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Cognitive Behavioral Therapy Should Be First-Line Treatment Approach for Binge Eating

Janis C. Kelly

January 11, 2010 — The first randomized controlled trial to compare psychological treatments for binge eating disorder shows that, for most patients, guided self-help based on cognitive behavior therapy (CBTgsh) should be considered first-line treatment.

The study, led by G. Terence Wilson, PhD,Rutgers, The State University of New Jersey, Piscataway, compared 2-year results with CBTgsh, behavioral weight loss treatment (BWL), and interpersonal psychotherapy (IPT) in 205 patients with a body mass index (BMI) between 27 and 45 who met Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for binge eating disorder. The main outcome variable was binge eating, assessed by the Eating Disorder Examination (EDE) semistructured interview.

Study coauthor W. Stewart Agras, MD, Stanford University School of Medicine, California, told Medscape Psychiatry that from the clinician's viewpoint, it would be reasonable to conclude that for most binge eating disorder patients, CBTgsh should be first-line treatment.

"The fact that a guided self-help treatment was as effective as IPT at the end of treatment and at 2-year follow-up [was a surprise]," Dr. Agras said. "This simpler therapy could be more easily disseminated than IPT."

The study is published in the January issue of Archives of General Psychiatry.

Significant Reduction

Subjects were randomized to 20 sessions of BWL, 20 sessions of IPT, or 10 sessions of CBTghs. BWL was delivered by master's-level therapists in clinical psychology or nutrition. IPT was delivered by doctoral-level PhD or PsyD therapists.

CBTghs was delivered by first- or second-year graduate students with no experience in CBTgsh or in treating binge eating disorder, who had been trained in a 3-hour workshop using manualized treatment based on Christopher G. Fairburn's book, Overcoming Binge Eating.

Participants' self-esteem was assessed using the Rosenberg Self Esteem Scale and binge eating severity using the EDE.

At 2-year follow-up, binge eating had decreased significantly in the IPT and CBTgsh groups, but not in the BWL group. Patients with low self-esteem and those with both low self-esteem and more severe binge eating did particularly poorly with BWL treatment.

IPT subjects with low self-esteem did as well as those with high self-esteem, regardless of binge eating severity. CBTgsh was equally effective in those with less severe binge eating regardless of whether they had high or low self-esteem.

Convincing Data

"From a clinical viewpoint, we have not established a cut point for self-esteem/more severe eating disorder. One way to proceed would be to begin with the cheapest treatment CBTgsh, and if that did not work, use IPT or alternatively go straight to IPT for more severe binge eating disorder," said Dr. Agras.

"I don't think that it tells us much about binge eating disorder, but the fact that a cheaper treatment is as good as a full-blown treatment is of great interest," Dr. Agras said. "For binge eating disorder weight loss is associated with less binge eating, but it appears that weight gain after the loss is associated with relapse."

Commenting on the findings, Albert J. Stunkard, MD, professor of psychiatry in the Weight and Eating Disorders Program at the University of Pennsylvania in Philadelphia, said the data are convincing.

"The authors' conclusion that guided self-help based on cognitive behavior therapy should be the first line of treatment for most patients with binge eating disorder is a reasonable conclusion from their data, and I do not know of any conflicting findings."

The study was supported by the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Arch Gen Psychiatry. 2010;67:94-101.


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