Intl J Eating Disorders - 2020 - Hilbert - Meta Analysis On The Long Term Effectiveness of Psychological and Medical Treatment of BED

Received: 15 October 2019 Revised: 17 March 2020 Accepted: 19 March 2020
DOI: 10.1002/eat.23297
SYNTHESIS AND REVIEW
Meta-analysis on the long-term effectiveness of psychological

and medical treatments for binge-eating disorder
Anja Hilbert PhD1 | David Petroff PhD2 | Stephan Herpertz MD2 |

Reinhard Pietrowsky PhD3 | Brunna Tuschen-Caffier PhD4 | Silja Vocks PhD5 |
Ricarda Schmidt PhD1
1
Integrated Research and Treatment Center AdiposityDiseases, Behavioral Medicine Research Unit, Department of Psychosomatic Medicine and Psychotherapy,
University of Leipzig Medical Center, Leipzig, Germany
2
Integrated Research and Treatment Center AdiposityDiseases, Clinical Trial Center Leipzig, University of Leipzig, Leipzig, Germany
3
Department of Psychosomatic Medicine and Psychotherapy, LWL-University Clinic, Ruhr-University Bochum, Germany
4
Department of Clinical Psychology, Institute of Experimental Psychology, University of Düsseldorf, Düsseldorf, Germany
5
Department of Psychology, University of Freiburg, Freiburg, Germany
Correspondence
Anja Hilbert, Integrated Research and Abstract
Treatment Center AdiposityDiseases, Objective: Long-term effectiveness is a critical aspect of the clinical utility of a treat-
Behavioral Medicine Research Unit,
Department of Psychosomatic Medicine and ment; however, a meta-analytic evaluation of psychological and medical treatments for
Psychotherapy, University of Leipzig Medical binge-eating disorder (BED), including weight loss treatments, is outstanding. This
Center, Philipp-Rosenthal-Strasse 27, 04103
Leipzig, Germany. meta-analysis sought to provide a comprehensive evaluation of the long-term effec-
Email: [email protected] tiveness in diverse treatments for BED regarding a range of clinically relevant
Funding information outcomes.
Bundesministerium für Bildung und Forschung, Method: Based on a systematic search up to February 2018, 114 published and
Grant/Award Number: 01EO1501; Christina
Barz Foundation unpublished randomized-controlled (RCTs), nonrandomized, and uncontrolled treat-
ment studies, totaling 8,862 individuals with BED (DSM-IV, DSM-5), were identified
and analyzed using within-group random-effect modeling.
Results: Effectiveness (regarding binge-eating episodes and abstinence, eating
disorder and general psychopathology) up to 12 months following treatment was
demonstrated for psychotherapy, structured self-help treatment, and combined
treatment, while the results regarding body weight reduction were inconsistent.
These results were confirmed in sensitivity analyses with RCTs on the most com-
mon treatments—cognitive-behavioral therapy and self-help treatment based on
this approach. Follow-up intervals longer than 12 months were rarely reported,
mostly supporting the long-term effectiveness of psychotherapy. Few follow-up
data were available for pharmacotherapy, and behavioral and self-help weight loss
treatment, while follow-up data were lacking for pharmacological and surgical
weight loss treatment. Study quality varied widely.
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1354 HILBERT ET AL.
Discussion: This comprehensive meta-analysis demonstrated the medium-term

effectiveness of psychotherapy, structured self-help treatment, and combined treatment
for patients with BED, and supported the long-term effectiveness of psychotherapy. The
results were derived from uncontrolled comparisons over time. Further long-term high
quality research on psychological and medical treatments for BED is required.
Resumen
Objectivo: La efectividad a largo plazo es un aspecto crítico de la utilidad clínica de
un tratamiento; sin embargo, una evaluación metaanalítica de los tratamientos
psicológicos y médicos para el trastorno por atracón (TpA), incluidos los tratamientos
para perder peso, es sobresaliente. Este metaanálisis buscó proporcionar una
evaluación integral de la efectividad a largo plazo en diversos tratamientos para TpA
con respecto a una gama de resultados clínicamente relevantes.
Método: En base a una búsqueda sistemática hasta febrero de 2018, se identificaron
114 estudios controlados aleatorios (ECA), no aleatorizados y no controlados, publicados
y no publicados, de tratamiento, con un total de 8,862 individuos con TpA (DSM-IV,
DSM-5), fueron identificados y analizados utilizando modelos de efecto aleatorio dentro
del grupo.
Resultados: Se demostró la efectividad para psicoterapia, tratamiento de autoayuda
estructurado y tratamiento combinado (con respecto a los episodios de atracones y la
abstinencia, el trastorno de la conducta alimentaria y la psicopatología general) hasta
12 meses después del tratamiento, mientras que los resultados con respecto a la reducción
del peso corporal fueron inconsistentes. Estos resultados se confirmaron en análisis de
sensibilidad con ECAs sobre los tratamientos más comunes – terapia cognitivo conductual
y tratamiento de autoayuda basado en este enfoque. Los intervalos de seguimiento de
más de 12 meses rara vez se reportaron, la mayoría apoyando la efectividad a largo plazo
de la psicoterapia. Había pocos datos de seguimiento disponibles para farmacoterapia y
tratamiento de pérdida de peso conductual y de autoayuda, mientras que faltaban datos
de seguimiento para el tratamiento farmacológico y quirúrgico de pérdida de peso. La
calidad del estudio varió ampliamente.
Discusión: Este metaanálisis integral demostró la efectividad a medio plazo de la
psicoterapia, el tratamiento de autoayuda estructurado y el tratamiento combinado para
pacientes con TpA, y apoyó la efectividad a largo plazo de la psicoterapia. Los resultados
se derivaron de comparaciones no controladas a lo largo del tiempo. Se requiere más
investigación a largo plazo de alta calidad sobre tratamientos psicológicos y médicos
para TpA.
KEYWORDS
binge-eating disorder, clinical trials, meta-analysis, nonrandomized-controlled trials, randomized-

controlled trials, therapeutics
1 | I N T RO DU CT I O N With a lifetime prevalence rate of 0.9%, BED is the most prevalent

