What are the treatment options for binge eating disorder?

Treatment Options for Binge Eating Disorder

First-line treatment for binge eating disorder is eating disorder-focused cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT), delivered in either individual or group formats, with lisdexamfetamine (50-70 mg/day) as the medication option for patients who prefer pharmacotherapy or have not responded to psychotherapy alone. 1

Primary Psychological Treatments

Cognitive-Behavioral Therapy (CBT)

• CBT is the most strongly supported psychological intervention for BED, producing sustained remission from binge eating that persists through 2-year follow-up. 2, 3
• CBT focuses on normalizing eating behaviors, addressing psychological aspects of the disorder, and reducing eating disorder psychopathology. 1
• Guided self-help CBT (CBTgsh) represents a lower-cost, scalable alternative that demonstrates efficacy comparable to full CBT and is significantly more effective than behavioral weight loss at 2-year follow-up (odds ratio 2.3). 3, 2
• Technology-based CBT interventions show medium to large effects for reducing binge eating behaviors and represent effective alternatives for patients with limited access to specialized care. 1

Interpersonal Psychotherapy (IPT)

• IPT is equally effective to CBT for eliminating binge eating, with particular benefit for patients with low self-esteem and high eating disorder psychopathology. 1, 3
• At 2-year follow-up, IPT produces significantly greater remission rates than behavioral weight loss (odds ratio 2.6). 3

Dialectical Behavior Therapy (DBT)

• DBT has demonstrated some efficacy for BED, though evidence is less robust than for CBT or IPT. 2, 4

Behavioral Weight Loss (BWL) Therapy

• BWL represents an important "generalist" intervention that approximates CBT's effectiveness for reducing binge eating while also producing modest weight loss (mean 2.1% BMI reduction). 2, 5
• BWL is more widely available than specialized eating disorder treatments and can serve as an alternative first-line option. 2, 6
• Binge eating remission is associated with significantly greater weight loss both cross-sectionally and prospectively. 5
• Sequential treatment (CBT followed by BWL) does not enhance outcomes compared to CBT alone. 5

Pharmacological Treatment

Lisdexamfetamine (FDA-Approved)

• Lisdexamfetamine is the only FDA-approved medication for moderate-to-severe BED, with doses of 50-70 mg/day demonstrating statistically significant superiority over placebo. 1, 7
• In two 12-week randomized controlled trials, lisdexamfetamine (50-70 mg/day) produced placebo-subtracted reductions of 1.35 and 1.66 binge days per week. 7
• The medication should be considered for adults who prefer pharmacotherapy or have minimal/no response to psychotherapy alone. 1
• The 30 mg/day dose was not statistically different from placebo and should not be used as a maintenance dose. 7

Antidepressants

• Selective serotonin reuptake inhibitors (SSRIs) can be considered as an alternative medication option, though evidence is more limited than for lisdexamfetamine. 1
• Research with "off-label" medications has yielded modest and mixed outcomes with few showing superiority to placebo long-term. 2

Combined Treatment Approaches

• Combining medications with psychological treatments has consistently failed to enhance outcomes beyond psychotherapy alone, though combined treatment appears superior to pharmacotherapy-only. 2
• The evidence does not support routinely combining CBT with pharmacotherapy as a first-line strategy. 2

Treatment Algorithm

Initial Assessment

• Quantify eating patterns and frequency of binge episodes (baseline average of binge days per week over 14 days prior to treatment). 1, 7
• Assess severity using Clinical Global Impression-Severity (CGI-S) scale; moderate-to-severe BED is defined as ≥3 binge days per week for 2 weeks and CGI-S score ≥4. 7
• Screen for co-occurring psychiatric disorders, which are common in eating disorders. 1
• Conduct physical examination including vital signs, height, weight, and BMI. 1
• Order laboratory assessment: complete blood count, comprehensive metabolic panel including electrolytes, liver enzymes, and renal function tests. 1
• Obtain electrocardiogram in patients with severe purging behavior or those taking medications that prolong QTc intervals. 1

Treatment Selection Based on Patient Characteristics

For most patients:

• Begin with guided self-help CBT (CBTgsh) as a first-line option due to its effectiveness, lower cost, and scalability. 3, 2

For patients with low self-esteem and high eating disorder psychopathology:

• Prioritize full IPT or full CBT over CBTgsh, as these patients show better outcomes with specialty therapy. 3

For patients with limited access to specialized care:

• Utilize technology-based CBT interventions including guided computer-based programs or videoconferencing. 1

For patients who also desire weight loss:

• Consider BWL as an alternative first-line treatment, recognizing it produces comparable binge eating reduction with the added benefit of modest weight loss. 2, 5

For patients preferring medication or with inadequate response to psychotherapy by 6 weeks:

• Add lisdexamfetamine 50-70 mg/day (starting at 30 mg/day for 1 week, then titrating to 50 mg/day, with further increases to 70 mg/day as tolerated and clinically indicated). 1, 7

Multidisciplinary Team Coordination

• Treatment requires a coordinated team incorporating medical, psychiatric, psychological, and nutritional expertise. 1
• The team typically includes a primary care physician, mental health practitioner, and registered dietitian. 1

Predictors of Treatment Response

Rapid Response

• Early response to treatment (within the first few weeks) is a significant predictor of long-term success and should be monitored closely. 6

Overvaluation of Body Shape and Weight

• Presence of overvaluation of body shape and weight predicts poorer treatment outcomes and may require more intensive intervention. 6

Important Clinical Considerations

Common Pitfalls

• Many patients with BED go untreated due to shame, stigma, and shortage of specialized providers; technology-based interventions can help overcome these barriers. 1
• Adherence to technology-based interventions can be challenging, with only 57% of participants completing full treatment courses; regular monitoring and support are essential. 8
• Avoid routinely combining psychotherapy with medications as first-line treatment, as this does not enhance outcomes beyond psychotherapy alone. 2

Treatment Duration and Monitoring

• Standard treatment protocols typically involve 10-20 sessions over 6 months for psychological interventions. 3
• Pharmacological trials demonstrating efficacy used 12-week treatment periods. 7
• Regular monitoring should assess binge eating frequency, psychological distress, and treatment adherence. 1

Long-Term Outcomes

• CBT and IPT demonstrate durable benefits after treatment completion, with sustained remission rates through 2-year follow-up. 2, 3
• Weight loss from BWL is modest (approximately 2% BMI reduction) and may not be maintained long-term without ongoing intervention. 5