This newsletter summarizes the updates of the American Psychiatric Association guidelines for treating patients with eating disorders, including recommendations for the initial and medical evaluations and for treating each eating disorder type.
We also discuss practical aspects of antipsychotic switching, key points from a presentation on parasomnias triggered by sedative-hypnotics, and our practical research summaries of adult, child, and adolescent psychiatry (Quick Takes and CAP Smart Takes).
An Update on APA Guidelines for Treating Eating Disorders
On February 1, 2023, the American Psychiatric Association published the fourth edition of the practice guidelines for treating patients with eating disorders, including 16 clinical recommendations, which begin with screening for an eating disorder as part of an initial psychiatric evaluation.
Guidelines focus exclusively on anorexia nervosa, bulimia nervosa, and binge-eating disorder. You can learn more here.
Summary of the current recommendations
Initial Evaluation of Eating Disorders:
- Height and weight history
- Eating-related behaviors
- Food repertoire
- Weight control behaviors
- Preoccupation with food, weight, and body shape
- Treatment history
- Psychosocial impairment related to eating or body image concerns/behaviors
- Family history of eating disorders, other psychiatric illnesses, and other medical conditions
Medical Evaluation of Eating Disorders:
- Co-occurring health conditions and psychiatric disorders
- Physical exam (i.e., vital signs, BMI, and signs of malnutrition or purging behaviors)
- Laboratory tests (i.e., CBC and comprehensive metabolic panel)
ECG Is Recommended for:
- Patients with a restrictive eating disorder
- Patients with severe purging behavior
- Patients on medications that prolong QTc intervals
Treatment Recommendations for:
- Anorexia nervosa:
- Individualize goals for weekly weight gain and target weight.
- Include eating disorder–focused psychotherapy.
- Include caregivers in an eating disorder–focused family-based treatment.
- Bulimia nervosa:
- Include eating disorder–focused cognitive–behavioral therapy.
- Use an SSRI, either initially or if there is minimal or no response to psychotherapy alone by 6 weeks of treatment.
- Include caregivers in an eating disorder–focused family-based treatment.
- Binge-eating disorder:
- Indicate eating disorder–focused cognitive–behavioral or interpersonal therapy (individual or group format).
- Use an antidepressant or lisdexamfetamine when patients prefer medications or do not respond to psychotherapy.
You can read the full guideline here.
Antipsychotic Switching: The Intersection of Art and Science, With Brian Miller, M.D.
In this interview, Dr. Brian Miller discusses practical considerations of the practice of antipsychotic switching. He tackles common concerns regarding switch-related adverse effects and tapering schedules and addresses questions about switching between specific antipsychotics.
Interview highlights include the following:
- The cross-taper switch is the most commonly employed and safest method of switching antipsychotics.
- An abrupt switch is indicated if the patient is experiencing severe adverse effects from a psychotropic medication, whereas a plateau cross-taper may be more advisable when switching to clozapine.
Learn more and earn 0.5 CME credits here.
Parasomnias Triggered by Sedative-Hypnotics: Sleepwalking and Sleep-Related Eating Disorder
Dr. Schenck, the career-long sleep disorders expert, brings to light non-REM sleep complex behaviors, which are often missed but strongly impact the lives of our patients. He discusses sleep-related eating disorder (SRED), sleepwalking, and sleep driving, while focusing on psychotropic medications associated with the occurrence of pathological behaviors during sleep. Dr. Schenck also presents a risk profile backed by clinical studies from around the world and personal research. The picture is completed by laboratory video recordings of sleepwalking and SRED.
Zolpidem-Induced Sleepwalking and SRED
- Zolpidem can induce de novo SRED.
- Females taking higher doses of zolpidem and other psychotropic medications are the most vulnerable patients.
- The risk of zolpidem-induced SRED increases with complex clinical scenarios.
- There is an FDA warning regarding complex sleep behaviors induced by insomnia medications.
- Get a family history and a personal history for parasomnia before prescribing zolpidem.
Learn more and earn 0.5 CME credits here.
Quick Takes: Research, Digested
C-Reactive Protein Could Predict the Efficacy of SSRIs in Clinical Practice
- The abstract and psychiatric newsletter review of this article suggest that patients with a CRP level of 1 or higher have better outcomes with an SNRI than with an SRI.
- This is true only after statistical adjustment for confounding factors and may not be clinically significant; but because the study is a retrospective chart review using the Clinical Global Improvement Scale, it lacks strength as a guide for a major change in clinical practice—especially consideration of early use of higher risk antidepressants (withdrawal severity). Learn more.
Listen to or read the full volume, and earn 0.5 CME credits here.
CAP Smart Takes: Research, Digested
Ketamine for Adolescent Depression
- Ketamine therapies can offer rapid relief of depression and an antisuicidal effect, making them of particular interest for adolescents with treatment-resistant depression.
- In 1 randomized, double-blind study of adolescents with severe major depression, ketamine had a strong effect size for reducing depressive symptoms 24 hours after infusion.
- Currently, there are few studies on the use of ketamine in treatment-resistant adolescents with depression. Learn more.
Listen to or read the full volume, and earn 0.5 CME credits here.
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References
- Crone, C., Fochtmann, L. J., Attia, E., Boland, R., Escobar, J., Fornari, V., Golden, N., Guarda, A., Jackson-Triche, M., Manzo, L., Mascolo, M., Pierce, K., Riddle, M., Seritan, A., Uniacke, B., Zucker, N., Yager, J., Craig, T. J., Hong, S. H., & Medicus, J. (2023). The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders. The American Journal of Psychiatry, 180(2), 167–171.
- American Psychiatric Association. (2023). The American psychiatric association practice guideline for the treatment of patients with eating disorders (4th ed.). American Psychiatric Pub.
