A review of the controlled trials of pharmacotherapy and psychotherapy in the treatment of bulimia nervosa

The treatment literature on bulimia nervosa includes several double-blind placebo controlled studies, the majority of which examine the use of antidepressants in bulimia nervosa. The psychotherapy literature has focused heavily on the use of cognitive behavioral therapy (CBT) in the treatment of this eating disorder. Some studies have compared CBT to other types of therapy or waiting list controls. The following review will examine the methodology and outcome of the pharmacotherapy and psychotherapy treatment studies of bulimia nervosa. The authors conclude that while the studies indicate treatment is somewhat effective, there remains uncertainty regarding the long-term effectiveness of most of the reported treatments. © 1993 by John Wiley & Sons, Inc.     

Treatment of bulimia nervosa: Where are we and where are we going?

OBJECTIVE: The purpose of this article is to review the extant treatment literature on bulimia nervosa and to offer suggestions for future research directions. METHOD: The available treatment studies regarding both pharmacotherapy and psychotherapy are reviewed. RESULTS: Both pharmacotherapy and psychotherapy appear to play a role in the treatment of bulimia nervosa; however, available data suggest that cognitive behavioral therapy remains the treatment of choice. CONCLUSION: Additional work is clearly indicated regarding assisted and unassisted self-help. An enhanced form of CBT and the integrative cognitive-affective therapy both deserve further study. New approaches need to be piloted. More research is needed on treatment modeling.     

Psychological treatment of eating disorders. A review of the literature

The aim of this study is to review the existing literature (PubMed database) on the psychological treatments for eating disorders (EDs), subdivided in individual, group and family therapies. Moreover new approaches and directions in this field are addressed. An extensive literature review is performed to identify the psychological treatment trials in anorexia nervosa (AN) and bulimia nervosa (BN) published over the past 2 decades. Eighty-two studies focused on psychotherapeutic treatment of EDs are reviewed. Only a minor part of these studies are randomised and controlled. While there is evidence of the efficacy of cognitive behavioral therapy (CBT), this is still missing for other psychotherapeutic approaches. However, there is general agreement about the importance of psychotherapy in multimodal treatments. There is still a need for a shared concept of outcome in EDs, since the efficacy of psychological treatment is greatly influenced by the definition of outcome adopted (concerning symptoms, psychosocial functioning, personality).     

Utilization of empirically supported psychotherapy treatments for individuals with eating disorders: A survey of psychologists

OBJECTIVE: The purpose of this study was to assess the primary methods used by psychotherapists in treating individuals with eating disorders and to determine the extent to which certain empirically supported psychotherapies (i.e., cognitive behavioral therapy [CBT] and interpersonal psychotherapy [IPT]) are used in clinical settings. METHOD: Surveys developed for this study were sent to 500 psychologists randomly selected from a list of all licensed doctoral-level psychologists in an upper midwestern state. RESULTS: Despite the findings that CBT techniques were reported to be frequently used, most respondents identified something other than CBT or IPT as their primary theoretical approach. In addition, the majority of respondents indicated not having received training in the use of manual-based, empirically supported treatment approaches for working with individuals with eating disorders, although most reported a desire to obtain such training. CONCLUSIONS: Although commonly referred to as the "treatments of choice" in research literature, manual-based, empirically supported approaches to working with individuals with eating disorders has not received adequate dissemination.     

The potential benefit of vacuum devices augmenting psychosexual therapy for erectile dysfunction: a randomized controlled trial

A cohort of 45 patients diagnosed with predominant psychogenic erectile disorder (ED) chose couples psychotherapy. We randomized 25 couples to also receive a vacuum constriction device (VCD), also known as a vacuum erectile device, at the second session (group 1), whereas 20 couples had psychotherapy without a VCD. Twenty-one couples (84%) in group 1 reported some improvement after the initial psychotherapy and VCD sessions compared with 12 of the 20 couples (60%) who reported some improvement after couples psychotherapy in group 2. We subsequently found that 3 of the 4 couples in group 1 reporting no improvement had not used the pump provided. Early combination treatment of couples psychotherapy and a physical treatment such as a VCD may lead to a greater beneficial response in men with ED than therapy alone. The delay of demonstrating the capacity and potential benefit from a physical intervention may have a marked effect on the initial and ongoing response to sex therapy.     