eating disorder (Udo & Grilo, 2019), co-occurring with increased
Binge-eating disorder (BED) is characterized by recurrent binge eating eating disorder and general psychopathology, and obesity and its
in the absence of regular inappropriate compensatory behaviors to associated sequelae (Hilbert, 2019; Mitchell, 2016; Wilfley, Citrome, &
prevent weight gain (American Psychiatric Association [APA], 2013). Herman, 2016).
HILBERT ET AL. 1355
Several comprehensive meta-analyses covering multiple broader conducted under ideal, highly controlled conditions maximizing
treatment categories evaluated the outcome of diverse psychological internal validity, and effectiveness evaluations addressing the
and medical treatment approaches to BED in randomized- transportability of efficacious treatments to “real world settings”;
controlled trials (RCTs). Psychotherapy and structured self-help, these can be examined not only in RCTs, but also in
mostly based on cognitive-behavioral therapy (CBT), were found nonrandomized-controlled (NRCTs, without random allocation of
to have significant posttreatment effects on binge-eating episodes patients to treatment and control conditions) or uncontrolled (UCT,
and abstinence from binge eating, as well as eating disorder psy- without control condition) designs, with the latter two being prone
chopathology when compared to inactive control groups (typically to a greater risk of bias. To our knowledge, only one previous com-
wait-list), whereas effects on depression were inconsistent and prehensive meta-analysis had examined these designs in diverse
weight loss effects were nonsignificant (Brownley et al., 2016; treatment of BED, but this meta-analysis focused only on post-
Ghaderi et al., 2018; Hilbert et al., 2019; Linardon, Wade, de la treatment effects (Vocks et al., 2010).
Piedad Garcia, & Brennan, 2017). Pharmacotherapy of BED, mostly To extend a current RCT-based meta-analysis with presumably
consisting of second generation antidepressants or, more recently, the most ample search (Hilbert et al., 2019), this meta-analysis sought
the central nervous system stimulant lisdexamfetamine, had signif- to evaluate the long-term effectiveness of diverse treatments for BED
icant posttreatment effects on binge-eating episodes and absti- in RCTs, NRCTs, and UCTs regarding binge eating, eating disorder and
nence when compared to pill placebo, while results on eating general psychopathology, and body weight.
disorder psychopathology and depression were inconsistent
(Brownley et al., 2016; Ghaderi et al., 2018; Hilbert et al., 2019).
A significant weight loss was especially demonstrated for 2 | METHODS
lisdexamfetamine. Combinations of CBT, behavioral weight loss
treatment (WLT), and/or pharmacotherapy did not show differen- This study was based on the meta-analysis by Hilbert et al. (Hilbert,
tial effects versus inactive control conditions on binge-eating Petroff, et al., 2017; Hilbert et al., 2019), registered in the PROSPERO
episodes and abstinence at posttreatment; however, eating disor- International Prospective Register of Systematic Reviews
der psychopathology, depression, and body weight were signifi- (CRD42016043604). From inception to February 2018, published,
cantly improved (Hilbert et al., 2019). unpublished, and ongoing studies were sought, using terms related
A limitation of these meta-analyses is a lack of analyses on long- to binge eating and psychological and medical interventions in a
term effects, except in meta-analytic evaluations of a low number of broad range of electronic databases, national and international trials
RCTs comparing active treatments (Ghaderi et al., 2018; Hilbert registers, and pharmaceutical industry trials registers, augmented by
et al., 2019; Linardon et al., 2017). While the latter analyses elucidated manual searches. Inclusion and exclusion criteria are summarized in
the comparative efficacy of different treatments over 1 year of Table 1. A standardized coding scheme with established interrater reli-
follow-up, long-term change in relation to inactive control conditions ability (Hilbert et al., 2019; Vocks et al., 2010) was used to extract
could not be determined. RCTs with long-term follow-up of inactive methods, results, and risk of bias. Search, screening, inclusion,
control condition are lacking, likely because withholding treatment for and coding were performed by two psychologists (M.Sc. level)
an extended period is ethically problematic. Currently, long-term independently.
effects can only be addressed in within-group comparisons over time,
which was, however, not targeted in the previous comprehensive
meta-analyses, likely because within-group effect sizes are more 2.1 | Outcome measures
prone to biases (e.g., patient and setting biases, expectancy and
demand characteristics, time and assessment effects) than between- Primary outcomes included the number of binge-eating episodes,
group effect sizes in RCTs (Cuijpers, Weitz, Cristea, & Twisk, 2017). defined as a sense of loss of control over eating a definitely large
Clinically, meta-analytical evaluations of long-term effects are, never- amount of food (APA, 2013), and abstinence from binge eating,
theless, highly important, complementing the knowledge base on defined as zero binge-eating episodes, reported within a specific time
short-term efficacy and comparative efficacy of psychological and period. As secondary outcomes, eating disorder psychopathology
medical treatments for BED over 1 year of follow-up (Brownley (attitudes regarding eating behavior and body image) and general
et al., 2016; Ghaderi et al., 2018; Hilbert et al., 2019; Linardon psychopathology (depressive symptoms) were operationalized
et al., 2017). through one psychometric instrument per study, using a hierarchical
A further limitation of the previous comprehensive meta- selection strategy (Hilbert et al., 2019). Body weight and body mass
analyses is that, with a concentration on RCTs, treatment catego- index (BMI, kg/m2) were examined if derived from objective mea-
ries where randomization or the use of a control group is practically surement. In addition, risk of bias assessment used the Cochrane
or ethically difficult (e.g., obesity surgery) were not considered. Effective Practice and Organization of Care (EPOC) Risk of Bias Tool
Notwithstanding, in order to inform evidence-based clinical (Effective Practice and Organization of Care [EPOC], 2015), with
decision-making (Hilbert, Hoek, & Schmidt, 2017), it appears vital consultation of the Risk of Bias in Nonrandomized Studies of Inter-
to integrate both efficacy evaluations from RCTs, typically ventions (Sterne et al., 2016).
1356 HILBERT ET AL.
2.2 | Meta-analyses follow-up(s)—grouped into 3–6 months and 6–12 months following
treatment for evaluating medium-term effectiveness, and more than
Within-group analyses for all active treatments were conducted per 12 months following treatment for evaluating long-term effective-
treatment category, comparing pretreatment with posttreatment and ness. Sensitivity analyses were performed for the most common treat-
ments and designs. For continuous outcomes, the treatment effect
was determined as a standardized mean difference between pre-
TABLE 1 Inclusion and exclusion criteria treatment and posttreatment or follow-up(s), using Hedge's g. The
Inclusion correlation was chosen per continuous outcome and estimated based
(1) Psychological (e.g., psychotherapy, self-help treatment) and on studies that provided measures of variance at each time point and
medical (e.g., pharmacotherapy, bariatric surgery) treatment for the change between points in time. For categorical outcomes, the
studies treatment effect was measured as rates at posttreatment and
(2) Individuals with a pretreatment diagnosis of BED according to follow-up(s), using a logarithmic scale and adding ½ to cells with
DSM-IV or DSM-5 (including BED of low frequency and/or
zero counts. For more than two arms from one study within a treat-
limited duration)
ment category, hierarchical methods using “arm within study” were
(3) Randomized-controlled, nonrandomized-controlled, or
uncontrolled trial design applied to account for the fact that arms from a single study
are correlated and to have appropriate weighting (Gleser &
(4) Assessment of the core symptomatology of BED (binge-eating
episodes or days, abstinence from binge eating, and/or Olkin, 2009). Meta-analyses, requiring data from at least two stud-
diagnosis of BED) ies, were conducted using random effects models. As heterogene-
(5) Provision of sufficient detail to allow the calculation of effect ity, evaluated with the statistic Q and variance τ2 , was high, a
sizes (e.g., M, SD and/or n, %), including a pretreatment and at sensitivity analysis including a comparison with fixed effects
least one posttreatment or follow-up assessment
models was not possible. To test robustness, “fail-safe N” was
(6) Separate data reports for patients with BED in studies determined—that is, the number of trials with a null result that
examining multiple patient groups
would be needed before a significant effect would be rendered
(7) Written in English
nonsignificant (Rosenthal, 1979). Potential moderator effects of
Exclusion study design and risk of bias on the primary outcomes at post-
(1) Double reports of the same trial treatment were indirectly examined in meta-regression analyses
(2) Case reports and studies with a sample size smaller than n = 10 (Hilbert, Petroff, et al., 2017). The “metafor” package of R version
Abbreviations: BED, binge-eating disorder; DSM, Diagnostic and Statistical 3.4.2 (R Core Team, 2016; Viechtbauer, 2010) was used for meta-
Manual of Mental Disorders, Fourth or Fifth Edition. analyses. A two-tailed α < .05 indicated significance.
Identification
Records identified through database Additional records identified

searching through other sources
(n = 22.840) (n = 7)
Records after duplicates removed

(n = 11.363)
Screening
Records screened Records excluded

(n = 11.363) (n = 10.784)
F I G U R E 1 Flow diagram of
included studies according to
Eligibility
Full-text articles assessed Full-text articles excluded

“Preferred reporting items for
for eligibility (n = 465) systematic review and meta-analysis
(n = 579) - No BED (DSM-5, DSM- protocols” (PRISMA-P; Moher
IV) n = 190 et al., 2015)
- No BED outcome n = 110
Source: Modified from “Meta-analysis
- No original study n = 78
- No separate data n = 39 of the efficacy of psychological and
Studies included in
- Sample size < 10 n = 22
Included
quantitative synthesis medical treatments for binge-eating

