Q Can a perineoplasty be performed in the office as a minor procedure or does this require an operating room? Is there some way to bill for a simple repair in the office?

A CPT code 56810 (perineoplasty, repair of perineum, nonobstetric [separate procedure]) was valued under the Resource-Based Relative Value Scale as an inpatient procedure, and there are no practice expense relative value units added if the procedure is done in the office. That does not mean that a private payer will not pay for it in an office setting, but you would not be paid for the added expense of performing it in the office setting. Also keep in mind that the perineoplasty code, which has a 10-day global period, was valued based on hospital admission and subsequent hospital care as well, so if the payer denies it in the office setting it will be because you are not providing these services.

If a repair only is documented, your other possibility is to use codes 12001–12004 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less up to 12.5 cm). These codes do have a practice expense differential when the procedure is carried out in the office. Like the perineoplasty code, this code series has a 10-day global period.

Q Can a perineoplasty be performed in the office as a minor procedure or does this require an operating room? Is there some way to bill for a simple repair in the office?

A CPT code 56810 (perineoplasty, repair of perineum, nonobstetric [separate procedure]) was valued under the Resource-Based Relative Value Scale as an inpatient procedure, and there are no practice expense relative value units added if the procedure is done in the office. That does not mean that a private payer will not pay for it in an office setting, but you would not be paid for the added expense of performing it in the office setting. Also keep in mind that the perineoplasty code, which has a 10-day global period, was valued based on hospital admission and subsequent hospital care as well, so if the payer denies it in the office setting it will be because you are not providing these services.

If a repair only is documented, your other possibility is to use codes 12001–12004 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less up to 12.5 cm). These codes do have a practice expense differential when the procedure is carried out in the office. Like the perineoplasty code, this code series has a 10-day global period.

Q Can a perineoplasty be performed in the office as a minor procedure or does this require an operating room? Is there some way to bill for a simple repair in the office?

A CPT code 56810 (perineoplasty, repair of perineum, nonobstetric [separate procedure]) was valued under the Resource-Based Relative Value Scale as an inpatient procedure, and there are no practice expense relative value units added if the procedure is done in the office. That does not mean that a private payer will not pay for it in an office setting, but you would not be paid for the added expense of performing it in the office setting. Also keep in mind that the perineoplasty code, which has a 10-day global period, was valued based on hospital admission and subsequent hospital care as well, so if the payer denies it in the office setting it will be because you are not providing these services.

If a repair only is documented, your other possibility is to use codes 12001–12004 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less up to 12.5 cm). These codes do have a practice expense differential when the procedure is carried out in the office. Like the perineoplasty code, this code series has a 10-day global period.

Man attempts suicide after telephone consultations

Kitsap County (WA) Superior Court

A 38-year-old man was hospitalized after a suicide attempt. He was diagnosed as having bipolar affective disorder and treated with lithium and olanzapine. Over the next 3 months a psychiatrist treated him, discontinued olanzapine and lithium, and started valproic acid.

Four months after the suicide attempt, the patient’s wife called the psychiatrist. The patient claims his wife told the psychiatrist he was having paranoid delusions similar to those he had experienced before the suicide attempt. The psychiatrist says the wife reported only that the patient was confused. The psychiatrist told her that her husband should resume taking olanzapine and report the results in 1 to 2 days.

Two days later, the psychiatrist received a voice mail from the patient’s wife, who reported that her husband had improved. The psychiatrist testified that he returned the call and was told that the patient was doing well. The patient denied that this call was made.

The next day, the patient concealed a knife in his briefcase, drove to a wooded area, and stabbed himself three times, lacerating his heart, lung, and diaphragm. He underwent surgery and survived.

In court, the patient argued that if the psychiatrist had evaluated him in person instead of over the telephone, the psychiatrist would have recommended hospitalization. He also alleged that the psychiatrist did not obtain informed consent before stopping olanzapine.

The psychiatrist argued that the patient gave informed consent to withdraw olanzapine and that the second suicide attempt was sudden, unpredictable, and impulsive.

• The jury decided for the defense.
  

Called-in prescription fails to prevent suicide

Unknown Massachusetts venue

A woman with a history of depression, anxiety, and difficulty following prescriptions attempted suicide and was hospitalized after she and her husband separated.

