BY: Christine Peat, PhD

DATE: February 4, 106

In May 2013, the American Psychiatric Association published the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and in doing so recognized binge-eating disorder (BED) as a formal eating disorder diagnosis. Although BED had been previously designated as a provisional diagnosis in DSM-IV, the formal recognition in DSM-5 created increased interest in elucidating the evidence for available BED treatments, as the field anticipated more patients would be screened, diagnosed, and provided with evidence-based care. In an effort to collect, analyze, and synthesize this information, the Agency for Healthcare Research and Quality (a division of the Department of Health and Human Services) funded a systematic review and meta-analysis of all available treatments for BED including pharmacological interventions, psychological interventions, and approaches that combined the two. Our own Drs. Cynthia Bulik, Kimberly Brownley, and myself served as key investigators in this review headed by Dr. Nancy Berkman, a senior health policy research analyst at RTI International.

In a process that involved a comprehensive literature search for all treatments relevant to BED and dual review of over 4000 relevant abstracts and 900 full text articles, a total of 83 articles were found to meet our inclusion and exclusion criteria. Important outcomes included: binge abstinence (zero binge eating episodes in the last assessment period, typically 28 days); reduction in binge frequency, depression, and weight. Data from these articles were analyzed and revealed the following:

• Pharmacological interventions (compared with placebo)
  • Second-generation anti-depressants (e.g., Prozac, Paxil, Zoloft):
    • Increased binge abstinence***
    • Decreased binge frequency***
    • Improved depressive symptoms*
  • Topiramate (i.e., Topamax):
    • Increased binge abstinence**
    • Decreased binge frequency**
    • Decreased weight**
  • Lisdexamphetamine (i.e., Vyvanse):
    • Increased binge abstinence***
    • Decreased binge frequency***
    • Decreased weight***

• Psychological interventions (compared with wait list controls)
  • Therapist-led cognitive behavioral therapy (CBT):
    • Increased binge abstinence***
    • Decreased binge frequency***
  • Guided self-help CBT:
    • Increased binge abstinence*
    • Decreased binge frequency*
  • Therapist-led CBT compared with behavioral weight loss (BWL):
    • CBT better than BWL in decreasing binge frequency*
    • BWL better than CBT in decreasing weight**

*** = High degree of confidence in the finding based on the analyzed evidence

** = Medium degree of confidence in the finding based on the analyzed evidence

* = Low degree of confidence in the finding based on the analyzed evidence

(The above list is not comprehensive. For the interested reader, a succinct summary of the full report can be accessed here, while the full report itself is also publicly available here.)

Thus, there are several efficacious and evidence-based approaches available for the treatment of BED including both pharmacological and psychological interventions. Other interventions such as interpersonal psychotherapy and dialectical behavior therapy also demonstrated promise based on evidence in the review; however, the limited availability of data prevented us from drawing firm conclusions about their effectiveness.

Collectively these findings have important implications not only to researchers in the field, but also to patients and caregivers alike. However, despite the encouraging results of the report, there remain gaps in our knowledge and challenges in providing care to individuals with BED. For example, many of the pharmacological trials did not include follow-up data beyond the trial period so it is unknown how long an individual might need to remain on a medication or if positive effects persist after medication is discontinued. Additionally, although CBT is an efficacious treatment, providers who are trained in CBT for BED remain limited throughout the country thereby making access to care a considerable challenge for those seeking a psychological approach to treatment. Further, the majority of the individuals studied in the reviewed trials were Caucasian women who were overweight or obese making it difficult to understand how the treatment results might generalize to men, racial/ethnic minorities, and/or individuals with lower weights/BMIs. Thus, it is imperative that the field adequately address these and other critical gaps in knowledge and treatment dissemination in order to provide the necessary care to individuals with BED.