Treating Bulimia Nervosa in a Primary Care Setting

Both cognitive behavior therapy (CBT) and antidepressants have been helpful for treating patients with bulimia nervosa. CBT is ideally given by a specially trained professional with advanced training, but there is currently a shortage of such therapists. Another drawback is that some patients cannot complete the recommended course of treatment, which can include twenty 50-minute sessions over 4 to 5 months.

As a result, self-help programs based on CBT principles have been developed in special books targeted at lay audiences. “Guided self-help” adds a number of short visits (4 to 8) with a therapist, who encourages the patient to follow the treatment program described in the book. The other major intervention, use of antidepressants, has been studied in more than a dozen randomized, placebo-controlled studies. The only selective serotonin reuptake inhibitor most commonly examined in these trials has been fluoxetine; however, nearly all of the data on the use of this agent has come from studies conducted in specialty clinics. Both treatment approaches seem suitable for use in primary care settings.

Treatment groups

B. Timothy Walsh, MD and colleagues at Columbia University studied the benefits of the two treatment approaches in a study of 91 female patients treated in two primary care settings (Am J Psychiatry 2004; 161:3). The women were randomly assigned to receive fluoxetine alone, fluoxetine plus guided self-help, or a placebo and guided self-help.

At the baseline visit, patients were assessed with an abbreviated version of the Structured Clinical Interview for DSM-IV, a shortened version of the Eating Disorder Examination interview, and several self-report questionnaires, including the Beck Depression Inventory. Subjects were given fluoxetine, in a dosage of 60/mg/day or a placebo. Patients assigned to the guided self-help group met with a nurse, who gave them a copy of the CBT self-help book and instructed them to read certain sections. In addition to their monthly visits with a physician, these patients were scheduled to see a nurse for 6 to 8 sessions.

The first four guided self-help visits were designed to occur weekly during the first month of the study; the fifth session was scheduled in the second month, the sixth session in the third month, and two optional sessions in the third or fourth months. These sessions were about 30 minutes long and focused on encouraging patients to work through the self-help program.

The mean age of the patients was 30.6 years and 83.5% (76) of the 91 patients met full DSM-IV criteria for bulimia nervosa. The mean reported duration of bulimia was 12 years, and 28 (32.2%) of the 87 patients had previously been treated for eating disorder symptoms.

High dropout rate

Less than a third of the 91 patients (28 patients) completed the full course of treatment. Twenty-three of the patients who did not complete treatment indicated that the treatment offered was either too demanding or not demanding enough. Others gave no reason or complained that important life events interfered with attendance. Eight patients, or 12.7%, including one receiving placebo treatment, felt their symptoms were not improving and one dropped out because she felt she was “cured.” Physicians withdrew 4 patients because they had concerns about the level of depression.

The dropout rate was considerably higher than the 20% to 35% rate of dropout of patients with bulimia in comparable trials, and guided self-help had no outward effect on either retention or symptomatic improvement. Fluoxetine was beneficial. Compliance with mental health treatment given in a primary are setting is also problematic for other psychiatric disorders. The authors point out that approximately one-third of depressed adults being treated in primary care settings stop complying with antidepressant treatment (Eff Clin Pract 2000; 3:170).

Treatment best given in specialty settings

According to the authors, the problems of noncompliance, the lack of evidence for usefulness of guided self-help, and the limited impact of fluoxetine suggest that early referral to a specialty clinic that treats eating disorders should be strongly considered for patients with bulimia first seen in primary care settings.