What is the recommended treatment for binge-eating disorder?

Treatment for Binge-Eating Disorder

Start with eating disorder-focused cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) as first-line treatment, with lisdexamfetamine 50-70 mg/day reserved for patients who prefer medication or have not responded to psychotherapy alone. 1

Initial Assessment

Before initiating treatment, conduct a structured evaluation:

• Quantify binge eating patterns by having patients track the frequency of binge episodes per week for at least 2 weeks 1
• Assess severity using the Clinical Global Impression-Severity (CGI-S) scale, with moderate-to-severe BED defined as CGI-S ≥4 1, 2
• Screen for co-occurring psychiatric disorders, particularly depression and personality disorders, which are common in BED 1, 3, 4
• Perform physical examination including vital signs, height, weight, and BMI 3
• Order laboratory tests including complete blood count, comprehensive metabolic panel, and electrolytes 3
• Obtain electrocardiogram in patients with severe purging behavior or those taking medications that prolong QTc intervals 1

First-Line Psychological Treatments

CBT is the most strongly supported intervention and should be offered as initial treatment for most patients:

• Traditional face-to-face CBT focuses on normalizing eating behaviors, addressing psychological aspects of the disorder, and reducing eating disorder psychopathology 1
• Guided self-help CBT (CBTgsh) produces remission rates of 61-73% and is significantly more effective than behavioral weight loss therapy at 2-year follow-up 5, 6
• Technology-based CBT interventions (computer-based or videoconferencing) show medium to large effects for reducing binge eating and represent effective alternatives for patients with limited access to specialized care 1, 3, 7

IPT is equally effective as CBT and may be particularly beneficial for specific patient subgroups:

• IPT produces similar long-term remission rates as CBT 1, 6
• IPT is preferred for patients with low self-esteem and high eating disorder psychopathology, as these factors moderate treatment outcomes favoring IPT over other approaches 6

Important Considerations for Psychological Treatment

• Rapid response to treatment (improvement within the first few weeks) is a significant predictor of good outcomes 8
• Presence of overvaluation of body shape and weight predicts poorer outcomes and may require more intensive intervention 8
• Technology-based interventions help overcome barriers such as shame, stigma, and shortage of specialized providers, but adherence can be challenging with only 57% of participants completing full treatment courses 3, 7

Pharmacological Treatment

Lisdexamfetamine is the only FDA-approved medication for moderate-to-severe BED:

• Dose: 50-70 mg/day after 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, 2
• Produces statistically significant reductions in binge days per week compared to placebo, with placebo-subtracted differences of -1.35 to -1.66 binge days per week 2
• Achieves higher remission rates and greater improvement on Clinical Global Impression-Improvement (CGI-I) scores 2
• Produces modest weight loss, unlike psychological treatments 9
• Long-term efficacy data are lacking, which is a significant limitation 9

Selective serotonin reuptake inhibitors (SSRIs) can be considered as alternatives:

• Evidence is more limited than for lisdexamfetamine 1
• Fluoxetine 60 mg/day was not superior to placebo in head-to-head comparison with CBT, producing only 22-29% remission rates 5
• SSRIs are less effective than psychotherapy for behavioral and psychological features of BED 5

Medication Caveats

• Do not use fluoxetine as monotherapy given its lack of superiority over placebo in controlled trials 5
• Combining CBT with fluoxetine does not improve outcomes compared to CBT alone 5
• Undesired side effects are more common with drug treatment compared to placebo 9

Treatment Algorithm

For most patients:

1. Offer guided self-help CBT as first-line treatment 6
2. If CBTgsh is ineffective or unavailable, provide traditional face-to-face CBT or technology-based CBT 1, 3

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

1. Offer IPT or full CBT rather than guided self-help 6

For patients who prefer pharmacotherapy or have not responded to psychotherapy:

1. Prescribe lisdexamfetamine 50-70 mg/day 1, 2
2. Consider SSRIs only if lisdexamfetamine is contraindicated or not tolerated 1

Multidisciplinary Team Coordination

Assemble a coordinated team incorporating:

• Primary care physician for medical monitoring 1, 3
• Mental health practitioner (psychologist or psychiatrist) for psychotherapy and/or medication management 1, 3
• Registered dietitian for nutritional counseling 1, 3

Ongoing Monitoring

Regularly assess:

• Frequency of binge eating episodes using daily binge diaries 1, 3
• Psychological distress and eating disorder psychopathology 1, 3
• Treatment adherence, particularly for technology-based interventions 1
• Need for continued treatment through periodic reassessment 3

Common Pitfalls to Avoid

• Do not prioritize weight loss as the primary treatment goal, as eating disorder treatments (except lisdexamfetamine) do not produce significant weight loss, and standard weight loss treatments do not address the core psychopathology 9, 4
• Do not use behavioral weight loss therapy alone as it is significantly less effective than CBT or IPT for achieving long-term remission from binge eating 6
• Do not assume bariatric surgery will exacerbate binge eating, as evidence suggests it does not worsen BED symptoms 4
• Treatment should first target disordered eating and associated psychopathology rather than obesity 4