Biomedical approaches to treatment are based on the assumption that biological factors are involved in the psychological disorder. A number of drugs are used to treat various disorders based on theories of the brain chemistry involved, but this does not mean that there is a full understanding of how neurotransmitters and symptoms are linked. Neither is it fully known why drugs work in some cases but not in others. The fact is that drugs are often used to alleviate symptoms to make other forms of therapy possible. Not all individuals respond in the same way to a drug and it is not known why. Clinicians must find an appropriate drug and dosage for each individual, and they must be prepared to replace the drug if the patient does not benefit from it.

Research has not found any drug that works effectively in the treatment of anorexia nervosa. Instead, drugs are often prescribed for symptoms of depression or obsessive-compulsive behaviours. The most commonly prescribed drugs are SSRIs (anti-depressants), lithium carbonate (for OCD) and Olanzapine (an anti-psychotic drug).

Research has been more promising for an anti-psychotic drug called Olanzapine. 

Dennis et al. (2006) studied five adolescents with anorexia nervosa who received olanzapine in addition to psychotherapy for their eating disorder. Body mass index (BMI) of each case increased while on olanzapine. The patients reported decreased anxiety around eating, improved sleep, and decreased rumination about food and body concerns. Although the patients all showed an improvement, they also all suffered from morning sedation - that is, a feeling of exhaustion in the morning.

A key limitation of Dennis et al.'s research is the small sample size.  Norris et al. (2011) carried out a retrospective, matched groups study of 86 female patients all treated for anorexia nervosa. It was retrospective because the researchers looked at records of patients who had already completed treatment.  It was a matched study because they compared women of the same age, diagnosis, and symptoms to each other. Patients treated with olanzapine were compared with patients that did not receive the treatment.

The rate of weight gain was not statistically different between those that received olanzapine and those patients that did not.   Notable side effects included sedation and 56% of the patients showed highly elevated levels of cholesterol. Those that had been treated with olanzapine actually showed more severity of anorexia related symptoms than those that were not treated with the drug.

 Teacher only box

With regard to the two studies above, which study do you feel is stronger? Be able to defend your answer.

These two studies are contradictory.  The small sample size of the Dennis et al (2006) is a serious limitation.  However, the study is also prospective in nature.  The study by Norris et al (2011) is retrospective, meaning that there was lower internal validity of the study.  The researchers are reliant on the measurements taken by others. However, the use of matched pairs to analyze the data adds to the internal validity of the study.

If you were a psychiatrist who worked with anorexic patients, would you prescribe the drug?  Why or why not?

You may want to share the following study with your students - Spettigue et al (2018)

There is the question of whether the side effects noted above are a greater cost than the possible benefit of weight gain for those suffering from anorexia. Students will have various arguments as to why they would or would not prescribe the drug.  Usually a good discussion - but important that students are able to back up their arguments with some logical or empirical argument.

Evaluation of drug therapy

The key strength of drug therapy is that for many people it alleviates the symptoms that make day-to-day living difficult.

There are some rather serious limitations of drug treatment, especially in the case of anorexia nervosa. One limitation is the problem of side-effects – negative effects of using the drug itself. For example, SSRIs are known to have the following side effects in some patients: nausea, increased weight gain, loss of sexual desire, insomnia, blurred vision, constipation, dizziness, and anxiety. Interestingly, you can see that some of these side effects could actually contribute to lowering one’s self-esteem or sense of autonomy – two characteristics of people living with anorexia.

Another limitation of drug therapy is that clinicians are still not sure why these drugs alleviate symptoms in some, but not all patients. In the study by Dennis et al. (2006), all five patients showed an improvement, while in the Norris et al. (2011) study, there was no significant improvement. How can we account for this?

One of the consequences of relying too heavily on drug treatments is that it may lead to the neglect of important psychological or social factors that may play a significant role in the disorder. It can be argued that simply using a drug to treat anorexia is a reductionist approach. A drug may alleviate symptoms, but it may not address the actual cause of the disorder. The drug then only provides temporary relief from the symptoms and relapse is likely.

 Teacher only box

Based on this information, would you take such a drug?  What would be your justification?  What would convince you to take the drug?  What would convince you not to take it?

The goal of this reflection is to get students to think about how they would make a decision about taking a drug.  All drugs have potential side effects, so this will always be an issue.  Many students will focus on some of the following points below:

• How important it is for you to improve your memory
• The actual effectiveness of the drug
• Looking at the incidence of the side effects
• The problem of discontinuation (withdrawal)
• The cost and whether such a drug could be covered by health insurance.

Finally, drug therapy presents some ethical concerns. Unless treatment is regarded as an emergency – for example, the client is suicidal - it cannot be given without the client’s consent, except in cases where the client may not be capable of giving consent. This consent should be given on the basis of full information about the potential benefits and drawbacks of the drugs concerned, in which case it fulfills the ethical criterion of informed consent.

There is a major concern about the rise in prescriptions of drugs such as SSRIs because they can cause harm if they are not prescribed appropriately. There is an ongoing debate among clinicians about possible medical and psychological risks in prescribing so many SSRIs as well as whether they are effective long-term since most clinical trials only last around 6 or 8 weeks and only address whether patients report a reduction in symptoms.

Seeing the potential limitations of drug treatment, it becomes even more apparent that there is a sincere ethical concern about the way that diagnoses are made.   When drug treatment is seen as necessary in spite of the potential limitations, it is important the diagnosis has been made in a way that increases its validity.  Ideally, every client is diagnosed as needing drug treatment would have had more than one series of tests carried out by more than one psychiatrist.  However, this is rarely the case. Often these drugs are prescribed by a family doctor, not a psychiatrist.

Checking for understanding