- No pre-post data n = 13 disorder,” by A. Hilbert et al., 2019,
(meta-analysis)
- Not in English n = 10
(n = 114) Journal of Consulting and Clinical
- No intervention n = 3
Psychology, 87, p. 91
TABLE 2 Included studies
Treatment
Source Design Intervention description category N Females (%) Ethnicity (%) Time points
HILBERT ET AL.
Psychotherapy
Agras et al. (1995) RCT CBT CBT 39 86%a NA Pre, post
b
Agüera et al. (2013) UCT CBT CBT 87 100% NA Pre, post
Alfonsson, Parling, and Ghaderi (2015) RCT Behavioral activation CBT 50 92% NA Pre, post, 3m, 6m
Allen and Craighead (1999) RCT Appetite awareness training CBT 15 100% NA Pre, post
Brambilla et al. (2009) RCT CBT CBT 10 100% NA Pre, post
Castellini et al. (2012) UCT CBT CBT 133 88% C-100% Pre, post, 36m
Ciano, Rocco, Angarano, Biasin, and NRCT Psychoanalytic psychotherapy Psychodynamic 6 100% NA Pre, post, 6m, 12m
Balestrieri (2002)
Ciano et al. (2002) NRCT Psychoeducation Other 5 100% NA Pre, post, 6m, 12m
Clyne and Blampied (2004) UCT Emotion regulation training CBT 14 100% C-100% Pre, post, 3m
Compare, Calugi, Marchesini, Molinari, NRCT Emotion focused therapy Other 63b 66% NA Pre, post, 6m
and Dalle Grave (2013); Compare
et al. (2013); Compare and
Tasca (2016)
Courbasson, Nishikawa, and UCT Mindfulness-based CBT CBT 38b 79% NA Pre, post
Shapira (2011)
de Zwaan et al. (2017) RCT CBT CBT 86 86% NA Pre, post
b a
Dingemans, Spinhoven, and van RCT CBT CBT 30 94% NA Pre, post, 12m
Furth (2007)
Duchesne et al. (2007) UCT CBT CBT 21b 86% NA Pre, post
Ferrer-García et al. (2017) RCT CBT CBT 13 NA NA Pre, post
Ferrer-García et al. (2017) RCT CBT with virtual reality cue CBT 16 NA NA Pre, post
exposure training
Gorin, Le Grange, and Stone (2003) RCT CBT CBT 32 100% C-86%a Pre, post, 6m
Gorin et al. (2003) RCT CBT with spouse involvement CBT 31 100% NA Pre, post, 6m
Grilo, Masheb, Wilson, Gueorguieva, RCT CBT CBT 45b 63% C-76%, Af-11%, Pre, post, 6m, 12m
and White (2011) H-7%, As-4%
Hilbert, Petroff, Neuhaus, and RCT CBT CBT 37b 82% C-92% Pre, post
Schmidt (2020)
Hilbert and Tuschen-Caffier (2004) RCT CBT with body exposure CBT 14 100% NA Pre, post, 4m
Hilbert and Tuschen-Caffier (2004) RCT CBT with cognitive body image CBT 14 100% NA Pre, post, 4m
intervention
Juarascio, Manasse, Schumacher, Espel, UCT Acceptance-based behavioral CBT 19 100% C-68%, Af-11%, Pre, post, 3m
and Forman (2017) therapy H-11%, As-11%
(Continues)
1357
TABLE 2 (Continued)
1358
Treatment
Kristeller and Hallett (1999) UCT Meditation Other 21 100% C-94% Pre, post, 0.7m
Kristeller, Wolever, and Sheets (2014) RCT Psychoeducational CBT CBT 35 NA NA Pre, post
Kristeller et al. (2014) RCT Mindfulness-based eating Other 31 88%a C-88%, H-13%, Pre, post
awareness training As-1%a
Le Grange, Gorin, Dymek, and RCT CBT CBT 22b 100% C-92% Pre, post, 12m
Stone (2002)
Lewer et al. (2017) RCT Body image therapy CBT 15 100% NA Pre, post
Munsch et al. (2007); Munsch, Meyer, RCT CBT CBT 44b 91% NA Pre, post, 72m
and Biedert (2012)
Nauta, Hospers, Kok, and Jansen (2000); RCT Cognitive therapy CBT 21b 100% NA Pre, post, 6m, 12m
Nauta, Hospers, and Jansen (2001)
Pendleton, Goodrick, Poston, Reeves, and RCT CBT CBT 29 100% C-76%, Af-13%, Pre, post, 6m, 12m
Foreyt (2002) H-8%
Pendleton et al. (2002) RCT CBT + maintenance CBT 28 100% NA Pre, post, 6m
b
Peterson et al. (1998), Peterson RCT CBT CBT 16 100% NA Pre, post, 1m, 6m, 12m
et al. (2001)
Peterson, Mitchell, Crow, Crosby, and RCT CBT CBT 60b 100% C-92% Pre, post, 6m, 12m
Wonderlich (2009)
Preuss, Pinnow, Schnicker, and RCT Inhibitory control training CBT 15b 93% NA Pre, post, 1m, 3m
Legenbauer (2017)
Preuss et al. (2017) RCT CBT CBT 8b 100% NA Pre, post, 1m, 3m
b
Ricca, Castellini, Lo Sauro, Rotella, and RCT CBT CBT 24 83% NA Pre, post, 12m
Faravelli (2009)
Ricca et al. (2010) RCT CBT individual CBT 72b 86% C-100% Pre, post, 36m
Ricca et al. (2010) RCT CBT group CBT 72b 90% C-100% Pre, post, 36m
Ricca et al. (2001) RCT CBT CBT 20 65% NA Pre, post, 6m
Richard et al. (n.d.) RCT Eye movement desensitization EMDR 16b 97%a NA Pre, post
(ACTRN12614000894695) reprocessing
Safer, Robinson, and Jo (2010) RCT DBT CBT 50b 86% C-80%, H-16%, Pre, post, 12m
As-4%
Safer et al. (2010) RCT Active comparison group Humanistic 51b 84% C-73%, Af-6%, Pre, post, 12m
therapy H-10%, As-6%
Schag et al. (2019) RCT Impulsivity-focused CBT CBT 41b 88% C-81% Pre, post, 3m
c
Schlup, Munsch, Meyer, Margraf, and UCT CBT CBT 41 88% NA Pre, post, 12m, 48m
Wilhelm (2009); Fischer, Meyer,
Dremmel, Schlup, and Munsch (2014)
HILBERT ET AL.
TABLE 2 (Continued)
Treatment
HILBERT ET AL.
a a
Tasca et al. (2006) RCT Psychodynamic IPT Psychodynamic 48 91% C-98% Pre, post, 6m, 12m
Tasca et al. (2006) RCT CBT CBT 47 91%a C-98%a Pre, post, 6m, 12m
b
Tasca et al. (2013); Maxwell, Tasca, UCT Psychodynamic IPT Psychodynamic 102 100% C-83% Pre, post, 6m, 12m
Ritchie, Balfour, and Bissada (2014),
Maxwell et al. (2017)
Telch, Agras, and Linehan (2000) UCT DBT CBT 11 100% C-91% Pre, post, 3m, 6m
Telch, Agras, and Linehan (2001) RCT DBT CBT 22 100% C-94%a Pre, post, 3m, 6m
Vancampfort et al. (2014) UCT CBT CBT 39 82% NA Pre, post
Vanderlinden et al. (2012) UCT CBT CBT 56b 86% NA Pre, post, 29m
b
Wagner et al. (2016) RCT CBT Internet-based CBT 69 94% NA Pre, post, 3m, 6m, 12m
Wilfley et al. (2002) RCT CBT CBT 81b 83% C-94%, Af-4%, H-1% Pre, post, 4m, 8m
Wilfley et al. (2002) RCT IPT IPT 81b 83% C-91%, Af-4%, H-5% Pre, post, 4m, 8m
Wilson, Wilfley, Agras, and Bryson (2010) RCT IPT IPT 75b 85% C-77%, Af-17%, Pre, post, 12m, 24m
H-4%
Yu et al. (2017) RCT CBT face-to-face CBT 9 100% C-63%, Af-25%, Pre, post
H-13%
Yu et al. (2017) RCT CBT web-based CBT 8 100% C-75%, As-25% Pre, post
Self-help treatment
Cachelin et al. (2014) UCT CBT guided self-help CBT guided self-help 22b 100% H-100% Pre, post
b
Carter and Fairburn (1998) RCT Unguided self-help CBT unguided self-help 24 100% C-97%, Af-1.5%, Pre, post, 3m, 6m
As-1.5%a
Carter and Fairburn (1998) RCT Guided self-help CBT guided self-help 24b 100% C-97%, Af-1.5%, Pre, post, 3m, 6m
As-1.5%a
de Zwaan et al. (2017) RCT Internet-based guided self-help CBT guided self-help 84 89% NA Pre, post
Duarte, Pinto-Gouveia, and Stubbs (2017) RCT Compassionate-based guided Other guided self-help 17 100% C-100% Pre, post, 1m
self-help
Grilo and Masheb (2005) RCT CBT guided self-help CBT guided self-help 37b 87% C-87%, Af-5%, H-8% Pre, post
Grilo, White, Gueorguieva, Barnes, and RCT CBT self-help CBT unguided self-help 24 88% C-46%, Af-25%, Pre, post
Masheb (2013) H-8%
Kelly and Carter (2015) RCT Self-compassion training Other unguided self-help 15b 83%a C-76%a Pre, post
self-help
Kelly and Carter (2015) RCT CBT self-help CBT unguided self-help 13b 83%a C-76%a Pre, post
Latner and Wilson (2002) UCT Self-monitoring Other unguided self-help 18 100% C-90%, H-3%, Pre, post
As-7%a
