|
Book Title: Treating and Preventing Adolescent Mental Health Disorders
> pp. [290]-[294]
UNDEFINED: AUTHORS
Treating and Preventing Adolescent Mental Health Disorders
Print ISBN 9780195173642, 2005
pp. [290]-[294]
olescence have proven effective. The theoretical models, treatment principles, and technical interventions that comprise these therapies are similar to those that would be applied to bulimia nervosa. It should also be noted that depression and anxiety disorders are commonly comorbid with bulimia nervosa (Bulik, 2002).
Interpersonal psychotherapy for treatment of depression in adolescents.
Two controlled studies have shown that IPT is effective with adolescents with major depression (Mufson, Weissman, Moreau, & Garfinkel, 1999; Rossello & Bernal, 1999). According to Curry ( 2001), IPT meets criteria “for possible efficacy in treating adolescent major depression” (p. 1092). In light of these data and the frequent co-occurrence of depression and bulimia nervosa, studies of the utility of IPT for adolescents with bulimia nervosa would be of interest.
Psychological Therapy for Adolescents with Eating Disorders: General Considerations
Developmental psychologists emphasize a connection between the psychological dimensions of development and the treatment of adolescents. Weisz and Hawley ( 2002) focused on the following issues: motivation, cognition, and social development.
The issue here is that many adolescents in treatment are not self-referred but pressured by family into seeking help. Weisz and Hawley ( 2002) state that interventions programs tacitly assume motivation for treatment. They recommend that therapists assess motivation prior to starting treatment and implement specific strategies for enhancing it.
Weisz and Hawley ( 2000) argue that the adolescent's developing cognitive abilities may impose limits on the utility of some therapeutic interventions. They emphasize the importance of three cognitive skills in adolescence “that are especially relevant to therapy: abstraction, consequential thinking, and hypothetical reasoning” (Holmbeck et al., 2000). They suggest that this might be especially relevant to CBT, with its explicit cognitive focus.
Developmental change in social interactions is a distinguishing feature of adolescence. Peer group and family relation
ships loom large in adolescent adjustment. Weisz and Hawley ( 2002) underscore the relevance of addressing interpersonal skills and relationship issues in adolescent treatments. They also assert that an adolescent's psychological and social adjustment and school performance can be enhanced by “authoritative parenting,” namely, “consistently enforced guidelines and limits with warmth and psychological autonomy granting” (p. 30). They suggest that the former is especially relevant to “externalizing” problem behaviors such as substance abuse, whereas the latter applies particularly to “internalizing” problems such as anxiety and depression. It can be argued that both sets of problems often characterize eating disorders, and that both limit setting and autonomy granting, a “complicated balancing act,” are required. Treatment of adolescents inescapably raises the question of how to involve parents in the therapy. Somewhat surprisingly, fewer than half the studies of empirically supported treatments identified by Weisz and Hawley addressed family relationships in therapy. Among those that did, the evidence on outcome was mixed.
Psychological Therapy for Adolescents with Bulimia Nervosa: Specific Considerations
The conceptual model of the maintenance of bulimia nervosa and the therapeutic principles and procedures of CBT appear to mesh well with the psychology of adolescence and the developmental factors summarized above. Bulimia nervosa occurs predominantly in females, and much is known about the developmental challenges (psychosocial tasks) facing adolescent girls (Striegel-Moore, 1993). Girls, far more than boys, are socially oriented. Girls' sense of personal identity is said to be interpersonally constructed, with self-esteem being strongly influenced by the perceptions of others' approval. Social approval is closely linked to physical attractiveness, and girls are socialized to evaluate themselves in terms of appearance. Striegel-Moore ( 1993) has argued that girls with an insecure identity who are concerned about how others view them may focus disproportionately on physical appearance as a concrete way to construct a sense of self. Bulimia nervosa is often marked by problems with
end p.290
PRINTED FROM Treating and Preventing Adolescent Mental Health Disorders (www.oup.com/amhi-treatingpreventing)
© Copyright Oxford University Press, 2006. All Rights Reserved
social adjustment and social-self difficulties. These findings about bulimia nervosa and the psychology of adolescence for girls indicate that treatment needs to address interpersonal relationships. Although body shape and weight concerns have been documented in prepubertal girls, it is the key developmental milestone of reaching puberty that poses biological and psychological challenges for adolescent girls. Concerns about body image are commonplace, and severe dissatisfaction with body shape and weight and pressure to be thin can drive the rigid, unhealthy dieting and negative affect (because appearance is a key evaluative dimension for females) that are proximal triggers for bulimia nervosa (Fairburn, 1997a; Stice, 2001).