An integration of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa: a case study using the case formulation method

OBJECTIVE: The current study provides an illustration of an integration of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for the treatment of bulimia nervosa (BN), based on the case formulation strategy. METHOD: A 25-year-old Hispanic female referred herself for the treatment of eating difficulties and depressed mood. Diagnostic criteria were met for BN, major depressive episode, and alcohol abuse. Components of both CBT and IPT were utilized throughout the course of treatment. RESULTS: CBT techniques appeared to be most effective in eliminating binge eating and binge drinking behavior, whereas IPT techniques seemed to be most effective in reducing purging behavior. Results revealed that the client was no longer experiencing clinically significant symptoms of BN, depression, or alcohol abuse at end of treatment and follow-up (18 months after treatment onset). DISCUSSION: Findings support the integration of CBT and IPT for the treatment of BN and, potentially, other eating disorders.     

Effectiveness of Psychological Treatments for Depressive Disorders in Primary Care: Systematic Review and Meta-Analysis

PURPOSEWe performed a systematic review of the currently available evidence on whether psychological treatments are effective for treating depressed primary care patients in comparison with usual care or placebo, taking the type of therapy and its delivery mode into account.METHODSRandomized controlled trials comparing a psychological treatment with a usual care or a placebo control in adult, depressed, primary care patients were identified by searches in MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and PsycINFO up to December 2013. At least 2 reviewers extracted information from included studies and assessed the risk of bias. Random effects meta-analyses were performed using posttreatment depression scores as outcome.RESULTSA total of 30 studies with 5,159 patients met the inclusion criteria. Compared with control, the effect (standardized mean difference) at completion of treatment was −0.30 (95% CI, −0.48 to −0.13) for face-to-face cognitive behavioral therapy (CBT), −0.14 (−0.40 to 0.12) for face-to-face problem-solving therapy, −0.24 (−0.47 to −0.02) for face-to-face interpersonal psychotherapy, −0.28 (−0.44 to −0.12) for other face-to-face psychological interventions, −0.43 (−0.62 to −0.24) for remote therapist-led CBT, −0.56 (−1.57 to 0.45) for remote therapist-led problem-solving therapy, −0.40 (−0.69 to −0.11) for guided self-help CBT, and −0.27 (−0.44 to −0.10) for no or minimal contact CBT.CONCLUSIONSThere is evidence that psychological treatments are effective in depressed primary care patients. For CBT approaches, substantial evidence suggests that interventions that are less resource intensive might have effects similar to more intense treatments.     

Psychotherapie der Depression

There are now several well evaluated (psychological) interventions available to treat depressive disorders. A large number of controlled randomized trials have been conducted to establish scientific evidence for treatments' short- and long-term outcome. If the patient meets the diagnostic criteria for depression, a decision has to be made about referral to a psychiatrist or a psychotherapist for specialized treatment. Depending on severity of symptomatology (suicidality) as well as the range of individual problems, supportive counselling or specific psychotherapy is indicated. Specific psychotherapies for depression are in particular cognitive behaviour therapy (CBT) and interpersonal psychotherapy (IPT), to a less extent short-term psychodynamic psychotherapy (STPP) and client centred psychotherapy (CCPT). For these specific psychotherapies, empirical evidence is available about short-term (successful symptom reduction) and long-term (relapse prevention) outcome as monotherapy or in combination with antidepressive medication. Based on available outcome studies, 14 up-to-date treatment recommendations conclude this presentation.     

An intensive DBT program for patients with multidiagnostic eating disorder presentations: A case series analysis

Objective:

This study presents case‐series data on a novel outpatient program that blends dialectical behavior therapy (DBT) with standard eating disorder (ED) interventions (i.e., food exposure, weight monitoring, cognitive modification, ED psychoeducation) for patients with complex and multidiagnostic ED presentations.

Method:

Quantitative and qualitative data was collected on a sample of seven consecutively admitted women who presented with a severe ED, a history of several failed treatment attempts, pervasive emotion dysregulation, and significant Axis I or II psychiatric comorbidity (e.g., PTSD, borderline personality disorder).

Results:

Treatment was associated with reductions in ED symptoms, suicidal and self‐injurious behaviors, treatment interfering behaviors, psychiatric and medical hospitalizations, and clinican burnout.