Masson, von Ranson, Wallace, and RCT DBT guided self-help CBT guided self-help 30b 90% C-93% Pre, post, 6m
Safer (2013)
1359
(Continues)
1360
TABLE 2 (Continued)
Treatment
b a
Peterson et al. (1998, 2001) RCT CBT structured self-help CBT unguided self-help 15 100% C-97% Pre, post, 1m, 6m, 12m
Peterson et al. (1998, 2001) RCT CBT partial self-help CBT guided self-help 19b 100% C-97%a Pre, post
b
Peterson et al. (2009) RCT CBT self-help CBT unguided self-help 67 90% C-100% Pre, post, 6m, 12m
Peterson et al. (2009) RCT CBT therapist-assisted CBT guided self-help 63b 81% C-95% Pre, post, 6m, 12m
Robinson (2013) UCT Integrative response therapy Other guided self-help 16 88% C-88%, H-6%, As-6% Pre, post, 3m
Wilson et al. (2010) RCT CBT guided self-help CBT guided self-help 66b 82% C-82%, Af-11%, Pre, post, 12m, 24m
H-8%
Pharmacotherapy
Arnold et al. (2002) RCT Fluoxetine Second generation 30b 93% C-90%, Af-10% Pre, post
antidepressants
Brennan et al. (2008) UCT Memantine Other 16b 81% C-94%, H-6% Pre, post
Brownley, Von Holle, Hamer, La Via, and RCT Chromium high dose Other 8 75% C-100% Pre, post
Bulik (2013)
Brownley et al. (2013) RCT Chromium moderate dose Other 9 78% C-78% Pre, post
Calandra, Russo, and Luca (2012) NRCT Bupropion Second generation 15 73% NA Pre, post
antidepressants
Calandra et al. (2012) NRCT Sertraline Second generation 15 73% NA Pre, post
antidepressants
Farci et al. (2015) UCT Disulfiram Other 12b 92% NA Pre, post
b
Grilo, Masheb, and Wilson (2005); RCT Fluoxetine Second generation 27 70% C-100% Pre, post, 6m, 12m
Grilo, Crosby, Wilson, and antidepressants
Masheb (2012)
Guerdjikova et al. (2008) RCT Escitalopram Second generation 21b 100% C-73% Pre, post
antidepressants
Guerdjikova et al. (2009) RCT Lamotrigine Anticonvulsants 26b 84% C-84% Pre, post
Guerdjikova et al. (2012) RCT Duloxetine Second generation 20b 80% C-90% Pre, post
antidepressants
Guerdjikova et al. (2016) RCT Lisdexamfetamine Central nervous system 25b 96% C-76%, Af-24% Pre, post
stimulants
Hudson et al. (1998) RCT Fluvoxamine Second generation 42b 93% C-98% Pre, post
antidepressants
Leombruni et al. (2008) RCT Fluoxetine Second generation 20 100% NA Pre, post
antidepressants
Leombruni et al. (2008) RCT Sertraline Second generation 22 100% NA Pre, post
antidepressants
HILBERT ET AL.
TABLE 2 (Continued)
Treatment
HILBERT ET AL.
Malhotra, King, Welge, Brusman-Lovins, UCT Venlafaxine Second generation 35 100% NA Pre, post
and McElroy (2002) antidepressants
McElroy et al. (2000) RCT Sertraline Second generation 18b 89% NA Pre, post
antidepressants
McElroy, Arnold, et al. (2003) RCT Topiramate Anticonvulsants 30b 87%a NA Pre, post
b
McElroy, Hudson, et al. (2003) RCT Citalopram Second generation 19 95% C-79% Pre, post
antidepressants
McElroy, Kotwal, Hudson, Nelson, and UCT Zonisamide Anticonvulsants 15b 93% C-100% Pre, post
Keck (2004)
McElroy et al. (2006) RCT Zonisamide Anticonvulsants 30b 90% C-77% Pre, post
McElroy, Guerdjikova, et al. (2007) RCT Atomoxetine Central nervous system 20b 80% C-85% Pre, post
stimulants
McElroy, Hudson, et al. (2007) RCT Topiramate Anticonvulsants 195b 84% C-76%, Af-19% Pre, post
McElroy et al. (2011a) UCT Sodium Other 12b 100% C-58%, Af-42% Pre, post
b
McElroy et al. (2011b) RCT Acamprosate Other 20 80% C-90% Pre, post
McElroy et al. (2013) RCT ALKS-33 Other 32b 88% C-85% Pre, post
b
McElroy et al. (2015a) RCT Armodafinil Other 30 93% C-73%, Af-27% Pre, post
McElroy et al. (2015b) RCT Lisdexamfetamine Central nervous system 192b 86% C-78%, Af-17%, Pre, post
stimulants H-1%, As-2%
McElroy et al. (2015b) RCT Lisdexamfetamine Central nervous system 195b 88% C-72%, Af-24%, Pre, post
stimulants H-1%, As-2%
McElroy et al. (2015c) RCT Lisdexamfetamine 30 mg Central nervous system 66b 86% C-73%, Af-23%, Pre, post
stimulants As-2%
McElroy et al. (2015c) RCT Lisdexamfetamine 50 mg Central nervous system 65b 77% C-82%, Af-15% Pre, post
stimulants
McElroy et al. (2015c) RCT Lisdexamfetamine 70 mg Central nervous system 65b 85% C-75%, Af-19%, Pre, post
stimulants As-2%
Navia et al. (2017) RCT Dasotraline Other 159b 88% C-83%, Af-12%, Pre, post
As-3%
Pearlstein et al. (2003) RCT Fluvoxamine Second generation 9 85%a C-90%a Pre, post
antidepressants
Ricca et al. (2001) RCT Fluoxetine Second generation 21 57% NA Pre, post, 6m
antidepressants
Ricca et al. (2001) RCT Fluvoxamine Second generation 22 59% NA Pre, post, 6m
antidepressants
Shapira, Goldsmith, and McElroy (2000) UCT Topiramate Anticonvulsants 13 100% NA Pre, post
1361
(Continues)
1362
TABLE 2 (Continued)
Treatment
b
White and Grilo (2013) RCT Bupropion Second generation 31 100% C-87% Pre, post
antidepressants
Behavioral weight loss treatment
Agras et al. (1994) RCT Weight-loss treatment Diet, exercise, behavioral 37 100% NA Pre, post, 12m
strategies
Compare, Calugi, Marchesini, Molinari, NRCT Dietary counseling Diet 63b 41% NA Pre, post, 6m
and Dalle Grave (2013); Compare,
Calugi, Marchesini, Shonin,
Tasca (2016)
de Zwaan et al. (2005) RCT Very low calorie diet Diet, exercise, behavioral 35b 100% C-97% Pre, post, 1m, 6m, 12m
strategies
Grilo et al. (2011) RCT Behavioral weight loss treatment Diet, exercise, behavioral 45b 62% C-80%, Af-16%, Pre, post, 6m, 12m
strategies H-4%
Levine, Marcus, and Moulton (1996) RCT Exercise Exercise 44 100% C-89% Pre, post
Munsch et al. (2007); Munsch RCT Behavioral weight loss treatment Diet, exercise, behavioral 36b 86% NA Pre, post
et al. (2012) strategies
Nauta et al. (2000); Nauta et al. (2001) RCT Behavioral therapy Diet, exercise, behavioral 16b 100% NA Pre, post, 6m, 12m
strategies
Wadden et al. (2011, 2016); Chao NRCT Behavioral weight loss treatment Diet, exercise, behavioral 51b 80% C-37%, Af-53%, Pre, post, 12m, 24m
et al. (2016) strategies H-6%
Wilson et al. (2010) RCT Behavioral weight loss treatment Diet, exercise 64b 89% C-88%, Af-11%, Pre, post, 12m, 24m
H-2%
Self-help weight loss treatment
Barnes and Barber (2017) RCT Behavioral weight loss guided Behavioral WLT guided 8 NA NA Pre, post, 3m, 12m
self-help with motivational self-help
interviewing
Barnes and Barber (2017) RCT Behavioral weight loss guided Behavioral WLT guided 7 NA NA Pre, post, 3m, 12m
self-help with nutrition self-help
psychoeducation
Grilo and Masheb (2005) RCT Behavioral weight loss guided Behavioral WLT guided 38b 76% C-61%, Af-16%, Pre, post
self-help self-help H-18%
Pharmacological weight loss treatment
Appolinario et al. (2002) UCT Sibutramine Antiobesity medication 10b 100% C-80%, Af-20% Pre, post
b
Appolinario et al. (2003) RCT Sibutramine Antiobesity medication 30 87% C-73% Pre, post
HILBERT ET AL.
TABLE 2 (Continued)
Treatment
HILBERT ET AL.
b
Grilo et al. (2014) RCT Sibutramine Antiobesity medication 26 73% C-50%, Af-31%, Pre, post, 6m, 12m
H-15%
Milano et al. (2005) RCT Sibutramine Antiobesity medication 10 100% NA Pre, post
