Management and Outcomes of Binge-Eating Disorder in Adults: Current State of the Evidence

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1 Clinicin Summry Mentl Helth Eting Disorders Mngement nd Outcomes of Binge-Eting Disorder in Adults: Current Stte of the Evidence Focus of This Summry This is summry of systemtic review evluting the evidence regrding the effectiveness, comprtive effectiveness, nd dverse effects of tretments for dults with binge-eting disorder (BED). The review ssessed psychologicl interventions, behviorl weight-loss tretment, nd phrmcologicl interventions. The systemtic review included 57 studies nd one systemtic review published through Jnury 19, The full report, listing ll studies, is vilble t hrq.gov/binge-eting-disorder. This summry is provided to ssist in informed clinicl decisionmking. However, reviews of evidence should not be construed to represent clinicl recommendtions or guidelines. Bckground In My 2013, the Americn Psychitric Assocition (APA) recognized BED s distinct eting disorder in the fifth edition of the Dignostic nd Sttisticl Mnul of Mentl Disorders (DSM-5). In the shift from provisionl to forml dignosis of BED, the APA chnged the criteri for frequency nd durtion of BED bsed on the expnded peer-reviewed literture, thereby bringing both criteri in line with those for bulimi nervos (see the full DSM-5 criteri in Appendix 1 below). The lifetime prevlence of BED mong dults in the United Sttes is 2.8 percent bsed on DSM-IV criteri; it is likely to be slightly higher bsed on DSM-5 criteri. BED tends to be slightly more common in women nd is more common mong individuls who re overweight or obese. BED is ssocited with significnt impirment in roles relted to eduction or employment nd disstisfction with personl reltionships. It is lso considered substntil helth problem seprte from obesity nd my be independently relted to chronic pin, other psychitric disorders, nd dibetes. BED tretment includes vrious pproches tht trget the core behviorl nd psychologicl fetures of the condition nd mood regultion. Psychologicl nd behviorl therpy interventions include cognitive behviorl therpy (CBT), interpersonl psychotherpy (IPT), nd dilecticl behvior therpy (DBT). Descriptions of ll these interventions re given in Appendix 2. In Jnury 2015, the U.S. Food nd Drug Administrtion (FDA) pproved lisdexmfetmine, centrl nervous system stimulnt, s tretment for BED. Other commonly used phrmcologicl interventions include nticonvulsnts nd ntidepressnts. Conclusions Psychologicl nd Behviorl Therpy Interventions Evidence for the effectiveness of psychologicl nd behviorl interventions comes from both efficcy nd comprtive effectiveness studies. Efficcy studies only mesured outcomes t the end of tretment (8 weeks to 6 months) nd hd no long-term followup. However, most comprtive effectiveness studies hd long-term followup (t 6 months, t 12 months, nd up to 6 yers in some cses). Met-nlysis provided strong evidence tht therpist-led CBT reduced binge-eting frequency nd incresed bingeeting bstinence. CBT hs been compred with behviorl weight-loss (BWL) tretment. Moderte-level evidence demonstrtes tht BWL decresed body mss index (BMI) more thn CBT t the end of tretment. However, it should be recognized tht BWL ws not clerly ssocited with improvement in bingeeting behviors. Evidence ws insufficient to determine with confidence the effectiveness of other psychologicl interventions; however, studies of IPT nd DBT hve been promising. Phrmcologicl Interventions Efficcy studies of phrmcologicl interventions only mesured outcomes t the end of tretment (6 to 16 weeks) nd hd no long-term followup. Met-nlyses provided strong evidence tht lisdexmfetmine incresed binge-eting bstinence nd tht secondgenertion ntidepressnts incresed binge-eting bstinence, reduced binge-eting frequency, nd reduced eting-relted obsessions nd compulsions. Qulittive ssessments provided dditionl evidence tht lisdexmfetmine nd topirmte reduced binge-eting frequency, eting-relted obsessions nd compulsions, nd weight. Topirmte lso incresed binge-eting bstinence. Adverse effects of BED tretments were minly ssocited with medictions nd were rrely severe. Becuse of uncertinty bout the definition of BED remission nd recovery, the term bstinence is used to men 0 binge-eting episodes in the most recent ssessment period (usully the pst month). In doing so, the term remission is reserved to reflect more sustined, globl stte of chnge mrked by the bsence not only of binge-eting episodes but lso of other BED criteri for n extended period.

