What is the recommended treatment for bulimia?

Treatment for Bulimia Nervosa

Cognitive-behavioral therapy (CBT) combined with fluoxetine (60 mg daily) is the recommended first-line treatment for adults with bulimia nervosa. 1

First-Line Treatment Approach

Psychotherapy

• Eating disorder-focused CBT is the primary psychological treatment for bulimia nervosa with strong evidence supporting its effectiveness 1
  • Focuses on normalizing eating patterns
  • Addresses dysfunctional thoughts about body image and weight
  • Targets binge-purge cycles
  • Typically delivered in 16-20 sessions over 4-5 months

Pharmacotherapy

• Fluoxetine (Prozac) at 60 mg/day is the recommended medication 1, 2
  • Start at lower doses (20 mg/day) and titrate up to 60 mg/day over several days 2
  • Administered in the morning
  • Only the 60 mg dose has been shown to be statistically superior to placebo in reducing binge-eating and purging behaviors 2
  • Medication can be prescribed either initially or if there is minimal response to psychotherapy alone after 6 weeks 1

Special Populations

Adolescents and Emerging Adults

• Family-based treatment is suggested for adolescents and emerging adults with involved caregivers 1
  • Includes caregiver education on normalizing eating behaviors
  • Focuses on disrupting binge-purge cycles
  • Empowers parents/caregivers to take an active role in recovery

Patients with Specific Medical Considerations

• Lower or less frequent dosing of fluoxetine should be used in:
  • Patients with hepatic impairment
  • Elderly patients
  • Patients with concurrent diseases or on multiple medications 2

Treatment Monitoring and Maintenance

• Regular assessment of vital signs, weight, and laboratory values is recommended 1
• Electrocardiogram monitoring is recommended for patients with severe purging behaviors 1
• Maintenance treatment with fluoxetine 60 mg/day for up to 52 weeks has demonstrated benefit for patients who respond to acute treatment 2
• Periodic reassessment to determine continued need for treatment is necessary 2

When First-Line Treatment Fails

When standard CBT fails (which occurs in approximately 50% of cases) 3:

1. Consider enhanced CBT (CBT-E) which addresses broader psychopathological processes 4
2. Intensify treatment through more concentrated exposure, possibly in an inpatient setting for severe cases 3
3. Consider interpersonal psychotherapy (IPT) as an alternative psychological approach, though evidence suggests it may not be effective for CBT non-responders 3

Technology-Based Interventions

For patients with limited access to specialized care or those reluctant to seek in-person treatment:

• Guided computer and internet-based interventions (CBIs) show promise, especially for compliant patients 1
• Videoconferencing appears to be an effective delivery method for therapy 1
• These approaches may help overcome barriers such as shame, stigma, and limited access to specialized care 1

Common Pitfalls to Avoid

• Inadequate medication dosing: Using less than 60 mg/day of fluoxetine, which has been shown to be less effective 2
• Premature treatment termination: Full therapeutic benefits may take time to develop
• Overlooking comorbidities: Personality disorders and other psychiatric conditions can complicate treatment and predict poorer outcomes 3
• Neglecting comprehensive care: Treatment should address all five core symptoms of bulimia: binge eating, purging, restrictive eating, shape/weight concerns, and self-esteem 5

Remember that a comprehensive, multidisciplinary approach incorporating medical, psychiatric, psychological, and nutritional expertise is recommended for optimal outcomes 1.