Stunkard, Berkowitz, Tanrikut, Reiss, and RCT d-Fenfluramine Antiobesity medication 14 100% NA Pre, post, 1m, 4m
Young (1996)
Wilfley et al. (2008) RCT Sibutramine Antiobesity medication 152b 90% C-80% Pre, post
Surgical weight loss treatment
Adami et al. (1995), Adami, Gandolfo, UCT Biliopancreatic diversion Bariatric surgery 30 70% NA Pre, post, 24m, 36m
Meneghelli, and Scopinaro (1996);
Adami, Bressani, and Marini (1998)
Çelik Erden et al. (2016) UCT Laparoscopic sleeve gastrectomy Bariatric surgery 18 61% NA Pre, post
a
Colles, Dixon, and O'Brien (2008) UCT Laparoscopic adjustable gastric Bariatric surgery 18 80% NA Pre, post
banding
Wadden et al. (2011, 2016); Chao NRCT Roux-en-Y gastric bypass or Bariatric surgery 51b 73% C-76%, Af-21% Pre, post, 12m, 24m
et al. (2016) adjustable gastric banding
Combined treatment
Adriaens, Pieters, Vancampfort, Probst, UCT CBT + sport CBT + WLT 23 83% NA Pre, post
and Vanderlinden (2008)
Agras et al. (1994) RCT CBT + weight-loss treatment CBT + WLT 36 100% NA Pre, post, 12m
Agras et al. (1994) RCT CBT + weight-loss treatment CBT + WLT + medication 36 100% NA Pre, post, 12m
+ desipramine
Brambilla et al. (2009) RCT Diet + CBT + sertraline CBT + WLT + medication 10 100% NA Pre, post
+ topiramate
Brambilla et al. (2009) RCT Diet + CBT + sertraline CBT + WLT + medication 10 100% Pre, post
Cassin, von Ranson, Heng, Brar, and RCT Self-help + adapted motivation CBT unguided self-help 54 100% C-89%a Pre, post
Wojtowicz (2008) interviewing + motivational
interview
Compare, Calugi, Marchesini, Molinari, NRCT Dietary counseling + emotion Psychotherapy + WLT 63b NA NA Pre, post, 6m
and Dalle Grave (2013); Compare, focused therapy
Calugi, Marchesini, Shonin,
Tasca (2016)
Devlin, Goldfein, Carino, and Wolk (2000) UCT CBT + phentermine/fluoxetine CBT + medication 14 100% C-63% Pre, post
Devlin et al. (2005) RCT Behavioral weight control WLT + CBT + medication 28b 78%a C-77%, Af-12%, Pre, post
+ CBT + fluoxetine H-10%a
Devlin et al. (2005) RCT Behavioral weight control + WLT + CBT + placebo 25b 78%a C-77%, Af-12%, Pre, post
CBT + placebo H-10%a
1363
(Continues)
TABLE 2 (Continued)
1364
Treatment
Devlin et al. (2005) RCT Behavioral weight control WLT + medication 32b 78%a C-77%, Af-12%, Pre, post
+ fluoxetine H-10%a
Devlin et al. (2005) RCT Behavioral weight control WLT + placebo 31b 78%a C-77%, Af-12%, Pre, post
+ placebo H-10%a
de Zwaan et al. (2005) RCT CBT + very low calorie diet CBT + WLT 36b 100% C-97% Pre, post, 1m, 6m, 12m
Friederich et al. (2007) UCT Multimodal treatment program CBT + WLT 39b 77% NA Pre, 3m
Golay et al. (2005) RCT Hypocaloric diet + orlistat WLT + medication 44b 91% C-97%a Pre, post
b
Grilo, Masheb, and Wilson (2005); Grilo RCT CBT + fluoxetine CBT + medication 26 77% C-89%, Af-8%, H-4% Pre, post, 6m, 12m
et al. (2012)
Grilo, Masheb, and Wilson (2005); Grilo RCT CBT + placebo CBT + placebo 28b 79% C-93%, Af-7% Pre, post, 6m, 12m
et al. (2012)
Grilo, Masheb, and Salant (2005) RCT CBT guided self-help + orlistat CBT guided self-help 25b 84% C-88%, Af-4%, H-8% Pre, post, 3m
+ medication
Grilo et al. (2011) RCT CBT + behavioral weight loss CBT + WLT 35 80% C-74%, Af-23%, Pre, post, 6m, 12m
treatment As-3%
Grilo and White (2013) RCT Orlistat + behavioral weight loss WLT + medication 20 85% H-100% Pre, post, 6m
Grilo et al. (2014) RCT CBT unguided self-help CBT unguided self-help 26b 62% C-39%, Af-39%, Pre, post, 6m, 12m
+ sibutramine + medication H-15%
Grilo et al. (2014) RCT CBT unguided self-help CBT unguided self-help 25b 80% C-48%, Af-24%, Pre, post, 6m, 12m
+ placebo + placebo H-16%
Le Grange et al. (2002) RCT CBT + ecological momentary CBT + other 19b 100% NA Pre, post, 12m
assessment
Masheb, Grilo, and Rolls (2011) RCT CBT + low energy-diet CBT + WLT 25b 80% C-72%, Af-24%, Pre, post, 6m, 12m
H-4%
Masheb et al. (2011) RCT CBT + general nutrition CBT + WLT 25b 72% C-88%, Af-12% Pre, post, 6m, 12m
counseling
Molinari, Baruffi, Croci, Marchi, and RCT CBT + diet CBT + WLT 22 100% NA Pre, post
Petroni (2005)
Molinari et al. (2005) RCT Diet + fluoxetine WLT + medication 22 100% NA Pre, post
Molinari et al. (2005) RCT CBT + diet + fluoxetine CBT + WLT + medication 21 100% NA Pre, post
Pataky et al. (2013) RCT Rimonabant + diet WLT + medication 143b 90% C-90%, Af-5%, As-1% Pre, post
Pendleton et al. (2002) RCT CBT + exercise CBT + WLT 28 100% NA Pre, post, 6m, 12m
Pendleton et al. (2002) RCT CBT + exercise maintenance CBT + WLT 29 100% NA Pre, post, 6m
Ricca et al. (2001) RCT CBT + fluoxetine CBT + medication 22 59% NA Pre, post, 6m
Ricca et al. (2001) RCT CBT + fluvoxamine CBT + medication 23 57% NA Pre, post, 6m
Ricca et al. (2009) RCT CBT + zonisamide CBT + medication 28b 82% NA Pre, post, 12m
HILBERT ET AL.
TABLE 2 (Continued)
Treatment
HILBERT ET AL.
Inpatient treatment
Calugi et al. (2016) UCT Inpatient multimodal treatment Multimodal inpatient 54b 100% NA Pre, 6m, 60m
WLT
Cesa et al. (2013) RCT Inpatient multimodal treatment Multimodal inpatient 30b 100% NA Pre, post, 12m
+ CBT BED treatment
including CBT
Cesa et al. (2013) RCT Inpatient multimodal treatment Multimodal inpatient 31a 100% NA Pre, post, 12m
+ virtual reality-enhanced CBT BED treatment
including virtual
reality-enhanced CBT
Cesa et al. (2013) RCT Inpatient multimodal treatment Multimodal inpatient 29b 100% NA Pre, post, 12m
WLT
Fichter, Quadflieg, and UCT Inpatient behavioral treatment Multimodal inpatient 68 100% NA Pre, post, 38m, 79m
Gnutzmann (1998); Fichter, Quadflieg, BED treatment + WLT
and Hedlund (2008)
Riva, Bacchetta, Cesa, Conti, and RCT Inpatient weight loss treatment Multimodal inpatient 9 100% NA Pre, post, 6m
Molinari (2003) WLT
Riva et al. (2003) RCT Inpatient weight loss treatment Multimodal inpatient 9 100% NA Pre, post, 38m, 78m, 146m
+ experiential cognitive BED treatment + WLT
therapy
Riva et al. (2003) RCT Inpatient weight loss treatment Multimodal inpatient 9 100% NA Pre, post, 6m
+ CBT BED treatment + WLT
Abbreviations: 3m, 3-month follow-up, and so forth; Af, African American; As, Asian; C, Caucasian; CBT, cognitive-behavioral therapy; DBT, dialectical behavior therapy; H, Hispanic; N, number of patients in
treatment condition; NA, not applicable; NRCT, nonrandomized controlled trial; post, posttreatment; pre, pretreatment; RCT, randomized-controlled trial; UCT, uncontrolled trial; WLT, behavioral weight loss
treatment.
a
Data refer to total sample.
b
Intent-to-treat data.
c
The study design by Schlup et al. (2009) was corrected from RCT to UCT because treatment group and waiting list were reported in combination only (Fischer et al., 2014).
1365
1366 HILBERT ET AL.
TABLE 3 Study characteristics: Active conditions with sample size per treatment category (k/n) in randomized-controlled (RCT),
nonrandomized-controlled (NRCT), and uncontrolled (UCT) study designs
Study design
Total RCT NRCT UCT

