Augmentation Therapy for Inpatients with Anorexia Nervosa

Effective treatments for adults with AN remain elusive, and the results of pharmacologic treatments have been particularly discouraging. Recently, researchers in Italy reported that augmentation of SSRI therapy with an atypical antipsychotic, aripiprazole, helped reduce eating-related obsessions and compulsions among a group of hospitalized patients with AN (PLOS One doi:10.1371,journal.pone. 0125569 April 29, 2015).

Dr. Enrica Marzola and colleagues at the University of Turin’s Eating Disorders Center for Treatment and Research, Turin, Italy, revisited the use of the atypical antipsychotics olanzapine and aripiprazole as augmentation agents of selective serotonin reuptake inhibitor (SSRIs) in adult inpatients with AN. The authors selected the two atypical antipsychotics based upon the neurobiology of AN. This included alterations of dopamine and serotonin in pathways to the brain; the dopamine-blocking properties of these agents; weight and body shape; and their positive effects on safety, anxiety, eating psychopathology, and on depression. The authors also noted that one effect of some atypical antipsychotics is increased appetite and food intake, enhancing weight gain.

Dr. Marzola and her team hypothesized that augmenting treatment with SSRIs with atypical antipsychotics could be more effective than SSRI monotherapy, particularly in the case of patients with depression and obsessive-compulsive disorders. To study this, the authors did a retrospective chart review of patients hospitalized at their eating disorders center between January 2012 and May 2014.

All subjects were assessed with the Structured Clinical Interview for DSM-IV Axis I disorders and were included in the study only if they had AN. In addition, all participants had been taking an SSRI for at least 6 weeks at admission and had either olanzapine or aripiprazole added as augmentation therapy while hospitalized. Patients were excluded who were receiving a different category of antidepressant, or who had lifetime use of any antipsychotic or mood stabilizers, or who had been hospitalized due to a comorbid Axis I disorder, or with certain medical comorbidities.

Measures included body mass index (BMI, kg/m²), weekly incidence of binge-purge behaviors, including use of diuretics or laxatives, and the amount of daily physical exercise. Anxiety and depression were measured with Hamilton scales for Anxiety and Depression and the Yale-Brown-Cornell Eating Disorders Scale.

One-hundred eighty-seven charts were reviewed, yielding a final group of 75 patients. Mean age was 25 years; mean BMI was 13.9, and the mean duration of illness was 6.9 years. All patients were receiving SSRIs (sertraline, citalopram, escitalopram, or fluoxetine) when they were admitted to the treatment center. After analysis, three treatment groups emerged: 32.9% remained on SSRIs as monotherapy; 32.0% received adjunctive aripiprazole; and 35.5% received adjunctive olanzapine.

Differences emerged in the treatment groups

While the sample was not randomized to treatment condition, there were no differences by age, gender, BMI, or by AN subtype, duration of illness, exercise, or use of diuretics. Significant improvements emerged across the three treatment groups. Those in the aripiprazole group had significantly greater improvement on the global score and both subscales of the Yale-Brown-Cornell Eating Disorders Scale compared with the two other treatment groups.

Clearly there are limitations to this study (including the small sample size and lack of randomization, for example). Nevertheless, the results support continued investigation of aripiprazole. They may also find a way to conceive of the role of medications in AN by targeting individual symptoms (in this case, ED-related cognitions and rigidity) as opposed to targeting AN as a whole.