Evaluation of Combined Therapy for Bulimia Nervosa
Description and Significance
Bulimia nervosa, simply bulimia or BN, refers to uncontrolled overeating or binging and then eliminating what has been eaten (SJH, 2012; Grange et al., 2004). Recent reports show alarming increases in the incidence, which now adolescents and pre-adolescents. The latest population statistics say that about 27.3 of the U.S. population is between 12 and 19 years old. BN affects up to 3% of these young people 15-18 years old at peak (SJH, Grange et al.).
Brief Description of BN
BN consists of eliminating or purging ingested food through induced vomiting, inappropriate use of laxatives or diuretics, fasting or extreme exercise to control weight (SJH 2012; Grange et al., 2004). The exact cause or causes are still unknown. But some factors are believed to contribute to it. These are cultural ideals and social attitudes about body appearance, self-evaluation on the basis of body weight and shape and family problems. Self-consciousness, especially about physical appearance, is most common and strongest in adolescence (SLH, Grange et al.).
The common symptoms indicative of BN include low or normal body weight viewed as overweight, recurring binge eating and the fear of not stopping it, self-induced vomiting, excessive fasting, excessive exercising, ritualistic and peculiar eating habits, inappropriate laxative use, irregular or no menstruation, anxiety, depression, scares at the back of the fingers from induced vomiting and over-achieving behavior (SJH 2012; Grange et al., 2004). Usual treatment is through a combination of individual therapy, family therapy, behavior change and nutritional adjustment. Treatment is decided after an evaluation of the person and his or her family. Additional medication may be prescribed or administered if depression is also present. Parents are counseled to be supportive of the patient. Hospitalization may also be required if case of complications like weight loss and malnutrition (SLH, Grange et al.).
Recent evidence suggests fluoxetine as the only USFDA-approved selective serotonin-reuptake inhibitor or SSRI for BN in adolescents and pre-adolescent persons (Blake & Rich, 2008). It is also more effective and beneficial than placebo. In combination with cognitive behavioral therapy or CBT, it is even better and superior to fluoxetine alone, CBT alone or placebo, according to trial results. Other drugs are citalopram or escitalopram, sertraline, paroxetine, and venlafaxine (Blake & Rich).
Relevance to Clinical Care and Nursing
The increase of BN incidence and prevalence among adolescents and pre-menarchial adolescents are specifically alarming to the health care profession (Grange et al., 2004). Partial eating syndromes add to the alarming situation. Community samples suggest that 10-50% of them develop BN yet diagnostic tests revealed that only 1-5% of the girls who responded reflected the BN condition. This meant that there are those whose symptoms have not been recognized and recorded in the statistical manual. These partial eating syndromes are likely to grow and become full-blast (Grange et al.).
Randomized Clinical Trials
1. Solomando et al. (2008) summarized recent evidence drawn from the clinical guidelines of the National Institute for Health and Clinical Excellence and high-quality systematic reviews on the use of CBT for treating children and adolescents with mental health problems, such as BN. The synthesis was limited to systematic reviews in identifying and examining the most reliable evidence available. The outcomes yielded the most reliable evidence of potential benefit or the lack of it for CBT. Data drawn from the meta-analyses of randomized controlled trials offered the best evidence for CBT in treating children and adolescents with generalized mental disorders, such as generalized anxiety disorder, depression, obsessive-compulsive disorder and post-traumatic disorder. There is limited evidence in efficacy for ADHD and other antisocial behavior, psychotic and related disorders, substance misuse, self-harm behavior and eating disorders (Solomando et al.). This is level-1 evidence, which is systematic and can be generalized for mental health problems but not for eating disorders like BN.
