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Answers missing in anorexia fight

Jun. 27--Anorexia nervosa has a disturbing distinction in the field of mental health: It's the most lethal of all disorders.

A key reason is the lack of effective treatments for this condition, which causes teenagers to obsess over their weight and severely restrict the food they eat.

About 3 million Americans, mostly girls and young women, struggle with anorexia; the mortality rate for this illness is 10 percent to 15 percent. Two recent reports confirm the sobering challenges faced by patients and medical practitioners.

In April, a comprehensive scientific review found that medications don't help people with anorexia and that behavioral therapies offer limited benefits. The eating-disorders study was prepared for the federal Agency for Healthcare Research and Quality.

"These findings underscore the need to learn more about the causes of these frightening and poorly understood illnesses," said Dr. Carolyn Clancy, who directs the government agency. A new study in the Journal of the American Medical Association sounds a similar theme. It concludes that the anti-depressant Prozac isn't effective in preventing relapses in anorexic patients who had attained a normal weight.

Relapses are a major problem with this illness. While inpatient hospital programs help young women put on extra pounds, those gains typically disappear when people leave the hospital, and as many as 50 percent of patients require re-hospitalization.

In the new JAMA report, 53 of 93 patients in Toronto and New York City who entered the study dropped out because their condition deteriorated significantly. The remaining 40 patients received 50 sessions of cognitive behavior therapy and either Prozac or a dummy pill. There was no evidence the drug produced any benefit compared with the placebo.

Impact of anti-depressants

"We've already known for a number of years that anti-depressants aren't useful for underweight patients in the acute phase of the illness," said Dr. B. Timothy Walsh, a professor of psychiatry at Columbia University and lead author of the report. "What we haven't known until now is whether these medications might be helpful once the underweight state is remedied."

There was reason to believe Prozac might work. An earlier clinical trial had shown that patients with bulimia nervosa who took the medication for 16 to 18 weeks were less likely to experience a relapse. Bulimia is a "binge and purge" eating disorder that involves gorging on food and then vomiting.

But anorexia appears to be more intractable than bulimia. That could be because the neurochemistry of the brain is altered when people suffer extreme food deprivation. Imaging studies indicate that the brains of people who suffer from chronic anorexia "aren't normal," said Dr. Allan Kaplan, head of the eating-disorders program at Toronto General Hospital and a co-author of the JAMA study.

Changes may be permanent

"A basic question is when someone lives for three or more years in a state of virtual starvation, does that permanently affect brain functioning and impair a person's response to a drug?" Kaplan said. "So far we just don't know."

If anything, the new results underscore the need to get young people with anorexia into treatment as soon as possible, before the illness takes hold. The illness typically strikes teenage girls 15 to 19 years old.

There is "no evidence of any treatments that are effective for chronic anorexia," said Dr. James Lock, director of the eating-disorders program at Packard Children's Hospital at Stanford University.

"By contrast, younger patients in the first few years of the illness do have a good chance of recovery, and you can change the outcome," he said.

"Diagnose the illness early on, use the treatments for which we have evidence, and these kids probably won't become the adults for whom we have such dismal outcomes," said Daniel le Grange, who directs the eating-disorders program at the University of Chicago.

Those treatments include family therapy and certain kinds of individual therapy with collateral sessions for parents. "It takes a long time to change the way these young people think about themselves and food and help them find other ways of dealing with the stresses of life," said Dr. Stephen Galston, medical director of the eating-disorders clinic at Highland Park Hospital.

For clinicians, the major message from the new research is that they shouldn't expect anti-depressants such as Prozac to make much, if any, difference.

Unpublished results from the JAMA report indicate that Prozac wasn't effective at treating the underlying anxiety and depression that often accompany this illness, a finding that suggests brain functioning may have been altered, Walsh said. And there is no evidence that medication is effective in younger patients either.