Hostname: page-component-745bb68f8f-kw2vx Total loading time: 0 Render date: 2025-02-04T17:28:06.202Z Has data issue: false hasContentIssue false
  • English
  • Français

Efficacy of psychotherapies and pharmacotherapies for Bulimia nervosa

Published online by Cambridge University Press:  05 December 2018

Jennifer Svaldi ,
Florian Schmitz ,
Julia Baur ,
Andrea S. Hartmann ,
Tanja Legenbauer ,
Charlotte Thaler ,
Jörn von Wietersheim ,
Martina de Zwaan  and
Brunna Tuschen-Caffier
Jennifer Svaldi*
Affiliation:
Department of Clinical Psychology and Psychotherapy, University of Tübingen, Schleichstrasse 4, 72076 Tuebingen, Germany
Florian Schmitz
Affiliation:
Department of Individual Differences and Psychological Assessment, Ulm University, Albert-Einstein-Allee 47, 89081 Ulm, Germany
Julia Baur
Affiliation:
Department of Clinical Psychology and Psychotherapy, University of Tübingen, Schleichstrasse 4, 72076 Tuebingen, Germany
Andrea S. Hartmann
Affiliation:
Department of Clinical Psychology and Psychotherapy, Osnabrück University, Knollstrasse 15, 49069 Osnabrück, Germany
Tanja Legenbauer
Affiliation:
LWL University Hospital Hamm for Child and Adolescent Psychiatry, Psychotherapy and Psychosomatic, Ruhr University Bochum, Heithofer Allee 64, 59071 Hamm, Germany
Charlotte Thaler
Affiliation:
Department of Clinical Psychology and Psychotherapy, University of Freiburg, Engelbergerstrasse 41, 79085 Freiburg, Germany
Jörn von Wietersheim
Affiliation:
Department of Psychosomatic Medicine and Psychotherapy, Ulm Medical School, Albert-Einstein-Allee 23, 89070 Ulm, Germany
Martina de Zwaan
Affiliation:
Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
Brunna Tuschen-Caffier
Affiliation:
Department of Clinical Psychology and Psychotherapy, University of Freiburg, Engelbergerstrasse 41, 79085 Freiburg, Germany
*
Author for correspondence: Jennifer Svaldi, E-mail: jennifer.svaldi@uni-tuebingen.de
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Bulimia nervosa (BN), a mental disorder that causes significant impairment, can be treated with psychological, pharmacological, nutrition-based and self-help interventions. We conducted a pre-registered meta-analysis of randomized-controlled trials (RCTs) to assess the efficacy of these interventions in up to 19 different interventions.

Methods

Database search terms were combined for BN and RCTs from database inception to March 2017. Abstinence from binge eating episodes, compensatory behaviors, the absence of a BN diagnosis and reduction of symptom severity were considered as primary outcome variables, reduction of self-reported eating pathology and depression served as secondary outcome variables. Retrieved RCTs were meta-analyzed using fixed and random effects models.

Results

RCT (79 trials; 5775 participants) effects post-treatment revealed moderate to large intervention effects for psychotherapy [mostly cognitive-behavioral therapy (CBT)] for primary outcome variables. Slightly reduced effects were obtained for self-help and moderate effects for pharmacotherapy. Similarly, psychotherapy yielded large to very large effects in regard to secondary outcome variables, while moderate to large effects were observed for self-help, Pharmacotherapy and combined therapies. Meta-analyses for the pre to post changes within group confirmed these findings. Additionally, follow-up analyses revealed the sustainability of psychotherapies in terms of large effects in primary outcome criteria, while these effects were moderate for self-help, pharmacotherapy, and combined therapies.

Conclusions

Most psychological and pharmacological interventions revealed to be effective in BN treatment. Taking effect size, sustainability of the intervention, as well as the consistency of findings and available evidence into consideration, CBT can be recommended as the best intervention for the initial treatment of BN.

