For eating disorders, food (and the normalization of eating patterns) is the primary medicine, along with therapy to help distorted thoughts (or unhelpful thoughts) surrounding food, weight, eating, and body image. In some cases, psychiatric medication (such as antidepressants, antipsychotics, or mood stabilizers) can make therapy more successful. Many people with eating disorders also struggle with anxiety and depression and medication may help with those symptoms. A thorough diagnostic evaluation with a psychiatrist is always recommended before beginning any regimen of psychiatric medication. Among other things, it can be important to determine whether anxiety and mood symptoms came before the eating disorder or could be symptoms of malnutrition.
Anorexia Nervosa
Medication should generally not be the initial or primary treatment for anorexia nervosa. While some success has been shown with pharmacological treatment for bulimia and binge eating disorder, there is far more evidence supporting nutritional rehabilitation and psychotherapy for treating anorexia nervosa, compared with medication. No medication has yet been FDA approved for the treatment of anorexia. Typically, when medication is prescribed, the primary goal tends to be weight gain, or to treat the anxiety or depressive symptoms that may co-occur with the anorexia. It is often prescribed for patients who have under-responded to nutritional restoration and psychotherapy. However, even in these cases, the efficacy of medication has not been well studied—treatment trials are considered difficult to conduct on patients with anorexia because these patients tend to be reluctant to take medication for fear of weight gain. There is some limited evidence that the second-generation antipsychotic medications (also called atypical antipsychotics), such as Zyprexa, can help lead to small weight increases. However, the mechanism by which these may work is not well-understood. Interestingly, even though patients with anorexia often have significantly distorted views of food and their body that seem similar to psychotic delusions, these symptoms do not seem to respond to antipsychotic medications. If antipsychotics are used, they are recommended to be used in conjunction with behavioral interventions that aim to help the patient achieve and maintain a healthy weight. Antidepressant medications typically do not help with weight gain, although they can be used to treat co-occurring anxiety and depression. Unfortunately, many medications do not seem to work well in patients with anorexia nervosa. This may be because starvation affects the function of neurotransmitters in the brain. Sometimes, benzodiazepines may be prescribed for use before meals to reduce anxiety; however, there is no research to support this practice and benzodiazepines can become addictive. Patients with anorexia nervosa are at risk for bone weakness (osteopenia and osteoporosis) and increased fractures due to malnutrition. This is often accompanied by the loss of a menstrual period (menses). Birth control pills are commonly prescribed by doctors in an attempt to restart menses and to minimize bone weakness. However, research has not shown this to be effective: birth control pills do not help with bone density and may mask the symptoms of anorexia by causing artificial periods. Ultimately, birth control pills are not recommended for purposes beyond birth control. Research reminds us that low bone density is best treated with weight restoration, which is, at this time, the only known way to normalize the hormones that contribute to bone weakening.
Bulimia Nervosa
Psychiatric medications have been shown to be helpful for the treatment of bulimia nervosa and are most often used in addition to nutritional rehabilitation and psychotherapy. Nutritional restoration is focused on establishing regular and structured meals. Medication alone is not usually recommended for bulimia nervosa unless a patient does not have access to psychotherapy and nutrition therapy. A primary goal of treatment for bulimia nervosa is stopping the bingeing and purging. Selective serotonin reuptake inhibitors (SSRI antidepressants) are the most studied medication for the treatment of bulimia nervosa and are generally well-tolerated by patients. It is not yet known exactly why they work; it is hypothesized that in at least some patients the central nervous system serotonin pathways are disturbed. This class of antidepressants has been shown to reduce binge eating, purging, and psychological symptoms such as the drive for thinness. This class of medications has demonstrated helpfulness with improving co-occurring symptoms of anxiety and depression. Treatment studies show that SSRIs are most effective when they are combined with psychotherapy. Medication may make psychotherapy more effective for some. Medication alone is not as effective for most patients as psychotherapy alone. Medication may also be effective when combined with self-help and guided self-help approaches. Of the SSRIs, Prozac (the commercial name for Fluoxetine) is the most studied for the treatment of bulimia nervosa, and it is also the only medication specifically approved by the US Food and Drug Administration(FDA) for adults with bulimia nervosa. For these reasons, it is often recommended as the first medication to try. However, it should be noted that many medications are used by psychiatrists “off-label,” which is defined by the FDA as “use of drugs for the indication, dosage form, regimen, patient or other use constraint not mentioned in the approved labeling.” Research shows that if a patient with bulimia nervosa will respond well to Prozac, they will likely show a positive response within three weeks of taking the medication. It is important to note that multiple randomized control trials have established 60 mg of Prozac as the standard dose for bulimia nervosa. This is higher than the standard dose used for major depression (20 mg). If Prozac does not work, other SSRIs are often tried next. It is not uncommon for other agents, such as the anticonvulsant Topiramate, to be used off-label for bulimia. It is generally recommended that patients stay on medication for six to 12 months after achieving improvement on the medication.
Binge Eating Disorder
Medications seem effective in helping patients with binge eating disorder (BED) stop binge eating but do not generally produce the weight loss that is a common goal for patients seeking help for this disorder. For BED, three main classes of medications have been studied: antidepressants (primarily the SSRIs, including Prozac); antiseizure medications, especially Topiramate; and Vyvanse (an ADHD medication). As they do for patients with bulimia nervosa, antidepressants can be helpful in reducing the frequency of binge eating in patients with BED. They can also help to reduce obsessive thoughts and symptoms of depression. Topiramate can also help reduce the frequency of binges and may also reduce obsessive thoughts and impulsivity. Stimulant medications used in the treatment of attention deficit hyperactivity disorder (ADHD) are noted to suppress appetite and so have been a recent focus of attention for the treatment of BED. Recently, Vyvanse (lisdexamfetamine), an ADHD medication, became the first medication approved by the FDA for treating BED. It has been studied in three trials and was associated with reductions in binge episodes per week, decreased eating-related obsessions and compulsions, and produced small weight losses. There have been insufficient studies directly comparing medication treatment to psychological treatment for BED, but medications are generally considered less effective than psychotherapy. Thus, they should usually be considered a second-line treatment after psychotherapy, as an adjunct to psychotherapy, or when therapy is inaccessible.
Warning About Wellbutrin
The antidepressant bupropion (often marketed as Wellbutrin) is often prescribed in patients who are trying to lose weight and who may also exhibit depressive symptoms. Wellbutrin has been associated with seizures in patients with purging bulimia, however, and is not recommended for patients with eating disorders.
A Word From Verywell
In general, medication is not typically the primary mode of treatment for an eating disorder. Medication may be helpful when added to psychotherapy or when psychotherapy is not available. Further, medication is often used when patients also have symptoms of anxiety and depression to help with these symptoms. However, medications can carry a risk for side effects that are not found with psychological therapies. Ultimately, the “medication” of choice for an eating disorder is food and normal eating as well as finding a way to cope with the unhelpful or distorted thoughts surrounding food, eating, and body image. There are various treatments for eating disorders that are considered efficacious, including cognitive behavioral therapy and family-based treatment.
