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

American Psychological Association
Journal of Consulting and Clinical Psychology
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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
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... CBT can be delivered in several formats, including individual, group, guided self-help (including digital guided self-help) and unguided self-help. Each of the treatment formats in CBT for eating disorders has been examined in multiple randomized trials (Linardon et al., 2017) and a considerable number of trials have also compared different formats with each other (e.g. Barakat et al., 2023;de Zwaan et al., 2017;Shapiro et al., 2007). ...
... Studies were identified through an earlier meta-analysis of CBT for eating disorders (Linardon et al., 2017) and an update of this meta-analysis up to 1 January 2024. For the update, we conducted new searches in PubMed, Embase, PsycINFO and CINAHL (deadline 1 January 2024), based on the search strings developed for the previous meta-analysis. ...
... We included 28 RCTs meeting inclusion criteria from the previous meta-analysis (Linardon et al., 2017). For the update, we identified 756 records (505 after removal of duplicates). ...
Article
Although CBT has been found to be effective in the treatment of eating disorders, it is not clear if there are differences between treatment formats. We conducted a network meta-analysis (NMA) of randomized trials of broadly defined CBT comparing individual, group, guided self-help (GSH) and unguided self-help (USH) with each other or with a control condition. The NMA used a frequentist graph-theoretical approach and included 36 trials (53 comparisons; 3,136 participants). Only one trial was aimed at anorexia nervosa. All formats resulted in large, significant effects when compared to waitlists, with no significant difference between formats (group: g = 1.08, 95% CI: 0.84; 1.31; GSH: g = 0.94, 95% CI: 0.75; 1.13; individual: g = 1.06, 95% CI: 0.77; 1.36; USH: g = 0.62, 95% CI: 0.30; 0.93). No significant difference was found between any format and care-as-usual. Analyses limited to binge eating disorder supported the effects of individual, group and GSH formats, with no significant differences between them. Few trials with low risk of bias were available. CBT for eating disorders can probably be delivered effectively in any format, without significant differences between the formats. These results should be considered with caution because of the non-significant differences when compared to care-as-usual and the considerable risk of bias.
... As evidenced, while previous systematic reviews have compared guided to non-guided selfhelp platforms, there is a gap in research collating findings regarding the effectiveness of only unguided internet-based computer self-help platforms for people with EDs [16,43,49]. Moreover, unguided internet-based computer self-help platforms are potentially effective in reducing risk for people with ED symptoms [47,48,50]. Therefore, this systematic review aims to evaluate the effectiveness of unguided internet-based computer self-help platforms for several outcomes: (1) global ED symptoms, (2) ED-related behaviours, such as thin idealisation, body dissatisfaction, quality of life, depression, perseverative thinking, and resistance to change, and (3) preventing the onset of EDs. ...
... Traditionally, especially pre-COVID-19, many therapeutic interventions were delivered face-to-face. For EDs, face-to-face family-based treatment for EDs and CBT-ED were the most commonly utilised therapeutic interventions supported by numerous evidence-based clinical effectiveness studies [36,50,61,62]. After COVID-19, interventions that were previously delivered face-to-face transitioned to internet-based computer self-help platforms to educate and provide resources aimed at effectively preventing and treating ED symptoms and related behaviours. ...
... When compared to face-to-face CBT, the findings are similar. A meta-analysis containing 79 studies [50] demonstrated that therapist-led CBT reduced short-term remission and binge or purge frequency in BN and BED compared to waitlisted conditions. A meta-analysis of 16 studies exploring ICBT effectiveness found that ICBT was effective in preventing ED in at-risk patients (-0. ...
Article
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Background Following the COVID-19 pandemic, internet-based computer self-help platforms for eating disorders (EDs) became increasingly prevalent as a tool to effectively prevent and treat ED symptoms and related behaviours. This systematic review explored the effectiveness of unguided internet-based computer self-help platforms for EDs. Methods From inception to the 31st of May 2024, a systematic search of Ovid MEDLINE, Embase, Global Health, and APA PsycInfo was conducted. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcome quality assessments were conducted according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results 12 RCTs, with a total of 3400 participants, were included. 2 studies explored the effectiveness as primary prevention, 7 as secondary prevention, and 3 as tertiary intervention. The gathered literature demonstrated unguided internet-based computer self-help platforms as effective in reducing ED core symptoms and related behaviours, with psychoeducation, cognitive behavioural, and dissonance-based approaches being the most prevalent approaches. Conclusions Unguided internet-based computer self-help platforms are effective in the short-term reduction of ED symptoms and associated behaviours and should be implemented in the early stages of a tiered healthcare system for ED treatments. Trial registration Prospero (CRD42024520866).