Psychotherapy 58/2,191 43/1,535 3/74 12/582
Cognitive-behavioral therapy 46/1,677 36/1,218 0/0 10/459
Interpersonal psychotherapy 2/156 2/156 0/0 0/0
Psychodynamic therapy 3/156 1/48 1/6 1/102
Humanistic therapy 1/51 1/51 0/0 0/0
Other psychotherapy 6/151 3/62 2/68 1/21
Self-help treatment 17/554 14/498 0/0 3/56
Guided self-help treatment 10/378 8/340 0/0 2/38
Cognitive-behavioral guided self-help treatment 8/345 7/323 0/0 1/22
Other guided self-help treatment 2/33 1/17 0/0 1/16
Unguided self-help treatment 7/176 6/158 0/0 1/18
Cognitive-behavioral unguided self-help treatment 5/143 5/143 0/0 0/0
Other unguided self-help treatment 2/33 1/15 0/0 1/18
Pharmacotherapy 38/1,602 30/1,469 2/30 6/103
Second generation antidepressants 17/393 14/328 2/30 1/35
Central nervous system stimulants 7/628 7/628 0/0 0/0
Anticonvulsants 5/283 3/255 0/0 2/28
Other pharmacotherapy 9/298 6/258 0/0 3/40
Behavioral weight loss treatment 9/391 7/277 2/114 0/0
Diet 1/63 0/0 1/63 0/0
Exercise 1/44 1/44 0/0 0/0
Diet, exercise 1/64 1/64 0/0 0/0
Diet, exercise, behavioral strategies 6/220 5/169 1/51 0/0
Self-help weight loss treatment 3/53 3/53 0/0 0/0
Pharmacological weight loss treatment 6/242 5/232 0/0 1/10
Surgical weight loss treatment 4/117 0/0 1/51 3/66
Combined treatment 34/1,073 30/934 1/63 3/76
Cognitive-behavioral therapy + pharmacological interventions 7/166 6/150 0/0 1/14
Cognitive-behavioral therapy + behavioral weight loss treatment 10/298 8/236 0/0 2/62
Cognitive-behavioral therapy + behavioral weight loss treatment 5/105 5/105 0/0 0/0
+ pharmacological interventions
Behavioral weight loss treatment + pharmacological interventions 4/118 4/118 0/0 0/0
Other combined treatment 8/388 7/225 1/63 0/0
Inpatient treatment 8/239 6/117 0/0 2/122
Multimodal inpatient binge-eating disorder and weight loss 5/147 4/79 0/0 1/68
treatment
Multimodal inpatient weight loss treatment 3/92 2/38 0/0 1/54
3 | RESULTS Systematic Review and Meta-analysis Protocols (PRISMA-P) Flow

