Psychological treatments for bulimia nervosa and binging.

BACKGROUND: A specific manual-based form of cognitive behavioural therapy (CBT) has been developed for the treatment of bulimia nervosa (CBT-BN) and other common related syndromes such as binge eating disorder. Other psychotherapies and modifications of CBT are also used. OBJECTIVES: To evaluate the efficacy of CBT, CBT-BN and other psychotherapies in the treatment of adults with bulimia nervosa or related syndromes of recurrent binge eating. SEARCH STRATEGY: Handsearch of The International Journal of Eating Disorders since first issue; database searches of MEDLINE, EXTRAMED, EMBASE, PsycInfo, CURRENT CONTENTS, LILACS, SCISEARCH, CENTRAL and the The Cochrane Collaboration Depression, Anxiety & Neurosis Controlled Trials Register; citation list searching and personal approaches to authors were used. Search date June 2007. SELECTION CRITERIA: Randomised controlled trials of psychotherapy for adults with bulimia nervosa, binge eating disorder and/or eating disorder not otherwise specified (EDNOS) of a bulimic type which applied a standardised outcome methodology and had less than 50% drop-out rate. DATA COLLECTION AND ANALYSIS: Data were analysed using the Review Manager software program. Relative risks were calculated for binary outcome data. Standardised mean differences were calculated for continuous variable outcome data. A random effects model was applied. MAIN RESULTS: 48 studies (n = 3054 participants) were included. The review supported the efficacy of CBT and particularly CBT-BN in the treatment of people with bulimia nervosa and also (but less strongly due to the small number of trials) related eating disorder syndromes.Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals were promising. Exposure and Response Prevention did not enhance the efficacy of CBT.Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders. AUTHORS' CONCLUSIONS: There is a small body of evidence for the efficacy of CBT in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small. More and larger trials are needed, particularly for binge eating disorder and other EDNOS syndromes. There is a need to develop more efficacious therapies for those with both a weight and an eating disorder.

Revisão sistemática e metanálise do uso de procinéticos no refluxo gastroesofágico e na doença do refluxo gastroesofágico em Pediatria / Systematic review and meta-analysis of the use of prokinetics in gastroesophageal reflux and in gastroesophageal reflux disease in Pediatrics

OBJETIVO: Avaliar, por meio de revisão sistemática e metanálise, estudos randomizados que comparam os procinéticos domperidona, bromoprida, metoclopramida e betanecol ao placebo no tratamento do refluxo gastroesofágico (RGE) e da doença do refluxo gastroesofágico (DRGE) em crianças. MÉTODOS: BUsca bibliográfica de ensaios clínicos randomizados (Medline, EMBASE, Biological Abstracts, ISI/Web of Science, CINAHL, Lilacs e Cochrane). O desfecho primário foi eficácia na modificação dos sintomas de refluxo, conforme definição de autores das fontes primárias. Outras variáveis de interesse foram: complicações relacionadas ao RGE, alterações nos exames laboratoriais de controle, qualidade de vida, eventos adversos e abandono do tratamento. RESULTADOS: Foram incluídos quatro estudos com domperidona, dois com metoclopramida, um com betanecol. Nenhum estudo com bromoprida foi localizado. O risco de não resposta ao tratamento foi significativamente menor para os procinéticos quando comparados ao placebo (RR 0,35; IC95 por cento 0,14-0,88). A vantagem terapêutica individual em relação ao placebo se manteve para a domperidona (n=126; RR 0,27; IC95 por cento 0,14-0,52; NNT 3; I2 0 por cento) e betanecol (n=44, RR 0,19, IC95 por cento 0,05-0,55, NNT 2), mas não para metoclopramida (n=71; RR 0,63; IC95 por cento 0,07-5,71, I2 92,2 por cento). CONCLUSÕES: A evidência para o uso de procinéticos no RGE e na DRGE em crianças é limitada, pois os poucos estudos são ensaios preliminares de resposta em curto prazo e com limitações metodológicas.

