Dr Grilo Replies

See letter by Dakanalis and Clerici and article by Grilo

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Dr Grilo Replies

To the Editor: The Grilo1 overview of psychological/behavioral treatments for binge-eating disorder (BED) concluded that cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are the most strongly supported interventions and that behavioral weight-loss (BWL) produces good outcomes plus modest short-term weight-loss. Grilo1 noted that combining medications with CBT/BWL produces superior outcomes to pharmacotherapy-only but does not substantially improve CBT/BWL-only outcomes2 and suggested that research on predictors/moderators of outcomes could provide important guidance to clinicians about which patients might require extra attention or how to rationally match treatments.

In their letter to the editor, Dakanalis and Clerici3 argue that "the absence of attention to durability of effects4 is among several factors requiring consideration when interpreting Grilo’s 1 assertions." Dakanalis and Clerici3 also suggested the importance of "severity-dependent response to CBT"; specifically, they (a) highlighted that the DSM-55 severity specifier of binge-eating frequency was associated with poorer outcomes in their naturalistic treatment study6 and (b) questioned my assertion that overvaluation of shape/weight was predictive of binge-eating remission outcomes by citing 1 negative study.7 Finally, Dakanalis and Clerici3 noted the importance of finding ways to help nonresponders to initial treatments and suggested that clinicians "should" combine psychological/behavioral with pharmacologic approaches for more severe cases, without citing any evidence. The present reply letter refutes each of these assertions and offers evidence-based clarifications regarding BED treatment outcomes and predictors.

First, Dakanalis and Clerici’s 3 comment regarding "the absence of durability of effects" reflects a mis-citation of Wilfley and colleagues,4 who in fact argued the clear longer-term superiority of CBT for BED based on documented longer-term outcomes.8,9 Additionally, I emphasize that CBT has demonstrated clear superiority to antidepressant pharmacotherapy both acutely and over the longer term in both blinded10,11 and unblinded12 comparative trials.

Second, Dakanalis and Clerici’s 3 assertions regarding the "significant" prognostic significance of the DSM-5 severity specifier for BED (based on binge-eating frequency) versus the "null" prognostic significance of overvaluation of shape/weight in one study7 require clarification. Although there are isolated previous reports that higher binge-eating frequency predicts nonremission,13 most controlled trials have not found that.14,15 In contrast, shape/weight overconcern has been reliably associated with nonremission in several rigorous trials15-18; importantly, the negative prognostic significance of overvaluation of shape/weight has been documented through 12-month follow-ups16,17 and even after adjusting for other indicators such as depression and self-esteem.15,16

Third, as reviewed critically,2 findings from 11 published controlled trials testing combination treatments indicate that combining medications with CBT/BWL produces superior outcomes to pharmacotherapy-only but does not substantially improve outcomes achieved with CBT/BWL-only. Moreover, I am unaware of any empirical data supporting the claim1 that clinicians "should" combine psychological/behavioral with pharmacologic approaches for more severe BED cases. I emphasize, however, that early "nonresponse" to treatment has reliably predicted poor outcomes (including nonremission) in several trials with psychological and medication approaches.19-22 Early nonresponse, which is not associated with patient characteristics or BED severity,19,21 represents a strong signal to clinicians that they consider alternative treatments.

References

1. Grilo CM. Psychological and behavioral treatments for binge-eating disorder. J Clin Psychiatry. 2017;78(suppl 1):20-24. PubMed doi:10.4088/JCP.sh16003su1c.04

2. Grilo CM, Reas DL, Mitchell JE. Combining pharmacological and psychological treatments for binge eating disorder: current status, limitations, and future directions. Curr Psychiatry Rep. 2016;18(6):55. PubMed doi:10.1007/s11920-016-0696-z

3. Dakanalis A, Clerici M. Severity of binge-eating disorder and its effects on treatment outcome. J Clin Psychiatry. 2017;78(7):e841.

4. Wilfley DE, Fitzsimmons-Craft EE, Eichen DM. Binge-eating disorder in adults. Ann Intern Med. 2017;166(3):230-231. PubMed doi:10.7326/L16-0622

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

6. Dakanalis A, Colmegna F, Riva G, et al. Validity and utility of the DSM-5 severity specifier for binge-eating disorder [published online ahead of print February 28, 2017]. Int J Eat Disord. 2017. PubMed doi:10.1002/eat.22696

7. Masheb RM, Grilo CM. Prognostic significance of two sub-categorization methods for the treatment of binge eating disorder: negative affect and overvaluation predict, but do not moderate, specific outcomes. Behav Res Ther. 2008;46(4):428-437. PubMed doi:10.1016/j.brat.2008.01.004

8. Wilson GT, Wilfley DE, Agras WS, et al. Psychological treatments of binge eating disorder. Arch Gen Psychiatry. 2010;67(1):94-101. PubMed doi:10.1001/archgenpsychiatry.2009.170

