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*
|Outcomes||Comparisons||Weighted event rates||RBI (95% CI)||NNT (CI)|
|Remission||PT vs AD||41% vs 20%||63% (−14 to 210)||Not significant|
|AD + PT vs AD||47% vs 23%||79% (11 to 188)||5 (3 to 21)|
|PT + AD vs PT||50% vs 36%||30% (1 to 68)||8 (5 to 37)|
|Clinical improvement||PT + AD vs PT||46% vs 52%||8% (−70 to 50)||Not significant|
|RRR (CI)||NNT (CI)|
|Dropouts||PT vs AD||18% vs 41%||54%% (9 to 76)||5 (3 to 10)|
|AD + PT vs AD||35% vs 41%||16% (−45 to 51)||Not significant|
|RRI (CI)||NNH (CI)|
|PT + AD vs PT||26% vs 16%||74% (14 to 167)||10 (6 to 40)|