OBJECTIVE: To evaluate, by systematic review and meta-analysis, randomized studies comparing the prokinetics (domperidone, bromopride, metoclopramide and bethanechol) to placebo in the treatment of gastroesophagic reflux (GER) and gastroesophagic reflux disease (GERD) in children. METHODS: Bibliographic search for randomized clinical trials (Medline, EMBASE, Biological Abstracts, ISI/Web of Science, CINAHL, Lilacs e Cochrane). The primary outcome was the modification of reflux symptoms. Other outcomes were: GER-related complications, alterations in control exams, life quality, adverse events and abandon of treatment. RESULTS: The metanalysis included four studies on domperidone, two on metoclopramide, and one on bethanechol. No study of bromopride was retrieved. The risk of non-response to the treatment was significantly smaller in children that received prokinetics in comparison to placebo (RR 0.35, 95 percentCI 0.14-0.88). Individual therapeutic advantage regarding placebo was related to domperidone (n=126; RR 0.27; 95 percentCI 0.14-0.52, NNT 3; I2 0 percent) and bethanechol (n=44; RR 0.19; 95 percentCI 0.05-0.55; NNT 2), but not to metoclopramide (n=71; RR 0.63; 95 percentCI 0.07-5.71; I2 92.2 percent). CONCLUSIONS: The evidence for prokinetic use in GER and GERD in children is limited because the few studies report preliminary trials that evaluate short-term responses and show methodological limitations.

Antidepressants in short-term treatment of binge eating disorder: systematic review and meta-analysis.

OBJECTIVE: To evaluate the effects of antidepressant interventions for patients with Binge Eating Disorder (BED). METHOD: A systematic review and meta-analysis of available randomized controlled trials including a quality appraisal was conducted. Six databases: PUBMED, EMBASE, PSYINFO, LILACS, The Cochrane Collaboration Controlled Trials Register and The Cochrane Depression, Anxiety and Neurosis Group Database of Trials were searched using an electronic search strategy. Articles published during the period from January 1994 to December 2005 were included. RESULTS: From the 3357 articles initially identified, 19 full manuscripts were selected and analyzed and 7 studies fulfilled the inclusion criteria and were included in the final analysis. Data from the meta-analysis revealed that binge-eating remission rates were higher in patients receiving antidepressants when compared with placebo. No difference in body weight has been found as measured by short-term change in body mass index. Most studies were short-term trials (median duration: 8 weeks). The only 16-week duration study did not show superiority of antidepressants over placebo. CONCLUSION: Available data are not sufficient to formally recommend antidepressants as a single first line therapy for both short-term remission of binge-eating episodes and weight reduction in patients with BED. BED is a chronic condition and very short-term studies (8 weeks) may be of limited value.

Bulimia nervosa.

INTRODUCTION: Up to 1% of young women may have bulimia nervosa, characterised by an intense preoccupation with body weight, uncontrolled binge-eating episodes, and use of extreme measures to counteract the feared effects of overeating. People with bulimia nervosa may be of normal weight, making it difficult to diagnose. After ten years, about half of people with bulimia nervosa will have recovered fully, a third will have made a partial recovery, and 10-20% will still have symptoms. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for bulimia nervosa in adults? What are the effects of discontinuing treatment in people with bulimia nervosa in remission? We searched: Medline, Embase, The Cochrane Library and other important databases up to June 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 26 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: cognitive behavioural therapy (alone or plus exposure response prevention enhancement); cognitive orientation therapy; dialectical behavioural therapy; discontinuing fluoxetine in people with remission; guided self-help cognitive behavioural therapy; hypnobehavioural therapy; interpersonal psychotherapy; mirtazapine; monoamine oxidase inhibitors (MAOIs); motivational enhancement therapy; pharmacotherapy plus psychotherapy; pure or unguided self-help cognitive behavioural therapy (CBT); reboxetine; selective serotonin reuptake inhibitors (SSRIs); topiramate; tricyclic antidepressants (TCAs); and venlafaxine.

