Second generation antipsychotics in adolescent anorexia nervosa: a new hypothesis of eligibility criteria.

Abstract

[Author Affiliation]Simone Pisano. 1 Department of Mental and Physical Health and Preventive Medicine, Child and Adolescent Psychiatry Division, Second University of Naples, Naples, Italy.Gennaro Catone. 1 Department of Mental and Physical Health and Preventive Medicine, Child and Adolescent Psychiatry Division, Second University of Naples, Naples, Italy.Antonio Pascotto. 1 Department of Mental and Physical Health and Preventive Medicine, Child and Adolescent Psychiatry Division, Second University of Naples, Naples, Italy.Antonella Gritti. 2 Faculty of Education Sciences, Department of Scienze Formative, Psicologiche e della Comunicazione, Suor Orsola Benincasa University, Naples, Italy.Address correspondence to: Pisano Simone, MD, Department of Mental and Physical Health and Preventive Medicine, Child and Adolescent Psychiatry Division, Second University of Naples, Via Pansini 5, 80100 Naples, Italy, E-mail: pisano.simone@gmail.comTo The Editor:Two rigorous meta-analyses have recently shed a new light on the use of second generation antipsychotics (SGA) in anorexia nervosa (AN) (Kishi et al. 2012; Lebow et al. 2013). Both agree that SGA are not superior to placebo regarding weight recovery, and some dimensions of psychopathology (specifically, drive for thinness and body dissatisfaction). One of these even recognized a higher level of anxiety and overall eating disorder (ED) psychopathology in SGA groups than in placebo groups (Lebow et al. 2013). On the other hand, patients treated with SGA experienced more sedation/somnolence. It has to be said that the two meta-analyses described only included placebo-controlled trials. Moreover, authors agree that all included studies were limited by low sample sizes and some methodological limitations. Studies involving children and adolescents are rare and, at the moment, only one placebo-controlled trial exists for olanzapine and one (with mixed population) exists for risperidone (limiting the possibility to extract meta-analytic data from this specific population), both without encouraging results (Hagman et al. 2011; Kafantaris et al. 2011). This is at the same time intuitive, because it is undoubtedly harder to perform placebo-controlled studies in younger populations (for ethical and technical reasons), but also challenging, because it is well known that the more frequent period of onset is adolescence, and that early-onset ED could be even harder to treat than late-onset ones. Difficulties in psychopharmacology research for AN are well explained in a recent articles, which described the large amount of resources spent to plan and to start a placebo-controlled trial that is never concluded (Norris et al. 2010). Despite these findings, psychotropic drugs in AN are widely used off label, and SGA are the most used class. Rationales for using SGA could be that body misperception is believed to be a body-focused delusional thought, or that the weight gain often occurring during SGA exposure could be exploited. Moreover, SGA use fits well with some neurobiological models of AN, focusing on monoamine dysfunction (Kishi et al. 2012). It is particularly challenging to understand why SGA are being more and more used (Fazeli et al. 2012), given their side effects, such as metabolic and hormonal disturbances, extrapyramidal side effects (EPS), somnolence, and hypotension, all occurring mainly at beginning of treatment, and potentially threatening the therapeutic alliance. In this article, we will present clinical data from a set of AN adolescents, followed up naturalistically for at least 6 months, who were much improved after adding olanzapine to usual clinical management. Data will specifically focus on baseline characteristics of these patients in order to drive a hypothesis regarding which kind of adolescent AN patients could improve with psychotropic medications.Clinical DataWe present a set of data, retrospectively collected, of five AN adolescent patients treated with olanzapine followed up for 6 months (four restrictive, one binge/purging subtype). …