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Review: Psychological treatment is as effective as antidepressants for bulimia nervosa, but a combination is best

John F. Morgan, MD, MA
[+] Article and Author Information

Source of funding: Not stated.

For correspondence: Dr. J. Bacaltchuk, Universidade Federal de São Paulo, São Paulo—SP, Brazil. E-mail bacaltc@ibm.net.


Ann Intern Med. 2002;136(3):107. doi:10.7326/ACPJC-2002-136-3-107
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Questions: In patients with bulimia nervosa (BN), are antidepressants as effective as psychological treatment (PT) for increasing remission and clinical improvement rates? Is a combination of antidepressants and PT better than each intervention alone?

Data sources: Studies were identified by searching MEDLINE; EMBASE/Excerpta Medica; LILACS; PsycLIT; SCISEARCH; the Cochrane Depression, Anxiety, and Neurosis Group Database of Trials; the Cochrane Controlled Trials Register; Clinical Evidence; and reference lists. The International Journal of Eating Disorders and book chapters on BN were also hand searched, and authors and pharmaceutical companies were contacted.

Study selection: Studies were selected if they were randomized controlled trials (RCTs) that compared antidepressants with PT in patients with BN. Studies were excluded if patients had binge-eating or purging-type anorexia nervosa or binge-eating disorder.

Data extraction: 2 reviewers assessed the quality of studies and extracted data on patients, study characteristics, interventions, and outcomes (including remission [100% reduction in binge or purge episodes], clinical improvement ≥ 50% reduction in binge or purge episodes], and dropouts).

Main results: 5 RCTs (237 patients) compared antidepressants with PT. Groups did not differ significantly for remission (5 RCTs); only 1 RCT reported on clinical improvement. More dropouts occurred in the antidepressant group than in the PT group (4 RCTs) (Table). 5 RCTs (247 patients) compared combination and single interventions.Antidepressants vs combination: More patients in the combination group than in the antidepressant-alone group had remission (4 RCTs) (Table); only 1 RCT reported on clinical improvement. Groups did not differ for dropout rates (4 RCTs).PT vs combination: More patients in the combination group than in the PT-alone group had remission (6 RCTs); fewer patients in the PT-alone group than in the combination group dropped out (6 RCTs) (Table). Groups did not differ for clinical improvement (2 RCTs) (Table).

Conclusions: In patients with bulimia nervosa, psychological treatment (PT) and antidepressants do not differ in remission rates, but dropout rates are lower with PT. A combination of antidepressants and PT is best for increasing remission.

Antidepressants (AD) vs psychological treatment (PT) for bulimia nervosa*

OutcomesComparisonsWeighted event ratesRBI (95% CI)NNT (CI)
RemissionPT vs AD41% vs 20%63% (−14 to 210)Not significant
AD + PT vs AD47% vs 23%79% (11 to 188)5 (3 to 21)
PT + AD vs PT50% vs 36%30% (1 to 68)8 (5 to 37)
RBR (CI)NNH
Clinical improvementPT + AD vs PT46% vs 52%8% (−70 to 50)Not significant
RRR (CI)NNT (CI)
DropoutsPT vs AD18% vs 41%54%% (9 to 76)5 (3 to 10)
AD + PT vs AD35% vs 41%16% (−45 to 51)Not significant
RRI (CI)NNH (CI)
PT + AD vs PT26% vs 16%74% (14 to 167)10 (6 to 40)

*RBR = relative benefit reduction. Other abbreviations defined in Glossary; RBI, RBR, RRR, RRI, NNT, NNH, and CI calculated from data in article. Follow-up ranged from 5 to 24 weeks.

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