2 Overview of Clinicl Reserch Evidence Strength of Evidence Scle* High: High confidence tht the evidence reflects the true effect. Further reserch is very unlikely to chnge our confidence in the estimte of effect. Moderte: Moderte confidence tht the evidence reflects the true effect. Further reserch my chnge our confidence in the estimte of effect nd my chnge the estimte. Low: Low confidence tht the evidence reflects the true effect. Further reserch is likely to chnge our confidence in the estimte of effect nd is likely to chnge the estimte. Insufficient: Evidence either is unvilble or does not permit conclusion. * Owens DK, Lohr KN, Atkins D, et l. AHRQ series pper 5: grding the strength of body of evidence when compring medicl interventions Agency for Helthcre Reserch nd Qulity nd the Effective Helth-Cre Progrm. J Clin Epidemiol My;63(5): PMID: Tble 1: Summry of Key Findings for the Efficcy nd Comprtive Effectiveness of Interventions To Tret BED Intervention nd Comprtor N RCTs N Subjects Outcomes nd Findings Strength of Evidence Psychologicl nd Behviorl Therpy Interventions Therpist-led CBT vs. 4 (MA c ) 295 CBT incresed binge-eting bstinence (RR 4.95; 95% CI 3.06 to 8.00). witlist b 3 (MA c ) 208 CBT decresed the frequency of binge-eting episodes per week (MD -2.32; 95% CI to -0.09) CBT decresed eting-relted psychopthology. Prtilly therpist-led CBT vs. witlist b CBT incresed binge-eting bstinence nd decresed binge-eting frequency. Structured self-help CBT vs. witlist b CBT decresed binge-eting frequency. Guided self-help CBT vs. witlist b CBT incresed binge-eting bstinence. CBT decresed binge-eting frequency nd eting-relted psychopthology. Therpist-led CBT vs. No differences were found in binge-eting bstinence or frequency, eting-relted prtilly therpist-led CBT psychopthology, BMI, or symptoms of depression. Therpist-led CBT vs. No differences were found in eting-relted psychopthology, BMI, or symptoms structured self-help CBT of depression. Prtilly therpist-led CBT No differences were found in binge-eting bstinence or frequency, eting-relted vs. structured self-help CBT psychopthology, BMI, or symptoms of depression. Therpist-led CBT vs. BWL BWL decresed BMI more thn CBT t the end of tretment. therpy CBT decresed binge-eting frequency more thn BWL t the end of tretment nd up to 12 months of followup. No differences were found in binge-eting bstinence, eting-relted psychopthology, or symptoms of depression. Phrmcologicl Interventions Lisdexmfetmine d 3 (MA c ) 966 Lisdexmfetmine incresed binge-eting bstinence (RR 2.61; 95% CI 2.04 to 3.33). ( CNS stimulnt) vs. Lisdexmfetmine decresed binge-eting dys per week, weight, nd etingrelted obsessions nd compulsions, s mesured by the YBOCS-BE totl score Second-genertion 8 (MA c ) 416 Antidepressnts incresed binge-eting bstinence (RR 1.67; 95% CI 1.24 to 2.26). ntidepressnts (s clss) 7 (MA c ) 331 Antidepressnts decresed the frequency of binge-eting episodes per week (MD vs ; 95% CI to -0.09). 3 (MA c ) 122 Antidepressnts decresed the frequency of binge-eting dys per week (MD -0.90; 95% CI to -0.32) nd eting-relted obsessions nd compulsions (MD in YBOCS-BE totl score -3.84, 95% CI to -1.13; MD in YBOCS-BE obsessions score -1.53, 95% CI to -0.37; MD in YBOCS-BE compulsions score -2.31, 95% CI to -0.76). 3 (MA c ) 142 Antidepressnts decresed symptoms of depression (MD -1.98; 95% CI to -0.28). 4 (MA c ) 182 No difference ws found in weight (MD kg; 95% CI to 2.32). 6 (MA c ) 297 No difference ws found in BMI (MD -1.05; 95% CI to 0.55). Topirmte Topirmte incresed binge-eting bstinence. (n nticonvulsnt) Topirmte decresed binge-eting frequency, weight, nd eting-relted vs. obsessions nd compulsions Topirmte improved generl nd eting-relted psychologicl functioning e nd decresed impulsivity nd disbility in fmily nd other socil domins. 