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There is a need for treatment interventions to address the high prevalence of disordered eating throughout adolescence and early adulthood. We developed an adolescent-specific manualized CBT protocol to treat female adolescents with recurrent binge eating and tested its efficacy in a small, pilot randomized controlled trial. We present lessons learned in recruiting adolescents, a description of our treatment approach, acceptability of the treatment for teens and parents, as well as results from the pilot trial. Participants in the CBT group had significantly fewer posttreatment eating binges than those in a treatment as usual/delayed treatment (TAU-DT) control group; 100% of CBT participants were abstinent at follow-up. Our results provide preliminary support for the efficacy of this adolescent adaptation of evidence-based CBT for recurrent binge eating. The large, robust effect size estimate observed for the main outcome (NNT = 2) places this among the larger effects observed for any mental health intervention. (Contains 4 tables and 2 figures.)

Objective: The longer term efficacy of medication treatments for binge-eating disorder (BED) remains unknown. This study examined the longer term effects of fluoxetine and cognitive behavioral therapy (CBT) either with fluoxetine (CBT + fluoxetine) or with placebo (CBT + placebo) for BED through 12-month follow-up after completing treatments. Method: 81 overweight patients with BED within a randomized double-blind placebo-controlled acute treatment trial allocated to fluoxetine-only, CBT + fluoxetine, and CBT + placebo were assessed before treatment, during treatment, posttreatment, and 6 and 12 months after completing treatments. Outcome variables comprised remission from binge eating (0 binge-eating episodes for 28 days) and continuous measures of binge-eating frequency, eating disorder psychopathology, depression, and weight. Results: Intent-to-treat remission rates (missing data coded as nonremission) differed significantly across treatments at posttreatment and at 6- and 12-month follow-ups. At 12-month follow-up remission rates were 3.7% for fluoxetine-only, 26.9% for CBT + fluoxetine, and 35.7% for CBT + placebo. Mixed-effects models of all available continuous data (without imputation) at posttreatment and at 6- and 12-month follow-ups (controlling for baseline scores) revealed the treatments differed on all clinical outcome variables, except for weight, across time. CBT + fluoxetine and CBT + placebo did not differ and both were significantly superior to fluoxetine-only on the majority of clinical outcomes. Conclusions: This represents the first report from any randomized placebo-controlled trial for BED that has reported follow-up data after completing a course of medication-only treatment. CBT + placebo was superior to fluoxetine-only, and adding fluoxetine to CBT did not enhance findings compared to adding placebo to CBT. The findings document the longer term effectiveness of CBT, but not fluoxetine, through 12 months after treatment completion. (Contains 1 table, 2 figures and 2 footnotes.)

Objective: Cognitive-behavioral therapy (CBT) is the best established treatment for binge-eating disorder (BED) but does not produce weight loss. The efficacy of behavioral weight loss (BWL) in obese patients with BED is uncertain. This study compared CBT, BWL, and a sequential approach in which CBT is delivered first, followed by BWL (CBT + BWL). Method: 125 obese patients with BED were randomly assigned to 1 of the 3 manualized treatments delivered in groups. Independent assessments were performed posttreatment and at 6- and 12-month follow-ups. Results: At 12-month follow-up, intent-to-treat binge-eating remission rates were 51% (CBT), 36% (BWL), and 40% (CBT + BWL), and mean percent BMI losses were -0.9, -2.1, and 1.5, respectively. Mixed-models analyses revealed that CBT produced significantly greater reductions in binge eating than BWL through 12-month follow-up and that BWL produced significantly greater percent BMI loss during treatment. The overall significant percent BMI loss in CBT + BWL was attributable to the significant effects during the BWL component. Binge-eating remission at major assessment points was associated significantly with greater percent BMI loss cross-sectionally and prospectively (i.e., at subsequent follow-ups). Conclusions: CBT was superior to BWL for producing reductions in binge eating through 12-month follow-up, while BWL produced statistically greater, albeit modest, weight losses during treatment. Results do not support the utility of the sequential approach of providing BWL following CBT. Remission from binge eating was associated with significantly greater percent BMI loss. Findings support BWL as an alternative treatment option to CBT for BED. (Contains 2 footnotes, 2 tables, and 3 figures.)

