Psychological features of BED typically include low levels of cognitive restraint and high levels of disinhibition, hunger, and shape and weight concerns. Improvements in these psychological measures were observed with CBT,15-20,22 IPT,22 and MI.24 In direct comparisons, self-help CBT demonstrated greater reductions in perceived hunger and disinhibition than self-help BWL,18 and individual CBT outperformed group CBT in reducing shape and weight concerns.19 Isolated studies reported improvements in depression after self-help CBT18 and MI,24 and sustained improvements22 after group CBT (6 months) and group IPT (12 months). Additional research is needed to determine whether CBT crafted specifically for BED improves self-rated depression or if enhancements targeting depressive symptoms are required.
The impact of behavioral interventions on weight in overweight patients has been mixed. Although some CBT studies reported a substantial decrease in weight,17,19 others suggested that weight loss among patients treated with CBT is not superior to those in a wait-list control group16 or is not significant over the course of treatment.20,21 The impact of BWL on weight outcomes in BED also has been unimpressive: after 12 weeks, self-help BWL was no better than self-help CBT in reducing BMI18; after 16 weeks, BWL was better than CBT and IPT in achieving clinically significant (≥5%) weight loss, but this advantage was not sustained at 1- and 2-year follow-up.23 It is difficult to determine why successfully treated BED patients fail to lose weight because one would expect decreases in binge eating to lead to weight loss. It is possible that calories previously consumed during binge eating episodes are distributed over non-binge meals or that patients label binges and non-binge meals differently as a result of treatment.
Combining treatments
BED patients often are treated with a combination of psychotherapy and pharmacotherapy (Table 4).25-29 When added to CBT, topiramate was associated with improvements in weight and some psychological outcomes,25,26 but fluoxetine was not.27,28 Direct comparisons also showed that CBT, alone or combined with fluoxetine, was better than fluoxetine alone in reducing binge eating.27 When combined with an individualized hypocaloric diet, the anti-obesity medication orlistat reduced weight in obese BED patients but had no appreciable effect on binge eating.29 Collectively, the studies we reviewed suggested that combining medication and CBT may improve binge eating and weight loss outcomes; however, additional trials are necessary to determine more definitively which medications combined with CBT are best at producing sustained weight loss while reducing binge eating frequency.
Table 4
Combining medication with behavioral interventions for BED
| Study | Drug/dosage | Comments |
|---|---|---|
| Brambilla et al, 200925 | 3 groups treated for 6 months: Group 1: CBT + setraline (50 to 150 mg/d) + topiramate (25 to 150 mg/d) + reduced calorie diet Group 2: CBT + sertraline (50 to 150 mg/d) + reduced calorie diet Group 3: CBT + nutritional counseling | Weight, BMI, and psychological features of BE reduced significantly only in group 1 |
| Claudino et al, 200726 | Group 1: CBT + topiramate (25 to 300 mg/d) Group 2: CBT + placebo 19 sessions over 21 weeks | Significant reductions in BE and depression in both groups; topiramate significantly better than placebo in reducing weight and in achieving BE remission |
| Devlin et al, 200527 | 4 groups, all received behavioral weight control intervention for 5 months (20 weeks) plus either: Group 1: CBT + fluoxetine Group 2: CBT + placebo Group 3: fluoxetineGroup 4 placebo (fluoxetine dose, 20 to 60 mg/d) | CBT groups (1 and 2) significantly better than non-CBT groups (3 and 4) in reducing BE and achieving abstinence from BE; fluoxetine significantly better than placebo in reducing depression |
| Molinari et al, 200528 | 3 groups, all received nutritional and diet counseling for 54 weeks (4 were inpatient) plus: Group 1: CBT Group 2: fluoxetine (20 to 60 mg/d) Group 3: CBT + fluoxetine | At 12 months, CBT (groups 1 and 3) associated with lower BE frequency and greater percentage of weight loss than fluoxetine |
| Golay et al, 200529 | Hypocaloric diet + orlistat (120 mg/d) vs hypocaloric diet + placebo for 24 weeks | Orlistat not different from placebo in reducing the number of patients classified with BED; orlistat significantly better than placebo in reducing weight and body fat |
| BE: binge eating; BED: binge eating disorder; BMI: body mass index; CBT: cognitive-behavioral therapy | ||
Recommendations
Evidence suggests that pharmacotherapy and CBT—alone or in combination—are effective in reducing binge eating, and pharmacotherapy is effective in reducing weight in overweight individuals with BED. More research is needed for IPT and MI. It is unclear which medications provide the greatest benefit in terms of binge eating remission; however, pharmacotherapy has a clear advantage in facilitating short-term weight loss. Also, all BED patients should receive medical management to address possible complications such as hypertension or type 2 diabetes. In addition to reducing binge eating, CBT can improve related psychological comorbidities (eg, eating-related psychopathology and depression) and may have additional benefit when combined with pharmacotherapy.