diagram (Moher et al., 2015). The full list of the 114 included studies
3.1 | Inclusion and study and sample is presented in Table 2. Of the 234 conditions (study arms) in these
characteristics studies, 177 were active treatment conditions. Overall, 138 of the
active conditions came from RCTs, while 9 and 30 of the active condi-
The literature search yielded 22,847 records; 11,363 records tions came from NRCTs and UCTs, respectively. A total of 109 studies
remained after removal of duplicates, and 579 full texts after title and were published as original articles, 2 studies had abstract or poster
abstract screening (Hilbert et al., 2019). After assessing these full texts publications, and 3 were unpublished at the time of data extraction.
for eligibility, 114 studies were included in the present study, as As displayed in Table 3, treatment categories included psychotherapy;
depicted in Figure 1, including the Preferred Reporting Items for structured self-help treatment; pharmacotherapy; behavioral,
HILBERT ET AL.
TABLE 4 Sample characteristics
Weight loss treatment

Combined Inpatient
Psychotherapy Self-help treatment Pharmacotherapy Behavioral Self-help Pharmacological Surgical treatment treatment
Sex, % female 90% (47/2,048) 90% (14/607) 85% (36/2,774) 82% (9/424) 76% (1/38) 89% (6/475) 57% (3/99) 89% (29/1,184) 94% (8/239)
Age, years 43.2 ± 10.9 44.9 ± 10.6 (13/592) 40.3 ± 10.4 42.7 ± 9.5 (7/345) 46.0 ± 9.2 (1/38) 41.0 ± 10.0 44.1 ± 11.5 (3/87) 42.0 ± 15.0 32.7 ± 9.8
(46/2,088) (36/2,815) (4/427) (28/1,152) (6/221)
Race, %
Caucasian 89% (17/905) 82% (9/496) 78% (26/2,565) 77% (5/272) 61% (1/38) 74% (4/427) 49% (1/51) 88% (13/647) —
African American 4% (13/708) 10% (7/282) 17% (13/1,997) 25% (3/160) 16% (1/38) 35% (2/63) 14% (1/51) 13% (12/611) —
Hispanic 4% (13/708) 13% (6/264) 1% (8/980) 4% (3/160) 18% (1/38) 11% (1/53) — 20% (11/322) —
Asian 1% (13/708) 1% (5/216) 2% (11/1,543) 0% (2/109) — — — 1% (8/518) —
Body weight, kg 101.9 ± 21.1 95.9 ± 14.7 (2/82) 101.4 ± 20.8 100.9 ± 16.3 — 101.2 ± 18.7 137.2 ± 27.9 104.5 ± 16.7 102.8 ± 19.9
(19/788) (30/2,526) (7/337) (4/445) (2/48) (16/735) (8/239)
Body mass index, 36.9 ± 7.4 35.7 ± 6.4 (15/588) 36.3 ± 6.4 37.0 ± 4.5 (8/408) 36.0 ± 6.6 (1/38) 36.4 ± 5.7 (2/357) 49.8 ± 11.2 (2/48) 37.3 ± 6.0 38.3 ± 6.9
kg/m2 (39/1,757) (36/2,823) (27/748) (5/212)
Binge-eating 15.2 ± 10.0 19.6 ± 13.3 (13/541) 22.7 ± 12.7 19.5 ± 14.0 13.0 ± 10.8 (3/61) 14.7 ± 9.9 (4/395) — 18.2 ± 13.9 —
episodes, n (31/1,062) (35/2,810) (4/193) (21/837)
Binge-eating days, 14.7 ± 7.0 16.0 ± 7.2 (5/365) 17.8 ± 5.2 15.6 ± 6.8 (3/116) 11.3 ± 7.2 (2/23) 13.0 ± 5.0 (4/394) — 15.0 ± 7.6 (4/215) —
n (18/1,036) (22/2,362)
Duration of BED, 15.6 ± 10.7 — 18.1 ± 10.8 — — — — 7.3 ± 10.8 (7/490) 11.6 ± 8.4
years (16/604) (10/636) (1/68)
Treatment sessions, 15.1 ± 5.6 10.7 ± 5.0 (11/541) — 21.0 ± 7.4 (8/347) 5.3 ± 0.6 (3/61) — — 21.9 ± 9.0 14.3 ± 5.2
n (57/2,463) (27/763) (6/142)
Duration of 16.7 ± 7.7 11.8 ± 6.6 (17/732) 14.3 ± 5.9 26.1 ± 11.5 12.0 ± 0.0 (3/61) 14.0 ± 5.5 (6/475) — 25.6 ± 11.7 6.2 ± 2.2
treatments, (57/2,463) (37/2,842) (9/424) (33/1,324) (8/239)
weeks
Note: Displayed are M ± SD and (k, number of study arms/n, number of participants).
Abbreviation: BED, binge-eating disorder.
1367
1368 HILBERT ET AL.
F I G U R E 2 Pretreatment to
posttreatment or follow-up change per
treatment category. Displayed are
standardized mean differences,
calculated from pretreatment values
minus posttreatment or follow-up
values, or proportions, and 95%
confidence intervals. Circles indicate
posttreatment, and squares indicate
3–6 months, rhombs indicate
6–12 months, and triangles indicate
more than 12 months of follow-up.
Black dots indicate significance
(p < .05), white dots indicate
nonsignificance (p ≥ .05), and gray dots
indicate absence of significance testing
for proportions
self-help, pharmacological, and surgical WLT; combined treatment, following treatment, despite a nonsignificant BMI effect at
mostly consisting of CBT, behavioral WLT, and pharmacological inter- 3–6 months. Abstinence rates ranged between 46 and 52% over time
ventions; and inpatient treatment. A total of N = 8,862 individuals and weight loss between 1.9 and 6.1 kg.
with BED were contained in the included studies. Of these, 5,115
were treated in active conditions in RCTs, 332 in NRCTs, and 1,015 in
UCTs. Patients under the age of 18 years were included in one study. 3.2.2 | Structured self-help treatment
Baseline sample characteristics are displayed in Table 4.
For structured self-help treatment, reductions in binge-eating epi-
sodes, eating disorder psychopathology, and depression were signifi-
3.2 | Pretreatment to follow-up change cant from posttreatment through 12 months following treatment,
while BMI was not significantly changed. Abstinence rates ranged
For within-group analyses from pretreatment to follow-up, data between 45 and 53%.
were available from 42 RCTs, NRCTs, and UCTs, with 84 active
study arms for pretreatment versus posttreatment and 3–6 months
or 6–12 months following treatment (cf. Table 2). A few data were 3.2.3 | Combined treatment
available for follow-up intervals longer than 12 months following
treatment, and long-term follow-up data were unavailable for phar- For combined treatment, significant posttreatment reductions in
macological and surgical WLT. The results on pretreatment to binge-eating episodes, eating disorder psychopathology, depression,
follow-up change are summarized in Figure 2 (see also Supporting and BMI were maintained through 12 months following treatment,
Information Table S1). although BMI effects were nonsignificant at 3–6 months. Abstinence
ranged from 36 to 48% up to 12 months following treatment and
weight loss from 5.7 to 6.3 kg.
3.2.1 | Psychotherapy
Psychotherapy showed maintenance of significant posttreatment 3.2.4 | Pharmacotherapy

