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The Efficacy of Cognitive-Behavioral Therapy for Eating Disorders: A Systematic Review and Meta-Analysis

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Abstract

Objective: This meta-analysis examined the efficacy of cognitive-behavioral therapy (CBT) for eating disorders. Method: Randomized controlled trials of CBT were searched. Seventy-nine trials were included. Results: Therapist-led CBT was more efficacious than inactive (wait-lists) and active (any psychotherapy) comparisons in individuals with bulimia nervosa and binge eating disorder. Therapist-led CBT was most efficacious when manualized CBT-BN or its enhanced version was delivered. No significant differences were observed between therapist-led CBT for bulimia nervosa and binge eating disorder and antidepressants at posttreatment. CBT was also directly compared to other specific psychological interventions, and therapist-led CBT resulted in greater reductions in behavioral and cognitive symptoms than interpersonal psychotherapy at posttreatment. At follow-up, CBT outperformed interpersonal psychotherapy only on cognitive symptoms. CBT for binge eating disorder also resulted in greater reductions in behavioral symptoms than behavioral weight loss interventions. There was no evidence that CBT was more efficacious than behavior therapy or nonspecific supportive therapies. Conclusions: CBT is efficacious for eating disorders. Although CBT was equally efficacious to certain psychological treatments, the fact that CBT outperformed all active psychological comparisons and interpersonal psychotherapy specifically, offers some support for the specificity of psychological treatments for eating disorders. Conclusions from this study are hampered by the fact that many trials were of poor quality. Higher quality RCTs are essential. (PsycINFO Database Record
The Efficacy of Cognitive-Behavioral Therapy for Eating Disorders:
A Systematic Review and Meta-Analysis
Jake Linardon
Australian Catholic University
Tracey D. Wade
Flinders University
Xochitl de la Piedad Garcia and Leah Brennan
Australian Catholic University
Objective: This meta-analysis examined the efficacy of cognitive– behavioral therapy (CBT) for eating
disorders. Method: Randomized controlled trials of CBT were searched. Seventy-nine trials were
included. Results: Therapist-led CBT was more efficacious than inactive (wait-lists) and active (any
psychotherapy) comparisons in individuals with bulimia nervosa and binge eating disorder. Therapist-led
CBT was most efficacious when manualized CBT-BN or its enhanced version was delivered. No
significant differences were observed between therapist-led CBT for bulimia nervosa and binge eating
disorder and antidepressants at posttreatment. CBT was also directly compared to other specific
psychological interventions, and therapist-led CBT resulted in greater reductions in behavioral and
cognitive symptoms than interpersonal psychotherapy at posttreatment. At follow-up, CBT outperformed
interpersonal psychotherapy only on cognitive symptoms. CBT for binge eating disorder also resulted in
greater reductions in behavioral symptoms than behavioral weight loss interventions. There was no
evidence that CBT was more efficacious than behavior therapy or nonspecific supportive therapies.
Conclusions: CBT is efficacious for eating disorders. Although CBT was equally efficacious to certain
psychological treatments, the fact that CBT outperformed all active psychological comparisons and
interpersonal psychotherapy specifically, offers some support for the specificity of psychological treat-
ments for eating disorders. Conclusions from this study are hampered by the fact that many trials were
of poor quality. Higher quality RCTs are essential.
What is the public health significance of this article?
This meta-analysis demonstrates that CBT is an efficacious psychological treatment for individuals
with eating disorders. CBT produces large and long lasting improvements in core behavioral and
cognitive symptoms of eating disorders.
Keywords: cognitive– behavioral therapy, eating disorders, bulimia nervosa, binge eating
Supplemental materials: http://dx.doi.org/10.1037/ccp0000245.supp
Cognitive– behavioral therapy (CBT) is the most widely inves-
tigated eating disorder treatment. Randomized controlled trials
(RCTs) demonstrate that specific forms of CBT produce large
improvements in eating disorder symptoms in individuals with
bulimia nervosa (BN), binge eating disorder (BED), Other Spec-
ified Feeding and Eating Disorders (OSFED), and anorexia ner-
vosa (AN; Byrne et al., 2017;Fairburn et al., 2015,1991). Clinical
guidelines recommend specific forms of CBT as the treatment of
choice for BN, BED, and OSFED, and also as one of the front-
running treatments for AN (Hay et al., 2014;Herpertz et al., 2011;
National Institute of Clinical Excellence, 2017).
