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.In general, medication trials have either no or only a short follow-upperiod after termination of drug treatment, and there is not enoughknowledge about the benefits of long-term treatment on binge eatingbehaviour.As in bulimia nervosa, attrition rates are generally higher formedication trials than for psychotherapy trials of BED [192], and in somestudies there was an extremely strong placebo effect, with reductions ofbinge eating frequency of 50% [100,182,184].Stunkard et al.[181] recruited50 patients for their d-fenfluramine trial.All received single-blind placebofor a period of 4 weeks.The average number of binges fell from 6 to 1.8 perweek and 22 patients no longer met the frequency criterion for BED.Theseresults suggest that BED often may improve even with placebo.Therefore,caution should be exercised in interpreting the results of open-labelpharmacological studies of BED.Also, these results argue for a conservativeapproach in offering treatment to such patients, because many will tend toimprove with only placebo treatment.Pharmacotherapy Combined with CBT for BEDMedication does not appear to add much to the effectiveness of CBT inreducing binge eating [123,193,194].Only one study found that imipramineincreased the reduction of binge eating episodes when added topsychological treatment during acute treatment, and the result persistedeven 6 months after withdrawal of the drug [185].However, antidepressant medication may enhance weight loss beyondthe effects of CBT [123,141,185,193].In a study in which patients who hadcompleted 3 months of group CBT received either open-label desipramineplus weight loss treatment or weight loss treatment alone [157], thedesipramine-treated patients lost significantly more weight during treat-ment and also during follow-up.There were, however, no clear indicationsthat the addition of desipramine led to a greater reduction in binge eatingduring treatment and at a 3-month follow-up.In this study patients whoentirely stopped binge eating during the CBT phase lost significantly moreweight than those who were not abstinent.Hence, early abstinence appearsto facilitate weight loss.This suggests that treating the eating disorder firstand then treating the weight problem might be a useful approach to themanagement of the overweight binge eater.Because only half of thepatients stop binge eating after treatment with CBT, a second level oftreatment that would benefit poor responders to CBT might be useful.Laederach-Hofmann et al.[185] accordingly showed that adding low-dose PHARMACOLOGICAL TREATMENT: A REVIEW ________________________________________ 269imipramine to diet counselling and psychological support may helppatients to lose weight after at least 6 months off medication.In an openstudy, Devlin et al.[195] added fluoxetine and phentermine to individualCBT.They reported an abstinence rate of binge eating of 86% and a weightreduction of 19 lb.However, as opposed to the two studies mentionedabove, there was a significant weight regain, particularly followingmedication discontinuation.In a randomized but open five-group designstudy, Ricca et al.[193] found a significant reduction in monthly bingeeating frequency only in patients receiving individual CBT alone orcombined with fluoxetine or fluvoxamine.Patients who received either ofthe drugs alone did not demonstrate a significant reduction of binge eatingepisodes.The same pattern of results was found for changes in BMI.However, there was again a trend towards a greater reduction of BMI inpatients treated with CBT plus fluoxetine or fluvoxamine.At a 1-yearfollow-up, patients in the CBT, CBT/fluoxetine and CBT/fluvoxaminegroups maintained most of the weight lost, and the eating behaviour wasnot significantly different when compared with that at the end of treatment.Fluoxetine and fluvoxamine did not appear to improve the medium-termoutcome in a relevant manner.The authors suggest that the benefits ofadding fluoxetine or fluvoxamine to CBT are only marginal in the treatmentof BED.Two recently presented controlled combination studies used a 4 celldesign: individual CBT plus fluoxetine (60 mg) or placebo, fluoxetine alone,and placebo alone.Grilo et al.[194] found significantly higher remissionrates for CBT compared to either fluoxetine or placebo alone.Fluoxetine didnot differ from placebo.Fluoxetine did not add to the effects of CBT
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