Discussion:

Overall, the results suggest that this blended DBT/cognitive behavior therapy for ED treatment model is a promising intervention for this complex and “hard to treat” population. © 2013 by Wiley Periodicals, Inc. (Int J Eat Disord 2013)     

认知行为疗法联合抗抑郁药改善产后抑郁症状的效果研究

目的系统评价认知行为疗法(cognitive behavioral therapy,CBT)联合抗抑郁药改善产后抑郁症(postpartum depression,PPD)患者抑郁症状的疗效。方法计算机检索Pubmed、Cochrane Library、OVID、中国知网(CNKI)、中国生物医学文献数据库(CBM)、中文科技期刊数据库(VIP)、万方数据库(Wanfang Data)中所有关于CBT联合抗抑郁药治疗PPD患者的随机对照试验,对符合纳入标准的文献用Rev Man 5.3软件对文献数据进行meta分析,对比两组的疗效。结果共纳入12个研究,共计849人。本文对CBT联合抗抑郁药治疗8周的疗效进行了分析,第1周、第2周、第4周、第6周及第8周的结果分别为[WMD=-1.31,95%CI(-2.53,-0.10),P=0.03]、[WMD=-2.87,95%CI(-3.46,-2.28),P0.00001]、[WMD=-3.40,95%CI(-3.98,-2.82),P0.00001]、[WMD=-2.66,95%CI(-3.67,-1.65),P0.00001]及[WMD=-3.60,95%CI(-3.95,-3.25),P0.00001]。CBT联合药物治疗组疗效优于单纯药物治疗组。结论CBT联合抗抑郁药较单纯使用抗抑郁药能更显著地改善PPD患者的抑郁症状,其疗效在治疗第1周开始便优于同期单纯药物治疗组。     

Cost-Effectiveness of Different Formats for Delivery of Cognitive Behavioral Therapy for Depression: A Systematic Review Based Economic Model

ObjectivesCognitive behavioral therapy (CBT) is an effective treatment for depression. Different CBT delivery formats (face-to-face [F2F], multimedia, and hybrid) and intensities have been used to expand access to the treatment. The aim of this study is to estimate the long-term cost-effectiveness of different CBT delivery modes.MethodsA decision-analytic model was developed to evaluate the cost-effectiveness of different CBT delivery modes and variations in intensity in comparison with treatment as usual (TAU). The model covered an average treatment period of 4 months with a 5-year follow-up period. The model was populated using a systematic review of randomized controlled trials and various sources from the literature.ResultsIncremental cost-effectiveness ratios of treatments compared with the next best option after excluding all the dominated and extended dominated options are: £209/quality-adjusted life year (QALY) for 6 (sessions) × 30 (minutes) F2F-CBT versus TAU; £4 453/QALY for 8 × 30 F2F versus 6 × 30 F2F; £12 216/QALY for 8 × 60 F2F versus 8 × 30 F2F; and £43 072/QALY for 16 × 60 F2F versus 8 × 60 F2F. The treatment with the highest net monetary benefit for thresholds of £20 000 to £30 000/QALY was 8 × 30 F2F-CBT. Probabilistic sensitivity analysis illustrated 6 × 30 F2F-CBT had the highest probability (32.8%) of being cost-effective at £20 000/QALY; 16 × 60 F2F-CBT had the highest probability (31.0%) at £30 000/QALY.ConclusionsAll CBT delivery modes on top of TAU were found to be more cost-effective than TAU alone. Four F2F-CBT options (6 × 30, 8 × 30, 8 × 60, 16 × 60) are on the cost-effectiveness frontier. F2F-CBT with intensities of 6 × 30 and 16 × 60 had the highest probabilities of being cost-effective. The results, however, should be interpreted with caution owing to the high level of uncertainty.     