The results across RCTs have been synthesized in meta-
analyses. A summary of these meta-analyses is presented in Table
1 of the supplementary materials. Compared with wait-list or
active controls, therapist-led CBT consistently results in greater
improvements in eating disorder symptoms in BN and BED (Hay,
Bacaltchuk, Stefano, & Kashyap, 2009;Linardon, Wade, De la
Piedad Garcia, & Brennan, 2017). Moreover, specific modes (e.g.,
E-therapy CBT) or formats (e.g., group-based CBT) have also
been shown to be superior to wait-list controls in BN and BED
(Loucas et al., 2014;Polnay et al., 2014). In contrast, one meta-
analysis has examined the effects of CBT for AN (Hay, Claudino,
Touyz, & Abd Elbaky, 2015), estimating effect sizes for two
comparisons: CBT compared with treatment as usual, and CBT
compared with interpersonal psychotherapy (IPT) or short-term
focal psychodynamic therapy. Effect sizes were based on two
Jake Linardon, School of Psychology, Australian Catholic University;
Tracey D. Wade, School of Psychology, Flinders University; Xochitl de la
Piedad Garcia and Leah Brennan, School of Psychology, Australian Cath-
olic University.
Correspondence concerning this article should be addressed to Jake
Linardon, Faculty of Health Sciences, Australian Catholic University, 115
Victoria Parade/Locked Bag 4115, Melbourne, Victoria, Australia, 3065.
E-mail: jake.linardon@acu.edu.au
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Journal of Consulting and Clinical Psychology © 2017 American Psychological Association
2017, Vol. 85, No. 11, 1080–1094 0022-006X/17/$12.00 http://dx.doi.org/10.1037/ccp0000245
1080
... To advance treatment for BED Linardon, Wade, de la Piedad Garcia, & Brennan, 2017), neuromodulation interventions are being developed (Dalton, Campbell, & Schmidt, 2017; Forcano, Mata, de la Torre, & Verdejo-Garcia, 2018; Imperatori, Mancini, Della Marca, Valenti, & Farina, 2018;Val-Laillet et al., 2015), directly targeting food-related neurobehavioral alterations. Neurofeedback (NF) is a noninvasive neuromodulation approach in which participants learn to self-regulate their brain activity, using online feedback through a brain-computer interface (Arns et al., 2017;Enriquez-Geppert, Huster, & Herrmann, 2017;Paret et al., 2019;Sitaram et al., 2017;Thibault, Lifshitz, & Raz, 2016). ...
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Background Binge-eating disorder (BED) co-occurs with neurobehavioral alterations in the processing of disorder-relevant content such as visual food stimuli. Whether neurofeedback (NF) directly targeting them is suited for treatment remains unclear. This study sought to determine feasibility and estimate effects of individualized, functional near-infrared spectroscopy-based real-time NF (rtfNIRS-NF) and high-beta electroencephalography-based NF (EEG-NF), assuming superiority over waitlist (WL). Methods Single-center, assessor-blinded feasibility study with randomization to rtfNIRS-NF, EEG-NF, or WL and assessments at baseline (t0), postassessment (t1), and 6-month follow-up (t2). NF comprised 12 60-min food-specific rtfNIRS-NF or EEG-NF sessions over 8 weeks. Primary outcome was the binge-eating frequency at t1 assessed interview-based. Secondary outcomes included feasibility, eating disorder symptoms, mental and physical health, weight management-related behavior, executive functions, and brain activity at t1 and t2. ResultsIn 72 patients (intent-to-treat), the results showed feasibility of NF regarding recruitment, attrition, adherence, compliance, acceptance, and assessment completion. Binge eating improved at t1 by −8.0 episodes, without superiority of NF v. WL (−0.8 episodes, 95% CI −2.4 to 4.0), but with improved estimates in NF at t2 relative to t1. NF was better than WL for food craving, anxiety symptoms, and body mass index, but overall effects were mostly small. Brain activity changes were near zero. Conclusions The results show feasibility of food-specific rtfNIRS-NF and EEG-NF in BED, and no posttreatment differences v. WL, but possible continued improvement of binge eating. Confirmatory and mechanistic evidence is warranted in a double-blind randomized design with long-term follow-up, considering dose–response relationships and modes of delivery.