After discharge and under the care of a psychiatrist, the patient became dependent on lorazepam. When she tried to renew her lorazepam prescription but could not reach the psychiatrist, she called the pharmacy and attempted to impersonate the psychiatrist. The pharmacy did not fill the prescription and notified the psychiatrist.

The psychiatrist called the patient that evening and spoke with the patient and her minister, who was with her. The psychiatrist informed the minister that the medication would be delivered to the house if the minister paid for it, administered it to the patient, and saw her to bed. The minister agreed and followed the psychiatrist’s instructions when the medication arrived.

Later that night, the woman broke into the minister’s church and was apprehended by police. She was released after the minister assured police that the break-in was not a criminal matter.

At home, the patient called the psychiatrist again and left a voice mail. Phone records indicate that she stayed on the line for 5 minutes. The psychiatrist reported that he did not receive the message until the next day. By that time, the patient had hanged herself with a leather strap.

The patient’s family claimed that the church break-in was a new, risky behavior that warranted an in-person evaluation. The psychiatrist argued that the patient often called his office, that the tone of her message did not suggest an imminent suicide attempt, and that neither the minister nor police feared she would harm herself. The psychiatrist’s records showed numerous office visits and telephone calls regarding the patient’s medication.

The family also claimed that the patient was extremely frustrated by her lack of progress. The psychiatrist countered that the patient refused his recommendations for further treatment.

• The case was settled for $600,000.
  

Dr. Grant’s observations

There are obvious benefits to dealing with patients over the telephone. First, phone consultations can prevent unnecessary office visits or a trip to the emergency room,¹ especially when a patient needs reassurance rather than an assessment.

Second, telephone contact can help you cost-effectively track an acute or chronic illness.² A short telephone conversation can spare some patients the expense of an office visit.

Recent data³ suggest that care management and psychotherapy via telephone may improve clinical outcomes for patients taking antidepressants for depression. Physician-patient telephone calls average 4.3 minutes and very few are considered urgent, so most calls will not result in a legal problem.⁴

The above cases reflect what many psychiatrists do routinely: assess a patient and change medication without seeing the patient. Roughly 25% of physician-patient interactions occur over the telephone.⁴ In one-third of these interactions, however, the physician and patient disagree on the reason for the call.⁵ Given this rate of miscommunication, beware of potential legal trouble when communicating with patients by telephone.

 

Phone management pitfalls

Improper diagnosis and treatment. The American Psychiatric Association (APA) considers starting a patient relationship without a face-to-face evaluation unethical, but office evaluations are not required when changing an established treatment plan.⁶ APA’s ethics committee suggests that face-to-face evaluations of established patients are required only if “clinically necessary,” so use your knowledge of the patient and the call to determine clinical necessity.

The above cases appear to stem from the psychiatrists’ failure to detect the severity of the patients’ problems and to offer more intensive interventions. Two limitations of telephone conversation can increase the risk of missed diagnosis and delayed or inappropriate treatment:

• Telephone assessments tend to be rushed and not as systematic as an office evaluation.
  
• Making a thorough assessment is difficult without seeing the patient’s nonverbal cues.
  

For example, an otherwise well-kempt person’s disheveled appearance or a previously nonpsychotic person’s apparent responses to internal stimuli would raise a red flag during an in-person visit.⁷

Breach of confidentiality occurs when a physician provides confidential medical information to someone other than the patient without the patient’s consent.⁷ In one study assessing physician telephone calls, the physician spoke to the patient in only 79% of cases.⁸

Disclosing information without consent could violate the patient’s privacy. When a caller identifies himself as your patient, make sure you know who’s on the phone. If the caller requests confidential information (such as HIV test results) and you’re not sure that the caller is your patient, tell him you’ll call back or ask the patient to come to your office for the test results. If the caller is giving but not requesting information, you are not violating the patient’s confidentiality.

In the above cases, the psychiatrists discussed symptoms and treatment with someone other than the patient. In the first case, the psychiatrist violated the patient’s confidentiality by discussing the patient’s medication needs not with him but with his wife. In the bargain, the doctor did not get informed consent. The psychiatrist should have spoken directly to the patient or asked him for permission to discuss care with his wife. The patient might have been too confused to talk with the psychiatrist, leading the psychiatrist to offer different treatment recommendations.