reductions in binge-eating episodes and depression up to 12 months
following treatment, and maintenance of significant reductions in eat- For pharmacotherapy, only studies using second generation antide-
ing disorder psychopathology and BMI through more than 12 months pressants were available for evaluating long-term effectiveness.
HILBERT ET AL. 1369
Herein, reductions in binge-eating episodes and BMI were significant posttreatment effects on the primary outcomes were not significantly
at posttreatment, but not at 6–12 months following treatment. moderated by risk of bias (low vs. unclear, high) and study design
(RCT vs. NRCT, UCT; Supporting Information Table S4).
3.2.5 | Behavioral WLT

4 | DI SCU SSION
Behavioral WLT showed maintenance of significant posttreatment
reductions in binge-eating episodes 6–12 months following treat- The present meta-analysis uniquely examined the long-term effective-
ment; maintenance of significant posttreatment reductions in eating ness in diverse psychological and medical treatments of BED, using
disorder psychopathology and depression up to 12 months following studies with an RCT, NRCT, or UCT design. Extending the RCT-based
treatment; and maintenance of significant posttreatment reductions results of a current comprehensive meta-analysis (Hilbert et al., 2019),
in BMI more than 12 months following treatment, with a weight loss this meta-analysis newly demonstrated the medium-term effective-
ranging from 3.2 to 7.2 kg. Abstinence ranged from 30 to 62% for ness in psychotherapy, self-help treatment, and combined treatment
longer than 12 months after treatment. on a range of binge-eating-related and associated outcomes in
patients with BED up to 12 months following treatment. The majority
of significant pretreatment to posttreatment changes—the scope of
3.2.6 | Self-help WLT which is generally consistent with the results reported by Vocks
et al. (2010)—remained significant through 12 months following treat-
For self-help WLT, significant reductions in binge-eating episodes ment, although in many cases the magnitude of effects tended to
from posttreatment through 12 months following treatment were decrease. Long-term follow-up intervals greater than 12 months were
found, but data on further outcomes were unavailable. rarely reported and mostly supported the long-term effectiveness of
psychotherapy. Few studies provided follow-up data on pharmaco-
therapy, behavioral and self-help WLT, and inpatient treatment,
3.2.7 | Inpatient treatment and follow-up data were unavailable for pharmacological and
surgical WLT.
For inpatient treatment, the 95% abstinence rate at posttreatment
was decreased to 44% at 3–6 months following treatment, and signifi-
cant posttreatment reductions in BMI were maintained at 4.1 | Long-term effectiveness by treatment
6–12 months, corresponding to a weight loss of 5.6–6.3 kg, but BMI category
reduction was nonsignificant at longer than 12 months of follow-up.
Psychotherapy, especially if based on CBT as the most frequently
used approach, showed not only significant long-term improvements
3.3 | Sensitivity analyses in binge-eating symptomatology and associated psychopathology, but
also significant reductions in BMI at posttreatment and longer than
Sensitivity analyses mostly confirmed these findings for the most 6 and 12 months following treatment. While confirming these results,
common treatments—CBT and CBT self-help treatment—in RCTs sensitivity analyses for CBT in RCTs did not show any significant post-
extending up to 12 months following treatment (cf. Supporting treatment or follow-up effect on BMI, likely related to the lower num-
Information Table S2). For CBT, effects on BMI were nonsignificant, ber of studies available for these analyses. Of note, the posttreatment
based on a lower number of studies than in the main analysis. For BMI loss was nonsignificant when meta-analytically compared with
lisdexamfetamine, only posttreatment RCT data were available. inactive control groups (Ghaderi et al., 2018; Hilbert et al., 2019).
As for psychotherapy, posttreatment effects of self-help
treatment—especially if based on CBT principles—on primary and sec-
3.4 | Study quality and moderation ondary psychopathological outcomes were maintained at a significant
level up to 12 months following treatment, while effects on BMI
The methodological quality was heterogeneous (cf. Supporting remained nonsignificant throughout. In contrast, psychotherapy had
Information Table S3). According to the EPOC criteria, only 4 (4%) out yielded some significant reduction of BMI across follow-ups, although
of the 109 published studies were assigned an overall low risk of bias. in RCTs the efficacy of self-help treatment and psychotherapy had
Most studies were assigned an unclear 31 (28%) or high (74, 68%) risk not been found to be significantly different across 12 months follow-
of bias. Within treatment categories, self-help treatment and pharma- ing treatment (Hilbert et al., 2019).
cological interventions were associated with the greatest number of Regarding treatments offering a combination of interventions,
low risk of bias ratings, while surgical WLT and inpatient treatment this meta-analysis documented medium-term maintenance of post-
had the greatest number of high risk of bias ratings (cf. Supporting treatment gains similar to psychotherapy and self-help treatment in
Information Figure S1). Meta-regression analyses showed that the the primary and secondary outcomes over 12 months following
1370 HILBERT ET AL.
treatment, except a nonsignificant BMI loss at 3-6 months. It needs to By including NRCTs and UCTs with generally higher risk of bias in
be noted that combined treatment was not found to produce signifi- addition to RCTs, we attempted to get closer to measuring effective-
cantly greater posttreatment effects on binge-eating episodes and ness under “real world,” less controlled conditions, although such trials
abstinence than inactive control groups (Hilbert et al., 2019). represented a small fraction of the sample. Indeed, study quality was
For pharmacotherapy, the significant posttreatment reductions heterogeneous, with only 32% of studies presenting a low or unclear
of binge-eating episodes and BMI were no longer significant at risk of bias according to the EPOC (2015) criteria. A meta-regression
6–12 months in the few studies providing data, suggesting a ten- analysis did not confirm study design and risk of bias as moderators of
dency to relapse after withdrawal of the pharmacological agent posttreatment effects on the primary outcomes, suggesting that
(Reas & Grilo, 2015). Accordingly, a need for long-term follow-up NRCTs and UCTs, or studies with a high or unclear risk of bias did not
data after pharmacotherapy for BED has been stated (Amodeo lead to an overestimation of effects when compared with RCTs or
et al., 2019; Brownley et al., 2016; Ghaderi et al., 2018; Reas & studies with a low risk of bias. The latter results are consistent with
Grilo, 2015). similar CBT-related abstinence from binge eating in meta-analyses on
For behavioral WLT, a few studies featured a potentially favor- a few nonrandomized studies (Linardon, Messer, & Fuller-
able long-term sustainability of posttreatment improvements in binge Tyszkiewicz, 2018) and RCTs (Linardon, 2018) and lend additional
eating, psychopathology, and BMI. Notably, however, the effect on support to the robustness of the results. Nevertheless, with an
BMI loss at posttreatment was reduced by about 80% at follow-ups increased necessity of dissemination and implementation of evidence-
longer than 12 months, underscoring a substantial tendency of weight based treatments as well as effectiveness evaluations in routine
regain (Diabetes Prevention Program Research Group, 2015). These care settings (Kazdin, Fitzsimmons-Craft, & Wilfley, 2017), considering
results highlight the necessity of weight loss maintenance interven- pertinent sources of risk (e.g., blinding of assessors, confounding
tions in behavioral WLT, including interventions targeting binge eating variables) at the time of study planning is recommended.
(da Luz, Hay, Touyz, & Sainsbury, 2018; Pacanowski, Senso, Oriogun, A further limitation is that the search period for this guidelines-
Crain, & Sherwood, 2014). related project ended in February 2018 (cf. Hilbert et al., 2019). A
For self-help WLT, a few studies suggested favorable medium- PubMED search revealed that between March 2018 (after the end of
term maintenance of the reduction in binge-eating episodes up to the search period for this meta-analysis project) and December
12 months following treatment; however, further long-term outcomes 15, 2019 treatment studies on BED were published meeting the inclu-
were unavailable. sion and exclusion criteria for this meta-analysis; however, only three
Inpatient treatment, an intensive form of combined treatment studies provided long-term follow-up data ranging from 1 to 12 years
with a focus on weight loss or on BED and weight loss induced signifi- after surgical WLT (n = 2) and psychotherapy (n = 1), and two studies
cant reductions in BMI in a few studies that remained significant reported data on medium-term effectiveness of psychotherapy
through 12 months following treatment, but not beyond, suggestive (6 months of follow-up). The results of this study are therefore
of weight regain as described for behavioral WLT. unlikely to be substantially modified by these nonincluded studies.
Regarding generalization, although we used all available data at
each time point, caution is required, especially when interpreting
4.2 | Methodological considerations follow-up results derived from only a few data. Finally, most included
studies had sampling biases, including an overrepresentation of female
This meta-analysis includes a comprehensive evaluation of long-term and Caucasian patients, and applied restrictions in age or BMI. Overall
effectiveness in psychological and medical treatments for BED regard- reporting of sample characteristics was heterogeneous, for example,
ing a range of clinically relevant primary and secondary outcomes, on race and socioeconomic status. Future clinical studies of BED
ensuring a high generalizability to clinical practice. Standard guidelines should more comprehensively report sample characteristics and spe-
for conducting and reporting meta-analyses were followed (Hilbert cifically target or not exclude underrepresented groups for health
et al., 2019; Hilbert, Petroff, et al., 2017), including the PRISMA-P equity reasons.
guidelines (Moher et al., 2015). Search, screening, and manual-based
data extraction were independently performed by two scientists. In
order to limit publication bias, unpublished studies were retrieved. 5 | CONC LU SION
Because of the multiple biases inherent to within-group effect sizes,
we focused on the significance of long-term effects in relation to the This meta-analysis, informing the renewal of the German evidence-
significance of posttreatment effects rather than on the magnitude of based clinical guideline for BED (Arbeitsgemeinschaft der
effects that is best ascertained in between-group comparisons in Wissenschaftlichen Medizinischen Fachgesellschaften, 2019), under-
RCTs. The results on medium-term effectiveness were confirmed lined the medium-term effectiveness for binge-eating outcome in psy-
in sensitivity analyses with RCTs on the most common treatments— chotherapy and structured self-help treatment, especially if using a
CBT and CBT self-help treatment—which are comparable to CBT approach, and combined treatment. Regarding BMI reduction,
Linardon's (2018) longitudinal meta-analytic results on abstinence some medium-term effectiveness was found for psychotherapy and
from binge eating in RCTs. combined treatment. Evidence beyond the first year after the end of
HILBERT ET AL. 1371
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org/10.1002/oby.21391 23297

Intl J Eating Disorders - 2020 - Hilbert - Meta Analysis On The Long Term Effectiveness of Psychological and Medical Treatment of BED

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Intl J Eating Disorders - 2020 - Hilbert - Meta Analysis On The Long Term Effectiveness of Psychological and Medical Treatment of BED

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Received: 15 October 2019 Revised: 17 March 2020 Accepted: 19 March 2020

SYNTHESIS AND REVIEW

Meta-analysis on the long-term effectiveness of psychological

Anja Hilbert PhD1 | David Petroff PhD2 | Stephan Herpertz MD2 |

Int J Eat Disord. 2020;53:1353–1376. wileyonlinelibrary.com/journal/eat 1353

Discussion: This comprehensive meta-analysis demonstrated the medium-term

binge-eating disorder, clinical trials, meta-analysis, nonrandomized-controlled trials, randomized-

1 | I N T RO DU CT I O N With a lifetime prevalence rate of 0.9%, BED is the most prevalent

Records identified through database Additional records identified

Records after duplicates removed

Records screened Records excluded

Full-text articles assessed Full-text articles excluded

quantitative synthesis medical treatments for binge-eating

Total RCT NRCT UCT

3 | RESULTS Systematic Review and Meta-analysis Protocols (PRISMA-P) Flow

TABLE 4 Sample characteristics

Weight loss treatment

Psychotherapy showed maintenance of significant posttreatment 3.2.4 | Pharmacotherapy

3.2.5 | Behavioral WLT

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