More on the Use of Atypical Neuroleptics for Anorexia Nervosa

Editor’s note: In the last issue, we examined the fact that little published information was available about the potential use of atypical neuroleptics in the treatment of anorexia nervosa (AN). Several new recent case reports add to the growing impression that atypical neuroleptics may be useful in the treatment of some patients with AN. Since this is potentially such an important clinical issue, a more detailed review may be of interest.

A recent letter in the British Journal of Psychiatry (2000; 177) reported that several patients with chronic AN responded well to 5 mg/day of olanzapine. These patients had previously been unsuccessfully treated with conventional treatments, including antidepressants and psychotherapy, and at least one had received conventional neuroleptics. This patient was a 50-year-old woman ill since age 17, who gained from 74.8 to 116.6 lb (height: 5’2″) over about 4 months. Another patient, a 30-year-old woman ill since age 18. had an increase in weight from 96.8 to 116.6 lb (height 5’6″) over 9 months.

In both patients, psychological symptoms, including disturbances of body image, improved with medication, and treatment was ongoing at the time the letter was written.

A report in the Journal of the American Academy of Child and Adolescent Psychiatry (2000; 39:941) describes two adolescent patients successfully treated with risperidone, 1.5 mg/day. The only side effect was mild sedation. A 19-year-old with a five-year history of restricting AN started at 80 lb (BMI 14.6 kg/m2). Sequential full trials of 4 selective serotonin reuptake inhibitors (SSRIs) did not help her major depression or weight. After discharge from 3 months of psychiatric hospitalization she was unable to maintain her 20-lb weight gain, and she was rehospitalized 4 months later. Venlafaxine, 150 mg twice daily, helped her depression but did not stem her weight loss. Within a week after 1.5 mg of risperidone was added to combat delusional thinking about weight and to avoid hospitalization, the patient’s anxiety and obsessions about food diminished, and weight increased, rapidly at first, and then more slowly. Four to five months after initiation of treatment she had achieved 97% ideal body weight (IBW), and menses returned. Over the following 10 months her anorexic thinking improved and she remained at IBW with regular menses even after risperidone was tapered and discontinued.

The second patient was a 12-year-old girl with two years of restricting AN, initially seen at 83 lb, 79% IBW (BMI: 15.9), and hospitalized for treatment of bradycardia. When she was an outpatient, sertraline had been minimally helpful. In an effort to avoid another hospitalization, risperidone was started at 0.5 mg and gradually increased to 0.5 mg tid. This treatment was accompanied by a gain of 8 lb in the first month, diminished anxiety, new insights and increased energy. When the dose was lowered to 0.5 mg bid, she experienced a return of eating-related obsessional symptoms and declining insight, both of which improved when the dose was increased to 0.5 mg tid. Nine months after the start of risperidone, she weighed 103 lb, and menses returned. At the time the report was published, she had maintained her weight for 6 months and was described as psychologically improved.

These medications require close medical monitoring and are accompanied by certain risks and side effects. But, because of the high morbidity and mortality of AN and the considerable extent to which the disorder may be treatment resistant, even while the field awaits controlled trials these medications may already deserve consideration for selected patients.

— J.Y.