New research suggests that psychedelics, and specifically ketamine, can increase neuroplasticity to help a patient with an eating disorder get “unstuck,” and help treat the disorder better than psychotherapy alone.
Reid Robison, MD, a leading figure in the field of psychedelic-assisted psychotherapy, discusses eating disorders with Pharmacy Times. Dr. Robison explains an eating disorder versus disordered eating, who is commonly affected, and barriers that believes prevent clinics from providing the best possible care.
Q: What classifies an eating disorder, and what does traditional treatment look like?
Reid Robison, MD: There are eating disorders, and then there's disordered eating that affects so many people. So, full blown eating disorders are estimated to affect over 30 million Americans, who are living with an eating disorder- examples are anorexia, bulimia, binge eating disorder and others. In fact, they are (I think) the third most common chronic illness among adolescent females. But the COVID-19 pandemic seems to have increased this prevalence and highlighted the need for treatment. And we've seen the incidence of eating disorders among certain populations rise by 10 or 20% or more in recent years. And in some studies, the people seeking treatment has even doubled. Eating disorders are complex illnesses with biological, societal, cultural, and environmental components- the stakes are high. And there's an urgency because some of them also have a high mortality rate coming with them.
Q: Did the COVID-19 pandemic affect this illness?
Reid Robison, MD: I think it parallels the increases that we've seen in depression, anxiety, and substance use. It's like it was a great kind of shake up and trigger for our underlying mental health vulnerabilities. And also, with the isolation that came along with it, it seemed to have there seems to have been a magnifying glass that was put on these conditions- and the urgent need for treatment that comes along with it.
Q: In your opinion, what are current barriers to treating this disorder? Especially amongst younger females?
Reid Robison, MD: These are serious, and worldwide it is estimated that 1 person dies every hour as a direct result of an eating disorder. And eating disorders do have the highest mortality rate of any mental health illness. Yet, conditions like anorexia nervosa don't have any FDA approved medications as options to treat them. We have therapies, but there's also so much work to be done. And the barriers to treatment are tricky ones. There are our culture and society components, and also socioeconomic factors, at play. So, in terms of culture and society, the best known environmental contributor to developing an eating disorder is what you could call the "thin beauty ideal" or the societal cultural idealization of fineness. That is both very deeply ingrained and hard to shake.It's everywhere. By age 6, we're seeing young girls start to express concerns about their own weight or shape. Over half of elementary school girls, say, admit concerns about their weight or becoming too fat. This is an enduring, enduring thing. And then you combine that with both the stigma that has been there for decades around seeking mental health help. A challenge we have is eating disorders with early recognition. To give you an example, if you had cancer, for example, you'd never know, never imagined the doctor or the health system saying, 'Okay, your cancer is at stage 1, why don't you come back when it's stage 2 or 3.' Yet that has been done with people with eating disorders. These are serious conditions. Early intervention is so helpful yet, when people do come in, it's either not recognized or there's this message from the system (often the health insurance company) saying you're not sick enough. You need to come back when there's more weight loss or or when there are, you know, more medical consequences. But, you know, I really believe that we need a sense of urgency about them- in terms of recognizing and treating eating disorders.
Q: That is pretty harrowing that such young individuals are expressing these issues...
Reid Robison, MD:It is tricky because on the one hand, there are concerns about obesity and the medical and mental health consequences of that. But on the other hand, you have this diet culture that is a big contributor to eating disorders in over half of teens. Female teens diet regularly and those who do diet are at least 10 times more likely to engage in binge episodes. It's estimated that a third of people who diet progress onto what would be called 'disordered eating' or 'pathological dieting'. And maybe upwards of 25% go on to develop full blown eating disorders.
Q: What is the significance of ketamine for current psychotherapy treatments?
Reid Robison, MD: In eating disorders, you need to have some self-awareness inserted into the mix. People don't choose eating disorders. No one wakes up and says, 'I'd like to have anorexia.' Or if someone says that, that's not what they mean or they are seriously misinformed. They are not choices, they're biologically influenced illnesses. And so we need interventions that aren't just kind of band aid approaches to treating symptoms, like numbing out anxiety. We need to get underneath the hood of these complex, multifaceted illnesses. And if there is an underlying anxiety disorder, we need to go for that root cause. If there's trauma contributing, we need to do some trauma healing. And these are (can be) serious illnesses that require intensive treatment. But on the positive side (thankfully), even deeply ingrained patterns and behaviors (they're learned) that can be unlearned. It just takes time. And with psychedelic medicines being 'therapy accelerators,' if you will, these become important tools in helping the individual see with a new perspective, and also creating more cognitive flexibility around one's relationship with food and body- and perhaps the patterns, behaviors, and rules that they imposed on themselves around food and eating. So from an eating disorder standpoint, as I mentioned, they're not choices- they're well-intended. The reason someone develops the disorder and keeps it are very different. So there may be a conscious decision to decide to purge, or restrict, or over-exercise the first time or 2, but then they become a subconscious pattern that takes on a life of its own. Psychedelic medicines are more and more understood to relax the grasp that these patterns have on us by creating a, what you could call, a window of neuroplasticity- where things can be both seen more clearly and shaped. And this applies to ketamine, as well as classic psychedelics like psilocybin, for example. Mind you, there's more. There's much more research that needs to be done to understand fully how psychedelics may help and the best ways of pairing them with therapy. But we are already seeing in early research that psychedelics can come in with this different approach. With that new perspective and that flexibility can help someone get unstuck, who might have been in a stuck place for years.