9. Hilbert A, Bishop ME, Stein RI, et al. Long-term efficacy of psychological treatments for binge eating disorder. Br J Psychiatry. 2012;200(3):232-237. PubMed doi:10.1192/bjp.bp.110.089664

10. Grilo CM, Masheb RM, Wilson GT. Efficacy of cognitive behavioral therapy and fluoxetine for the treatment of binge eating disorder: a randomized double-blind placebo-controlled comparison. Biol Psychiatry. 2005;57(3):301-309. PubMed doi:10.1016/j.biopsych.2004.11.002

11. Grilo CM, Crosby RD, Wilson GT, et al. 12-month follow-up of fluoxetine and cognitive behavioral therapy for binge eating disorder. J Consult Clin Psychol. 2012;80(6):1108-1113. PubMed doi:10.1037/a0030061

12. Ricca V, Mannucci E, Mezzani B, et al. Fluoxetine and fluvoxamine combined with individual cognitive-behaviour therapy in binge eating disorder: a one-year follow-up study. Psychother Psychosom. 2001;70(6):298-306. PubMed doi:10.1159/000056270

13. Peterson CB, Crow SJ, Nugent S, et al. Predictors of treatment outcome for binge eating disorder. Int J Eat Disord. 2000;28(2):131-138. PubMed doi:10.1002/1098-108X(200009)28:2<131::AID-EAT1>3.0.CO;2-6

14. Masheb RM, Grilo CM. Examination of predictors and moderators for self-help treatments of binge-eating disorder. J Consult Clin Psychol. 2008;76(5):900-904. PubMed doi:10.1037/a0012917

15. Grilo CM, Masheb RM, Crosby RD. Predictors and moderators of response to cognitive behavioral therapy and medication for the treatment of binge eating disorder. J Consult Clin Psychol. 2012;80(5):897-906. PubMed doi:10.1037/a0027001

16. Grilo CM, White MA, Gueorguieva R, et al. Predictive significance of the overvaluation of shape/weight in obese patients with binge eating disorder: findings from a randomized controlled trial with 12-month follow-up. Psychol Med. 2013;43(6):1335-1344. PubMed doi:10.1017/S0033291712002097

17. Hilbert A, Saelens BE, Stein RI, et al. Pretreatment and process predictors of outcome in interpersonal and cognitive behavioral psychotherapy for binge eating disorder. J Consult Clin Psychol. 2007;75(4):645-651. PubMed doi:10.1037/0022-006X.75.4.645

18. Sysko R, Hildebrandt T, Wilson GT, et al. Heterogeneity moderates treatment response among patients with binge eating disorder. J Consult Clin Psychol. 2010;78(5):681-690. PubMed doi:10.1037/a0019735

19. Grilo CM, Masheb RM, Wilson GT. Rapid response to treatment for binge eating disorder. J Consult Clin Psychol. 2006;74(3):602-613. PubMed doi:10.1037/0022-006X.74.3.602

20. Grilo CM, White MA, Wilson GT, et al. Rapid response predicts 12-month post-treatment outcomes in binge-eating disorder: theoretical and clinical implications. Psychol Med. 2012;42(4):807-817. PubMed doi:10.1017/S0033291711001875

21. Grilo CM, White MA, Masheb RM, et al. Predicting meaningful outcomes to medication and self-help treatments for binge-eating disorder in primary care: the significance of early rapid response. J Consult Clin Psychol. 2015;83(2):387-394. PubMed doi:10.1037/a0038635

22. Hilbert A, Hildebrandt T, Agras WS, et al. Rapid response in psychological treatments for binge eating disorder. J Consult Clin Psychol. 2015;83(3):649-654. PubMed doi:10.1037/ccp0000018

Carlos M. Grilo, PhDa

carlos.grilo@yale.edu

aDepartment of Psychiatry, Yale University School of Medicine, New Haven, Connecticut

Potential conflicts of interest: Dr Grilo reports no financial or other conflicts of interest with respect to the content of this letter. More generally, Dr Grilo reports grants from the National Institutes of Health; consulting fees from Shire and Sunovion; honoraria from the American Psychological Association and from universities and scientific conferences for grand rounds and lecture presentations; speaking and preparation fees for various CME activities; consulting fees from American Academy of CME, Vindico Medical Education CME, General Medical Education CME, Medscape/WebMD Education CME, and CME Institute of Physicians Postgraduate Press; and academic book royalties from Guilford Press and Taylor Francis Publishers.

Funding/support: Preparation of this letter was supported, in part, by National Institutes of Health (NIH) Grant K24 DK070052.

Role of the sponsor: The NIH had no role or influence on the content of the this letter, nor does the content reflect the views of the NIH. No academic, pharmaceutical, or industry entity of any kind influenced the preparation of this letter in any manner.

J Clin Psychiatry 2017;78(7):e842-e843

https://doi.org/10.4088/JCP.17lr11589a

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