Keywords

Bulimia nervosameta-analysistreatment
Type
Review Article
Information
Psychological Medicine , Volume 49 , Issue 6 , April 2019 , pp. 898 - 910
Copyright
Copyright © Cambridge University Press 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Agras, WS, Schneider, JA, Arnow, B, Raeburn, SD and Telch, CF (1989) Cognitive-Behavioral and response-prevention treatments for bulimia nervosa. Journal of Consulting and Clinical Psychology 57, 215–221.Google Scholar
Agras, WS, Walsh, BT, Fairburn, CG, Wilson, GT and Kraemer, HC (2000) A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Archives of General Psychiatry 57, 459–466.Google Scholar
American Psychiatric Association (APA) (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th Edn. DSM 5. Washington, DC, US: Author.Google Scholar
Arbaizar, B, Gomez-Acebo, I and Llorca, J (2008) Efficacy of topiramate in bulimia nervosa and binge-eating disorder: a systematic review. General Hospital Psychiatry 30, 471–475.Google Scholar
Association of the Scientific Medical Societies [Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften – AWMF] (2010) S3 Leitlinie Diagnostik und Therapie von Essstörungen [S3 Guidelines of Diagnosis and Treatment of Eating Disorders]. Available at http://www.awmf.org/leitlinien/detail/ll/051-026.html (Accessed 29 October 2018).Google Scholar
Bacaltchuk, J and Hay, PPJ (2003) Antidepressants versus placebo for people with bulimia nervosa. Cochrane Database of Systematic Reviews 4, CD003391.Google Scholar
Bacaltchuk, J, Trefiglio, RP, Oliveira, IR, Hay, P, Lima, MS and Mari, JJ (2000) Combination of antidepressants and psychological treatments for bulimia nervosa: a systematic review. Acta Psychiatrica Scandinavica 101, 256–264.Google Scholar
Bachar, E, Latzer, Y, Kreitler, S and Berry, EM (1999) Empirical comparison of two psychological therapies. Self psychology and cognitive orientation in the treatment of anorexia and bulimia. Journal of Psychotherapy Practice and Research 8, 115–128.Google Scholar
Baiano, M, Salvo, P, Righetti, P, Cereser, L, Baldissera, E, Camponogara, I and Balestrieri, M (2014) Exploring health-related quality of life in eating disorders by a cross-sectional study and a comprehensive review. BMC Psychiatry 14, 165.Google Scholar
Banasiak, SJ, Paxton, SJ and Hay, P (2005) Guided self-help for bulimia nervosa in primary care: a randomized controlled trial. Psychological Medicine 35, 1283–1294.Google Scholar
Beck, AT, Steer, RA and Garbin, MG (1988) Psychometric properties of the beck depression inventory: twenty-five years of evaluation. Psychology Review 8, 77–100.Google Scholar
Chen, H, Cohen, P and Chen, S (2010) How big is a big odds ratio? Interpreting the magnitudes of odds ratios in epidemiological studies. Communications in Statistics – Simulation and Computation 39, 860–864.Google Scholar
Crow, SJ, Peterson, CB, Swanson, SA, Raymond, NC, Specker, S, Eckert, ED and Mitchell, JE (2009) Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry 166, 1342–1346.Google Scholar
Davis, R and McVey, G (1999) Sequencing of cognitive-behavioral treatments for bulimia nervosa. International Journal of Eating Disorders 25, 361–374.Google Scholar
Duval, S and Tweedie, R (2000 a) A nonparametric “Trim and Fill” method of accounting for publication bias in meta-analysis. Journal of the American Statistical Association 95, 89–98.Google Scholar
Duval, S and Tweedie, R (2000 b) Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56, 455–463.Google Scholar
Effective Practice and Organisation of Care (EPOC) (2015) Suggested Risk of Bias Criteria for EPOC Reviews. EPOC Resources for Review Authors. Oslo: Norwegian Knowledge Centre for the Health Services.Google Scholar
Esplen, M, Garfinkel, P, Olmsted, M, Gallop, R and Kennedy, S (1998) A randomized controlled trial of guided imagery in bulimia nervosa. Psychological Medicine 28, 1347–1357.Google Scholar
Fairburn, CG and Beglin, SJ (1994) Assessment of eating disorders: interview or self-report questionnaire? International Journal of Eating Disorders 16, 363–370.Google Scholar