... Cognitive behavioral therapy (CBT) for patients with BN and BED has been shown to be effective and durable. Controlled studies of CBT have shown benefit not only for binge or purge frequencies but also for cognitive symptoms [11][12][13]. CBT is one of the most used evidence-based psychological interventions for BN, and clinical practice guidelines for eating disorders therefore generally recommend the use of CBT for patients with BN [14][15][16]. ...
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Background The purpose of this study was to develop an internet-based Guided Self-Help CBT (iGSH-CBT) for Bulimia Nervosa (BN) / Binge Eating Disorder (BED) for Japanese patients and to test its feasibility. Methods A single-arm feasibility study. After baseline assessment, patients underwent a 16-week iGSH-CBT program, our Japanese adaption of the European-based Salut BN program. During the treatment period, weekly email support from trained counselors was provided. Evaluations were performed at baseline, after 8 weeks, at the end of the 16-week intervention, and at 2 months after treatment had ended. The primary outcome measure was the change in the weekly frequency of objective binging. Secondary outcomes were the change in the weekly frequency of objective purge episodes, responses on self-report questionnaires of the frequencies of binging and purging, psychopathological characteristics of eating disorders found on BITE, EDE-Q, EDI-2, HADS and EQ-5D, measurements of motivation, and completion of intervention (vs. dropout). Results Participants were 9 female outpatients with BN (n = 5) or BED (n = 4), of whom 8 (88.9%) attended the assessment at the end of the 16-week intervention. Mean age was 28 years (SD = 7.9). Percent change of the weekly frequency of objective binging was -4.40%, and at the end of the 16-week intervention 25% of the participants had achieved symptom abstinence. Conclusions No adverse events were observed during the treatment period and follow-up, and the implementation and operation of the program could be performed without any major problems, confirming the feasibility of iGSH-CBT for BN and BED for Japanese patients. Although no significant change was observed in the weekly frequency of objective binging, the abstinence rate from bulimic behaviors of those who completed the assessments was 25.0% at the end of treatment, and the drop-out rate was 11.1%. iGSH-CBT may be an acceptable and possibly even a preferred method of CBT delivery for Japanese patients with BN or BED, and our Japanese adaptation of Salut BN seems feasible. Trial registration UMIN, UMIN000031962. Registered 1 April 2018 - Retrospectively registered, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000036334
Article
Eating disorders are serious mental health disorders characterized by persistent disturbances in eating that impair physical health and/or psychosocial functioning. Widespread screening for eating disorders can help reduce disparities in diagnosis and may prevent the physical, psychological, and social consequences associated with delayed treatment. Evidence-based recommendations involve intervention by specialized mental healthcare providers; however, dietitians are pivotal in the prevention, identification, and treatment of eating disorders, leading to improved outcomes for the patient. Developing skills aimed at identification of disordered eating and basic treatment guidelines is of critical importance due to the ubiquity of these behaviors and symptoms.
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The physical and mental benefits of physical activity are unquestionable. However, while much research has been done into the benefits of exercise in the prevention and treatment of numerous physical illnesses, the study of the impact of exercise on psychopathological conditions is more recent. Moreover, for several reasons, there are some grey areas and some controversy regarding physical exercise in patients with feeding and eating disorders such as anorexia nervosa or bulimia. This controversy may stem from several issues. On the one hand, because there is a fine line between healthy physical exercise and over-exercising (which may become exercise dependence); on the other hand, because of the strong association that some mental disorders (such as anorexia) have with disruptive exercise use, with several clinicians and researchers implying that exercise may eventually cause a feeding and eating disorder.
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Objective Prominent theories of binge‐eating (BE) maintenance highlight dietary restriction as a key precipitant of BE episodes. Consequently, treatment approaches for eating disorders (including binge‐eating disorder; BED) seek to reduce dietary restriction in order to improve BE symptoms. The present study tested the hypothesis that dietary restriction promotes BE among 112 individuals with BED. Methods Participants completed a 7‐day ecological momentary assessment (EMA) protocol before and after completing 17 weeks of either Integrative Cognitive‐Affective Therapy or guided self‐help cognitive behavioral therapy. Analyses examined whether dietary restriction on 1 day of the baseline EMA protocol predicted risk for BE later that same day, and on the following day. Changes in dietary restriction over the course of treatment were also evaluated as a predictor of change in BE from pre‐treatment to post‐treatment. Baseline dietary restraint was examined as a moderator of the above associations. Results Dietary restriction did not predict BE later the same day, and changes in restriction were not related to changes in BE across treatment, regardless of baseline dietary restraint levels. Restriction on 1 day did predict increased BE risk on the following day for individuals with higher levels of dietary restraint, but not those with lower levels. Discussion These findings challenge the assumption that dietary restriction maintains BE among all individuals with BED. Rather, results suggest that dietary restriction may be largely unrelated to BE maintenance in this population, and that reducing dietary restriction generally does not have the intended effect on BE frequency.