认知行为联合药物治疗精神分裂症残留型40例临床研究

目的探讨认知行为治疗精神分裂症残留型的临床效果,为临床治疗提供参考。方法选择2011年1月—2012年8月收治的79例精神分裂症残留型患者作为观察对象,随机将79例患者分成药物治疗组39例与认知行为治疗组40例,药物治疗组患者单纯应用利培酮进行治疗,剂量控制在3～6 mg,平均剂量(4.58±1.19)mg/次,4周为1个疗程,共治疗6个疗程。认知行为治疗组在药物治疗组基础上同时对患者进行认知行为治疗,具体方法如下:选择6名经验丰富的心理治疗师进行个体心理治疗,每周1次,每次治疗时间约60 min,4周为1个疗程,共治疗6个疗程。治疗后通过阳性与阴性症状量表、精神分裂症认知功能量表进行疗效评定。结果治疗后药物治疗组阴性症状分数[(14.3±4.7)分]明显高于认知行为治疗组[(10.8±2.5)分],差异有统计学意义(t=3.863,P<0.05),其他症状比较差异均无统计学意义(均P>0.05)。认知行为治疗组患者治疗后与治疗前相比阴性症状的明显改善,差异有统计学意义(t=4.207,P<0.05)。两组患者阳性症状、一般病理症状及总分比较差异均无统计学意义(均P>0.05)。认知行为治疗组患者后各项分数明显降低,均有统计学意义(均P<0.05);认知行为治疗组患者治疗后各项分数明显低于药物治疗组,均有统计学意义(均P<0.05)。结论认知行为治疗可明显改善精神分裂症残留型患者的阴性症状,且对认知功能有明显的改善,能明显改善患者的社会功能及生活质量,故可作为精神分裂症残留型患者康复的治疗方法。     

A comparison of sequenced individual and group psychotherapy for patients with bulimia nervosa

OBJECTIVE: The current study examined the effectiveness of individual (IND) versus group (GRP) therapy for patients with bulimia nervosa (BN), using a manual of sequenced treatment with cognitive-behavioral therapy (CBT) followed by interpersonal psychotherapy (IPT). METHOD: Eighty-six participants with BN were matched and randomized to 23 sessions of IND or GRP. Participants were measured pretreatment and posttreatment and at 1-year and 2.5-year follow-ups using both intent-to-treat and completer samples. RESULTS: The intent-to-treat analysis revealed that the percentage of participants recovered and remitted was equivalent between IND and GRP. Significant group differences were found between completers on binge eating and compensatory behavior with greater improvement for IND. On most measures, effect sizes were larger for IND at 1-year follow-up. CONCLUSION: Sequencing CBT and IPT worked well in both IND and GRP formats. We found few outcome differences between IND as opposed to GRP.     

Cognitive behavioral therapy and fluoxetine as adjuncts to group behavioral therapy for binge eating disorder

OBJECTIVE: Although binge eating disorder is a common and distressing concomitant of obesity, it has not yet been established whether affected individuals presenting to behavioral weight control programs should receive specialized treatments to supplement standard treatment. This study was designed to examine the added benefit of two adjunctive interventions, individual cognitive behavioral therapy (CBT) and fluoxetine, offered in the context of group behavioral weight control treatment. RESEARCH METHODS AND PROCEDURES: One hundred sixteen overweight/obese women and men with binge eating disorder were all assigned to receive a 16-session group behavioral weight control treatment over 20 weeks. Simultaneously, subjects were randomly assigned to receive CBT+fluoxetine, CBT+placebo, fluoxetine, or placebo in a two-by-two factorial design. Outcome measures, assessed at the end of the 16-session acute treatment phase, included binge frequency, weight, and measures of eating-related and general psychopathology. RESULTS: Overall, subjects showed substantial improvement in binge eating and both general and eating-related psychopathology, but little weight loss. Subjects who received individual CBT improved more in binge frequency than did those not receiving CBT (p<0.001), and binge abstinence was significantly more common in subjects receiving CBT vs. those who did not (62% vs. 33%, p<0.001). Fluoxetine treatment was associated with greater reduction in depressive symptoms (p<0.05). The 54 subjects who achieved binge abstinence improved more on all measures than the 62 subjects who did not. In particular, these subjects lost, on average, 6.2 kg compared with a gain of 0.7 kg among non-abstainers. DISCUSSION: Adjunctive individual CBT results in significant additional binge reduction in obese binge eaters receiving standard behavioral weight control treatment.     