Changing medication or dosages requires a thorough discussion of the drug’s side effects, benefits, and alternatives with the patient.

Telephone protocol for your practice

Talk to the patient directly. As stated, discussing the patient’s treatment with a spouse or someone else without the patient’s permission violates the patient’s privacy. Also, be cautious when interpreting information provided by someone else.

Speaking with the patient directly is crucial to accurate assessment. Without visual cues, the patient’s words become crucial.

During the phone call, have the patient repeat any instructions you give.⁹ This will minimize the risk for error.⁵

Document the call. In one study of psychiatrists receiving or making calls, only 45% documented the calls in the patient’s chart.²

Your defense against a malpractice suit could hinge on the thoroughness of documentation. Make sure you record:

• the date and time of the call
  
• the patient’s name
  
• the chief complaint and his or her disposition
  
• your assessment and any advice given
  
• necessary follow-up action
  
• requests for prescription refills
  
• and any symptoms that indicate that the patient should call back.⁷
  

For example, document that you told the patient to call back if certain serious symptoms result from a medication change, such as a rash after starting lamotrigine or signs of toxicity after increasing lithium. Otherwise, tell the patient you will call back.

How long you wait to call the patient depends on his or her condition. If he or she is fairly stable, you might call after 1 week; if the condition is more serious, you might call the next day.

Avoid managing high-risk patients over the phone. In the above cases, an urgent office visit or a recommendation to report to the nearest emergency room might have been prudent.

Discuss your phone policy during the initial visit. Ask the patient if you can leave a personal message and if his or her message service is private.

Also discuss whether you will charge for phone consultation. Insurance companies often consider telephone conversations “incidental” and usually do not reimburse them separately. From an ethical standpoint, you can charge the patient for such calls if you discuss payment during the initial treatment contact.⁶

Telephone calls to patients can be time-consuming. Although 86% of psychiatrists feel they should receive compensation for these calls, less than 1% do.²

Man attempts suicide after telephone consultations

Kitsap County (WA) Superior Court

A 38-year-old man was hospitalized after a suicide attempt. He was diagnosed as having bipolar affective disorder and treated with lithium and olanzapine. Over the next 3 months a psychiatrist treated him, discontinued olanzapine and lithium, and started valproic acid.

Four months after the suicide attempt, the patient’s wife called the psychiatrist. The patient claims his wife told the psychiatrist he was having paranoid delusions similar to those he had experienced before the suicide attempt. The psychiatrist says the wife reported only that the patient was confused. The psychiatrist told her that her husband should resume taking olanzapine and report the results in 1 to 2 days.

Two days later, the psychiatrist received a voice mail from the patient’s wife, who reported that her husband had improved. The psychiatrist testified that he returned the call and was told that the patient was doing well. The patient denied that this call was made.

The next day, the patient concealed a knife in his briefcase, drove to a wooded area, and stabbed himself three times, lacerating his heart, lung, and diaphragm. He underwent surgery and survived.

In court, the patient argued that if the psychiatrist had evaluated him in person instead of over the telephone, the psychiatrist would have recommended hospitalization. He also alleged that the psychiatrist did not obtain informed consent before stopping olanzapine.

The psychiatrist argued that the patient gave informed consent to withdraw olanzapine and that the second suicide attempt was sudden, unpredictable, and impulsive.

• The jury decided for the defense.
  

Called-in prescription fails to prevent suicide

Unknown Massachusetts venue

A woman with a history of depression, anxiety, and difficulty following prescriptions attempted suicide and was hospitalized after she and her husband separated.

After discharge and under the care of a psychiatrist, the patient became dependent on lorazepam. When she tried to renew her lorazepam prescription but could not reach the psychiatrist, she called the pharmacy and attempted to impersonate the psychiatrist. The pharmacy did not fill the prescription and notified the psychiatrist.

The psychiatrist called the patient that evening and spoke with the patient and her minister, who was with her. The psychiatrist informed the minister that the medication would be delivered to the house if the minister paid for it, administered it to the patient, and saw her to bed. The minister agreed and followed the psychiatrist’s instructions when the medication arrived.

Later that night, the woman broke into the minister’s church and was apprehended by police. She was released after the minister assured police that the break-in was not a criminal matter.