Psychological Treatments for Other Adolescent Eating Disorders
As discussed previously, most adolescent patients who present for treatment do not meet the DSM-IV diagnostic criteria for anorexia nervosa or bulimia nervosa. Their eating disorder is therefore categorized as eating disorder not otherwise specified (Brewerton, 2002; Dancyger & Garfinkel, 1995; Eliot & Baker, 2001; Engelsen, 1999; Fisher et al., 1995; Muscari, 2002; Nicholls et al., 2000). Thus, treatment for adolescents must be able to accommodate a wide range of eating disorder pathology. A recently described manual-based form of CBT provides a transdiagnostic model of eating disorders (Fairburn, Cooper, & Shafran, 2003): specific therapeutic interventions are matched to particular clinical features of the eating disorder, rather than a heterogeneous diagnostic category. The flexibility of this enhanced CBT allows different clinical features to be targeted with theory-driven and evidence-based treatment modules within the overall framework of the core CBT approach. This approach could be useful in treating adolescent patients with an eating disorder not otherwise specified.
Cognitive-behavioral therapy is the leading evidence-based therapy for bulimia nervosa
among adults (NICE, 2004) and is likely to be adaptable to the treatment of adolescents. The flexibility of CBT and recent evidence for its utility in preventing relapse among adults with anorexia nervosa (see below) suggest that when suitably adapted, it may be useful for the wide spectrum of eating disturbances in adolescents. Examination of the efficacy of CBT for adolescents with bulimia nervosa is clearly warranted. Interpersonal psychotherapy has some utility in the treatment of adults with bulimia nervosa and has been successfully employed in the treatment of depression among adolescents. Thus IPT might be useful for adolescents with bulimia nervosa. Finally, the apparent success of family-based interventions for anorexia nervosa suggests that this approach may also have merit in the treatment of bulimia nervosa.
PHARMACOLOGICAL TREATMENTS FOR ADOLESCENTS WITH EATING DISORDERS
With rare exception (e.g., Biederman et al., 1985), there are no studies of the efficacy of pharmacological treatment for adolescents with eating disorders. Therefore, as is the case with psychological treatments for adolescents, information about pharmacological interventions must be adapted from the literature for adults. Recent evidence that some pharmacological treatments of clear efficacy for adults with disorders such as major depression can be successfully employed for adolescents (Varley, 2003) should encourage further research on the utility of pharmacological treatments for adolescents with eating disorders.
Pharmacological Treatments for Anorexia Nervosa
There are no empirically supported pharmacological treatments for the acute symptoms of anorexia nervosa in either adolescents or adults. As in the case of the existing psychotherapy research, however, data from pharmacological studies of adults with eating disorders may provide some guidance in developing promising therapeutic interventions.
end p.291
PRINTED FROM Treating and Preventing Adolescent Mental Health Disorders (www.oup.com/amhi-treatingpreventing)
© Copyright Oxford University Press, 2006. All Rights Reserved
Antidepressant Medications
Four placebo-controlled trials of antidepressants in the treatment of anorexia nervosa have been published (Attia, Haiman, Walsh, & Flater, 1998; Biederman et al., 1985; Halmi, Eckert, LaDu, & Cohen, 1986; Lacey & Crisp, 1980). None of the trials documented more than a slight therapeutic effect. Given the evidence of utility of antidepressant medication for conditions with substantial symptomatic overlap with anorexia nervosa, such as major depression and bulimia nervosa, the lack of any significant effect is surprising and raises the possibility that the malnutrition inherent in anorexia nervosa somehow interferes with the therapeutic action of antidepressant medication. Circumstantial evidence consistent with this hypothesis has emerged from studies of serotonin function. For example, in healthy women, dieting significantly lowers plasma levels of tryptophan, the precursor of serotonin (Andersen, Parry-Billings, Newsholme, Fairburn, & Cowen, 1990). Individuals with anorexia nervosa who are malnourished have reduced plasma tryptophan availability (Schweiger, Warnoff, Pahl, & Pirke, 1986) and reduced levels of cerebrospinal fluid 5-hydroxyindoleacetic acid (CSF 5-HIAA), the major metabolite of serotonin, which increases with weight gain (Kaye, Gwirtsman, George, Jimerson, & Ebert, 1988). Depletion of serotonin in anorexia nervosa might interfere with the effects of antidepressants in general and the selective serotonin reuptake inhibitors (SSRIs) in particular (Delgado et al., 1990).
