A randomized controlled trial of family therapy and cognitive behavior guided self-care for adolescents with bulimia nervosa and related disorders

Objective: To date no trial has focused

on the treatment of adolescents with bulimia

nervosa. The aim of this study was

to compare the efficacy and cost-effectiveness

of family therapy and cognitive

behavior therapy (CBT) guided self-care in

adolescents with bulimia nervosa or eating

disorder not otherwise specified.

Method: Eighty-five adolescents with bulimia

nervosa or eating disorder not otherwise

specified were recruited from eating

disorder services in the United Kingdom.

Participants were randomly assigned to

family therapy for bulimia nervosa or individual

CBT guided self-care supported by a

health professional. The primary outcome

measures were abstinence from bingeeating

and vomiting, as assessed by interview

at end of treatment (6 months) and

again at 12 months. Secondary outcome

measures included other bulimic symptoms

and cost of care.

Results: Of the 85 study participants, 41

were assigned to family therapy and 44 to

CBT guided self-care. At 6 months, bingeing

had undergone a significantly greater

reduction in the guided self-care group

than in the family therapy group; however,

this difference disappeared at 12

months. There were no other differences

between groups in behavioral or attitudinal

eating disorder symptoms. The direct

cost of treatment was lower for guided

self-care than for family therapy. The two

treatments did not differ in other cost

categories.

Conclusions: Compared with family

therapy, CBT guided self-care has the

slight advantage of offering a more rapid

reduction of bingeing, lower cost, and

greater acceptability for adolescents with

bulimia or eating disorder not otherwise

specified.

(Am J Psychiatry 2007; 164:591–598)

Some 4%–7% of young females in Western countries

suffer from full or partial bulimia nervosa (1). Typically, bulimia

develops in adolescence, and individuals with a partial

syndrome are at risk of developing the full syndrome.

Without treatment, bulimia nervosa tends to persist into

adulthood. The disorder is associated with secondary

physical and mental disorders and imposes a major burden

on families (1).

Although numerous randomized controlled trials have

been conducted with adults with bulimia nervosa (2), none

have been conducted with adolescents. U.K. guidelines on

eating disorders (2) have identified treatment of adolescent

eating disorders as a research priority. The guidelines

also noted that little is known about the health service utilization

costs associated with these disorders.

Family-based treatment produces excellent outcomes in

adolescents with anorexia nervosa (2), and it has been

adapted for adolescents with bulimia nervosa (3). Cognitive

behavior therapy (CBT) is the treatment of choice for

adults with bulimia nervosa (2). Self-care formats of CBT

for bulimia nervosa can be as effective as therapist-delivered

CBT if guided by a therapist (4). Guided self-care was

recommended as a first-line intervention for adults with

bulimia nervosa in the U.K. guidelines (2), and it may be a

useful early intervention for bulimia in adolescents.

The aim of this study was to compare the efficacy and

cost-effectiveness of family therapy and CBT guided selfcare

in adolescents with bulimia nervosa or eating disorder

not otherwise specified. Our primary hypothesis was that in

adolescents with bulimia nervosa or eating disorder not otherwise

specified, family therapy would produce higher rates

of abstinence from binge-eating and vomiting, both at completion

of treatment and at follow-up. Our secondary hypothesis

was that guided self-care would be less costly than

family therapy.