Thursday, June 15, 2006

Prozac Doesn't Get Anorexics Eating Again

Joseph from Corpus Callosum reported on a recently published study that demonstrated that fluoxetine (Prozac) does nothing to treat anorexic patients. Joseph points out that one problem with this study is that all of the patients were also receiving cutting edge Cognitive Behavior therapy, hence making it hard to determine whether or not giving fluoxetine to patients who do not have access to such therapy will be improved by taking Prozac.

What was of particular interest to me in Joseph's post was the following:

Often, for patients with anorexia, an antidepressant might be recommended, not to help maintain weight, but to treat anxiety and/or depression.

Could it be that the study showed no benefit in maintaining body weight, but that patients benefited in other ways? Maybe they experienced improvement in depression or anxiety, or overall quality of life.

It turns out that the authors looked at all of that. The only benefit they found was in a reduction of anxiety, as assessed by the Beck Anxiety Inventory. Depression did not improve, and quality of life (as measured by the Quality of Life Enjoyment and Satisfaction Questionnaire) did not improve.

So, although anxiety scores declined, if that is the only benefit, and overall quality of life did not improve, I would have to agree with the conclusion that the medication simply did not help these people.

What intrigues me about this finding--that the fluoxetine did some good in reducing anxiety levels--is how the researchers tease out anxiety from depression. I am not disagreeing with the distinction between depression and anxiety, in principle, but I just think in practice it is hard to figure out what sort of mood disorder a patient has (yes, I am an armchair Psychiatrist, so you shouldn't listen to me!) In obvious cases, depression looks very different from anxiety. The depressed person is totally immobilized, hopeless, guilt-ridden, while the anxious person is often moving a mile a minute, worrying over every little thing and unable to sit still and relax. The depressed person cannot get going, the anxious person cannot stop going.

Alas, these are just some phenomenological observations. So, given how differently I perceive these disorders, an anxious depressed person (with anorexia to boot!) has got to be hard to diagnose well. Hence, this is why I am intrigued that the fluoxetine can treat just the anxiety without touching the depression.

In fact, this confirms my view that SSRIs, particularly fluoxetine, are not very good at treating depression, that is Major Depression. They are much better at taking the edge off of anxiety in patients that are not really depressed, but have low self-esteem or constitutionally fearful of change.

I would imagine that anorexics are often quite anxious and their eating disorder is a manifestation of a desire to exert some control over their unruly self, if they cannot control the world. (Perhaps I sound too psychoanalytic here?). Anyway, the ability for a drug compound to effectively turn down the internal amplifier (one of Peter Kramer's metaphors) and thereby lessen the anxiety of non-depressed patients (who for whatever reason turn out to be women) is such an interesting technological development. While it does seem to do little to help really sick people (i.e. MDD or anorexics), it does help neurotic chicks chill out a bit.