Atypical Antipsychotic Medications
Almost 50 years ago, experience with chlorpromazine, the first antipsychotic medication in clinical use, led to substantial enthusiasm about its potential role in the treatment of anorexia nervosa. With greater experience, however, the enthusiasm waned, and two small, placebo-controlled trials of antipsychotic medication found little evidence of efficacy (Vandereycken, 1984; Vandereycken & Pierloot, 1982). The recent introduction of the atypical antipsychotic drugs, a number of which are associated with
considerable weight gain, has prompted reconsideration of this class of medication as a treatment for acute anorexia nervosa. Several case reports and open studies have described improvement associated with olanzapine treatment of children, adolescents, and adults with anorexia nervosa (Boachie, Goldfield, & Spettigue, 2003; Hansen, 1999; Jensen & Mejlhede, 2000; La Via, Gray, & Kaye, 2000; Mehler et al., 2001; Powers, Santana, & Bannon, 2002). By contrast, one open study reported no appreciable weight gain with olanzapine among patients treated on a specialized inpatient unit (Gaskill, Treat, McCabe, Marcus, 2001). In the absence of randomized placebo-controlled trials, no conclusion about the role of atypical antipsychotic medications in the treatment of anorexia nervosa in either adults or adolescents is possible. This is nonetheless a potentially promising area for new research.
Zinc deficiency is associated with weight loss, a decrease in appetite, changes in taste perception, amenorrhea, and depression, all symptoms described by patients with anorexia nervosa. This observation, coupled with reports of zinc deficiency associated with anorexia nervosa, has prompted several controlled trials of zinc supplementation. While one controlled trial in adults found zinc to be associated with an increased rate of weight gain (Birmingham, Goldner, & Bakan, 1994), two other trials among adolescents found no effect (Katz et al., 1987; Lask, Fosson, Rolfe, & Thomas, 1993). The role of zinc supplementation as a treatment for anorexia nervosa is uncertain. The benefits of lithium in the treatment of bipolar (manic-depressive) disorder among adults are very well established, and, like many antipsychotic medications, the use of lithium is associated with weight gain. These considerations prompted a single controlled trial of lithium among inpatients with anorexia nervosa, which provided little support for the utility of this agent (Gross, Ebert, Faden, Goldberg, Nee, & Kaye, 1981).
end p.292
PRINTED FROM Treating and Preventing Adolescent Mental Health Disorders (www.oup.com/amhi-treatingpreventing)
© Copyright Oxford University Press, 2006. All Rights Reserved
Issues to Consider in Treating Adolescents with Pharmacotherapy
The pharmacokinetics and pharmacodynamics of psychotropic drugs in children and adolescents are not well studied. Some biological factors inherent to adolescents may affect the metab-olism and efficacy of psychiatric medications, such as immature neurotransmitter systems, rapid hepatic metabolism, and shifting hormonal levels in adolescents (Hazell, O'Connell, Heathcote, Robertson, & Henry, 1995). Dramatic shifts in weight, especially weight loss, can also occur much more rapidly in adolescents than in adults with eating disorders. As a result, there may be differences in the metabolism and/or the effects of medications in adolescents with eating disorders, which could necessitate adjustments in dosage and medication response. The safety of psychotropic medications should be considered when prescribing medications for patients with an eating disorder, especially when patients are medically unstable. Tricyclic antidepressants (TCAs) and mood stabilizers, which tend to be less frequently used today than in the past, have potential for serious side effects. In particular, although a clear causal link has not been documented, TCAs have been associated with sudden death among adolescents without eating disorders (Geller, Reising, Leonard, Riddle, & Walsh, 1999), and the cardiac abnormalities associated with anorexia nervosa, in theory, should increase the risks of tricyclic use in this population. Careful medical and psychiatric monitoring is required when prescribing psychotropic drugs to adolescents with eating disorders. As with adults, adolescent patients with eating disorders are prone to develop other behavioral problems, such as substance abuse, which may increase the risk of side effects. In addition, in sexually active adolescents, ensuring adequate birth control is important to prevent the potential harmful effects of medications during pregnancy (Kotler & Walsh, 2000). Finally, concerns have recently been raised about the potential for some SSRIs to increase suicidal ideation among adolescents (Dalrymple, 2003; Harris, 2003; United Kingdom Department of Health, 2003; United States Food and Drug Administration, 2004). The potential for SSRIs to increase the risk of suicide among ad
olescents is controversial, but suggests a need for close monitoring of suicidal ideation when such treatment is initiated. Finally, as noted in the discussion of psychotherapeutic approaches, the motivation of adolescents for treatment is quite variable, and a lack of motivation may compromise patients' compliance with following treatment recommendations, including taking psychotropic drugs as prescribed. For adolescents, compliance may be increased by family psychoeducation and parental involvement with treatment.
