BETHESDA, MD. – The release this year of American Psychiatric Association guidelines on treating eating disorders and two analyses of the available evidence to support such treatments have highlighted the dearth of effective, evidence-based interventions for the disorders.
The lack of such data and the funding to support eating disorders research show that much remains to be accomplished before the disorders get the recognition they deserve from the medical community and insurers, said speakers and attendees at the annual conference of the National Eating Disorders Association. At least 5 million Americans have the disorders, and anorexia nervosa has the highest premature mortality of any mental illness.
The National Institute of Mental Health is funding 10 extramural studies on eating disorders at outside locations (seven of which are in New York), but none of the institutes within the National Institutes of Health are conducting any intramural studies on the disorders. In comparison, the NIMH and other NIH institutes are funding 12 intramural studies on schizophrenia and 14 on bipolar disorder, in addition to many more extramural studies, said Dr. Pauline S. Powers of the department of psychiatry at the University of South Florida, Tampa. The total NIMH/NIH funding for schizophrenia, which affects 3 million Americans, is estimated to be $291 million, while about $30 million is spent on eating disorders research, Dr. Powers said.
Efforts aimed at spreading the word about the high prevalence, morbidity, and mortality of eating disorders to legislators may be the best bet for greater funding of eating disorders, which in turn may attract greater interest from researchers to submit research grant proposals, said Dr. Thomas R. Insel, director of the NIMH.
While the lack of research funding has made it difficult to discern which treatments are best for particular eating disorders, the APA's new guidelines will still be helpful for clinicians who “are not real familiar with the kinds of things that you see as complications in patients with eating disorders,” said Dr. Powers, who was a member of the APA work group on eating disorders that wrote the guidelines.
For providers to make the best judgment of the level of care and specific type of treatment that a patient needs, the APA guidelines stress the assessment of physical complications and laboratory tests that may be relevant in patients with anorexia nervosa or bulimia nervosa (Am. J. Psychiatry 2006;163[suppl.]:1–54). For different organ systems, the guidelines list symptoms and signs to look for and particular laboratory tests that may help to diagnose the problem.
“Almost everyone seeing patients with eating disorders should at least know the symptoms and then be able to choose how they're going to work with those particular problems–either by themselves, or [by] consult with a primary care doctor or a specialist,” Dr. Powers advised.
Bulimia nervosa patients may have many of the same symptoms as anorexia nervosa patients because they have a past history of anorexia.
According to the guidelines, basic laboratory tests for bulimia and anorexia patients should include urinalysis for ketones and blood tests for electrolytes, urea nitrogen, creatinine, thyroid-stimulating hormone, a complete blood count, liver enzymes, and erythrocyte sedimentation rate.
Other tests may be necessary in certain circumstances, such as dual-energy x-ray absorptiometry in anorexic patients who haven't had a menstrual period for more than 6 months, Dr. Powers said. At her center, clinicians also routinely order an electrocardiogram, a 24-hour urine creatinine clearance test, and a test for level of complement 3, which is an immune system protein that often drops to low levels early in anorexic patients.
It also may be easier to make a case for insurance coverage with reviewers if you have baseline values for laboratory tests, she noted.
The guidelines recommend placing patients at different levels of care (outpatient, intensive outpatient, partial hospitalization, residential treatment center, inpatient hospitalization) according to categories that are used to assess the severity of their illness, even though there is little evidence to substantiate such placements.
The independent, nonprofit health services research agency ECRI (formerly the Emergency Care Research Institute) conducted a meta-analysis of 48 unique randomized clinical trials on bulimia nervosa.
The report found weak to moderate evidence supporting the effectiveness of medications in reducing bingeing and purging behaviors, as well as anxiety and depression. Except for moderate evidence suggesting some benefit of cognitive-behavioral therapy (CBT) on purging, little data were available to support its effectiveness on bingeing and anxiety or depression.
Weak evidence suggests that CBT may be more effective than medications for purging behaviors, but no other distinction between the two interventions could be made.