What is the treatment approach for bulimia disorder?

Treatment Approach for Bulimia Nervosa

For adults with bulimia nervosa, the recommended treatment is a combination of eating disorder-focused cognitive-behavioral therapy (CBT) and a serotonin reuptake inhibitor, specifically fluoxetine 60 mg daily. 1

First-Line Treatment

• Eating disorder-focused cognitive-behavioral therapy (CBT) is the cornerstone psychological treatment for bulimia nervosa, focusing on normalizing eating behaviors and addressing psychological aspects like fear of weight gain and body image disturbance 1
• Fluoxetine at 60 mg/day is the recommended pharmacological treatment, administered in the morning, as this dose was statistically significantly superior to placebo in reducing the frequency of binge-eating and vomiting 2
• For some patients, it may be advisable to titrate up to the target dose of fluoxetine over several days to improve tolerability 2
• The combination of CBT and medication has shown greater improvement in binge eating and depression symptoms than either treatment alone 3

Treatment Algorithm

1. Initial Assessment:

   • Comprehensive evaluation including weighing the patient and quantifying eating and weight control behaviors (frequency, intensity, time spent on binge eating, purging, exercise) 1
   • Identify co-occurring psychiatric disorders which are common in bulimia nervosa 1
   • Physical examination including vital signs, height, weight, BMI, and signs of purging behaviors 1
   • Laboratory assessment including complete blood count, comprehensive metabolic panel, electrolytes, liver enzymes, and renal function tests 1
   • Electrocardiogram for patients with severe purging behavior 1

2. Treatment Implementation:

   • Begin CBT focused specifically on eating disorder behaviors 1
   • Simultaneously start fluoxetine at 60 mg/day (or titrate up if needed) 2
   • If there is minimal or no response to psychotherapy alone by 6 weeks, ensure medication is added if not already prescribed 1

3. Special Populations:

   • For adolescents and emerging adults with an involved caregiver, eating disorder-focused family-based treatment is suggested 1
   • Lower or less frequent fluoxetine dosage should be used in patients with hepatic impairment and considered for elderly patients 2

Multidisciplinary Team Approach

• Treatment should be delivered by a coordinated multidisciplinary team incorporating medical, psychiatric, psychological, and nutritional expertise 4
• The team typically includes:
  • Primary care physician for medical monitoring and coordination of care 4
  • Mental health practitioner delivering specialized eating disorder-focused psychotherapy 4
  • Registered dietitian providing nutritional rehabilitation and meal planning 4
  • Psychiatrist for medication management 4

Treatment Efficacy and Duration

• Remission rates are approximately 49% for combined therapy versus 36% for psychological treatment alone and 23% for antidepressants alone 5
• Systematic evaluation has demonstrated benefit of continuing fluoxetine 60 mg/day for up to 52 weeks in patients who responded during an 8-week acute treatment phase 2
• Patients should be periodically reassessed to determine the need for maintenance treatment 2

Common Pitfalls and Considerations

• Dropout rates tend to be higher for medication alone compared to psychotherapy alone, suggesting psychotherapy may be more acceptable to patients 5
• When antidepressants are combined with psychological treatments, the acceptability of the latter may be significantly reduced 5
• Fluoxetine doses above 60 mg/day have not been systematically studied in patients with bulimia and are not recommended 2
• Technology-based interventions, including guided computer-based interventions and videoconferencing, show promise for treating bulimia nervosa and may help overcome barriers such as shame, stigma, and shortage of specialized providers 1, 4

Treatment Resistant Cases

• If a patient doesn't respond to first-line treatment, consider:
  • Ensuring adequate dose and duration of both CBT and medication 2
  • Evaluating for comorbid conditions that may be interfering with treatment response 1
  • A two-stage medication intervention, trying a different antidepressant if the first is ineffective or poorly tolerated 3
  • Intensifying the psychological approach or trying interpersonal therapy as an alternative 6

Despite decades of treatment development, a sizable proportion of individuals with bulimia nervosa do not respond to current evidence-based treatments, highlighting the need for continued research and development of new approaches 7.