Fairburn, CG and Cooper, Z (1993). The eating disorder examination. In Fairburn, CG and Wilson, GT (eds), Binge Eating: Nature, Assessment, and Treatment. New York: Guilford Press, pp. 317–360.Google Scholar
Fairburn, CG, Jones, R, Peveler, RC, Carr, SJ, Solomon, RA, O'Connor, ME, Burton, J and Hope, RA (1991) Three psychological treatments for bulimia nervosa. A comparative trial. Archives of General Psychiatry 48, 463–469.Google Scholar
Fairburn, CG, Jones, R, Peveler, RC, Hope, RA and O'connor, M (1993) Psychotherapy and bulimia nervosa: longer-term effects of interpersonal psychotherapy, behavior therapy, and cognitive behavior therapy. Archives of General Psychiatry 50, 419–428.Google Scholar
Faris, PL, Kim, SW, Meller, WH, Goodale, RL, Oakman, SA, Hofbauer, RD, Marshall, AM, Daughters, RS, Banerjee-Stevens, D, Eckert, ED and Hartman, BK (2000) Effect of decreasing afferent vagal activity with ondansetron on symptoms of bulimia nervosa: a randomised, double-blind trial. Lancet 355, 792–797.Google Scholar
Fluoxetine Bulimia Nervosa Collaborative Study Group (1992) Fluoxetine in the treatment of bulimia nervosa. A multicenter, placebo-controlled, double-blind trial. Fluoxetine Bulimia Nervosa Collaborative Study Group. Archives of General Psychiatry 49, 139–147.Google Scholar
Freeman, MF and Tukey, JW (1950) Transformations related to the angular and the square root. Annals of Mathematical Statistics 21, 607–611.Google Scholar
Freeman, CP, Barry, F, Dunkeld-Turnbull, J and Henderson, A (1988) Controlled trial of psychotherapy for bulimia nervosa. British Medical Journal (Clinical Research) 296, 521–525.Google Scholar
Furukawa, T, Noma, H, Caldwell, D, Honyashiki, M, Shinohara, K, Imai, H, Chen, P, Hunot, V and Churchill, R (2014) Waiting list may be a nocebo condition in psychotherapy trials: a contribution from network meta-analysis. Acta Psychiatrica Scandinavica 130, 181–192.Google Scholar
Garner, DM and Garfinkel, DE (1985) Eating attitudes test. Psychopharmacology Bulletin 21, 1008–1008.Google Scholar
Garner, DM, Olmstead, MP and Polivy, J (1983) Development and validation of a multidimensional eating disorder inventory for anorexia-nervosa and bulimia. International Journal of Eating Disorders 2, 15–34.Google Scholar
Griffiths, RA, Hadz-Pavlovic, D and Channon-Little, L (1994) A controlled evaluation of hypnobehavioural treatment for bulimia-nervosa – immediate pre-post-treatment effects. European Eating Disorders Review 2, 202–220.Google Scholar
Griffiths, RA, Hadzi-Pavlovic, D and Channon-Little, L (1996) The short-term follow-up effects of hypnobehavioural and cognitive behavioural treatment for bulimia Nervosa. European Eating Disorders Review 4, 12–31.Google Scholar
Hay, PPJ, Bacaltchuk, J, Stefano, S and Kashyap, P (2009) Psychological treatments for bulimia nervosa and binging. Cochrane Database of Systematic Reviews 4, CD000562.Google Scholar
Hedges, DW, Reimherr, FW, Hoopes, SP, Rosenthal, NR, Kamin, M, Karim, R and Capece, JA (2003) Treatment of bulimia nervosa with topiramate in a randomized, double-blind, placebo-controlled trial, part 2: improvement in psychiatric measures. Journal of Clinical Psychiatry 64, 1449–1454.Google Scholar
Higgins, JPT and Green, S (eds) (2011). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration.Google Scholar
Higgins, JPT and Thompson, SG (2002) Quantifying heterogeneity in a meta-analysis. Statistics in Medicine 21, 1539–1558.Google Scholar
Higgins, JPT, Thompson, SG, Deeks, JJ and Altman, DG (2003) Measuring inconsistency in meta-analyses. BMJ: British Medical Journal 327, 557–560.Google Scholar
Hoopes, SP, Reimherr, FW, Hedges, DW, Rosenthal, NR, Kamin, M, Karim, R, Capece, JA and Karvois, D (2003) Treatment of bulimia nervosa with topiramate in a randomized, double-blind, placebo-controlled trial, part 1: improvement in binge and purge measures. Journal of Clinical Psychiatry 64, 1335–1341.Google Scholar
Horne, RL, Ferguson, JM, Pope, HG Jr, Hudson, JI, Lineberry, CG, Ascher, J and Cato, A (1988) Treatment of bulimia with bupropion: a multicenter controlled trial. Journal of Clinical Psychiatry 49, 262–266.Google Scholar
Hsu, LKG, Clement, L, Santhouse, R and Ju, E (1991) Treatment of bulimia nervosa with lithium carbonate – a controlled study. The Journal of Nervous and Mental Disease 179, 351–355.Google Scholar