Cognitive behavioral therapy improves diet and body composition in overweight and obese adolescents

BACKGROUND: Cognitive behavioral therapy (CBT) teaches behavioral and cognitive strategies that focus on achieving and maintaining lifestyle changes. OBJECTIVE: We examined the effectiveness of a CBT program (CHOOSE HEALTH) for improving body composition, diet, and physical activity in overweight and obese adolescents. DESIGN: Adolescents [16 male, 31 female; aged 14.5 +/- 1.6 y; body mass index (BMI; in kg/m(2)) 30.9 +/- 4.2] were block-matched into 2 groups by age, sex, Tanner stage, BMI, and hip and waist circumferences and were randomly assigned to CBT or no treatment (control). CBT consisted of 10 weekly sessions, followed by 5 fortnightly telephone sessions. RESULTS: Compared with the control, over 20 wk, CBT improved (significant group x time interactions) BMI (CBT, -1.3 +/- 0.4; control, 0.3 +/- 0.3; P = 0.007), weight (CBT, -1.9 +/- 1.0 kg; control, 3.8 +/- 0.9 kg; P = 0.001), body fat (CBT, -1.5 +/- 0.9 kg; control, 2.3 +/- 1.0 kg; P = 0.001), and abdominal fat (CBT, -124.0 +/- 46.9 g; control, 50.1 +/- 53.5 g; P = 0.008). CBT showed a greater reduction in intake of sugared soft drinks as a percentage of total energy (CBT, -4.0 +/- 0.9%; control, -0.3 +/- 0.9%; P = 0.005 for group x time interaction), which was related to reductions in weight (r = 0.48, P = 0.04), BMI (r = 0.53, P = 0.02), and waist circumference (r = 0.54, P = 0.02). Physical activity did not change significantly. CONCLUSIONS: A 10-wk CBT program followed by 10 wk of fortnightly phone contact improved body composition in overweight and obese adolescents. Changes in soft drink consumption may have contributed to this benefit.     

Management of Dyspnea and Anxiety in Chronic Obstructive Pulmonary Disease: A Critical Review

Background

Anxiety and dyspnea, 2 major symptoms in patients with chronic obstructive pulmonary disease (COPD), are associated with high morbidity and mortality. Thus, critically evaluating and synthesizing the existing literature employing pulmonary rehabilitation (PR) and other behavioral therapies in the treatment of anxiety and dyspnea in patients with COPD may help clinicians determine the most efficacious potential treatments. We aim to examine the efficacy of PR and behavioral therapy [eg, cognitive behavioral therapy (CBT) and counseling] and other adjunct modalities used in patients with COPD.

A case series of family‐based treatment for adolescents with atypical anorexia nervosa

The aim of this case series was to examine engagement in and outcomes of family‐based treatment (FBT) for adolescents with DSM‐5 atypical AN, that is, adolescents who were not underweight at presentation. Consecutive referrals for FBT of adolescents with atypical AN to a specialist child and adolescent eating disorder program were examined. Engagement in treatment (i.e., dose of treatment, completion rate), and changes in psychological symptomatology (i.e., eating disorder symptoms, depressive symptoms, self‐esteem, obsessive compulsiveness), weight, and menstrual function were examined. The need for additional interventions (i.e., hospitalization and medication), and estimated remission rates were also examined. The sample comprised 42 adolescents aged 12–18 years (88% female). Engagement in FBT was high, with 83% completing at least half the treatment dose. There were significant decreases in eating disorder and depressive symptoms during FBT (p < .05) but no improvement in self‐esteem. There was no significant change in percent of median BMI for age and gender for the sample as a whole (105 vs. 106%, p = .128). However, adolescents who were not admitted to hospital prior to FBT gained some weight (M = 3.4 kg) while those who were admitted did not gain weight during FBT (M = 0.2 kg, p < .01). The overall remission rate ranged from 38 to 52% depending on the criteria applied. FBT appears to be an effective treatment for adolescents with atypical AN. However, more research is needed into systematic adaptations of FBT and other treatments that could improve overall remission rates.     

Stage of change as a predictor of response to psychotherapy for bulimia nervosa.

OBJECTIVE: This study was designed to test the hypotheses that stage of change is a useful predictor of dropout and that it is related to treatment outcome in patients receiving brief psychotherapy for bulimia nervosa. METHOD: One hundred ten patients with bulimia nervosa were randomly assigned treatment with cognitive-behavioral therapy (CBT) or interpersonal therapy (IPT). On initial screening, patients were classified as being in the stage of precontemplation, contemplation, or preparation. RESULTS: Initial stage of change was not related to dropout either before or following randomization. Among all treatment completers, stage of change was related to outcome. Of the patients assigned to CBT, stage of change was not related to outcome. However, stage of change was related to outcome in patients randomized to IPT. DISCUSSION: This study suggests that initial stage of change may, under certain circumstances, be a useful predictor of outcome and that its utility as an outcome predictor may vary according to treatment.