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Comorbidity of mental disorders and substance use: a brief guide for the primary care clinician

9.4 Major clinical issues with eating disorders and alcohol use

Table of contents

Alcohol is one of the most commonly used substances amongst people with eating disorders, in particular, those with purging behaviours.
Alcohol can exacerbate the sedative effects of some antidepressants such as tricyclics and mirtazepine, which may be used in the management of some eating disorders.
Alcohol dependence and the eating disorders need to be addressed in an integrated manner.
CBT is effective for treatment of eating disorders (in particular bulimia) and there is no evidence that alcohol dependence affects the efficacy of CBT negatively.
Assistance with stress management (structured problem solving, coping skills therapy) has been found to be effective in the treatment of alcohol use and is useful for people with eating disorders.

9.4.1 Effects of alcohol on eating disorders

Alcohol is one of the most commonly used substances amongst people with eating disorders, in particular, those with the purging behaviours^{(341, 351, 352)}.
People with bulimia or bingeing/purging behaviours have higher rates of alcohol use than people with anorexia (up to twice as likely in people with the restrictive type of anorexia) and control groups without eating disorders^{(341, 346, 349-351, 354, 355, 362, 363, 370, 371)}.
People with anorexia have reported avoiding alcohol to prevent weight gain from the calories it contains⁽³⁴¹⁾.
The majority of people affected by eating disorders and alcohol-use disorders report that the eating disorder developed first⁽³⁶³⁾. This may explain the fact that eating disorder symptoms (vomiting and exercise) seem to be predictive of the course of alcohol-related problems in people with comorbid alcohol use and eating disorders⁽³⁵⁷⁾.
People with both bulimia and alcohol dependency have higher rates of self-harm, and borderline personality disorders, and poorer outcomes than those without alcohol-related problems^{(370, 371)}.

Alcohol can exacerbate the sedative effects of some antidepressants such as tricyclics and mirtazepine which may be used in the management of some eating disorders. Alcohol toxicity and risk of overdose may occur through the inhibition of CYPs involved in the metabolism of alcohol^x(133).
Interactions between antidepressants and acamprosate used to treat alcohol dependence are minimal as are interactions between antidepressants and disulfiram and naltrexone also used to treat alcohol dependence^x(134).

Alcohol dependence and the eating disorder need to be addressed in an integrated manner^{(3, 372)}.
Antidepressants have been shown to reduce depressive symptoms and alcohol consumption in depressed people with alcohol dependence***⁽¹³⁰⁾. However, there have been no specific studies of the role of SSRIs in people with eating disorders and alcohol dependence.
CBT is effective for treatment of eating disorders (in particular bulimia)****^{(343, 344)}. There is no evidence that alcohol dependence affects the efficacy of CBT negatively. However, no available studies have reported effectiveness of CBT in managing alcohol use and eating disorders^{(3, 372)}.
Naltrexone has been shown to be effective in the treatment of alcohol dependence ****^{(141, 235, 236)} and in early studies shows some efficacy in reducing bingeing/purging behaviours^{(3, 372)}. However, it has not been rigorously tested for the combination of eating disorders and alcohol use^{(372, 373)}.
Assistance with stress management (structured problem solving, coping skills therapy) has been found to be effective in the treatment of alcohol use, is useful for people with eating disorders and can be easily integrated with pharmacological approaches⁽³⁾.