95% CI = 95-percent confidence intervl; BMI = body mss index; BWL = behviorl weight loss; CBT = cognitive behviorl therpy; CNS = centrl nervous system; MA = met-nlysis; MD = men difference; N = number; RCT = rndomized controlled tril; RR = risk rtio; YBOCS-BE = Yle-Brown Obsessions nd Compulsions Scle modified for binge eting See Appendix 2 for descriptions of ech type of CBT. b Witlist refers to ptients who received no tretment t ll. c For quntittive synthesis, met-nlyses to estimte overll effect sizes were conducted using Comprehensive Met-Anlysis softwre, version 3.2. d Lisdexmphetimine is not indicted by the FDA for weight loss. The FDA notes tht use of other sympthomimetic drugs for weight loss hs been ssocited with serious crdiovsculr dverse events, nd the sfety nd effectiveness of lisdexmfetmine for the tretment of obesity hve not been estblished. e Indicted by increses in cognitive control of eting nd decreses in symptoms of psychologicl distress, susceptibility to hunger, nd disinhibition of control over eting.

3 Overview of Clinicl Reserch Evidence (Continued) Tble 2: Summry of Key Findings for Adverse Effects of Phrmcologicl Interventions N Reported Events Intervention nd Comprtor N RCTs N Subjects (Intervention vs. Plcebo) Outcomes nd Findings Strength of Evidence Lisdexmfetmine Lisdexmfetmine ws ssocited with greter insomni (RR 2.66; 95% 78 (11% vs. 5%) vs. CI 1.63 to 4.31). 3 (MA ) 938 Lisdexmfetmine ws ssocited with greter risk of hedche (RR 111 (14% vs. 9%) 1.63; 95% CI 1.13 to 2.36). 119 (88 vs. 31) Lisdexmfetmine ws ssocited with higher number of events relted to GI upset Lisdexmfetmine ws ssocited with higher number of events 342 (283 vs. 59) relted to sympthetic nervous system rousl. 66 (53 vs. 13) Lisdexmfetmine ws ssocited with decresed ppetite. Fluvoxmine vs. Fluvoxmine ws ssocited with higher number of events relted to GI 24 (18 vs. 6) upset (15 vs. 7) Fluvoxmine ws ssocited with higher number of events relted to sympthetic nervous system rousl. 57 (42 vs. 15) Fluvoxmine ws ssocited with higher number of events relted to sleep disturbnce. Topirmte vs. Topirmte ws ssocited with higher number of events relted to 243 (181 vs. 62) sympthetic nervous system rousl. 199 (152 vs. 47) Topirmte ws ssocited with higher number of other dverse events, including upper respirtory trct infection, tste perversion, difficulty with ttention nd memory, dizziness, confusion, nd bck pin. 73 (37 vs. 36) No difference ws found in the number of hedches. 94 (52 vs. 42) No difference ws found in the number of events relted to GI upset. 89 (48 vs. 41) No difference ws found in the number of events relted to sleep disturbnce. 95% CI = 95-percent confidence intervl; BMI = body mss index; BWL = behviorl weight-loss; GI = gstrointestinl; MA = met-nlysis; RCT = rndomized controlled tril; RR = risk rtio For quntittive synthesis, met-nlyses to estimte overll effect sizes were conducted using Comprehensive Met-Anlysis softwre, version 3.2. Tble 3: FDA Mediction Wrnings The FDA lists the following wrnings: CNS stimulnts (mphetmines nd methylphenidte-contining products), including lisdexmfetmine, hve high potentil for buse nd dependence. Lisdexmfetmine cn cuse sudden deth, stroke, nd myocrdil infrction in dults. Avoid use in ptients with known structurl crdic bnormlities, crdiomyopthy, serious hert rrhythmi, or coronry rtery disese. Topirmte is clssified s pregnncy ctegory D, nd use during pregnncy cn cuse cleft lip, cleft plte, or both. Lisdexmfetmine nd second-genertion ntidepressnts re clssified s pregnncy ctegory C. There is n incresed risk of suicidl thinking nd behvior in children, dolescents, nd young dults tking ntidepressnts. These ptients should be monitored for emergence nd worsening of suicidl thoughts nd behviors. Tble 4: Other Findings of the Review Tretment Evidence ws inconclusive bout the comprtive effectiveness of phrmcologicl interventions to improve BED outcomes. ( ) Evidence ws inconclusive bout the effectiveness of ny combintion of phrmcologicl nd psychologicl tretments to improve BED outcomes. ( ) Course of Illness A study (mesuring ttempted suicides) nd review rticle of three studies (mesuring suicides) found no incresed risk of suicide mong ptients with BED 5 yers fter tretment. () Evidence ws inconclusive for ll other course-of-illness symptoms for ptients with BED. ( )

