Does Interpersonal Therapy Help Patients With Binge Eating Disorder Who Fail to Respond to Cognitive-Behavioral Therapy?

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1 Journal of Consulting and Clinical Psychology 1995, Vol. 63, No. 3, Copyright 1995 by the American Psychological Association, Inc X/95/S3.00 Does Interpersonal Therapy Help Patients With Binge Eating Disorder Who Fail to Respond to Cognitive-Behavioral Therapy? W. Stewart Agras, Christy F. Telch, Bruce Arnow, Kathleen Eldredge, Mark J. Detzer, Judith Henderson, and Margaret Marnell Stanford University The aim of this quasi-experimental study was to examine the effectiveness of group interpersonal therapy (IPT) in treating overweight patients with binge eating disorder who did not stop binge eating after 12 weeks of group cognitive-behavioral therapy (CBT). Participants in this study were randomly allocated to either group CBT or to an assessment-only control group. After 12 weeks of treatment with CBT, 55% of participants met criteria for improvement and began 12 weeks of weight loss therapy, whereas the nonresponders began 12 weeks of group IPT. Over the 24-week period, participants who received treatment reduced binge eating and weight significantly more than the waiting-list control group. However, IPT led to no further improvement for those who did not improve with CBT. Predictors of poor outcome were early onset of, and more severe, binge eating. Binge eating disorder (BED), a condition for which the proposed criteria have only recently been denned (Walsh, 1992), is characterized by episodes of binge eating without purging and is often accompanied by overweight. Among those seeking treatment for overweight, between 25% and 35% are binge eaters (Loro & Orleans, 1981; Marcus, Wing, & Lamparski, 1985; Telch, Agras, & Rossiter, 1988), and the prevalence of binge eating increases with increasing adiposity (Telch, Agras, & Rossiter, 1988). Hence, this is a relatively common problem, and because of the accompanying overweight and comorbid psychopathology (Telch & Agras, 1994), it poses a serious threat to mental and physical well-being. Moreover, the combination of an eating disorder and overweight, both difficult to treat in their own right, poses a challenge for the clinician. Cognitive-behavioral therapy (CBT), an effective treatment in bulimia nervosa (Wilson & Fairburn, 1993), is also effective in the treatment of BED, reducing both the frequency of binge eating and aspects of the comorbid psychopathology (Smith, Marcus, & Kaye, 1992; Telch, Agras, Rossiter, Wilfley, & Kenardy, 1990). Additionally, two studies have demonstrated that individuals who stop binge eating during CBT lose more weight than those who do not (Agras et al., 1994; Smith et al., 1992). This suggests that treating the eating disorder first and then treating the overweight is a logical approach to the management of the overweight binge eater. Because only about one half of patients stop binge eating after W. Stewart Agras, Christy F. Telch, Bruce Arnow, Kathleen Eldredge, Mark J. Detzer, Judith Henderson, and Margaret Marnell, Behavioral Medicine Program, Department of Psychiatry, Stanford University School of Medicine. This research was supported in part by Grant MH from the National Institutes of Health. Correspondence concerning this article should be addressed to W. Stewart Agras, Behavioral Medicine Program, Room 1322, Department of Psychiatry, Stanford University, School of Medicine, Stanford, California treatment with CBT (Agras et al., 1994; Smith et al., 1992; Telch et al., 1990) a second-level treatment that would benefit poor responders to CBT is needed. One such treatment is interpersonal therapy (IPT; Klerman, Weissman, Rounsaville, & Chevron, 1984), which has been demonstrated to be as effective in reducing binge eating as CBT both in bulimia nervosa (Fairburn etal, 1991) and BED (Wilfley etal., 1993). Because these very different treatments may work through different mechanisms, it is reasonable to hypothesize that patients with binge eating disorder who do not respond to CBT may respond to IPT. In the present study, overweight patients with BED were randomly allocated to either 12 weeks of group CBT or to an assessment-only control group. Those who did not meet criteria for improvement after CBT, received 12 weeks of group IPT, whereas those treated successfully