Up to 1% of young women may have bulimia nervosa, characterised by an intense preoccupation with body weight, uncontrolled binge-eating episodes, and use of extreme measures to counteract the feared effects of overeating. People with bulimia nervosa may be of normal weight, making it difficult to diagnose. After 10 years, about half of people with bulimia nervosa will have recovered fully, one third will have made a partial recovery, and 10% to 20% will still have symptoms.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for bulimia nervosa in adults? What are the effects of discontinuing treatment in people with bulimia nervosa in remission? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 27 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: cognitive behavioural therapy (CBT; alone or plus exposure/response prevention enhancement), cognitive orientation therapy, dialectical behavioural therapy, discontinuing fluoxetine in people with remission, guided self-help cognitive behavioural therapy, hypnobehavioural therapy, interpersonal psychotherapy, mirtazapine, monoamine oxidase inhibitors (MAOIs), motivational enhancement therapy, pharmacotherapy plus psychotherapy, pure or unguided self-help cognitive behavioural therapy, reboxetine, selective serotonin reuptake inhibitors (SSRIs), topiramate, tricyclic antidepressants (TCAs), and venlafaxine.
Up to 1% of young women may have bulimia nervosa, characterised by an intense preoccupation with body weight, uncontrolled binge-eating episodes, and use of extreme measures to counteract the feared effects of overeating.
People with bulimia nervosa may be of normal weight, making it difficult to diagnose.Obesity has been associated with both an increased risk of bulimia nervosa and a worse prognosis, as have personality disorders and substance misuse.After 10 years, about half of people with bulimia nervosa will have recovered fully, one third will have made a partial recovery, and 10% to 20% will still have symptoms.
Cognitive behavioural therapy for bulimia nervosa (CBT-BN) may improve clinical problems of bulimia nervosa compared with no treatment, and may be as effective in reducing symptoms as interpersonal psychotherapy at 1 year, or as other psychological treatments, or antidepressants. However, we found no RCTs meeting eligibility criteria comparing the efficacy of interpersonal psychotherapy with waiting list control.
We don't know whether other psychological therapies such as cognitive orientation therapy, hypnobehavioural therapy, dialectical behavioural therapy, or motivational enhancement therapy are more effective than a waiting list control at improving symptoms, as we found only a few trials. We found insufficient evidence to support enhancing CBT-BN with exposure and response prevention (ERP).
Pure or unguided self-help CBT is likely to be no more effective than waiting list control at reducing binge eating. The evidence we found for guided self-help CBT is insufficient to judge this intervention because of high attrition in trials.
Some antidepressant drugs (fluoxetine, citalopram, desipramine, and imipramine) may improve symptoms in people with bulimia nervosa compared with placebo.
Monoamine oxidase inhibitors (MAOIs) may increase remission rates compared with placebo, but may not reduce bulimic symptoms or depression scores.We don't know whether other antidepressants (topiramate, mirtazapine, reboxetine, or venlafaxine) can improve symptoms or remission in people with bulimia nervosa.
We don't know whether continuation of antidepressant treatment may maintain a reduction in vomiting frequency compared with withdrawing treatment in people in remission.
We don't know if combining pharmacotherapy with psychotherapy enhances outcome. Trials that have suggested combinations may enhance outcomes have been limited in power.