terms of the active pharmacological substance, its dose, its route of administration, and the duration of treatment. Decisions should be made with regard to the specific health risks of patients with EDs and the entire treatment approach, and should take alternative measures, additional therapies, and specific combinations of therapies into account. The differences in the expectations of patients, carers, and clinicians towards drug treatment, the lack of specific suggestions in clinical practice guidelines, and the lack of approved psychopharmacological treatment options make SDM necessary, but also a challenge. However, SDM may be limited due to the patient's impaired insight or limited capacity due to the ED. Thus, the legal framework must be taken into consideration.

Epigenetics in eating disorders: a systematic review

Eating disorders are complex heritable conditions influenced by both genetic and environmental factors. Given the progress of genomic discovery in anorexia nervosa, with the identification of the first genome-wide significant locus, as well as animated discussion of epigenetic mechanisms in linking environmental factors with disease onset, our goal was to conduct a systematic review of the current body of evidence on epigenetic factors in eating disorders to inform future directions in this area. Following PRISMA guidelines, two independent authors conducted a search within PubMed and Web of Science and identified 18 journal articles and conference abstracts addressing anorexia nervosa (n = 13), bulimia nervosa (n = 6), and binge-eating disorder (n = 1), published between January 2003 and October 2017. We reviewed all articles and included a critical discussion of field-specific methodological considerations. The majority of epigenetic analyses of eating disorders investigated methylation at candidate genes (n = 13), focusing on anorexia and bulimia nervosa in very small samples with considerable sample overlap across published studies. Three studies used microarray-based technologies to examine DNA methylation across the genome of anorexia nervosa and binge-eating disorder patients. Overall, results were inconclusive and were primarily exploratory in nature. The field of epigenetics in eating disorders remains in its infancy. We encourage the scientific community to apply methodologically sound approaches using genome-wide designs including epigenome-wide association studies (EWAS), to increase sample sizes, and to broaden the focus to include all eating disorder types.