with CBT, began weight loss therapy. Two questions were posed. First, was the overall treatment package more effective than the assessment-only group? Second, did IPT add anything for those who responded poorly to CBT? Participants Method Fifty participants meeting the proposed criteria for BED (Walsh, 1992) participated in this study. Potential participants were excluded if they were currently involved in a weight loss program, if they were taking antidepressant medication or any medication that might influence weight, if they abused drugs or alcohol, if they had a current major psychiatric condition such as a psychosis, if there was a history of purging within the previous 6 months, or if their body mass index (BMI) was below 27. The latter criterion excluded individuals who did not require treatment for overweight. Two hundred sixty-two individuals either were referred to this study or responded to advertisements placed in the local media. Of these, 163 were excluded during a detailed telephone interview. The principal reasons for exclusion were either a lack of interest in the study or inability to make the necessary time committment (87 individuals). Forty-five

2 TREATMENT OF BINGE EATING DISORDER 357 individuals were excluded because they did not meet criteria either for overweight or for binge eating frequency, and another 12 were excluded because they were currently purging. The remaining participants were excluded for a variety of reasons. Of the 89 individuals invited for a diagnostic interview, 18 either cancelled or did not keep their appointment. Seven individuals met exclusion criteria (e.g., current purging or current major psychiatric conditions). Of the 64 individuals eligible for the study, 14 did not complete the baseline assessment; hence, 50 participants were entered into the study. All participants were fully informed concerning the nature of the study and signed consent forms indicating their willingness to participate. Forty-three of the participants were women, and 7 were men. Their ages ranged from 24 to 65 years (M = 47.6, SD = 10.1), and participants reported an onset of overweight at a mean age of 18.9 years (SD = 12.8), and of binge eating at 21.1 years (SD = 12.0). Participants pretreatment weight averaged kg (SD = 25.4) with a BMI of 37.1 (SD = 7.3). They reported binge eating on an average of 4.5 days per week(sd = 1.7). Design and Procedure After a structured clinical interview and baseline assessment, eligible participants were allocated at random in a ratio of approximately 4:1 to either 24 weeks of treatment or to a waiting-list condition in which participants were seen only for assessment. Thirty-nine participants were allocated to treatment and 11 to the waiting-list control group. The initial CBT consisted of twelve 90-min sessions held at weekly intervals. The three treatment groups were each led by two PhD-level therapists experienced in the treatment of eating disorders. CBT was based on a modified version of the manual developed for the Telch et al. (1990) study. The principal modifications were to add weekly weighings, an exercise program with 30 min of walking three times a week as a minimum, and education in making food choices that are lower in fat. These modifications were made to stop the weight gain observed during CBT in a previous study (Agras et al., 1994). Participants were taught to monitor their food intake, binge eating episodes, and thoughts and moods before and after binge eating. These records formed the focus of treatment, which aimed at gradually changing the restricted and chaotic eating patterns so that participants established a regular pattern that included eating at least three well-balanced meals each day. Participants were also taught to reduce their avoidance of "forbidden foods" to enhance self-control and minimize feelings of deprivation. Precipitants to episodes of binge eating were examined in detail and more adaptive coping behavior devised for handling such antecedent events. Finally, relapse prevention procedures specific to binge eating were introduced during the last few sessions. Given our previous finding of an overall increase in weight during CBT (Agras et al., 1994) we felt it important that individuals complied with the minimal weight loss regimen, which as noted earlier, had been added to the CBT module. Hence, three criteria were set for