What is the recommended evidence‑based treatment algorithm for binge‑eating disorder, including first‑line psychotherapy and subsequent medication options?

Evidence-Based Treatment Algorithm for Binge Eating Disorder

First-Line Treatment: Psychotherapy

Eating disorder-focused cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) should be offered as the initial treatment for binge eating disorder, delivered in either individual or group formats. 1, 2

• CBT targets normalization of eating behaviors, addresses psychological aspects of the disorder, and reduces eating disorder psychopathology through structured intervention 1
• The enhanced transdiagnostic version (CBT-E) shows particular efficacy for patients with severe comorbidity 3
• IPT represents an equally valid first-line option, focusing on interpersonal relationships and their connection to binge eating patterns 1, 4
• Technology-based CBT interventions demonstrate medium to large effects for reducing binge eating and serve as effective alternatives when specialized in-person care is unavailable 1

Common pitfall: Technology-based interventions face adherence challenges; guided formats outperform unguided self-help programs 1

When to Add or Switch to Pharmacotherapy

Lisdexamfetamine 50-70 mg/day should be initiated when patients prefer medication over psychotherapy or have not responded adequately to psychotherapy alone. 1, 2

• Lisdexamfetamine is the only FDA-approved medication for moderate-to-severe BED and demonstrates statistically significant superiority over placebo 1
• Titrate dosing gradually to minimize side effects (cardiovascular stimulation, insomnia, dry mouth) 2
• This medication is particularly appropriate when weight management is a concurrent treatment goal 2

Alternative Medication Options (Off-Label)

If lisdexamfetamine is contraindicated or not tolerated, consider topiramate (as phentermine/topiramate ER) or naltrexone/bupropion (Contrave) for patients with comorbid obesity. 2

• Topiramate reduces binge eating through GABA modulation and glutamate antagonism, though FDA approval is only for obesity, not BED specifically 2
• Naltrexone/bupropion works synergistically through POMC neuron activation and is particularly useful for patients describing food cravings or addictive eating patterns 2
• Selective serotonin reuptake inhibitors (SSRIs) represent another alternative, though evidence is more limited than for lisdexamfetamine 1

Critical caveat: Avoid weight gain-inducing medications such as mirtazapine and tricyclic antidepressants in BED patients with obesity 2

Initial Assessment Requirements

Quantify binge eating frequency, assess severity using the Clinical Global Impression-Severity (CGI-S) scale, and screen for co-occurring psychiatric disorders at baseline. 1

• Conduct physical examination including vital signs (temperature, resting heart rate, blood pressure with orthostatic measurements), height, weight, and BMI 5
• Order complete blood count and comprehensive metabolic panel (electrolytes, liver enzymes, renal function) 5
• Obtain electrocardiogram in patients with severe purging behavior or those taking medications that prolong QTc intervals 1, 5

Multidisciplinary Team Structure

Assemble a coordinated team incorporating a primary care physician for medical monitoring, a mental health practitioner for specialized eating disorder-focused psychotherapy, and a registered dietitian for nutritional rehabilitation and meal planning. 1, 5

• Additional specialists may include a psychiatrist for medication management and complex psychiatric comorbidities, particularly when combining treatments 5
• The mental health practitioner delivers the cornerstone of treatment—specialized eating disorder-focused psychotherapy 5

Monitoring Protocol

Assess efficacy and safety monthly for the first 3 months, then at least every 3 months when using pharmacotherapy. 2

• Discontinue medication if ≤5% weight loss at 12 weeks when weight management is a treatment goal 2
• Monitor binge eating frequency, psychological distress, and treatment adherence at each visit 1
• Medications should serve as adjuncts to lifestyle modifications, not monotherapy 2

Evidence Hierarchy

The American Psychiatric Association guidelines (2023-2025) provide the strongest evidence base for this algorithm 1, 5, 2. The recommendation for CBT as primary intervention is supported by multiple controlled trials and represents the highest-quality guideline evidence 5, 3. Lisdexamfetamine's specific dosing and indication are endorsed by both APA guidelines and FDA labeling 1, 2.