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Objective The neurobehavioral underpinnings of binge‐eating disorder (BED), co‐occurring with obesity (OB), are largely unknown. This research project conceptualizes BED as a disorder with dysfunctional emotion regulation (ER) linked with changes in central noradrenaline (NA) transmission and NA‐modulated neuronal networks. Methods We expect abnormalities in NA activity in both BED and OB, but most pronounced in BED. We expect these abnormalities to be modifiable through state‐of‐the‐art ER intervention, specifically in BED. To assess the role of NA transmission, we will quantify changes in NA transporter (NAT) availability using the highly NAT‐specific [ ¹¹ C]methylreboxetin (MRB) and positron emission tomography‐magnetic resonance imaging (PET‐MRI) that allows measuring molecular and neuronal changes before and after an ER intervention. Individual 12‐session smartphone‐supported acceptance‐based behavioral therapy will be conducted to improve ER. Thirty individuals with OB and BED (OB + BED), 30 individuals with OB without BED (OB ‐ BED), and 20 individuals with normal weight will undergo assessments of NAT availability and neuronal network activity under rest and stimulated conditions, clinical interviews, self‐report questionnaires on eating behavior, ER, mental and physical health, and quality of life, and neuropsychological tests on executive function. Afterwards, in an experimental randomized‐controlled design, individuals with OB + BED and OB ‐ BED will be allocated to smartphone‐supported ER intervention versus a waitlist and re‐assessed after 10 weeks. Discussion By obtaining biological and behavioral markers, the proposed study will disentangle the involvement of NAT and the central NA system in the modulation of emotion‐supporting neuronal networks that influence eating behavior. Neurobehavioral mechanisms of change during an ER intervention will be determined. Trial Registration German Clinical Trials Register (DRKS): DRKS00029367. Public Significance This study investigates the central noradrenaline system by using hybrid brain imaging in conjunction with emotion regulation as a putative core biological mechanism in individuals with obesity with or without binge‐eating disorder that is targeted by emotion regulation intervention. The results will provide a molecular signature beyond functional imaging biomarkers as a predictive biomarker toward precision medicine for tailoring treatments for individuals with binge‐eating disorders and obesity.
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Objective Digital interventions show promise as an effective prevention or self‐management option for eating disorders (EDs). However, it remains unclear how, for whom, and through what mechanisms they work in this population, as a synthesis of outcome predictors, moderators, and mediators is lacking. This systematic review synthesized empirical research investigating predictors, mediators, and moderators of response to digital interventions for EDs. Method Six databases were searched (PROSPERO CRD42022295565) for studies that assessed predictors, moderators, or mediators of response (i.e., uptake, drop‐out, engagement, and symptom level change) to a digital prevention or treatment program for EDs. Variables were grouped into several overarching categories (demographic, symptom severity, psychological, etc.) and were synthesized qualitatively across samples without a formally diagnosed ED (typically prevention‐focused) and samples with a formally diagnosed ED (typically treatment‐focused). Results Eighty‐six studies were included. For studies recruiting samples without a formal diagnosis ( n = 70 studies), most predictors explored were statistically unrelated to outcome, although participant age, baseline symptom severity, confidence to change, motivation, and program engagement showed preliminary evidence of prognostic potential. No robust moderators or mediators were identified. Few studies recruiting samples with a formal diagnosis emerged ( n = 16), of which no reliable predictors, moderators, or mediators were identified. Discussion It remains unclear how, for whom, and under what circumstances digital programs targeting EDs work. We offer several recommendations for future research with the aim of advancing understanding of client characteristics and intervention elements that signal success from this intervention modality. Public Significance Digital interventions have shown potential as an effective, scalable, and accessible intervention option for EDs. However, responsiveness varies, so advancing understanding of predictors, mediators, and moderators of outcome to digital interventions for EDs is needed. Such knowledge is important for enabling safe and efficient treatment matching, and for informing future development of effective digital interventions.
