What is the recommended treatment for bulimia nervosa?

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

Psychological Intervention

• Eating disorder-focused CBT is the primary psychological treatment 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
  • Has demonstrated superiority over other psychological approaches in reducing behavioral symptoms 2, 3

Pharmacological Treatment

• Fluoxetine (Prozac) 60 mg/day is the FDA-approved medication for bulimia nervosa 4
  • Should be administered in the morning
  • Higher dose (60 mg) is specifically recommended for bulimia, as lower doses (20 mg) have not shown statistical significance in reducing binge-eating and vomiting behaviors 4
  • Maintenance treatment with fluoxetine has demonstrated benefit for up to 52 weeks in patients who initially responded to treatment 4

Treatment Algorithm

1. Initial Treatment:

   • Begin with CBT and fluoxetine 60 mg/day concurrently for optimal outcomes
   • If medication cannot be initiated immediately, start with CBT alone
   • For patients who cannot access CBT, medication alone can be considered, though outcomes may be less robust 2

2. Medication Titration:

   • Start with lower dose (e.g., 20 mg/day) and titrate up to 60 mg/day over several days
   • Lower or less frequent dosing should be considered for:
     • Patients with hepatic impairment
     • Elderly patients
     • Patients with concurrent disease or on multiple medications 4

3. Monitoring:

   • Regular assessment of vital signs, weight, and laboratory values 1
   • ECG monitoring for patients with severe purging behaviors 1
   • Periodic reassessment to determine need for continued treatment 4

Special Populations

Adolescents

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

Patients with Limited Access to Care

• Guided computer and internet-based interventions (CBIs) show promise for compliant patients 5, 1
• Videoconferencing appears to be an effective delivery method for therapy 5, 1
  • Helps overcome barriers such as shame, stigma, and limited access to specialized care

Treatment Efficacy and Outcomes

• Combined CBT and medication treatment produces greater improvement in binge eating and depression than either treatment alone 2, 6
• CBT alone has shown 56-59% abstinence rates from binge eating and purging by the end of treatment, with effects maintained at 6-month follow-up 3
• Meta-analyses show that psychological interventions (primarily CBT) yield large to very large effects for primary outcome variables, while pharmacotherapy shows moderate effects 7
• Long-term follow-up analyses reveal better sustainability of psychotherapies compared to pharmacotherapy alone 7

Common Pitfalls to Avoid

1. Underdosing medication: The standard 20 mg dose of fluoxetine used for depression is insufficient for bulimia nervosa; 60 mg is required 4

2. Premature discontinuation: Maintenance treatment is important as bulimia is often chronic; patients should be periodically reassessed to determine need for continued treatment 4

3. Overlooking medical complications: Regular monitoring of vital signs, weight, and laboratory values is essential, especially for patients with severe purging behaviors 1

4. Focusing only on behavioral symptoms: Treatment should address all five core symptoms: binge eating, purging, restrictive eating, shape/weight concerns, and self-esteem 1