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Stepped care and cognitive–behavioural therapy for bulimia nervosa: randomised trial

  • James E. Mitchell (a1), Stewart Agras (a2), Scott Crow (a3), Katherine Halmi (a4), Christopher G. Fairburn (a5), Susan Bryson (a2) and Helena Kraemer (a2)...

Abstract

Background

This study compared the best available treatment for bulimia nervosa, cognitive–behavioural therapy (CBT) augmented by fluoxetine if indicated, with a stepped-care treatment approach in order to enhance treatment effectiveness.

Aims

To establish the relative effectiveness of these two approaches.

Method

This was a randomised trial conducted at four clinical centres (Clinicaltrials.gov registration number: NCT00733525). A total of 293 participants with bulimia nervosa were randomised to one of two treatment conditions: manual-based CBT delivered in an individual therapy format involving 20 sessions over 18 weeks and participants who were predicted to be non-responders after 6 sessions of CBT had fluoxetine added to treatment; or a stepped-care approach that began with supervised self-help, with the addition of fluoxetine in participants who were predicted to be non-responders after six sessions, followed by CBT for those who failed to achieve abstinence with self-help and medication management.

Results

Both in the intent-to-treat and completer samples, there were no differences between the two treatment conditions in inducing recovery (no binge eating or purging behaviours for 28 days) or remission (no longer meeting DSM–IV criteria). At the end of 1-year follow-up, the stepped-care condition was significantly superior to CBT.

Conclusions

Therapist-assisted self-help was an effective first-level treatment in the stepped-care sequence, and the full sequence was more effective than CBT suggesting that treatment is enhanced with a more individualised approach.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial licence (http://creativecommons.org/licenses/by-nc/4.0/), which permits noncommercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work.

Corresponding author

James E. Mitchell, MD, Neuropsychiatric Research Institute, 120 South 8th Street, Fargo, North Dakota 58103, USA. Email: jmitchell@nrifargo.com

Footnotes

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The active drug was provided by Eli Lilly. Support was provided by National Institutes of Health (NIH) RO1 MH59100, RO1 MH59234, KO2 MH65919 and P30 DK30456. C.G.F. is supported by the Wellcome Trust, London (046386).

Declaration of interest

C.G.F. authored the self-help manual used in this trial.

Footnotes

References

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Stepped care and cognitive–behavioural therapy for bulimia nervosa: randomised trial

  • James E. Mitchell (a1), Stewart Agras (a2), Scott Crow (a3), Katherine Halmi (a4), Christopher G. Fairburn (a5), Susan Bryson (a2) and Helena Kraemer (a2)...

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Stepped care and cognitive–behavioural therapy for bulimia nervosa: randomised trial

  • James E. Mitchell (a1), Stewart Agras (a2), Scott Crow (a3), Katherine Halmi (a4), Christopher G. Fairburn (a5), Susan Bryson (a2) and Helena Kraemer (a2)...
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