Objective: The purpose of the study was to explore heterogeneity and differential treatment outcome among a sample of patients with binge eating disorder (BED). Method: A latent class analysis was conducted with 205 treatment-seeking, overweight or obese individuals with BED randomized to interpersonal psychotherapy (IPT), behavioral weight loss (BWL), or guided self-help based on cognitive behavioral therapy (CBTgsh). A latent transition analysis tested the predictive validity of the latent class analysis model. Results: A 4-class model yielded the best overall fit to the data. Class 1 was characterized by a lower mean body mass index (BMI) and increased physical activity. Individuals in Class 2 reported the most binge eating, shape and weight concerns, compensatory behaviors, and negative affect. Class 3 patients reported similar binge eating frequencies to Class 2, with lower levels of exercise or compensation. Class 4 was characterized by the highest average BMI, the most overeating episodes, fewer binge episodes, and an absence of compensatory behaviors. Classes 1 and 3 had the highest and lowest percentage of individuals with a past eating disorder diagnosis, respectively. The latent transition analysis found a higher probability of remission from binge eating among those receiving IPT in Class 2 and CBTgsh in Class 3. Conclusions: The latent class analysis identified 4 distinct classes using baseline measures of eating disorder and depressive symptoms, body weight, and physical activity. Implications of the observed differential treatment response are discussed. (Contains 5 tables and 2 footnotes.)

Cognitive behavior therapy (CBT) is an effective treatment for bulimia nervosa (BN). However, among patients with BN, symptom improvement is more pronounced for behavioral eating symptoms (i.e., bingeing and purging) than for body image disturbance, and the persistence of body image disturbance is associated with relapse. The need for more effective body image interventions led to the development of mirror exposure, which focuses on encouraging patients to view themselves in a holistic, nonjudgmental, mindful fashion. Behavioral manifestations of body image disturbance--body checking and avoidance--are also targeted in order to reduce and eliminate such behaviors and their associated preoccupation and distress. A preliminary trial of Body Image Exposure has shown promise, but it has not yet been tested in the context of CBT for BN. The case of "Sara" illustrates the application of this targeted treatment for body image disturbance. Central clinical issues around the perceptual, cognitive, and behavioral components of body image are delineated as they arose in treatment, as are issues of motivation and compliance. Treatment was associated with improvement in eating symptoms, body image, and mood. (Contains 1 table.)

Objective: Despite proven efficacy of cognitive behavioral therapy (CBT) for treating eating disorders with binge eating as the core symptom, few patients receive CBT in clinical practice. Our blended efficacy-effectiveness study sought to evaluate whether a manual-based guided self-help form of CBT (CBT-GSH), delivered in 8 sessions in a health maintenance organization setting over a 12-week period by master's-level interventionists, is more effective than treatment as usual (TAU). Method: In all, 123 individuals (mean age = 37.2; 91.9% female, 96.7% non-Hispanic White) were randomized, including 10.6% with bulimia nervosa (BN), 48% with binge eating disorder (BED), and 41.4% with recurrent binge eating in the absence of BN or BED. Baseline, posttreatment, and 6- and 12-month follow-up data were used in intent-to-treat analyses. Results: At 12-month follow-up, CBT-GSH resulted in greater abstinence from binge eating (64.2%) than TAU (44.6%; number needed to treat = 5), as measured by the Eating Disorder Examination (EDE). Secondary outcomes reflected greater improvements in the CBT-GSH group in dietary restraint (d = 0.30); eating, shape, and weight concern (ds = 0.54, 1.01, 0.49, respectively; measured by the EDE Questionnaire); depression (d = 0.56; Beck Depression Inventory); and social adjustment (d = 0.58; Work and Social Adjustment Scale), but not weight change. Conclusions: CBT-GSH is a viable first-line treatment option for the majority of patients with recurrent binge eating who do not meet diagnostic criteria for BN or anorexia nervosa. (Contains 3 tables and 2 figures.)