... The BED treatment literature suggests specific psychological interventions, most notably cognitive behavioral therapy (CBT) interventions, are the treatment of choice (Grilo and Juarascio 2023). Meta-analyses reveal that CBT outperforms inactive (e.g., waitlist) and other psychological treatments (Linardon et al. 2017); one exception is that CBT outperforms interpersonal psychotherapy at the end of treatment but not at follow-up (Linardon et al. 2017). The literature regarding pharmacotherapy for BED is evolving. ...
... The BED treatment literature suggests specific psychological interventions, most notably cognitive behavioral therapy (CBT) interventions, are the treatment of choice (Grilo and Juarascio 2023). Meta-analyses reveal that CBT outperforms inactive (e.g., waitlist) and other psychological treatments (Linardon et al. 2017); one exception is that CBT outperforms interpersonal psychotherapy at the end of treatment but not at follow-up (Linardon et al. 2017). The literature regarding pharmacotherapy for BED is evolving. ...
Article
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Objective To determine the effectiveness of adding a brief psychological eating‐disorder treatment (CBT) to weight management for addressing DSM‐5 binge‐eating disorder (BED) in US military Veterans with high weight. Method One hundred and nine Veterans, with DSM‐5 BED, seeking weight management services were randomly assigned to VA's Weight Management Program (MOVE!), or MOVE! plus a brief, clinician‐led cognitive‐behavioral therapy (MOVE! + CBT). Primary (eating disorder psychopathology and binge eating), secondary (mental health, quality of life, and eating‐ and appearance‐related), and exploratory (weight) outcomes were analyzed with mixed‐effects models for four timepoints (baseline, 3‐month [post‐treatment], and 9‐ and 15‐month follow‐ups). Results MOVE! + CBT reported significantly less overall eating disorder psychopathology compared to MOVE! at all post‐randomization timepoints: difference at 3 months −0.18 (−0.3, −0.06, p = 0.003), 9 months −0.15 (−0.3, 0, p = 0.05), and 15 months −0.27 (−0.42, −0.12, p < 0.001). There were no differences between groups in binge‐eating frequency. MOVE! + CBT remission rates were 28% at 3 months, 42% at 9 months, and 27% at 15 months. MOVE! remission rates were 22% at 3 months, 26% at 9 months, and 20% at 15 months. MOVE! + CBT was superior at post‐treatment through 15 months on eating‐, weight‐, and shape‐related (p's < 0.05), but few other, secondary outcomes. A 5% weight loss ranged from 26% to 38% for MOVE! + CBT, and 17% to 33% for MOVE!. Discussion Weight management alone and with concurrent CBT resulted in significant improvements in BED. The addition of CBT enhanced some specific outcomes but not weight loss. Findings provide evidence‐based clinical guidance and population‐level impact for addressing BED in the context of high weight, especially among Veteran populations. Trial Registration: Clinical Trial Registry Number: NCT03234881(Weight Loss Treatment for Veterans with Binge Eating)
... The patient's misinterpretation of CGM trend data, particularly the direction of trend arrows, highlighted a significant gap in health literacy, contributing not only to inappropriate carbohydrate correction but also to a fear of food intake, which contributed to restrictive food intake [11]. A meta-analysis examining the role of CBT in eating disorders concluded that CBT is an effective treatment approach for this population [12]. ...
... Self-help is often categorized as guided, when it includes support from a health professional, or unguided, when no additional support is provided. Both approaches have demonstrated efficacy for improving BED symptoms and are generally superior to inactive controls (Linardon et al., 2017). Self-help for BED may be equivalent to psychotherapy on some posttreatment outcomes, including general ED psychopathology, with improvements potentially sustained at follow-up, although long-term data beyond 12 months are sparse (Hilbert et al., 2019). ...
