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NEDA TOOLKIT for Parents Several different antidepressants may have to be tried sequentially to identify the specific medication with the optimum effect [I]. Clinicians should attend to the black box warnings relating to antidepressants and discuss the potential benefits and risks of antidepressant treatment with patients and families if such medications are to be prescribed [I]. Small controlled trials have demonstrated the efficacy of the anticonvulsant medication topiramate, but because adverse reactions to this medication are common, it should be used only when other medications have proven ineffective [III]. Also, because patients tend to lose weight on topiramate, its use is problematic for normal or underweight individuals [III]. Two drugs that are used for mood stabilization, lithium and valproic acid, are both prone to induce weight gain in patients [I] and may be less acceptable to patients who are weight preoccupied. However, lithium is not recommended for patients with bulimia nervosa because it is ineffective [I]. In patients with co- occurring bulimia nervosa and bipolar disorder, treatment with lithium is more likely to be associated with toxicity [I]. iii. Combining Psychosocial Interventions and Medications In some research, the combination of antidepressant therapy and CBT results in the highest remission rates; therefore, this combination is recommended initially when qualified CBT therapists are available [II]. In addition, when CBT alone does not result in a substantial reduction in symptoms after 10 sessions, it is recommended that fluoxetine be added [II]. iv. Other Treatments Bright light therapy has been shown to reduce binge frequency in several controlled trials and may be used as an adjunct when CBT and antidepressant therapy have not been effective in reducing bingeing symptoms[III]. 5. Eating Disorder Not Otherwise Specified Patients with subsyndromal anorexia nervosa or bulimia nervosa who meet most but not all of the DSM-IV-TR criteria (e.g., weight >85% of expected weight, binge and purge frequency less than twice per week) merit treatment similar to that of patients who fulfill all criteria for these diagnoses [II]. a. Binge Eating Disorder i. ii. Nutritional Rehabilitation and Counseling Maintenance Phase Limited evidence supports the use of fluoxetine for relapse prevention [II], but substantial rates of relapse occur even with treatment. In the absence of adequate data, most clinicians recommend continuing antidepressant therapy for a minimum of 9 months and probably for a year in most patients with bulimia nervosa [II]. Case reports indicate that methylphenidate may be helpful for bulimia nervosa patients with concurrent attention- deficit/hyperactivity disorder (ADHD) [III], but it should be used only for patients who have a very clear diagnosis of ADHD [I]. Behavioral weight control programs incorporating low- or very-low-calorie diets may help with weight loss and usually with reduction of symptoms of binge eating [I]. It is important to advise patients that weight loss is often not maintained and that binge eating may recur when weight is gained [I]. It is also important to advise them that weight gain after weight loss may be accompanied by a return of binge eating patterns [I]. Various combinations of diets, behavior therapies, interpersonal therapies, psychodynamic psychotherapies, non-weight-directed psychosocial treatments, and even some “non-diet/health at every size” psychotherapy approaches may be of benefit for binge eating and weight loss or stabilization [III]. Page | 54