Evidence-based treatments for mental health conditions have come on in leaps and bounds in the last 20 years. I remember as a young elf, skipping around the country and running workshops on evidence-based mental health; training psychiatrists, psychologists, nurses and others.
There wasn’t much gold standard evidence to choose from back then and there was always a buzz of excitement (from us nerdy types at least) when a new systematic review or randomised controlled trial was published. These days there are dozens of good quality studies coming out every week and the challenge is how to keep up to date with everything. At least that’s the case for many mental health conditions, but certainly not all.
Anorexia nervosa remains a mysterious condition, which is potentially life-threatening, but for which clinicians have a remarkably limited choice of evidence-based treatment options. Research funding is scarce and it’s only really the family-based treatment programme for adolescents, developed at the Maudsley Hospital, that has a systematic review supporting it’s use, and even that is a fairly inconclusive Cochrane review based on a small number of trials.
I’m always on the look out for new systematic reviews in this area, so was encouraged to see a new review and meta-analysis published in the Journal of Clinical Psychiatry, which investigates the effectiveness of antipsychotic drugs for increasing body weight and reducing anorexia symptoms.
The reviewers searched Cochrane, PubMed and PsycInfo for randomised controlled trials (RCTs) that compared antipsychotics (quetiapine, olanzapine, risperidone, pimozide or sulpiride) with placebo or usual care in people with anorexia nervosa. Two reviewers appraised the studies, rated study quality and extracted data.
Random effect meta-analyses were carried out, but only on outcomes reported in 3 or more studies and based on intention-to-treat. Heterogeneity was investigated using the I² statistic.
They found 8 RCTs including a total of 221 patients (99% women and mean age 22.5 years).
When comparing antipsychotics with placebo or usual care, there were no significant differences in relation to:
- BMI/body weight (7 RCTs, n=195; SMD +0.27, 95% CI -0.01 to +0.56, p=0.67; I²=0%)
- Anorexia symptoms (5 RCTs, n=114; SMD -0.27, 95% CI -0.81 to +0.27, p=0.32; I²=49%)
- Depressive symptoms (4 RCTs, n=103, SMD -0.39, 95% CI -0.84 to +0.05, p=0.08)
- Anxiety symptoms (4 RCTs, n=121; SMD -0.17, 95% CI -0.71 to +0.36, p=0.08)
In terms of side-effects:
- Antipsychotics increased drowsiness compared with usual care (5 RCTs, n=129; RR 3.69, 95% CI 1.34 to 9.95, p=0.01)
- There was no difference in akathisia between groups (3 RCTs, n=76, RR 3.77, 95% CI 0.70 to 20.3, p=0.12)
- And no significant differences between groups in all cause discontinuation (7 RCTs, n=181; RR 0.94, 95% CI 0.53 to 1.67, p=0.54)
So it seems that we have to wait a while longer before we can add another piece of gold standard evidence to our collection, that can be used by clinicians to care for people with anorexia nervosa. This review shows quite clearly that antipsychotics do not increase weight gain or body mass index in anorexia. It also shows that anorexia symptoms are not reduced by antipsychotics.
The included studies are all quite small and of short duration (7-12 weeks), so the overall power of this review and analysis is fairly weak. However, it’s a well conducted piece of research and the first meta-analysis that tackles this question (there’s a Cochrane protocol but no review as yet), so it provides something that can now be built on.
Few studies in this field report on the duration of the illness and it will be interesting to see if this is more of a focus for future research. Clinicians will continue to seek advice on the optimal time during the course of the illness for drug interventions, so we can only hope that new RCTs address this issue before another 20 years have passed.
Kishi T, Kafantaris V, Sunday S, et al. Are antipsychotics effective for the treatment of anorexia nervosa? Results from a systematic review and meta-analysis. J Clin Psychiatry 2012;73:e757–66. [PubMed abstract]
Fisher CA, Hetrick SE, Rushford N. Family therapy for anorexia nervosa. Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD004780. DOI: 10.1002/14651858.CD004780.pub2.
Claudino AM, Hay PPJ, Silva de Lima M, Schmidt UUS, Bacaltchuk J, Treasure J. Antipsychotic drugs for anorexia nervosa (Protocol). Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006816. DOI: 10.1002/14651858.CD006816.
Hay PPJ, Bacaltchuk J, Byrnes RT, Claudino AM, Ekmejian AA, Yong PY. Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003909. DOI: 10.1002/14651858.CD003909.
Claudino AM, Silva de Lima M, Hay PPJ, Bacaltchuk J, Schmidt UUS, Treasure J. Antidepressants for anorexia nervosa. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004365. DOI: 10.1002/14651858.CD004365.pub2.