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Background: There is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). The aim of this study was to compare three psychological treatments for AN: Specialist Supportive Clinical Management, Maudsley Model Anorexia Nervosa Treatment for Adults and Enhanced Cognitive Behavioural Therapy. Method: A multi-centre randomised controlled trial was conducted with outcomes assessed at pre-, mid- and post-treatment, and 6- and 12-month follow-up by researchers blind to treatment allocation. All analyses were intention-to-treat. One hundred and twenty individuals meeting diagnostic criteria for AN were recruited from outpatient treatment settings in three Australian cities and offered 25-40 sessions over a 10-month period. Primary outcomes were body mass index (BMI) and eating disorder psychopathology. Secondary outcomes included depression, anxiety, stress and psychosocial impairment. Results: Treatment was completed by 60% of participants and 52.5% of the total sample completed 12-month follow-up. Completion rates did not differ between treatments. There were no significant differences between treatments on continuous outcomes; all resulted in clinically significant improvements in BMI, eating disorder psychopathology, general psychopathology and psychosocial impairment that were maintained over follow-up. There were no significant differences between treatments with regard to the achievement of a healthy weight (mean = 50%) or remission (mean = 28.3%) at 12-month follow-up. Conclusion: The findings add to the evidence base for these three psychological treatments for adults with AN, but the results underscore the need for continued efforts to improve outpatient treatments for this disorder. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN 12611000725965) http://www.anzctr.org.au/.
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Objective: Depressive symptoms are an important risk factor and consequence of binge eating and purging behavior in bulimia nervosa (BN). Although psychotherapy is effective in reducing symptoms of BN in the short- and long-term, it is unclear whether psychotherapy for BN is also effective in reducing depressive symptoms. This meta-analysis examined the efficacy of psychotherapy for BN on depressive symptoms in the short- and long-term. Method: Randomized controlled trials (RCTs) on BN that assessed depressive symptoms as an outcome were identified. Twenty-six RCTs were included. Results: Psychotherapy was more efficacious at reducing symptoms of depression at post-treatment (g = 0.47) than wait-lists. This effect was strongest when studies delivered therapist-led, rather than guided self-help, treatment. No significant differences were observed between psychotherapy and antidepressants. There was no significant post-treatment difference between CBT and other active psychological comparisons at reducing symptoms of depression. However, when only therapist-led CBT was analyzed, therapist-led CBT was significantly more efficacious (g = 0.25) than active comparisons at reducing depressive symptoms. The magnitude of the improvement in depressive symptoms was predicted by the magnitude of the improvement in BN symptoms. Discussion: These findings suggest that psychotherapy is effective for reducing depressive symptoms in BN in the short-term. Whether these effects are sustained in the long-term is yet to be determined, as too few studies conducted follow-up assessments. Moreover, findings demonstrate that, in addition to being the front-running treatment for BN symptoms, CBT might also be the most effective psychotherapy for improving the symptoms of depression that commonly co-occur in BN.
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Objective: Meta-analyses have documented the efficacy of cognitive-behavioral therapy (CBT) for reducing symptoms of eating disorders. However, it is not known whether CBT for eating disorders can also improve quality of life (QoL). This meta-analysis therefore examined the effects of CBT for eating disorders on subjective QoL and health-related quality of life (QoL). Method: Studies that assessed QoL before and after CBT for eating disorders were searched in the PsycInfo and Medline database. Thirty-four articles met inclusion criteria. Pooled within and between-groups Hedge's g were calculated at post-treatment and follow-up for treatment changes on both subjective and HRQoL using a random effects model. Results: CBT led to significant and modest improvements in subjective QoL and HRQoL from pre to post-treatment and follow-up. CBT led to greater subjective QoL improvements than inactive (i.e., wait-list) and active (i.e., a combination of bona fide therapies, psychoeducation) comparisons. CBT also led to greater HRQoL improvements than inactive, but not active, comparisons. Prepost QoL improvements were larger in studies that delivered CBT individually and by a therapist or according to the cognitive maintenance model of eating disorders (CBT-BN or CBT-E); though this was not replicated at follow-up CONCLUSIONS: Findings provide preliminary evidence that CBT for eating disorders is associated with modest improvements in QOL, and that CBT may be associated with greater improvements in QOL relative to comparison conditions.