4 Gps in Knowledge nd Limittions of the Evidence Bse The report identified severl gps nd limittions in the evidence bse: A criticl gp exists in long-term efficcy nd hrms; this deficiency is most evident for phrmcologicl nd combintion tretments. The evidence bse for tretment efficcy ws very limited for ll medictions (except lisdexmfetmine, topirmte, nd second-genertion ntidepressnts), ll psychologicl interventions (except vrious pproches to CBT delivery), nd ll combintion tretments. Evidence ws insufficient to permit conclusions bout the comprtive effectiveness of phrmcologicl interventions or the effectiveness of ny specific combintion of tretments to improve outcomes in ptients with BED. No trils compred single phrmcologicl intervention with single behviorl or psychologicl therpy intervention. Becuse studies did not uniformly collect or report dverse events, serious dverse events, nd study discontinutions clerly ttributble to dverse events, comprisons of hrms cross medictions were limited. Psychologicl trils rrely reported hrms relted to tretment. No studies ddressed differences in tretment outcomes mong importnt subgroups defined by ge, sex, rce, ethnicity, or other relevnt ptient chrcteristics. Despite current interest in complementry nd lterntive medicine, neutrceuticls, nd mindfulness-bsed interventions for regulting ppetite, eting behvior, nd weight, the literture is deficient regrding these types of interventions for BED. Applicbility Most studies were conducted in supervised settings generlly ssocited with cdemic reserch nd medicl centers, where mediction tretment ws likely mnged by psychitrist nd psychologicl nd behviorl therpy tretments were likely delivered by highly trined personnel. Whether the findings of this report pply to tretment settings more generlly is uncler. The number of therpists with expertise in CBT for BED is limited. Wht To Discuss With Your Ptients Tretment options for BED Evidence on the effectiveness of CBT, BWL, nd other types of psychologicl or behviorl therpy in treting BED Evidence on the effectiveness of medictions to tret BED Potentil dverse effects ssocited with medictions nd the importnce of tlking with their helth cre professionls if ny dverse effects develop Ptient tretment preferences nd fctors tht my impct ccess to or dherence to tretment Resource for Ptients Ordering Informtion Treting Binge-Eting Disorder: A Review of the Reserch for Adults is free compnion to this clinicin reserch summry. It cn help ptients nd their cregivers tlk with their helth cre professionls bout tretments for BED. For electronic copies of Treting Binge-Eting Disorder: A Review of the Reserch for Adults, this clinicin reserch summry, nd the full systemtic review, visit To order free print copies of the ptient resource, cll the AHRQ Publictions Cleringhouse t Source The informtion in this summry is bsed on Mngement nd Outcomes of Binge-Eting Disorder, Comprtive Effectiveness Review No. 160, prepred by the RTI Interntionl University of North Crolin Evidence-bsed Prctice Center under Contrct No I for the Agency for Helthcre Reserch nd Qulity, December Avilble t This summry ws prepred by the John M. Eisenberg Center for Clinicl Decisions nd Communictions Science t Bylor College of Medicine, Houston, TX.