Hsu, LKG, Rand, W, Sullivan, S, Liu, DW, Mulliken, B, McDonagh, B and Kaye, WH (2001) Cognitive therapy, nutritional therapy and their combination in the treatment of bulimia nervosa. Psychological Medicine 31, 871–879.Google Scholar
Hudson, JI, Hiripi, E, Pope, HG Jr and Kessler, RC (2007) The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry 61, 348–358.Google Scholar
Hughes, PL, Wells, LA, Cunningham, CJ and Ilstrup, DM (1986) Treating bulimia with desipramine. A double-blind, placebo-controlled study. Archives of General Psychiatry 43, 182–186.Google Scholar
Huseman, C, Pearson, P, Madison, J and Leuschen, M (1990) Bulimia as a form of self-addiction-treatment with naltrexone hydrochloride (Trexan) – A pilot study. Clinical Trials Journal 27, 77–83.Google Scholar
Koenig, AM, Eagly, AH, Mitchell, AA and Ristikari, T (2011) Are leader stereotypes masculine? A meta-analysis of three research paradigms. Psychological Bulletin 137, 616–642.Google Scholar
Laessle, R, Beumont, P, Butow, P, Lennerts, W, O'connor, M, Pirke, K, Touyz, S and Waadt, S (1991) A comparison of nutritional management with stress management in the treatment of bulimia nervosa. The British Journal of Psychiatry 159, 250–261.Google Scholar
Le Grange, D, Crosby, RD, Rathouz, PJ and Leventhal, BL (2007) A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa. Archives of General Psychiatry 64, 1049–1056.Google Scholar
Le Grange, D, Lock, J, Agras, WS, Bryson, SW and Jo, B (2015) Randomized clinical trial of family-based treatment and cognitive-behavioral therapy for adolescent bulimia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry 54, 886–894.Google Scholar
Linardon, J (2018 a) Meta-analysis of the effects of cognitive-behavioral therapy on the core eating disorder maintaining mechanisms: implications for mechanisms of therapeutic change. Cognitive Behaviour Therapy 47, 107–125.Google Scholar
Linardon, J (2018 b) Rates of abstinence following psychological or behavioral treatments for binge-eating disorder: meta-analysis. International Journal of Eating Disorders 51, 785–797. doi: 10.1002/eat.22897.Google Scholar
Linardon, J and Wade, TD (2018) How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta-analytic review. International Journal of Eating Disorders 51, 287–294.Google Scholar
Linardon, J, Brennan, L and Garcia, XD (2016) Rapid response to eating disorder treatment: a systematic review and meta-analysis. International Journal of Eating Disorders 49, 905–919.Google Scholar
Linardon, J, Fairburn, CG, Fitzsimmons-Craft, EE, Wilfley, DE and Brennan, L (2017 a) The empirical status of the third-wave behaviour therapies for the treatment of eating disorders: a systematic review. Clinical Psychology Review 58, 125–140.Google Scholar
Linardon, J, Garcia, XD and Brennan, L (2017 b) Predictors, moderators, and mediators of treatment outcome following manualised cognitive-behavioural therapy for eating disorders: a systematic review. European Eating Disorders Review 25, 3–12.Google Scholar
Linardon, J, Wade, TD, Garcia, XD and Brennan, L (2017 c) The efficacy of cognitive-behavioral therapy for eating disorders: a systematic review and meta-analysis. Journal of Consulting and Clinical Psychology 85, 1080–1094.Google Scholar
Lundgren, JD, Danoff-Burg, S and Anderson, DA (2004) Cognitive-behavioral therapy for bulimia nervosa: an empirical analysis of clinical significance. International Journal of Eating Disorders 35, 262–274.Google Scholar
Mitchell, JE, Fletcher, L, Hanson, K, Mussell, MP, Seim, H, Crosby, R and Al-Banna, M (2001) The relative efficacy of fluoxetine and manual-based self-help in the treatment of outpatients with bulimia nervosa. Journal of Clinical Psychopharmacology 21, 298–304.Google Scholar
Mitchell, JE, Halmi, K, Wilson, GT, Agras, WS, Kraemer, H and Crow, S (2002) A randomized secondary treatment study of women with bulimia nervosa who fail to respond to CBT. The International Journal of Eating Disorders 32, 271–281.Google Scholar
