What are the treatment options for bulimia?

From the Guidelines

Treatment for bulimia nervosa should involve a combination of eating disorder-focused cognitive-behavioral therapy and a serotonin reuptake inhibitor, such as 60 mg fluoxetine daily, as recommended by the American Psychiatric Association 1. The goal of treatment is to normalize eating behaviors, address underlying psychological issues, and prevent relapse.

• Cognitive-behavioral therapy (CBT) is considered the most effective psychotherapy approach, helping patients identify and change unhealthy thought patterns related to food and body image over 16-20 sessions.
• Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac), are often prescribed at doses of 60mg daily, which is higher than typical depression treatment doses.
• Fluoxetine is the only FDA-approved medication specifically for bulimia.
• Nutritional counseling helps establish regular eating patterns and healthy attitudes toward food.
• For severe cases, more intensive treatment options include partial hospitalization programs, residential treatment, or inpatient hospitalization.
• Family-based treatment may be beneficial, especially for adolescents, as suggested by the American Psychiatric Association 1. The combination of these approaches is important because bulimia involves both psychological and physiological components, with the binge-purge cycle often becoming self-perpetuating due to both emotional triggers and physical hunger from restriction. Key considerations in treatment include:
• Individualized goals for weekly weight gain and target weight
• Comprehensive review of systems
• Laboratory assessment, including complete blood count and comprehensive metabolic panel
• Electrocardiogram for patients with restrictive eating disorder, severe purging behavior, or taking medications that prolong QTc intervals
• Documented, comprehensive, culturally appropriate, and person-centered treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise, as recommended by the American Psychiatric Association 1.

From the FDA Drug Label

Prozac is indicated for the treatment of binge–eating and vomiting behaviors in patients with moderate to severe bulimia nervosa The efficacy of Prozac was established in 8– to 16–week trials for adult outpatients with moderate to severe bulimia nervosa, i.e., at least 3 bulimic episodes per week for 6 months The recommended dose is 60 mg/day, administered in the morning. Systematic evaluation of continuing Prozac 60 mg/day for periods of up to 52 weeks in patients with bulimia who have responded while taking Prozac 60 mg/day during an 8–week acute treatment phase has demonstrated a benefit of such maintenance treatment

The treatment options for bulimia include:

• Fluoxetine (Prozac): The recommended dose is 60 mg/day, administered in the morning.
• Maintenance/Continuation Treatment: Continuing Prozac 60 mg/day for periods of up to 52 weeks has demonstrated a benefit of such maintenance treatment. 2

From the Research

Treatment Options for Bulimia

• Cognitive-behavioral therapy (CBT) is a first-line psychotherapeutic treatment for bulimia nervosa (BN) 3, 4, 5
• Interpersonal therapy is a second-line evidence-based treatment for adults with BN 4
• Dialectical behavior therapy and integrative cognitive-affective therapy are also promising treatments for BN 4
• Family-based treatment for BN or CBT are evidence-based approaches for adolescents with BN 4
• Pharmacotherapy, such as fluoxetine 60 mg/d, can be considered adjunctive to psychotherapy in adults with BN, and may be helpful in certain cases 4, 6, 7

Medication Treatment

• Fluoxetine 60 mg/d is the medication of choice for adults with BN 4, 7
• A two-stage medication intervention using fluoxetine may add to the benefit of psychological treatment 6
• Pharmacologic treatment of BN in adolescents is less well-studied, but fluoxetine 60 mg/d may be a useful intervention 4

Psychotherapy Treatment

• CBT is the psychological treatment of choice for bulimia nervosa, with a structured program and evidence-based efficacy 3, 5
• Supportive psychotherapy may not be as effective as CBT in reducing behavioral symptoms of BN 6
• Cognitive-behavioral therapy plus medication may be superior to medication alone or supportive psychotherapy plus medication 6