5 Appendix 1: DSM-IV nd DSM-5 Dignostic Criteri for BED Ctegory Criterion 1 Criterion 2 Criterion 3 Criterion 4 Criterion 5 Severity Grding Definition Recurrent episodes of binge eting. An episode of binge eting is chrcterized by both of the following:. Eting, in discrete period of time (e.g., within ny 2-hour period), n mount of food tht is definitely lrger thn most people would et in similr period of time under similr circumstnces b. Feeling lck of control over eting during the episode (e.g., sensing tht one cnnot stop eting or control wht or how much one is eting) Binge-eting episodes re ssocited with three (or more) of the following:. Eting much more rpidly thn norml b. Eting until feeling uncomfortbly full c. Eting lrge mounts of food when not feeling physiclly hungry d. Eting lone becuse of embrrssment by how much one is eting e. Feeling disgusted with oneself, depressed, or very guilty fter overeting Mrked distress regrding binge eting is present. The binge eting occurs, on verge:. At lest 2 dys week for 6 months (DSM-IV frequency nd durtion criteri) b. At lest 1 dy week for 3 months (DSM-5 frequency nd durtion criteri) Binge eting is not ssocited with the regulr use of inpproprite compenstory behvior (e.g., purging, fsting, excessive exercise) nd does not occur exclusively during the course of norexi nervos or bulimi nervos. DSM-IV does not include BED severity grding scle. Applicble to DSM-5 only, BED severity is grded s follows: Mild: 1 to 3 episodes per week Moderte: 4 to 7 episodes per week Severe: 8 to 13 episodes per week Extreme: 14 or more episodes per week BED = binge-eting disorder; DSM = Dignostic nd Sttisticl Mnul of Mentl Disorders Appendix 2: Psychologicl nd Behviorl Therpy Interventions for BED Cognitive behviorl therpy (CBT) Psychotherpy tht focuses on identifying reltionships mong thoughts, feelings, nd behviors nd ims to chnge negtive thoughts bout oneself nd the world nd, by doing so, reduce negtive emotions nd undesirble behvior ptterns. CBT is delivered in vrious wys for exmple, therpist-led individul nd group sessions, structured self-help, nd guided self-help. Therpist-led CBT CBT in which therpist is present for the durtion of ech group or individul session to provide psychoeduction, tech new skills, nd support prticipnts. Prtilly therpist-led CBT CBT tht involves group or individul sessions in which prticipnts first wtch psychoeductionl video tht is similr to wht would be presented in person by therpist. The therpist then joins the second hlf of the session. Structured self-help CBT CBT in which prticipnts re given tretment mnul tht wlks them through ech session tht therpist would present. Prticipnts typiclly meet in groups for ech session nd wtch psychoeductionl video tilored to the session. A group member then fcilittes discussion for the second hlf of the session. Guided self-help CBT CBT in which prticipnts re given tretment mnul tht wlks them through ech session tht therpist would present. Prticipnts typiclly hve brief meetings with fcilittor (in person or on the Internet) to supplement the self-help pproch. Dilecticl behviorl therpy (DBT) Psychotherpy tht helps prticipnts understnd how negtive feelings cn led to binge eting s coping mechnism. DBT focuses on mindfulness, emotion regultion, nd distress tolernce. DBT is delivered in individul sessions or s group therpy. Interpersonl psychotherpy (IPT) Psychotherpy tht helps prticipnts understnd how problems with socil interctions cn led to binge eting s coping mechnism. IPT helps prticipnts lern to cope better with negtive emotions stemming from problems with socil interctions. It lso helps prticipnts develop helthy interpersonl skills. IPT is delivered in individul sessions or s group therpy. Behviorl weight-loss therpy Tretment tht incorportes vrious behviorl strtegies, such s cloric restriction nd incresed physicl ctivity, to promote weight loss. Icovino JM, Gredys DM, Altmn M, et l. Psychologicl tretments for binge eting disorder. Curr Psychitry Rep Aug;14(4): PMID: AHRQ Pub. No. 15(16)-EHC030-3-EF My