Double-blind, randomized, placebo-controlled trial of topiramate plus cognitive-behavior therapy in binge-eating disorder.

OBJECTIVE: To evaluate the efficacy and tolerability of adjunctive topiramate compared to placebo in reducing weight and binge eating in obese patients with binge-eating disorder (BED) receiving cognitive-behavior therapy (CBT). METHOD: A double-blind, randomized, placebo-controlled trial of 21 weeks' duration was conducted at 4 university centers. Participants were 73 obese (body mass index >or= 30 kg/m(2)) outpatients with BED (DSM-IV criteria), both genders, and aged from 18 to 60 years. After a 2- to 5-week run-in period, selected participants were treated with group CBT (19 sessions) and topiramate (target daily dose, 200 mg) or placebo (September 2003-April 2005). The main outcome measure was weight change, and secondary outcome measures were binge frequencies, binge remission, Binge Eating Scale (BES) scores, and Beck Depression Inventory (BDI) scores. RESULTS: Repeated-measures random regression analysis revealed a greater rate of weight reduction associated with topiramate over the course of treatment (p < .001), with patients taking topiramate attaining a clinically significant weight loss (-6.8 kg) compared to patients taking placebo (-0.9 kg). Although rates of reduction of binge frequencies, BES scores, and BDI scores did not differ between groups during treatment, a greater number of patients of the topiramate plus CBT group (31/37) attained binge remission compared to patients taking placebo (22/36) during the trial (p = .03). No difference between groups was found in completion rates; 1 patient (topiramate group) withdrew for adverse effect. Paresthesia and taste perversion were more frequent with topiramate, and insomnia was more frequent with placebo (p < .05). CONCLUSIONS: Topiramate added to CBT improved the efficacy of the later, increasing binge remission and weight loss in the short run. Topiramate was well tolerated, as shown by few adverse events during treatment. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov identifier NCT00307619.

A systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders.

OBJECTIVE: Interpersonal psychotherapy (IPT) is a time-limited psychotherapy for major depression. The aim of this study is to summarize findings from controlled trials of the efficacy of IPT in the treatment of depressive spectrum disorders (DSD) using a meta-analytic approach. METHODS: Studies of randomized clinical trials of IPT efficacy were located by searching all available data bases from 1974 to 2002. The searches employed the following MeSH categories: Depression/ Depressive Disorder; Interpersonal therapy; Outcome/Adverse Effects/Efficacy; in the identified studies. The efficacy outcomes were: remission; clinical improvement; the difference in depressive symptoms between the two arms of the trial at endpoint, and no recurrence. Drop out rates were used as an index of treatment acceptability. RESULTS: Thirteen studies fulfilled inclusion criteria and four meta-analyses were performed. IPT was superior in efficacy to placebo in nine studies (Weight Mean Difference (WMD) - 3.57 [-5.9, -1.16]). The combination of IPT and medication did not show an adjunctive effect compared to medication alone for acute treatment (RR 0.78 [0.30, 2.04]), for maintenance treatment (RR 1.01 [0.81, 1.25]), or for prophylactic treatment (RR 0.70 [0.30, 1.65]). IPT was significantly better than CBT (WMD -2.16 [-4.16,-0.15]). CONCLUSION: The efficacy of IPT proved to be superior to placebo, similar to medication and did not increase when combined with medication. Overall, IPT was more efficacious than CBT. Current evidence indicates that IPT is an efficacious psychotherapy for DSD and may be superior to some other manualized psychotherapies.

A randomized, double-blind, placebo-controlled study of sibutramine in the treatment of binge-eating disorder.

