title: A randomized secondary treatment study of women with bulimia nervosa who fail to respond to CBT.
abstract: OBJECTIVE
  Since the description of bulimia nervosa as a distinct diagnostic entity in 1979, several psychological and pharmacological interventions have been developed and empirically tested. The existence of several effective treatments, none of which is completely effective, is common to most psychiatric conditions. The research question that flows from such findings is whether second-level treatments would be effective for those who fail initial treatment.
  
  
  METHODS
  In the case of bulimia nervosa, the research findings suggest that cognitive behavioral therapy (CBT) is the first level of treatment and that both antidepressant medication and interpersonal psychotherapy (IPT) may potentially be effective second-level treatments. This was a multicenter study in which 194 patients were initially treated with CBT. Those treated unsuccessfully (n = 62) were then randomized to treatment with IPT or medication management.
  
  
  RESULTS
  Of those assigned to secondary treatment, 37 completed such treatment and 25 dropped out or were withdrawn. The abstinence rate for subjects assigned to treatment with IPT was 16% and for those assigned to medication management was 10%. No significant differences were found between medication and IPT in either the intent-to-treat or completer analysis.
  
  
  CONCLUSIONS
  Dropout rates were high, and response rates were low among BN patients assigned to secondary treatments who failed to achieve remission with CBT. Offering lengthy sequential treatments appears to have little value, and alternative models for therapy need to be tested.
authors.affiliation: Neuropsychiatric Research Institute and the Department of Neurosciences, University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota, USA. mitchell@mail.med.und.nodak.edu
authors.forename: James E
authors.initials: JE
authors.lastname: Mitchell
authors.forename: Katherine
authors.initials: K
authors.lastname: Halmi
authors.forename: G Terence
authors.initials: GT
authors.lastname: Wilson
authors.forename: W Stewart
authors.initials: WS
authors.lastname: Agras
authors.forename: Helena
authors.initials: H
authors.lastname: Kraemer
authors.forename: Scott
authors.initials: S
authors.lastname: Crow
mesh_terms: D000328:Adult; D002032:Bulimia / Q000628:therapy*; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D005260:Female; D006801:Humans; D017211:Treatment Failure