Pharmacological Treatments for Bulimia Nervosa
Antidepressant Medications
Virtually every class of antidepressant medication has been studied in placebo-controlled, double-blind trials for adult patients with bulimia nervosa. Antidepressant medications, including both TCAs and SSRIs, appear to have approximately equal efficacy in the acute treatment of bulimia nervosa; however, SSRI antidepressants are generally better tolerated and have fewer side effects (Zhu & Walsh, 2002), thus they are the first pharmacological treatment of choice for adults with bulimia nervosa. Specifically, the SSRI fluoxetine is the only drug approved by the U.S. Food and Drug Administration for the treatment of bulimia nervosa. It is most effective at a dose of 60 mg/day, significantly higher than the standard dose used to treat major depression. A recent open trial suggests that fluoxetine at this dose is well tolerated and may be useful for adolescents with bulimia nervosa (Kotler, Devlin, Davies, & Walsh, 2003). Newer selective noradrenergic/serotonergic reuptake inhibitors such as venlafaxine have not been systematically studied in treatment of bulimia nervosa. Although wide variability exists across studies, the rates of reduction in binge eating and vomiting with antidepressant treatment have ranged between 50% and 75% in controlled trials. A comprehensive review of the overall effectiveness of such studies (Agras, 1997) found a median reduction in binge eating and vomiting of about 70% and complete abstinence in about 30% of subjects. The mechanism of action of an
end p.293
PRINTED FROM Treating and Preventing Adolescent Mental Health Disorders (www.oup.com/amhi-treatingpreventing)
© Copyright Oxford University Press, 2006. All Rights Reserved
tidepressant medications in bulimia nervosa may be different from that in depression, as the response to antidepressant drugs in bulimia nervosa is independent of mood state; nondepressed bulimia nervosa patients respond equally as well as depressed bulimia nervosa patients to these drugs (Hughes, Wells, & Cunningham, 1986; Walsh, Hadigan, Devlin, Gladis, & Roose, 1991). Many patients with eating disorders are reluctant to use medication and a significant number of patients who initiate medication terminate treatment prematurely. In addition, despite convincing empirical evidence of efficacy in treating bulimia nervosa with antidepressant medications, residual symptoms persist in the majority of subjects treated with a single antidepressant medication (Nakash-Eisikovits, Dierberger, & Westen, 2002). Several studies have examined the effectiveness of a combination of antidepressant pharmacotherapy with psychotherapy, usually CBT, for adults with bulimia nervosa. A meta-analysis of controlled trials using combined treatments for bulimia nervosa (Nakash-Eisikovits et al., 2002) demonstrated that combined treatments are superior to medication alone, but the advantage of combined treatments over psychotherapy alone is small.
Experience with several novel pharmacological agents may hold promise for the development of other medications for bulimia nervosa. Both the antiobesity agent sibutramine and the anticonvulsant topiramate may be beneficial for the treatment of binge eating in adults (Appolinario et al., 2002; McElroy et al., 2003). The serotonin antagonist ondansetron, which is used for the treatment of chemotherapy-induced nausea and vomiting, has been found to be of use in the treatment of adults with refractory bulimia nervosa (Faris et al., 2000). However, much work will be required to extend these preliminary findings to the treatment of adolescents.
Despite the widespread use of psychotropic medications for adolescents with eating disorders,
there is little empirical information about the utility and safety of such interventions. Reports that atypical antipsychotic medications may be useful for adolescents with anorexia nervosa are encouraging but need to be examined in controlled trials. Antidepressant medications have been shown to be useful in the treatment of adults with bulimia nervosa, but studies are needed to assess their utility and safety for adolescents with bulimia nervosa.
Combined Treatments for Anorexia Nervosa and Bulimia Nervosa
Virtually all of the studies of acute pharmacological treatment for anorexia nervosa have been conducted in settings such as hospitals where patients receive psychological treatment in addition to medication. There have been no controlled trials examining the combination of psychological and pharmacological treatment for anorexia nervosa. Given the dearth of evidence that medication is useful in the treatment of anorexia nervosa, it is not possible to draw any conclusions about the potential utility of combined treatments. For adults with bulimia nervosa, studies suggest that the addition of antidepressant medication to psychotherapy leads to a small but detectable increase in improvement of bulimic symptoms (Walsh et al., 1997). There have been no controlled studies of combined treatments in adolescents with bulimia nervosa.
PREVENTION OF RELAPSE WITH PSYCHOLOGICAL TREATMENTS
Relapse prevention, as initially formulated by Marlatt and colleagues, was conceptualized as a maintenance therapy for individuals who had completed initial treatment and had achieved a certain measure of symptomatic recovery (Brownell, Marlatt, Lichtenstein, & Wilson, 1986; Marlatt & Gordon, 1985). The prevention of relapse among anorexia nervosa and bulimia nervosa patients is an essential goal and an integral step in the course of recovery. Standardized definitions of relapse, or uniform goals of relapse pre
end p.294
doi:10.1093/9780195173642.003.0015
|
|
|
|