Significant progress has been achieved in the development and evaluation of evidence-based psychological treatments for eating disorders over the past 25 years. Cognitive behavioral therapy is currently the treatment of choice for bulimia nervosa and binge-eating disorder, and existing evidence supports the use of a specific form of family therapy for adolescents with anorexia nervosa. Important challenges remain. Even the most effective interventions for bulimia nervosa and binge-eating disorder fail to help a substantial number of patients. A priority must be the extension and adaptation of these treatments to a broader range of eating disorders (eating disorder not otherwise specified), to adolescents, who have been largely overlooked in clinical research, and to chronic, treatment-resistant cases of anorexia nervosa. The article highlights current conceptual and clinical innovations designed to improve on existing therapeutic efficacy. The problems of increasing the dissemination of evidence-based treatments that are unavailable in most clinical service settings are discussed.

The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist ? Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment.

Objective: Adoption of effective treatments for recurrent binge-eating disorders depends on the balance of costs and benefits. Using data from a recent randomized controlled trial, we conducted an incremental cost-effectiveness analysis (CEA) of a cognitive--behavioral therapy guided self-help intervention (CBT-GSH) to treat recurrent binge eating compared to treatment as usual (TAU). Method: Participants were 123 adult members of an HMO (mean age = 37.2 years, 91.9% female, 96.7% non-Hispanic White) who met criteria for eating disorders involving binge eating as measured by the Eating Disorder Examination (C. G. Fairburn & Z. Cooper, 1993). Participants were randomized either to treatment as usual (TAU) or to TAU plus CBT--GSH. The clinical outcomes were binge-free days and quality-adjusted life years (QALYs); total societal cost was estimated using costs to patients and the health plan and related costs. Results: Compared to those receiving TAU only, those who received TAU plus CBT--GSH experienced 25.2 more binge-free days and had lower total societal costs of $427 over 12 months following the intervention (incremental CEA ratio of -$20.23 per binge-free day or -$26,847 per QALY). Lower costs in the TAU plus CBT--GSH group were due to reduced use of TAU services in that group, resulting in lower net costs for the TAU plus CBT group despite the additional cost of CBT--GSH. Conclusions: Findings support CBT--GSH dissemination for recurrent binge-eating treatment. Keywords: cost-effectiveness analysis, binge eating, cognitive behavior therapy, guided self-help, evidence-based treatment programs DOI: 10.1037/a0018982

Background Counselling for Alcohol Problems (CAP), a brief intervention delivered by lay counsellors, enhanced remission and abstinence over 3 months among male primary care attendees with harmful drinking in a setting in India. We evaluated the sustainability of the effects after treatment termination, the cost-effectiveness of CAP over 12 months, and the effects of the hypothesized mediator 'readiness to change' on clinical outcomes. Methods and findings Male primary care attendees aged 18-65 years screening with harmful drinking on the Alcohol Use Disorders Identification Test (AUDIT) were randomised to either CAP plus enhanced usual care (EUC) (n = 188) or EUC alone (n = 189), of whom 89% completed assessments at 3 months, and 84% at 12 months. Primary outcomes were remission and mean standard ethanol consumed in the past 14 days, and the proposed mediating variable was readiness to change at 3 months. CAP participants maintained the gains they showed at the end of treatment through the 12-month follow-up, with the proportion with remission (AUDIT score < 8: 54.3% versus 31.9%; adjusted prevalence ratio [aPR] 1.71 [95% CI 1.32, 2.22]; p < 0.001) and abstinence in the past 14 days (45.1% versus 26.4%; adjusted odds ratio 1.92 [95% CI 1.19, 3.10]; p = 0.008) being significantly higher in the CAP plus EUC arm than in the EUC alone arm. CAP participants also fared better on secondary outcomes including recovery (AUDIT score < 8 at 3 and 12 months: 27.4% versus 15.1%; aPR 1.90 [95% CI 1.21, 3.00]; p = 0.006) and percent of days abstinent (mean percent [SD] 71.0% [38.2] versus 55.0% [39.8]; adjusted mean difference 16.1 [95% CI 7.1, 25.0]; p = 0.001). The intervention effect for remission was higher at 12 months than at 3 months (aPR 1.50 [95% CI 1.09, 2.07]). There was no evidence of an intervention effect on Patient Health Questionnaire 9 score, suicidal behaviour, percentage of days of heavy drinking, Short Inventory of Problems score, WHO Disability Assessment Schedule 2.0 score, days unable to work, or perpetration of intimate partner violence. Economic analyses indicated that CAP plus EUC was dominant over EUC alone, with lower costs and better outcomes; uncertainty analysis showed a 99% chance of CAP being cost-effective per remission achieved from a health system perspective, using a willingness to pay threshold equivalent to 1 month's wages for an unskilled manual worker in Goa. Readiness to change level at 3 months mediated the effect of CAP on mean standard ethanol consumption at 12 months (indirect effect -6.014 [95% CI -13.99, -0.046]). Serious adverse events were infrequent, and prevalence was similar by arm. The methodological limitations of this trial are the susceptibility of self-reported drinking to social desirability bias, the modest participation rates of eligible patients, and the examination of mediation effects of only 1 mediator and in only half of our sample. Conclusions CAP's superiority over EUC at the end of treatment was largely stable over time and was mediated by readiness to change. CAP provides better outcomes at lower costs from a societal perspective. Trial registration ISRCTN registry ISRCTN76465238, Author(s): Abhijit Nadkarni 1,2, Helen A. Weiss 2, Benedict Weobong 1,2, David McDaid 3, Daisy R. Singla 4, A-La Park 3, Bhargav Bhat 1, Basavaraj Katti 1, Jim McCambridge 5, [...]

