Few randomized, controlled trials of treatment for the illness exist, principally because it’s difficult to enroll an adequate sample size into such studies. "Also, anorexia nervosa patients are resistant to treatment, so to get them to enter a treatment trial is a real effort," she said. "In addition, medical complications can require withdrawal from treatment protocols."
Dr. Halmi described ideal treatment of patients with the illness as multifocused with compatible team personnel. Medical management is necessary, along with nutritional rehabilitation, psychotherapy, and family therapy, which is essential for adolescents, she said. "I emphasize this because once patients reach age 18, they are legal citizens, and you cannot force them to receive treatment unless they are near death. They have to be very ill before you can convince a judge they need to be committed. The longer they stay in their behavior of losing weight in their malnutrition state, the less likely they are to recover. People who are chronically underweight for longer than 6 years do not recover from this illness. Therefore, it’s important to diagnose this disorder and get them into treatment with an experienced team."
Limited positive evidence exists for cognitive-behavioral therapy for adults and family-based therapy for adolescents. Behavioral family therapy has been shown to be effective in five randomized trials. "Parents with high expressed emotion or criticism will do better with their anorectic adolescents in separated rather than whole family therapy," Dr. Halmi said. "In the short term, 10 sessions over 6 months is effective for intact families and patients low in obsessive-compulsive features."
Although about 20 randomized controlled studies of pharmacologic treatment have been performed to date, no "grade A" evidence exists for using medication in patients with anorexia nervosa. Category B evidence supports the use of 100 mg zinc gluconate or 14 mg elemental zinc per day for 2 months or olanzapine 5-15 mg/day. "The main problem in using olanzapine is compliance," Dr. Halmi said.
Negative evidence exists for prescribing antidepressants for patients with this illness, and insufficient evidence exists for using cyproheptadine up to 24 mg/day, but Dr. Halmi said she has found that some patients benefit from cyproheptadine. "It mainly acts not by increasing appetite, but by slightly reducing body movements," she said.
Dr. Halmi said she had no relevant financial conflicts to disclose.