Binge eating disorder (BED) is prevalent, associated with obesity and elevated psychiatric co-morbidity, and represents a treatment challenge.

A controlled comparison of multi-modal, stepped-care versus behavioral-weight-loss (BWL) for BED.

One hundred and ninety-one patients (71% female, 79% white) with BED and co-morbid obesity (mean BMI 39) were randomly assigned to 6 months of BWL (n=39) or stepped-care (n=152). Within stepped-care, patients started BWL for one month; treatment-responders continued BWL while non-responders switched to cognitive-behavioral-therapy (CBT) and all stepped-care patients were additionally randomized to anti-obesity medication or placebo (double-blind) for five months. Independent assessments were performed by research-clinicians at baseline, throughout treatment, and post-treatment (90% assessed) with reliably-administered structured interviews.

Intent-to-treat analyses of remission rates (0 binges/month) revealed BWL and stepped-care did not differ significantly overall (74% vs 64%); within stepped-care, remission rates differed (range 40% - 79%) with medication significantly superior to placebo (P<0.005) and among initial non-responders switched to CBT (P<0.002). Mixed-models analyses of binge eating frequency revealed significant time effects but BWL and stepped-care did not differ overall; within stepped-care, medication was significantly superior to placebo overall and among initial non-responders switched to CBT. Mixed models revealed significant weight-loss but BWL and stepped-care did not differ overall; within stepped-care, medication was significantly superior to placebo overall and among both initial responders continued on BWL and non-responders switched to CBT.

Overall, BWL and stepped-care treatments produced improvements in binge-eating and weight loss in obese BED patients. Anti-obesity medication enhanced outcomes within a stepped-care model.