Background The Healthy Activity Programme (HAP), a brief behavioural intervention delivered by lay counsellors, enhanced remission over 3 months among primary care attendees with depression in peri-urban and rural settings in India. We evaluated the sustainability of the effects after treatment termination, the cost-effectiveness of HAP over 12 months, and the effects of the hypothesized mediator of activation on clinical outcomes. Methods and findings Primary care attendees aged 18-65 years screened with moderately severe to severe depression on the Patient Health Questionnaire 9 (PHQ-9) were randomised to either HAP plus enhanced usual care (EUC) (n = 247) or EUC alone (n = 248), of whom 95% completed assessments at 3 months, and 91% at 12 months. Primary outcomes were severity on the Beck Depression Inventory-II (BDI-II) and remission on the PHQ-9. HAP participants maintained the gains they showed at the end of treatment through the 12-month follow-up (difference in mean BDI-II score between 3 and 12 months = -0.34; 95% CI -2.37, 1.69; p = 0.74), with lower symptom severity scores than participants who received EUC alone (adjusted mean difference in BDI-II score = -4.45; 95% CI -7.26, -1.63; p = 0.002) and higher rates of remission (adjusted prevalence ratio [aPR] = 1.36; 95% CI 1.15, 1.61; p < 0.009). They also fared better on most secondary outcomes, including recovery (aPR = 1.98; 95% CI 1.29, 3.03; p = 0.002), any response over time (aPR = 1.45; 95% CI 1.27, 1.66; p < 0.001), higher likelihood of reporting a minimal clinically important difference (aPR = 1.42; 95% CI 1.17, 1.71; p < 0.001), and lower likelihood of reporting suicidal behaviour (aPR = 0.71; 95% CI 0.51, 1.01; p = 0.06). HAP plus EUC also had a marginal effect on WHO Disability Assessment Schedule score at 12 months (aPR = -1.58; 95% CI -3.33, 0.17; p = 0.08); other outcomes (days unable to work, intimate partner violence toward females) did not statistically significantly differ between the two arms. Economic analyses indicated that HAP plus EUC was dominant over EUC alone, with lower costs and better outcomes; uncertainty analysis showed that from this health system perspective there was a 95% chance of HAP being cost-effective, given a willingness to pay threshold of Intl$16,060-equivalent to GDP per capita in Goa-per quality-adjusted life year gained. Patient-reported behavioural activation level at 3 months mediated the effect of the HAP intervention on the 12-month depression score ([beta] = -2.62; 95% CI -3.28, -1.97; p < 0.001). Serious adverse events were infrequent, and prevalence was similar by arm. We were unable to assess possible episodes of remission and relapse that may have occurred between our outcome assessment time points of 3 and 12 months after randomisation. We did not account for or evaluate the effect of mediators other than behavioural activation. Conclusions HAP's superiority over EUC at the end of treatment was largely stable over time and was mediated by patient activation. HAP provides better outcomes at lower costs from a perspective covering publicly funded healthcare services and productivity impacts on patients and their families. Trial registration ISRCTN registry ISRCTN95149997, Author(s): Benedict Weobong 1,6, Helen A. Weiss 2, David McDaid 3, Daisy R. Singla 4, Steven D. Hollon 5, Abhijit Nadkarni 1,6, A-La Park 3, Bhargav Bhat 6, Basavraj Katti [...]

