Dr. Powers is professor of psychiatry in the Department of Psychiatry and Behavioral Medicine at the University of South Florida in Tampa.
Disclosure: Dr. Powers receives grant and/or research support from AstraZeneca and Eli Lilly.
Please direct all correspondence to: Pauline S. Powers, MD, Department of Psychiatry and Behavioral Medicine, University of South Florida, 3515 E Fletcher Ave, Tampa, FL 33613; Tel: 813-974-2926; Fax: 813-974-2882; E-mail: firstname.lastname@example.org.
The practicing clinician is frequently inundated with information about the latest research findings in eating disorders and is expected to integrate these findings into a coherent, effective treatment plan for patients. This concept of “evidenced-based medicine” has been widely accepted as a standard for practice, but the practical meaning of this term is not always clear. One exacting definition for evidence-based medicine is a treatment that has been scientifically validated by randomized controlled trials. At present, very few, if any, treatments for eating disorders meet this criterion. A more practical definition of evidence-based medicine proposed by Jenicek1 states that evidence-based medicine is the systematic process of finding, appraising, and using contemporaneous research findings as the basis for clinical decisions. The goal of the “Clinical Focus” articles in this issue of Primary Psychiatry is to help the practicing clinician understand and utilize the current research in eating disorders and to evaluate future research.
In the first article, Yvonne S. Bannon, BSN, MSHS, describes key terms that are used in clinical research, some of which have very specific idiosyncratic meanings (eg, “adverse events” are not equivalent to “side effects”). The investigational phases through which drugs must pass to obtain Food and Drug Administration approval are also described. The very real barriers to translating research into clinical practice are explained, including the fact that patients selected for clinical trials are frequently very different from patients who present for treatment in a clinical setting. Innovative ways of addressing this issue include evidence-based research centers (or network groups) that replicate research in actual clinical settings. The author concludes by discussing the use of various semi-structured interviews and questionnaires that are utilized in research and how they might be fruitfully integrated into clinical practice.
In the next article, Pauline S. Powers, MD, and colleagues examine research findings that suggest that some patients with anorexia nervosa may have psychotic symptoms. They propose that the next version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) should include a severity modifier for anorexia nervosa termed “Severe with Psychotic Features,” which would indicate the presence of either delusions or hallucinations consistent with weight, food, and shape themes. The current data available on the use of typical and atypical antipsychotics for anorexia nervosa is summarized along with cautions about the very preliminary nature of the research data thus far available. A practical guide to determine if use of antipsychotics is appropriate in the clinical situation is provided.
Although binge-eating disorder (BED) is not yet an official diagnosis in the DSM-IV-TR,2 it is not a new condition. Stunkard3 first described this symptom complex in obese patients who were often treatment resistant. In the last decade, there has been a much greater interest in this disorder, since it is more common than the other eating disorders and its successful treatment might mean that some progress could be made toward resolving part of the obesity epidemic. David S. Husted, MD, and Nathan A. Shapira, MD, PhD, describe characteristic features of BED and outline common comorbid medical and psychiatric conditions. The current treatment recommendations, as well as the pharmacologic treatments that have been investigated, including antidepressants, anticonvulsants, and appetite suppressants, are reviewed. Here again, the authors emphasize the need for further research to adequately determine the efficacy of psychotropic medications in the management of BED.
Although knowledge about the treatment of adults with eating disorders is still very limited, the clinical research in child and adolescent eating disorders is even more limited. In their article, Mae S. Sokol, MD, and colleagues discuss this problem and possible solutions for it. The classification system for adults with eating disorders frequently does not apply to children and adolescents. Because children are at different stages of development, cognitive and perceptual disturbances are difficult to evaluate. Sokol and colleagues describe the Great Ormond Street criteria developed for prepubertal children with eating disorders. These criteria offer promise in identifying groups of children with similar symptom complexes. The authors note that the treatments for children are based primarily on expert opinion or consensus guidelines rather than formal research findings. As with the other authors, this group advocates for additional research to help guide treatment for very young patients with eating disorders who may be at even greater medical risk of complications than older patients.
These articles highlight the need for further research and examine ways of ensuring that current information is useful for practicing clinicians. Although knowledge of eating disorders is still limited, guidelines exist for assessing what is known and for making clinical decisions. Jenicek,1 for example, has outlined the steps in evidence-based medicine: when a patient with an eating disorder is seen in the clinic, the practitioner should formulate the question about the patient’s problem that needs to be answered, search the literature, appraise the quality of the evidence (including the limitations), and select the best or most useful findings. Then, this information must be linked with the physician’s clinical experience and the patient’s values and preferences. The agreed-upon plan is then implemented and the effectiveness of the intervention needs to be routinely evaluated. Although research has not provided the answers to many important questions about eating disorders and clinicians routinely lack needed information, research has provided tools (including structured interviews and questionnaires) for evaluating clinical strategies that, if used routinely, are likely to improve clinical practice. PP
1. Jenicek M. Foundations of Evidence-Based Medicine. Boca Raton, FL: Parthenon Publishing; 2002:15-44.
2. Diagnostic and Statistical Manual of Mental Disorders. 4th ed text rev. Washington, DC: American Psychiatric Association; 2000.
3. Stunkard AJ. Eating patterns and obesity. Psychiatr Q. 1959;33:284-294.