BACKGROUND: Although antidepressants are the pharmacological agents most often studied in the treatment of binge-eating disorder (BED), preliminary evidence from an open trial suggests that the antiobesity agent sibutramine hydrochloride may be effective. The objective of this study was to evaluate the efficacy and tolerability of sibutramine in obese patients with BED. METHODS: After a 2-week run-in period, 60 obese outpatients (body mass index [calculated as weight in kilograms divided by the square of height in meters] 30-45), who met DSM-IV criteria for BED were randomly assigned to receive sibutramine hydrochloride (n = 30), 15 mg/d, or placebo (n = 30) in a 12-week double-blind study at 2 centers. The primary outcome measure was binge frequency, expressed as the number of days with binge-eating episodes during the past week. Secondary outcome measures included Binge Eating Scale, Beck Depression Inventory scores, weight, and treatment responder status (remission and response). For each efficacy outcome, an intent-to-treat analysis was performed using random regression methods. RESULTS: There was a significant reduction in the number of days with binge episodes in the sibutramine group compared with the placebo group (t203 = 2.14; P =.03); this was associated with an important and significant weight loss (-7.4 kg) compared with a small weight gain in the placebo group (1.4 kg) (t147 = 4.88; P<.001). Sibutramine was also associated with a significantly greater rate of reduction in Binge Eating Scale (t202 = 3.64; P<.001) and Beck Depression Inventory (t201 = 3.72; P<.001) scores. Dry mouth (P =.01) and constipation (P<.001) were more common adverse reactions with sibutramine than placebo. CONCLUSIONS: Sibutramine is effective and well tolerated in the treatment of obese patients with BED. Its effects address 3 main domains of the BED syndrome, ie, binge eating, weight, and related depressive symptoms.

Tratamento farmacológico dos transtornos alimentares / Pharmacological treatment of eating disorders

O tratamento dos transtornos alimentares (TA) geralmente exige uma abordagem multidisciplinar em que a farmacoterapia é adjuvante de abordagens psicológicas e nutricionais. Psicotrópicos säo indicados para a maioria dos pacientes com TA para tratar as comorbidades e também os sintomas chamados nucleares. Progressos importantes estäo ocorrendo nos últimos anos. Este artigo apresenta uma revisäo das evidências atuais e perspectivas futuras para o tratamento farmacológico da anorexia nervosa, bulimia nervosa e do transtorno da compulsäo alimentar periódica

Efficacy and safety of risperidone oral solution in agitation associated with dementia in the elderly

BACKGROUND: Behavioral and psychological symptoms in dementia (BPSD) contribute to caregiver burden and institutionalization of elderly. Neuroleptics are prescribed to control agitation. Side effects of typical neuroleptics are harmful, making atypical neuroleptics an indication. OBJECTIVES: To evaluate efficacy and tolerability of risperidone oral solution (ROS) given once daily to demented elderly outpatients with BPSD (agitation). METHOD: Patients (n=26), 76.35 + or 8.63 years, Diagnostic and Statistical Manual of Mental Disorders 4th ed. (DSM-IV) criteria for dementia. RSO was given, starting dose of 0.25 mg and increments of 0.25 mg every week. Mini-Mental State Examination (MMSE) assessed cognitive status, Behavioral and Emotional Activities Manifested in Dementia (BEAM-D) and Clinical Global Impression (CGI) measured BPSD, Extrapiramidal Symptom Rating Scale (ESRS) evaluated extrapyramidal symptoms. Cardiovascular side effects were evaluated clinically. RESULTS: There was a 26 percent reduction in agitation and no cardiovascular side effects in the range from 1.0 to 1.25 mg. Side effects were more prevalent above 2.5 mg. CONCLUSION: Risperidone oral solution improved agitation with good tolerability from 0.5 to 1.25 mg. A single dose with increments of 0.25 mg may be more acceptable to patients and caregivers

Tratamento farmacológico de acatísia induzida por antipsicóticos / Pharmacological treatment of neuroleptic-induced akathisia