success: stabilization (or loss) of weight for at least the last 4 weeks of treatment, a minimum aerobic exercise program in place (i.e., 30 min of walking three times each week) and abstinence from binge eating for at least the last 2 weeks of treatment. The latter criterion was chosen because, in our previous study, abstinence was associated with a 92% chance of weight loss, whereas all other levels of reduction in binge eating were associated with a 60% or less chance of weight loss. Participants who met these criteria then proceeded with weight loss treatment, whereas the remainder proceeded with IPT. Weight loss therapy was based on the first 12 sessions of the LEARN Program for Weight Control (Brownell, 1985) with some modification for this particular population. For example, continued attention was paid to maintaining a pattern of at least three meals each day, with snacks if necessary, and participants were cautioned against extreme dieting that might cause a relapse in binge eating. These group sessions were led by two PhD-level therapists and each session lasted 90 min. IPT was provided in a group format, using an adaptation of the manual for the group treatment of BED described in the Wilfley et al. (1993) study. Participants in this group led by two PhD-level therapists attended min sessions. The focus of treatment was on current interpersonal issues as described for depression (KJerman et al., 1984). The initial sessions focused on the rationale for treatment (i.e., that binge eating is often triggered by negative feelings arising from interpersonal problems) and on identification of the principal interpersonal problem areas for the group participants. The middle phase of therapy focused on clarifying and changing the identified interpersonal problems, and the final phase was spent evaluating progress to date and dealing with issues concerning termination of therapy. Measures Assessments for this study took place on three occasions: pretreatment, 12 weeks, and 24 weeks. The primary measures were of binge eating and weight. Binge eating, assessed as the number of days on which patients hinged each week, was measured by means of a diary on which participants recorded whether they had engaged in binge eating each day for a 14-day period. Both "objective" (i.e., binges consisting of a large amount of food and a sense of loss of control of eating behavior) and "subjective" (i.e., binges consisting of a normal or small amount of food accompanied by a sense of loss of control), were counted as binges. Weight was measured in lightweight clothing on a balance beam scale. The secondary measures included the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), a measure of depressed mood; the Three-Factor Eating Questionnaire (Stunkard & Messick, 1985), which measures cognitive restraint, disinhibition of eating, and hunger; the Binge Eating Scale (BES; Gormally, Black, Daston, & Rardin, 1982), which measures severity of binge eating; the Inventory of Interpersonal Problems (Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988); the Symptom Check List (Derogatis, 1977); and the Rosenberg Self-Esteem Scale (Rosenberg, 1965). Results In a comparison of the pretreatment characteristics of those allocated to the treatment and waiting-list groups, only the score on the BES was significantly different (p >.01), with a score of 33.3 (SD = 5.9) for the treatment group and 27.2 (SD = 6.3) for the waiting-list control group, denoting a slightly greater severity of binge eating for those receiving treatment. Two participants dropped out of the study before treatment began. Five participants (14.3%) dropped out during the 24-week treatment period, whereas one (9.0%) dropped out of the waitinglist control group. A comparison of treatment dropouts and completers revealed no significant differences on any measure. The first analysis examined whether the treatment package as a whole was more effective than the assessment-only condition, using a repeated measures multivariate analysis of variance (MANOVA) at the three time points for the primary measures of frequency of binge eating and weight. Forty-two participants who completed treatment and the assessments were included in this analysis. Using Hotelling's T 2 test, there was a significant interaction between group and time, F(4, 156) = 9.49, p = Univariate comparisons showed significant differences for both weight, F( 2, 80) = 4.05, p =.02, and binge eating F( 2, 80) = 170.0, p = (See Table 1 for means and standard deviations.) The number of days on which binges occurred, de-

