Review: Bulimia nervosa and treatment-related disparities. Image Credit: Studio 34 / Shutterstock

In a recent review article published in the journal Frontiers in Psychology, researchers Kim Wilson and Robert Kagabo at the College of Health Sciences, Utah Tech University, discussed the disparities in bulimia nervosa (BN) treatment, highlighting significant exclusions in clinical research.

Their conclusions emphasize the need for more inclusive research that addresses the treatment needs of older adults, males, LGBTQ individuals, and racial minorities to improve BN treatment outcomes across diverse populations.

The review identified critical gaps in current research, particularly the exclusion of individuals with severe mental illness, substance use disorders, and those in inpatient settings. The study calls for these groups to be included in future research to ensure effective treatment approaches across all populations affected by BN.

Background

BN is a serious eating disorder that typically begins in adolescence or early adulthood and is marked by episodes of binge eating followed by compensatory behaviors like vomiting, laxative misuse, or excessive exercise.

Although BN can occur at any age, with a median onset age of 12.4 years, it affects a significant number of people, with prevalence rates varying by gender. Unfortunately, most individuals with BN do not seek timely treatment, which can lead to severe health complications, including an increased risk of suicide and other medical issues related to purging behaviors.

About the study

In this review, researchers explored treatment disparities in BN, particularly focusing on how differences in race, gender, age, socioeconomic status, and mental health affect access to and outcomes of treatment across diverse settings.

The review followed a narrative overview approach to analyze randomized controlled trials (RCTs) on BN treatment published between 2010 and 2021. Researchers searched medical databases using specific terms related to BN treatment and diagnosis, ultimately selecting 17 studies that met the inclusion criteria.

These studies primarily involved female participants aged 18-60, with most being white. The review highlighted that participants under 18 and over 60, as well as non-white populations, were underrepresented. The reviewed interventions included pharmacological treatments and various psychosocial therapies, such as cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), and mindfulness-based therapies.

Most of the studies were conducted in outpatient settings, focusing on the effectiveness of different treatments and their outcomes in managing BN.

Behavioral treatments for BN

Behavioral treatments for BN include a range of interventions, with BNT being the most commonly used and effective method. CBT is particularly effective in restructuring cognitive distortions related to body image, weight, and self-esteem, thereby reducing binge eating and purging behaviors.

Other behavioral therapies include DBT, family-based therapy (FBT), and emerging approaches like virtual reality (VR) therapy and mindfulness and acceptance-based therapy (MABT). FBT, while generally effective, has shown particular promise in treating adolescents with BN.

While CBT is widely preferred, studies have found that alternative treatments like physical exercise combined with dietary therapy (PED-t) can be equally effective, especially in reducing depression and BN symptoms. For instance, PED-t has been shown to perform comparably to CBT in improving psychosocial outcomes and reducing binge eating, making it a viable alternative when CBT is not feasible.

Some innovative approaches, such as the Identity Intervention Program (IIP) and repetitive transcranial magnetic stimulation (rTMS), have also been explored, although with mixed results. Notably, IIP has demonstrated an increase in positive self-schemas, though further research is needed to establish its long-term efficacy.

While CBT remains the gold standard, other methods, including guided self-help (GSH) and transcranial Direct Current Stimulation (tDCS), offer promising alternatives, particularly when CBT is not feasible or sufficient on its own.

Pharmacological treatments for BN

Pharmacological treatments for BN are often used when patients have additional mental health issues, such as depression, anxiety, or obsessive-compulsive disorder. More than 50% of those with BN also experience major depressive episodes.

Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed to reduce the frequency of binge eating and purging, particularly for those who do not respond well to therapy alone. However, Bupropion is not recommended as it has been associated with an increased risk of seizures. Furthermore, stimulant medications are typically discontinued until purging behaviors have ceased due to the associated risks.

While behavioral therapies like FBT and CBT can improve self-esteem and mood, they may not be sufficient on their own, making pharmacological interventions a helpful addition, especially for adolescents with BN and comorbid mood disorders.

Treatment gaps

The study highlighted several gaps in the treatment of BN. A significant gap was the underrepresentation of individuals under 12, over 60, and those with severe mental illness in the reviewed studies. Most research focuses on adults aged 18-60, leaving limited information on those under 12, over 60, and adolescents. Only three of the 17 included studies included participants aged 12-18, despite evidence that BN affects younger and older individuals.

Additionally, males, non-White populations, LGBTQ individuals, and other minority groups are often underrepresented in studies, even though these groups also experience BN. Furthermore, individuals in inpatient settings are frequently excluded, limiting the applicability of outpatient-focused research findings. The review also pointed out that individuals who experience severe mental illness or substance use disorders and those in inpatient settings are frequently excluded from research. This exclusion creates a significant gap in understanding how these groups might respond to various treatments.

Furthermore, while most treatments reviewed were behavioral, there is a need for more studies on the effectiveness of psychotropic and holistic medicines, either alone or combined with behavioral therapies.

Conclusions

The study concludes that while treatments for BN exist, research often excludes certain groups, such as males, older adults, LGBTQ individuals, and individuals from racial and other minorities. This exclusion contributes to significant treatment-related disparities in BN care.  To address these issues, practitioners and researchers should include these marginalized and vulnerable populations in both treatment and research to ensure more equitable care for everyone with BN.