What is the best treatment approach for a patient with binge eating disorder, including medication and therapy options?

Treatment of Binge Eating Disorder

Start with eating disorder-focused cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) as first-line treatment, and add lisdexamfetamine 50-70 mg/day if the patient prefers medication or has not responded adequately to psychotherapy alone. 1

Initial Assessment Requirements

Before initiating treatment, conduct a structured evaluation that includes:

• Quantify binge eating patterns by documenting the frequency of binge episodes per week using the Clinical Global Impression-Severity (CGI-S) scale to establish baseline severity 1
• Screen for co-occurring psychiatric disorders including depression, anxiety, and substance use disorders, which are highly prevalent in this population 1
• Perform physical examination measuring vital signs, height, weight, and BMI to establish baseline metabolic status 1
• Order laboratory assessment including complete blood count, comprehensive metabolic panel with electrolytes, liver enzymes, and renal function tests 1
• Obtain electrocardiogram if the patient has severe purging behaviors or is taking medications that prolong QTc intervals 1

First-Line Psychological Treatment

CBT is the cornerstone psychological intervention and should be offered as the initial treatment approach:

• CBT focuses on normalizing eating behaviors, addressing the psychological aspects of binge eating, and reducing eating disorder psychopathology through structured sessions 1
• IPT represents an equally effective alternative that addresses interpersonal difficulties and emotional triggers for binge eating, particularly useful for patients with low self-esteem and high eating disorder psychopathology 1, 2
• Technology-based CBT interventions (guided computer-based programs, videoconferencing) demonstrate medium to large effects for reducing binge eating and represent effective alternatives for patients with limited access to specialized care, though adherence can be challenging 1

Treatment Format Options

• Individual or group formats are both effective for delivering CBT and IPT 1
• Guided self-help CBT (CBTgsh) is a cost-effective, scalable first-line option that works as well as specialty therapy for most patients, particularly those without high levels of eating disorder psychopathology 2, 3

Pharmacological Treatment

Lisdexamfetamine is the only FDA-approved medication for moderate-to-severe binge eating disorder:

• Dose lisdexamfetamine at 50-70 mg/day, which demonstrates statistically significant superiority over placebo in reducing binge eating frequency 1
• Consider lisdexamfetamine for patients who prefer pharmacotherapy or have not responded to psychotherapy alone after 6-8 weeks 1

Alternative Medication Options

• SSRIs can be considered as second-line pharmacotherapy, though evidence is more limited than for lisdexamfetamine 1
• Fluoxetine at 60 mg/day has been studied in bulimia nervosa and may reduce binge eating frequency, though it is not FDA-approved for binge eating disorder specifically 4, 5

Important caveat: The evidence for SSRIs in binge eating disorder is modest, with short-term benefits and almost no long-term data demonstrating sustained efficacy 6, 5

Combined Treatment Approach

Combining medications with psychotherapy does not enhance outcomes beyond psychotherapy alone:

• Combined treatment appears superior to pharmacotherapy-only but not to psychotherapy-only in research trials 6
• Reserve combined treatment for patients with partial response to psychotherapy alone rather than as a routine first-line approach 1

Multidisciplinary Team Coordination

Assemble a coordinated team incorporating:

• Primary care physician to monitor medical complications and metabolic parameters 1
• Mental health practitioner (psychologist, psychiatrist, or trained therapist) to deliver evidence-based psychotherapy 1
• Registered dietitian to provide nutritional counseling and normalize eating patterns 1

Monitoring and Follow-Up

Regularly assess treatment response by tracking:

• Binge eating frequency using structured interviews or validated questionnaires at each visit 1
• Psychological distress including depression, anxiety, and eating disorder psychopathology 1
• Treatment adherence to both psychotherapy sessions and medication regimens 1
• Weight changes as many patients with binge eating disorder also struggle with obesity, though weight loss is not the primary treatment goal 6, 3

Treatment Duration and Maintenance

• Psychotherapy typically requires 12-20 sessions over 3-6 months for acute treatment 2, 3
• Long-term benefits of CBT and IPT are well-maintained over 1-2 years of follow-up without ongoing treatment 3
• Periodically reevaluate the need for continued medication as long-term pharmacotherapy data beyond 12 weeks is limited 1

Common Pitfalls to Avoid

• Do not recommend behavioral weight loss (BWL) as first-line treatment for patients with high levels of eating disorder psychopathology (overvaluation of body shape/weight), as CBT and IPT are significantly more effective in this subgroup 2, 3
• Do not delay treatment due to patient shame or stigma, as technology-based interventions can help overcome these barriers 1
• Do not expect pharmacotherapy alone to produce durable benefits, as medication effects are typically modest and not well-maintained after discontinuation 6, 3