Introduçäo: A acatisia por antipsicóticos é um transtorno de movimento relacionado ao sistema motor e caracterizado por sensaçäo subjetiva de inquietude interna, irritabilidade ou disforia que podem ser intensas. Associa-se à sensaçäo física e objetiva de desassossego e a movimentos näo discinéticos. Esse efeito adverso pode predispor à pobre adesäo ao tratamento e, consequentemente, favorecer recaídas. Assim, a escolha do melhor tratamento contribui para o alívio do sofrimento dos pacientes e favorece o melhor prognóstico. Objetivos: Avaliar a eficácia e a tolerabilidade dos betabloqueadores, benzodiazepínicos e anticolinérgicos, comparados ao placebo e entre si, no tratamento de acatisia induzida por antipsicóticos, independente de idade ou diagnóstico psiquiátrico. Métodos: Todos os estudos controlados, obtidos a partir das estratégias de busca que compararam betabloqueadores de açäo central, benzodiazepínicos ou anticolinérgicos ao placebo e entre si, independente de sexo, idade ou diagnóstico psiquiátrico, foram considerados para esta atualizaçäo. Até março de 1999, foram consultadas sete bases de dados eletrônicos, sendo também examinadas as referências bibliográficas dos artigos selecionados. Resultados: Säo apresentados 22 estudos controlados, sendo 13 comparando betabloqueadores, benzodiazepínicos e anticolinérgicos ao placebo e nove comparando diretamente as intervenções entre si. Conclusões: As três intervenções farmacológicas demonstraram eficácia superior comparadas ao placebo. Betabloqueadores de açäo central mostraram-se mais eficazes, quando comparados a betabloqueadores de açäo periférica, benzodiazepínicos e anticolinérgicos

Hipóteses fisiopatológicas e considerações terapêuticas da acatisia induzida por antipsicóticos / Pathophysiological hypothesis and therapeutic considerations of neurolepticðinduced akathisia

A fisiopatologia da acatisia induzida por antipsicóticos não está totalmente compreendida. Muitas hipóteses propostas têm demonstrado o possível envolvimento de diversas vias neuronais do sistema nervoso central, incluindo os sistemas noradrenérgico, dopaminérgico, serotoninérgico, colinérgico e gabaérgico. Os autores apresentam hipóteses fisiopatológicas e considerações terapêuticas da acatisia induzida por antipsicóticos

Psiquiatria baseada em evidências / Evidence-based psychiatry

Em psiquiatria, observa-se grande variabilidade de práticas clínicas, muitas vezes desnecessária. Essas variações podem estar relacionadas à ausência de evidência científica confiável ou ao desconhecimento das evidências de boa qualidade disponíveis. A medicina baseada em evidências (MBE) é uma combinação de estratégias que busca assegurar que o cuidado individual do paciente seja baseado na melhor informação disponível, a qual deve ser incorporada a prática clínica. Neste artigo, conceitos de MBE são discutidos com relação a aspectos e desafios no tratamento de pacientes com distimia, bulimia nervosa e esquizofrenia. A partir de resultados de três revisões sistemáticas recentemente publicadas, conclui-se que a prática de psiquiatria baseada em evidências acrescenta qualidade à prática psiquiátrica tradicional

Psiquiatria baseada em evidencias

Em psiquiatria, observa-se grande variabilidade de praticas clinicas, muitas vezes desnecessaria. Essas variacoes podem estar relacionadas a ausendia de evidencia cientifica confiavel ou ao desconhecimento das evidencias de boa qualidade disponiveis. A medicina baseada em evidencias (MBE) e uma combinacao de estrategias que busca assegurar que o cuidado individual do paciente seja baseado na melhor informacao disponivel, a qual deve ser incorporada a pratica clinica. Neste artigo, conceitos de MBE sao discutidos com relacao a aspectos e desafios no tratamento de pacientes com distimia, bulimia nervosa e esquizofrenia. a partir de resultados de tres revisoes sistematicas recentemente publicadas, conclui-se que a pratica de psiquiatria baseada em evidencias acrescenta qualidade a pratica psiquiatrica tradicional.