Behavioral Addictions _ _______________________________________________________________________
Pharmacotherapy Overall, strong evidence shows that second-generation antidepressants, lisdexamfetamine, and therapist-led CBT increases the likelihood of achieving abstinence. CBT and second-generation antidepressants reduce binge frequency, and second-generation antidepressants reduce obsessions and compulsions related to binge eating. Lisdexamfetamine reduces binge frequency and obsessions and compulsions related to binge eating [81]. Lisdexamfetamine The prodrug lisdexamfetamine is the sole FDA-approved drug for the treatment of moderate-to-severe binge eating disorder. The FDA has withdrawn several investigational or approved binge eating disorder pharmacotherapies from the U.S. market over safety concerns and adverse effects (e.g., sibutramine, rimonabant, d-fenfluramine) [81]. Lisdexamfetamine improved binge-eating outcomes in several rigorously designed studies. In aggregate, patients treated with lisdexamfetamine were 2.61 times more likely to achieve binge- eating abstinence than with placebo [81]. Lisdexamfetamine led to greater reduction in binge-eating days than placebo and was associated with superior eating-related psychopathol- ogy and weight-reduction outcomes. The most common side effects reported by patients receiving lisdexamfetamine were gastrointestinal upset, sympathetic nervous system arousal, insomnia, headache, and decreased appetite [81]. Lisdexamfetamine product labeling includes a “limitation of use” that the drug is not indicated for weight loss, its effects on obesity are unknown, and similar medication classes have been associated with cardiovascular adverse events in the past. Lisdexamfetamine is also considered a controlled substance, and the product labeling includes a warning that CNS stimu- lants have high potential for abuse and dependence. Careful assessment and on-going monitoring for signs of misuse are indicated [261]. Another FDA-approved drug for ADHD treatment, atomox- etine, was significantly superior to placebo in reducing binge eating and achieving binge-eating remission in a small random- ized controlled trial [261]. However, its use in the treatment of binge eating disorder is off-label. Selective Serotonin Reuptake Inhibitors SSRIs are the most frequently studied binge eating disorder medications, likely due to the efficacy and FDA approval of fluoxetine for bulimia nervosa [261]. Fluoxetine was superior on some measures of binge eating to placebo in a 6-week study, but not in a 16-week trial. In the six-week study, fluoxetine rapidly reduced binge eating versus placebo, but binge eating reduction and abstinence did not differ at study conclusion. Fluoxetine did not differ significantly from sertraline or flu- voxamine, and fluoxetine and fluvoxamine were significantly inferior to CBT alone in another trial [261].
lower emotional eating, and lower pretreatment binge eat- ing severity. Low emotional eating was the only predictor of weight reduction. Predictors of treatment resistance included overweight in childhood, full binge eating disorder diagnosis, and high prevalence of emotional eating [263]. The American Psychiatric Association recommends that patients with binge-eating disorder be treated with eating disorder-focused CBT or interpersonal therapy, either in individual or group formats. Patients with binge eating disor- der who prefer treatment with medication or who have not responded to psychotherapy alone may be treated either with an antidepressant or lisdexamfetamine [364]. Interpersonal Psychotherapy Patients with binge eating disorder receiving therapist-led CBT and IPT showed differing abstinence trajectories at 46-month follow-up. Patients receiving CBT had high initial abstinence (81%) at the end of treatment, declining to 52% at final follow-up. Patients undergoing IPT had lower post- treatment abstinence (64%), but this increased (to 77%) by last follow-up [264]. Group Psychodynamic Interpersonal Psychotherapy Compared with patients on a wait list, patients receiving 16 weekly group PIPT sessions showed greater binge frequency reductions (-0.5 vs. -3.0 binge days per week) and greater binge- eating abstinence (9.1% vs. 59.5%) [265]. Group PIPT also led to greater improvements in dietary restraint, depression, and interpersonal problems, but it did not differ from controls in BMI, self-esteem, or susceptibility to hunger at the end of treatment [81]. Behavioral Weight Loss Behavioral weight loss treatment in binge eating disorder incorporates various behavioral strategies to promote weight loss, such as caloric restriction and increased physical activity. A meta-analysis compared CBT and behavioral weight loss on measures of binge frequency, abstinence, weight, and eating- related psychopathology [81]. Both CBT and behavioral weight loss were associated with substantial improvement in binge frequency, but CBT was superior to behavioral weight loss at the end of treatment and at 12-month follow-up. Behavioral weight loss led to larger BMI reductions than CBT at the end of treatment. There were no differences in binge-eating absti- nence or eating-related psychopathology at any point in the study [81]. One study evaluated a combined online interven- tion for binge eating disorders and high body weight in young adults [266]. Sixty adults 18 to 39 years of age were randomized to a combined condition or a CBT-only condition for eight weeks. Participants self-reported frequency of binge eating, compensatory behaviors, and weight at baseline, four weeks, and eight weeks. Participants also received self-help content for the duration of the study. Both conditions evaluated achieved significant reductions in binge episodes and compensatory behaviors from baseline to 8 weeks, but neither condition demonstrated significant weight loss [266].
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