2. Goodyer S. et al. (2007) performed a randomized controlled superiority trial in order to determine the effectiveness of SSRIs and CBT in the short-term as compared with an SSRI and clinical care alone in adolescents with moderate to severe major depression, as co-occurring in BN. The team surveyed 208 adolescents, aged 11-17, from 6 outpatient clinics in Manchester and Cambridge. They were diagnosed with major or probable major depression and unresponsiveness to a brief initial intervention. Included were adolescents with suicidal tendencies, depressive psychosis, and conduct disorders. The team administered SSRI and routine care to 103 respondents and SSRI, routine care and CBT to 105 for 12 weeks and maintenance for 16 weeks. Secondary measures were change in scores on moods and feelings through a questionnaire, the revised children's rating scale, the children's global assessment scale, and the clinical global impression improvement scale. Results yielded no evidence of efficacy of combined CBT and SSRIs with routine clinical care on short-term as contributing to improvement by 28 weeks for the respondents. This was in comparison with routine clinical care and SSRI alone (Goodyer et al.). This is a Level-2 evidence of a single experimental study, which can be generalized for short-term generalization.
3. The TADS Team (2007) performed randomized controlled trial on the effectiveness of a combination of treatments on adolescents with major depressive disorder. These treatments were fluoxetine hydrochloride therapy, CBT and their combination. The RCT was conducted on 320 participants, aged 12-17, in 13 academic community sites for 36 weeks. The team, an independent evaluator, used the Children's Depression Rating Scale. CBT and combination therapies were not masked but placebo and fluoxetine therapies were double blind for 12 weeks. The treatments were un-blinded afterwards. The placebo group was excluded in these analyses. Findings showed that treatment with fluoxetine alone or in combination with CBT sped up the rate of improvement. The addition of CBT increased safety levels. The combination appeared superior to either in treating depression, which frequently accompanies BN. This is level-1 evidence, which can be generalized for depression (TADS Team).
4. Brent (2008) and his team, in a separate RCT, found that the combination of CBT and a change of SSRIs would raise clinical response for adolescents with depression who were unresponsive to SSRI as an initial treatment. The team's aim was to evaluate and compare the effectiveness of four treatment alternatives on 334 patients, aged 12-18, from 6 U.S. academic and community clinics from 2000-2006. The team switches between SSRIs and CBT and compared the treatments for 12 weeks. Venlafaxine with CBT was also tested. The outcome measures used were the Clinical Global Impressions-Improvement Scale and the Children's Depression Ration Scale (Brent et al.). This is a Level -3 evidence as it was quasi-experimental.
5. Walkup (2008) and his team similarly concluded that both CBT and SSRI reduced severe anxiety symptoms in children and adolescents to a superior level. They conducted an RCT to explore the relative or combined efficacy of these treatments on 488 participants, aged 7-17 with varying diagnoses of anxiety disorders. The participants went through 14 CBT sessions and received the SSRI sertraline, a combination of CBT and sertraline or a placebo for 12 weeks. The team used categorical and dimensional ratings at baseline in weeks 4, 8 and 12. Results showed a high 80% of improvement from combination therapy, according to the Clinician Global Impression Improvement test. The Pediatric Anxiety Rating Scale yielded a similarly high pattern of response, particularly for the combination therapy. Other symptoms associated with CBT, such as insomnia, fatigue, sedation and restlessness, were also reduced (Walkup et al.). This is level-2 evidence, which can be generalized for anxiety, which often accompanies BN.
6. Hay (2008) and his associates conducted 26 systematic reviews, RCTs and observational studies on the effectiveness of treatments on young BN patients. These were retrieved from Medline, Embase, The Cochrane Library, among others, up to June 2007. They used a GRADE evaluation in assessing the quality of evidence. The team found 17 interventions for BN. Summary of results showed that up to 1% of young women, who are body conscious, develop BN; they were of normal weight; half of them would have fully recover in 10 years' time; CBT alone could produce improvement compared with no treatment; CBT is comparably effective as other treatment in reducing symptoms; the efficacy of other psychological therapies remained unknown; and some SSRIs can work against symptoms better than can placebos (Hay et al.). This is a level-1 evidence that can be generalized.
7. Dubicka et al. (2010) attempted to resolve the conflicting findings from RCTs on the efficacy of SSRIs combined with CBT. In determining whether CBT produces additional benefits to SSRI treatment on adolescents suffering from depression, the team performed a meta-analysis of RCT s on new lines of SSRIs in combination with CBT on sample adolescents. These participants, aged 11-18, were diagnosed with depression as defined by DSM-IV. They were given a new type of SSRI in combination with CBT and the results were compared with those with SSRI without CBT. The focus was on depression and impairment scores, overall improvement, suicidality, and adverse…