Article
Binge Focused Therapy (BFT) is a 3-session, group-based, guided self-help treatment for binge-eating disorder (BED). In this parallel-group randomized controlled trial (RCT), adults with BED were randomized to virtual BFT or a traditional unguided self-help approach (Overcoming Binge Eating; Fairburn, 2013). Self-report measures were collected at baseline, week 6, week 10 (posttreatment), 6- and 12-month follow-up. We hypothesized BFT (n = 82) would lead to better BED outcomes and lower dropout than unguided self-help (n = 82). Our intention-to-treat analysis demonstrated a significant effect of treatment group on BED symptomatology (primary outcome; β= - 5.04, p < .001, 95% CI [ - 7.57, - 2.52]), binge frequency (β= - 3.24, p = .001, 95% CI [ - 5.22, - 1.26]), general ED symptomatology (β= - 0.91, p < .001, 95% CI [ - 1.17, - 0.65]), clinical impairment (β= - 6.27, p < .001, 95% CI [ - 8.78, - 3.77]), confidence to change binge eating (β = 1.22, p < .001, 95% CI [0.56, 1.89]), BED remission (OR = 4.98, p = .003, 95% CI [1.72, 14.40]), and treatment attrition (β = 0.456, p < .001), with the BFT group reporting greater improvements and lower dropout. We did not find evidence of a significant effect of group on binge-eating abstinence (OR = 2.01, p = .103, 95% CI [0.87, 4.64]). BFT may be an effective BED treatment that could overcome common barriers to treatment implementation and accessibility.
... During M1-M3, retention was high (99.2%) with significant BMI reduction, likely from glycogen and water loss [4,78,[122][123][124][125][126][127][128]. Retention declined at M6 (23.6%) and M9 (8.4%) alongside modest weight regain and muscle mass increases-possibly reflecting carb reintroduction and glycogen restoration [129,130]. ...
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Background/Objectives: Ketogenic diets (KDs) have gained attention for their potential to promote weight loss and metabolic improvements. However, data on long-term body composition changes and adherence rates in real-world settings remain limited. Objective: This study aimed to assess the effects of a personalized ketogenic dietary program on anthropometric parameters over a 9-month period and to evaluate adherence across time. Methods: A total of 491 adults participated in a longitudinal intervention involving a structured ketogenic nutrition plan with follow-up at 3, 6, and 9 months. Body weight, fat mass (FM), skeletal muscle mass (SMM), and other composition metrics were measured at each visit. Results: Significant reductions in body weight (–12.6 kg) and fat mass (–10.3 kg) were observed after 3 months (p < 0.001), with minimal changes at 6 months and partial regain by Month 9. SMM remained relatively stable throughout the study. Retention dropped substantially after 3 months, dropping from 487 to 115 participants at Month 6 and 41 at Month 9. Despite this, participants who completed the program maintained significant anthropometric improvements. Conclusions: A well-formulated ketogenic diet may promote rapid fat loss while preserving lean mass in the short term. However, long-term adherence poses significant challenges. Strategies to enhance dietary sustainability and retention are essential for maximizing the benefits of KDs in clinical practice.
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The aim of the empirical study presented in this thesis was to identify and describe the relationship between personality traits and eating behavior in middle-aged women, based on the analysis of risk factors for the development of eating disorders.
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Objective This study evaluated the feasibility, acceptability, and preliminary effectiveness of the first digital intervention tailored for lower‐income adults with eating disorders, who are poorly served by the public health care system. Method Adults ( N = 30) with public insurance or without insurance coverage who endorsed ≥ 6 binge eating episodes, ≥ 6 vomiting episodes, and/or ≥ 6 laxative/diuretic episodes in the past three months with a body mass index ≥ 18.5 kg/m ² were enrolled in this open pilot trial. Participants received access to the coached digital CBT‐based intervention, which included individualized guidance and twice‐weekly SMS feedback from a program coach over three months. Results Almost all participants (93.3%, n = 28) accessed the program after enrollment, completing about half (M = 4.15, SD = 2.68) of the 8 sessions and sending an average of 32.5 (SD = 35.2) texts to their coach over three months. From pre‐ to post‐intervention, there were large improvements in eating disorder psychopathology ( d = 0.79, p < 0.001) and moderate decreases in binge eating ( d = 0.62, p = 0.003) and self‐induced vomiting episodes ( d = 0.43, p = 0.031). There were also large improvements in clinical impairment ( d = 0.83, p < 0.001) and moderate to large reductions in anxiety ( d = 0.47, p = 0.019) and depression ( d = 0.84, p < 0.001). Most participants indicated that they were somewhat to very satisfied with the program (67.9%, n = 19). Discussion The results from this pilot trial testing a brief online guided self‐help intervention are promising, with relatively high treatment engagement, indicating good feasibility and acceptability and signals of preliminary effectiveness. Future research is needed to examine longer‐term effectiveness relative to other active treatments or waitlist control.
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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 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.