Abstract
Antipsychotic medications have been used in the treatment of anorexia nervosa since the 1960s and are prescribed for distressing obsessionality, anxiety, and psychotic-like thinking [1]. Recent case reports and openlabel trials suggest that atypical antipsychotics such as olanzapine [2], risperidone [3, 4] and amisulpride [5] may be beneficial in the specific treatment of anorexia nervosa.
We report the results of a retrospective case note analysis of 14 female patients aged 19–49 years with DSM-IV anorexia nervosa (57% restricting and 43% binge-eating/purging subtype) admitted to the Eating Disorders Unit at the Austin and Repatriation Medical Centre between 1996 and 2001, and who were prescribed olanzapine. Most had a chronic illness (average duration 10.46 years, SD 7.46) with significant psychiatric comorbidity. Six (43%) patients also had DSM-IV major depressive disorder, and their mean Hamilton Depression Rating Scale score was 27.2 (SD 4.9) before, and 23.7 (SD 6.8) after olanzapine prescribed concurrently with antidepressant medication. Two patients had DSM-IV borderline personality disorder, and one DSM-IV schizophrenia, paranoid type. Two patients had partially remitted substance abuse in addition to borderline personality disorder and major depressive disorder, respectively. The average body mass index (BMI) before olanzapine was 14.2 kg/m2 (SD 1.9 kg/m2) and postolanzapine was 15.3 kg/m2 (SD 1.2 kg/m2) following an inpatient course. The comorbidity and low initial BMIs were indicative of selection biases inherent in this patient population. The improvement in BMI was clinically and statistically significant with olanzapine alone and in conjunction with other psychotropics (two tailed t-test: p = 0.027 and p = 0.013, respectively). Five patients had a drop in BMI (average 0.8 kg/m2, SD 0.4 kg/m2) not of clinical significance. Two of these had been prescribed olanzapine alone, two had comordid major depressive disorder and one, borderline personality disorder.
All 14 patients were prescribed olanzapine to diminish anxiety that was interfering with nutritional rehabilitation. Other indications included: overvalued ideation impacting on normalization of eating behaviours; facilitation of weight gain not effected with other treatments; comorbid psychotic phenomena; and dampening of excessive motor activity. The mean duration of inpatient olanzapine treatment was 24.9 days (SD 15.5). The mean inpatient dose was 9.7 mg/day (SD 5.7). Nine women (64%) and 11 of the total 18 admissions were prescribed olanzapine alone, whilst five (35%) were prescribed concurrent psychotropic medication including SSRIs (fluvoxamine, sertraline, paroxetine) SNRI (venlafaxine) and tetracyclic (mianserin) antidepressants. Two patients prescribed antidepressant medication had a subsequent course of electroconvulsive therapy. None of those readmitted were prescribed concurrent psychotropic medication.
This study explored the use of olanzapine in anorexia nervosa in a specialized unit and covered a period when this treatment was preliminary in nature. The study's limitations include: retrospective design; absence of a control group; small sample size; varying and ill-defined illness severity; heterogenous comorbidity; varying indications for olanzapine; and prescription of concurrent psychotropics. Further evaluation of the role of serotonin-dopamine antagonists in anorexia nervosa with controlled trials using defined outcome measures are required to determine whether there is specific benefit as opposed to the side-effect of weight gain countering the anorectic state, or weight gain secondary to anxiolysis or treatment of psychiatric comorbidity.