Moher, D, Liberati, A, Tetzlaff, J, Altman, DG and Grupo Prisma (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. British Medical Journal 339, b2535.Google Scholar
Morris, SB (2008) Estimating effect sizes from pretest-posttest-control group designs. Organizational Research Methods 11, 364–386.Google Scholar
Nickel, C, Tritt, K, Muehlbacher, M, Pedrosa Gil, F, Mitterlehner, FO, Kaplan, P, Lahmann, C, Leiberich, PK, Krawczyk, J, Kettler, C, Rother, WK, Loew, TH and Nickel, MK (2005) Topiramate treatment in bulimia nervosa patients: a randomized, double-blind, placebo-controlled trial. International Journal of Eating Disorders 38, 295–300.Google Scholar
Pope, HG, Keck, PE, McElroy, SL and Hudson, JI (1989) A placebo-controlled study of trazodone in bulimia nervosa. Journal of Clinical Psychopharmacology 9, 254–259.Google Scholar
Poulsen, S, Lunn, S, Daniel, SIF, Folke, S, Mathiesen, BB, Katznelson, H and Fairburn, CG (2014) A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa. American Journal of Psychiatry 171, 109–116.Google Scholar
Preti, A, de Girolamo, G, Vilagut, G, Alonso, J, de Graaf, R, Bruffaerts, R, Demyttenaere, K, Pinto-Meza, A, Haro, JM, Morosini, P and Investigators, E-W (2009) The epidemiology of eating disorders in six European countries: results of the ESEMeD-WMH project. Journal of Psychiatric Research 43, 1125–1132.Google Scholar
R Core Team (2018) R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing.Google Scholar
Sawilowsky, S (2009) New effect size rules of thumb. Journal of Modern Applied Statistical Methods 8, 467–474.Google Scholar
Shapiro, JR, Berkman, ND, Brownley, KA, Sedway, JA, Lohr, KN and Bulik, CM (2007) Bulimia nervosa treatment: a systematic review of randomized controlled trials. International Journal of Eating Disorders 40, 321–336.Google Scholar
Slade, E, Keeney, E, Mavranezouli, I, Dias, S, Fou, L, Stockton, S, Saxon, L, Waller, G, Turner, H, Serpell, L, Fairburn, CG and Kendall, T (2018) Treatments for bulimia nervosa: a network meta-analysis. Psychological Medicine 48, 1–8.Google Scholar
Stefini, A, Salzer, S, Reich, G, Horn, H, Winkelmann, K, Bents, H, Rutz, U, Frost, U, von Boetticher, A, Ruhl, U, Specht, N and Kronmuller, KT (2017) Cognitive-behavioral and psychodynamic therapy in female adolescents with bulimia nervosa: a randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry 56, 329–335.Google Scholar
Stice, E, Marti, CN and Rohde, P (2013) Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women. Journal of Abnormal Psychology 122, 445–457.Google Scholar
Sundgot-Borgen, J, Rosenvinge, JH, Bahr, R and Schneider, LS (2002) The effect of exercise, cognitive therapy, and nutritional counseling in treating bulimia nervosa. Medicine & Science in Sports & Exercise 34, 190–195.Google Scholar
Suokas, JT, Suvisaari, JM, Grainger, M, Raevuori, A, Gissler, M and Haukka, J (2014) Suicide attempts and mortality in eating disorders: a follow-up study of eating disorder patients. General Hospital Psychiatry 36, 355–357.Google Scholar
Swanson, SA, Crow, SJ, Le Grange, D, Swendsen, J and Merikangas, KR (2011) Prevalence and correlates of eating disorders in adolescents results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry 68, 714–723.Google Scholar
Thompson-Brenner, H, Shingleton, RM, Sauer-Zavala, S, Richards, LK and Pratt, EM (2015) Multiple measures of rapid response as predictors of remission in cognitive behavior therapy for bulimia nervosa. Behaviour Research and Therapy 64, 9–14.Google Scholar
Treasure, J, Schmidt, U, Troop, N, Tiller, J, Todd, G, Keilen, M and Dodge, E (1994) First step in managing bulimia nervosa: controlled trial of therapeutic manual. BMJ 308, 686–689.Google Scholar
Viechtbauer, W (2010) Conducting meta-analyses in R with the metafor package. Journal of Statistical Software 36, 1–47.Google Scholar
Walsh, BT, Wilson, GT, Loeb, KL, Devlin, MJ, Pike, KM, Roose, SP, Fleiss, J and Waternaux, C (1997) Medication and psychotherapy in the treatment of bulimia nervosa. American Journal of Psychiatry 154, 523–531.Google Scholar
Supplementary material: File

Svaldi et al. supplementary material

Svaldi et al. supplementary material 1

Download Svaldi et al. supplementary material(File)
File 21.7 MB