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Objective The authors compared cognitive-behavioral therapy (CBT) and psychodynamic therapy (PDT) for the treatment of bulimia nervosa (BN) in female adolescents. Method In this randomized controlled trial, 81 female adolescents with BN or partial BN according to the DSM-IV received a mean of 36.6 sessions of manualized disorder−oriented PDT or CBT. Trained psychologists blinded to treatment condition administered the outcome measures at baseline, during treatment, at the end of treatment, and 12 months after treatment. The primary outcome was the rate of remission, defined as a lack of DSM-IV diagnosis for BN or partial BN at the end of therapy. Several secondary outcome measures were evaluated. Results The remission rates for CBT and PDT were 33.3% and 31.0%, respectively, with no significant differences between them (odds ratio [OR] = 0.90, 95% CI = 0.35−2.28, p = .82). The within-group effect sizes were h = 1.22 for CBT and h = 1.18 for PDT. Significant improvements in all secondary outcome measures were found for both CBT (d = 0.51−0.82) and PDT (d = 0.24−1.10). The improvements remained stable at the 12-month follow-up in both groups. There were small between-group effect sizes for binge eating (d = 0.23) and purging (d = 0.26) in favor of CBT and for eating concern (d = −0.35) in favor of PDT. Conclusion CBT and PDT were effective in promoting recovery from BN in female adolescents. The rates of remission for both therapies were similar to those in other studies evaluating CBT. This trial identified differences with small effects in binge eating, purging, and eating concern. Clinical trial registration information—Treating Bulimia Nervosa in Female Adolescents With Either Cognitive-Behavioral Therapy (CBT) or Psychodynamic Therapy (PDT). http://isrctn.com/; ISRCTN14806095.
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This systematic review synthesised the literature on predictors, moderators, and mediators of outcome following Fairburn's CBT for eating disorders. Sixty-five articles were included. The relationship between individual variables and outcome was synthesised separately across diagnoses and treatment format. Early change was found to be a consistent mediator of better outcomes across all eating disorders. Moderators were mostly tested in binge eating disorder, and most moderators did not affect cognitive-behavioural treatment outcome relative to other treatments. No consistent predictors emerged. Findings suggest that it is unclear how and for whom this treatment works. More research testing mediators and moderators is needed, and variables selected for analyses need to be empirically and theoretically driven. Future recommendations include the need for authors to (i) interpret the clinical and statistical significance of findings; (ii) use a consistent definition of outcome so that studies can be directly compared; and (iii) report null and statistically significant findings.
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Background. Early weak treatment response is one of the few trans-diagnostic, treatment-agnostic predictors of poor outcome following a full treatment course. We sought to improve the outcome of clients with weak initial response to guided self-help cognitive behavior therapy (GSH). Method. One hundred and nine women with binge-eating disorder (BED) or bulimia nervosa (BN) (DSM-IV-TR) received 4 weeks of GSH. Based on their response, they were grouped into: (1) early strong responders who continued GSH (cGSH), and early weak responders randomized to (2) dialectical behavior therapy (DBT), or (3) individual and additional group cognitive behavior therapy (CBT+). Results. Baseline objective binge-eating-day (OBD) frequency was similar between DBT, CBT+ and cGSH. During treatment, OBD frequency reduction was significantly slower in DBT and CBT+ relative to cGSH. Relative to cGSH, OBD frequency was significantly greater at the end of DBT (d = 0.27) and CBT+ (d = 0.31) although these effects were small and within-treatment effects from baseline were large (d = 1.41, 0.95, 1.11, respectively). OBD improvements significantly diminished in all groups during 12 months follow-up but were significantly better sustained in DBT relative to cGSH (d = −0.43). At 6- and 12-month follow-up assessments, DBT, CBT and cGSH did not differ in OBD. Conclusions. Early weak response to GSH may be overcome by additional intensive treatment. Evidence was insufficient to support superiority of either DBT or CBT+ for early weak responders relative to early strong responders in cGSH; both were helpful. Future studies using adaptive designs are needed to assess the use of early response to efficiently deliver care to large heterogeneous client groups.