The authors examined rapid response among 108 patients with binge eating disorder (BED) who were randomly assigned to 1 of 4 16-week treatments: fluoxetine, placebo, cognitive-behavioral therapy (CBT) plus fluoxetine, or CBT plus placebo. Rapid response, defined as 65% or greater reduction in binge eating by the 4th treatment week, was determined by receiver operating characteristic curves. Rapid response characterized 44% of participants and was unrelated to participants' demographic or baseline characteristics. Participants with rapid response were more likely to achieve binge-eating remission, had greater improvements in eating-disorder psychopathology, and had greater weight loss than participants without rapid response. Rapid response had different prognostic significance and distinct time courses for CBT versus pharmacotherapy-only treatments. Rapid response has utility for predicting outcomes and provides evidence for specificity of treatment effects with BED. Keywords: rapid response, binge eating disorder, cognitive-behavioral therapy, fluoxetine, obesity

D. Westen, C. M. Novotny, and H, Thompson-Brenner (2004) suggested that efforts to identify empirically supported treatments are misguided because they are based on assumptions that are not appropriate for some types of treatment and patients. The authors of this comment argue that Westen and colleagues are simply incorrect when they assert that empirically supported treatments require that psychopathology must be highly malleable, that treatments must be brief, or that the samples studied are unrepresentative of the kinds of patients typically encountered in clinical practice--comorbidity is common in many clinical trials. Randomized controlled trials remain the most powerful way to test notions of causal agency. Keywords: empirically supported psychotherapies, randomized clinical trials, comorbidity

Thirty women diagnosed with either bulimia nervosa (BN) or binge eating disorder (BED) kept continuous prospective records of their food intake without receiving additional simultaneous treatment. Compared with the frequency of binge eating assessed during initial structured interviews, participants showed a substantial decrease in their frequency of binge eating during self-monitoring. Average binge-eating frequency fell from 0.91 to 0.40 binge episodes per day, t(29) = 5.04, p[less than or equal to] 001. Participants with both disorders reduced their binge eating at similar rates. Half of all participants with BED and 16.6% of those with BN ceased to meet DSM-IV binge-eating frequency criteria for their disorder during the self-monitoring phase. Of participants with BED, 27.8% were abstinent from binge eating during self-monitoring. These findings suggest that self-monitoring of food intake may substantially reduce binge eating in women with bulimia nervosa or binge eating disorder.

Cognitive--behavioral therapy (CBT) is an effective treatment of bulimia nervosa, but its mechanisms of action have not been established. In this study the authors analyzed the results of a randomized control trial comparing CBT with Interpersonal Psychotherapy (IPT) to identify possible mediators of change of CBT for BN and its time course of action. Reduction in dietary restraint as early as Week 4 mediated posttreatment improvement in both binge eating and vomiting. Measures of self-efficacy concerning eating behavior, negative affect, and body shape and weight at midtreatment were also significantly associated with posttreatment outcome at 20 weeks. No evidence was found that the therapeutic alliance mediated treatment outcome. CBT had a significantly more rapid treatment effect than IPT, with 62% of posttreatment improvement evident by Week 6.

Cluster-analytic studies of bulimia nervosa and binge eating disorder (BED) have yielded 2 subtypes (pure dietary and mixed dietary-negative affect). The authors aimed to (a) replicate the subtyping with BED, (b) consider alternative approaches to subtyping, and (c) test the stability in individual differences in the subtyping. Cluster analyses of 101 patients revealed a dietary-negative affect subtype (33%) and a pure dietary subtype (67%). The dietary-negative affect subtype was characterized by greater eating-related psychopathology and psychological disturbance. Cluster analysis produced different results from alternative subtyping approaches (by major depression or by binge eating frequency). Cluster-analytic subtyping of data at 2 time points 4 weeks apart for a subset of 73 patients demonstrated significant consistency ([kappa] = .55). Findings suggest that moderate dieting is characteristic of BED and that affective disturbances occur in a subset of cases that represent a more disturbed variant. The subtypes may represent reasonably stable individual differences.

A new study compares the Eating Disorder Examination and the self-assessed EDE-Q questionnaire assessments of the psychology of eating disorders in patients waiting for bariatric surgery.