3 358 AGRAS ET AL. Table 1 Means and Standard Deviations for the Treatment Package and Waiting- List Control Group at Pretreatment, 12 Weeks (After Completion of Cognitive-Behavioral Therapy), and 24 Weeks (After Completion of Interpersonal Therapy of Weight Loss Treatment) Measure 2 Pretreatment 1 2 weeks 24 weeks Binges/week Treatment 4. 4 ± ±1.4 Control 3.7 ± ± ±2.0 Weight (kg) Treatment ± ±28 Control Disinhibition ± ± ±22.8 Treatment 14.1 ± ± ±2.9 Control 13.6 ± ± Hunger Treatment 10.1 ± ± ± 2.9 Control Restraint Treatment 7.0 ± Control Binge Eating Scale 7.1 ± ± ±4.8 Treatment 29.4 ± ±7.1 Control 25.2 ± IIP Treatment ± ±0.6 Control 1.5 ± ±0.6 SCL-90 (Global) Treatment Control ± BDI Treatment 14.6 ± ± ± 8.2 Control ± Self-Esteem Treatment 2.8 ± ±1.8 Control 2.5 ± ± ±1.4 Note. IIP = Inventory of Interpersonal Problems; SCL-90 = Symptom Check List 90; BDI = Beck Depression Inventory. a For treatment groups, n = 3 1 ; for control group, n = 1 1. clined by 77% in the treatment group and by 22% in the assessment only group over 24-weeks. Fifty-five percent of participants abstained from binge eating over a 2-week period after 12 weeks of CBT, compared with 9% of the control group, x 2 ( 1, N = 42) = 6.9, p <.008. Weight declined by 0.6 kg in the treatment group and increased by 4. 1 kg in the waiting-list control group. A second MANOVA was performed for the secondary variables. There was a significant Group X Time interaction, F( 1 6, 1 80 ) = 1.8, p = We found differences using univariate tests for disinhibition, F(2, 78) = 6.0, p =.004, and the BES, F(2, 78) = 12.6, p = A second analysis was performed by intent to treat, bringing forward data from the previous assessment to later assessment (or assessments) for participants with missing data. There were no differences between this analysis and that reported earlier. The second question was whether the participants who did not meet criteria for improvement after 1 2 weeks of group CBT, improved with the addition of 12-weeks of group IPT. Binge eating for this group increased from 1.4 days/week (SD = 1.0) to 1.9 days/week (SD= 1.7) from beginning to end of interpersonal therapy (Weeks 13-24), while weight increased by 0.6 kg over the same period (see Table 2 for means and standard deviations). These changes were not significant using repeated measure MANO\A for a within group comparison. Only one person in this group no longer met criteria for BED, an individual who had not met criteria for BED at the end of CBT. Similarly analyses of the secondary variables showed no significant differences. For those who had responded to CBT, (i.e., had met the three criteria for success), a within-group analysis for the primary and secondary variables was performed using a repeated measures MANOVA from 12 to 24 weeks. For the primary variables, MANOVA results showed a significant change, F(2, 15) = 23.5, p = Post hoc univariate analysis indicated that changes occurred in weight, with a loss of 4.1 kg over the 12 weeks of weight loss treatment, F( 1, 16) = 40.9, p = Binge eating remained at a low level of 0.2 days/ week. No participant in this group met criteria for BED posttreatment. For the secondary variables, a Table 2 Means and Standard Deviations for Those Receiving the CBT- WL Treatment (i.e., CBT Treatment Responders) and for Those Receiving the CBT-IPT Treatment (i.e., CBT Nonresponders) at Pretreatment, at 12 Weeks (After Completion of CBT), and at 24 Weeks Measure 3 Pretreatment 12 weeks 24 weeks Binges/week CBT-WL 4.2 ± CBT-IPT 4.5 ± ± Weight (kg) f^rt WT in"? f\ -+- J1 8 1 H9 Q + 99 Q QS R -t- 79 ^ CBT-IPT ± Disinhibition CBT-WL 14.1 ± ± CBT-IPT 14.1 ± ± ±1.5 Hunger CBT-WL 10.2 ± ± ± 2.5 CBT-PT 9.7 ± Restraint CBT-WL 6.5 ± ± CBT-IPT 8.1 ± ± 2.6 Binge Eating Scale CBT-WL CBT-IPT ± ±5.1 IIP CBT-WL 1.4 ± ± CBT-IPT 1.6 ± ± SCL-90 (Global) CBT-WL 0.7 ± CBT-IPT 1.2 ± ± ±0.4 BDI CBT-WL ± ± ±9.7 CBT-IPT ±5.1 Self-esteem CBT-WL CBT-IPT 3.5 ± ± Note. CBT = cognitive-behavioral treatment; WL = weight loss; IPT = interpersonal treatment; IIP = Inventory of Interpersonal problems; SCL-90 = Symptom Check List-90; BDI = Beck Depression Inventory. " For CBT-WL, n = 1 7; for CBT-IPT, n = 1 3.

4 TREATMENT OF BINGE EATING DISORDER 359 similar MANOVA was significant, F(8, 9) = 4.9, p =.014. Univariate tests show a decrease for hunger, F( 1, 16) = 2.69, p=.02, and disinhibition, F(\, 16) = 5.9, p =.03, whereas restraint increased, F(l, 16)= 12.1,/? =.003. Effect of Abstinence on Weight A comparison for weight changes from 12 to 24 weeks was made for those who became abstinent during the first 12 study weeks and those who did not, regardless of group assignment. Weight decreased by 3.5 kg (SD = 2.95) for those who became abstinent and increased by 0.14 kg (SD = 2.0) for those who were not abstinent, t(40) = 4.65, p < Predictor Variables A comparison of the pretreatment primary and secondary variables for those receiving CBT followed by weight loss and those receiving CBT followed by IPT (see Table 2) revealed that only the BES was significantly different between groups at the pretreatment assessment, F( 1, 29) = 7.5, p =.01. In an exploratory analysis, signal detection methods (Kraemer, 1992) were used to detect baseline characteristics of participants that might predict the outcome of treatment at 24 weeks. Two predictors were found. First, a score on the BES <31 divided the participants into two groups, one with a score below 31 (n = 17) with a 76% success rate and the other with the higher scores (n = 14) with a 36% success rate. No further subdivision for the first group was found. However, for the second group an onset of binge eating at or earlier than 16 years of age divided the group into two parts, with those beginning binge eating after 16 years with a success rate of 75% and those beginning earlier with a success rate of 0%. Hence, the sensitivity of this two-part test is 100% and the specificity is 54%, with a predictive value of a positive test equal to 75% and that of a negative test equal to 100%. Discussion The results of this study were somewhat surprising in that IPT did not add to the effects of CBT for either the primary or secondary outcome variables. It is, of course, possible that the IPT offered to these patients was deficient in some respect. The experimental design used does not address this possibility, for example, by using both CBT and IPT as primary therapies and secondary therapies for failures from either treatment. However, the manual used was developed in our laboratory and was shown to be effective as a primary therapy for BED (Wilfley et al., 1993); furthermore, the therapists were familiar with it and each session was supervised in detail. A second possibility is that the patients in this study and the Wilfley et al. (1993) study differed in some important manner. For example, the mean weight of participants in the latter study was 87.3 kg, compared with a mean weight of kg in the present study. As shown in Table 2, those who did not demonstrate optimal improvement with CBT weighed 10.9 kg more on average than those who improved, although this difference was not statistically significant. The principal finding from this study raises both theoretical and practical questions. From a theoretical perspective, it appears that CBT and IPT may not target individuals with different characteristics. This raises the question whether the two treatments might work by means of a common mechanism to reduce binge eating. To definitively answer this question, a study of sufficient sample size, with frequent measures of the critical variables is required. Bolstering the common mechanism hypothesis is the fact that the two predictors associated with poor outcome for this study were indices of severity and chronicity of the condition, a high score on the BES, a measure of binge severity, and beginning binge eating in childhood or early adolescence. As we and others have found in previous studies (Agras et al., 1994; Smith et al., 1992), those who became abstinent from binge eating lost more weight than those who did not. Indeed, those who were not abstinent at 12 weeks gained weight on average. This gives further credence to the notion that it is important to first treat the eating disorder successfully and then to treat the weight problem. It is interesting to note that those in the waiting-list control group had gained 4.1 kg on average over the 24-week duration of this study. This confirms the notion, posed by the findings of an association between binge eating and weight (Telch et al., 1988), that BED, if left untreated, will lead to continued weight gain. This finding also underlines the importance of having a no-treatment comparison group in studies of weight loss with patients with BED, because the actual differences in weight will be underestimated without such a group. From a clinical viewpoint, the results of this study are both encouraging and discouraging. Although we failed to find a secondary treatment that might have helped those who did not respond to CBT, we found that those treated successfully with the CBT-weight loss package lost a reasonable amount of weight, as compared with the control group. This finding emphasizes the importance of discovering methods to further the improvement of those who do not respond to initial treatment. Some potential approaches suggest themselves. First, the optimal length of CBT for BED has not been established; hence, it may make sense to continue this treatment for those who do not respond in the first 12 weeks of therapy. Two points lead in this direction. First, when we asked those in the IPT group at 24 weeks what had helped them most, they responded with elements from CBT. Second, many of the studies using CBT in bulimia nervosa have much longer treatment periods than 12 weeks, often as many as 20 sessions over a 6-month period (Agras etal., 1992; Wilson &Fairburn, 1991). Other approaches such as the use of medication for those who fail initial therapy may also be useful. The use of either a tricyclic antidepressant (e.g., imipramine or desipramine; Agras et al., 1992; McCann & Agras, 1990; Mitchell et al., 1990) or a serotonin re-uptake inhibitor (such as fluoxetine; Fluoxetine Bulimia Nervosa Collaborative Study Group, 1992), which reduces binge eating, may be indicated. Moreover, there is also evidence that fluoxetine is associated with weight loss (Ferguson & Feighner, 1987), making it an interesting choice for further study. References Agras, W. S., Rossiter, E. M., Arnow, B., Telch, C. E, Raeburn, S. D., Schneider, J., Bruce, B., Perl, M., & Koran, L. (1992). Pharmaco-

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