At home, the patient called the psychiatrist again and left a voice mail. Phone records indicate that she stayed on the line for 5 minutes. The psychiatrist reported that he did not receive the message until the next day. By that time, the patient had hanged herself with a leather strap.

The patient’s family claimed that the church break-in was a new, risky behavior that warranted an in-person evaluation. The psychiatrist argued that the patient often called his office, that the tone of her message did not suggest an imminent suicide attempt, and that neither the minister nor police feared she would harm herself. The psychiatrist’s records showed numerous office visits and telephone calls regarding the patient’s medication.

The family also claimed that the patient was extremely frustrated by her lack of progress. The psychiatrist countered that the patient refused his recommendations for further treatment.

• The case was settled for $600,000.
  

Dr. Grant’s observations

There are obvious benefits to dealing with patients over the telephone. First, phone consultations can prevent unnecessary office visits or a trip to the emergency room,¹ especially when a patient needs reassurance rather than an assessment.

Second, telephone contact can help you cost-effectively track an acute or chronic illness.² A short telephone conversation can spare some patients the expense of an office visit.

Recent data³ suggest that care management and psychotherapy via telephone may improve clinical outcomes for patients taking antidepressants for depression. Physician-patient telephone calls average 4.3 minutes and very few are considered urgent, so most calls will not result in a legal problem.⁴

The above cases reflect what many psychiatrists do routinely: assess a patient and change medication without seeing the patient. Roughly 25% of physician-patient interactions occur over the telephone.⁴ In one-third of these interactions, however, the physician and patient disagree on the reason for the call.⁵ Given this rate of miscommunication, beware of potential legal trouble when communicating with patients by telephone.

 

Phone management pitfalls

Improper diagnosis and treatment. The American Psychiatric Association (APA) considers starting a patient relationship without a face-to-face evaluation unethical, but office evaluations are not required when changing an established treatment plan.⁶ APA’s ethics committee suggests that face-to-face evaluations of established patients are required only if “clinically necessary,” so use your knowledge of the patient and the call to determine clinical necessity.

The above cases appear to stem from the psychiatrists’ failure to detect the severity of the patients’ problems and to offer more intensive interventions. Two limitations of telephone conversation can increase the risk of missed diagnosis and delayed or inappropriate treatment:

• Telephone assessments tend to be rushed and not as systematic as an office evaluation.
  
• Making a thorough assessment is difficult without seeing the patient’s nonverbal cues.
  

For example, an otherwise well-kempt person’s disheveled appearance or a previously nonpsychotic person’s apparent responses to internal stimuli would raise a red flag during an in-person visit.⁷

Breach of confidentiality occurs when a physician provides confidential medical information to someone other than the patient without the patient’s consent.⁷ In one study assessing physician telephone calls, the physician spoke to the patient in only 79% of cases.⁸

Disclosing information without consent could violate the patient’s privacy. When a caller identifies himself as your patient, make sure you know who’s on the phone. If the caller requests confidential information (such as HIV test results) and you’re not sure that the caller is your patient, tell him you’ll call back or ask the patient to come to your office for the test results. If the caller is giving but not requesting information, you are not violating the patient’s confidentiality.

In the above cases, the psychiatrists discussed symptoms and treatment with someone other than the patient. In the first case, the psychiatrist violated the patient’s confidentiality by discussing the patient’s medication needs not with him but with his wife. In the bargain, the doctor did not get informed consent. The psychiatrist should have spoken directly to the patient or asked him for permission to discuss care with his wife. The patient might have been too confused to talk with the psychiatrist, leading the psychiatrist to offer different treatment recommendations.

Changing medication or dosages requires a thorough discussion of the drug’s side effects, benefits, and alternatives with the patient.

Telephone protocol for your practice

Talk to the patient directly. As stated, discussing the patient’s treatment with a spouse or someone else without the patient’s permission violates the patient’s privacy. Also, be cautious when interpreting information provided by someone else.

Speaking with the patient directly is crucial to accurate assessment. Without visual cues, the patient’s words become crucial.

During the phone call, have the patient repeat any instructions you give.⁹ This will minimize the risk for error.⁵

Document the call. In one study of psychiatrists receiving or making calls, only 45% documented the calls in the patient’s chart.²

Your defense against a malpractice suit could hinge on the thoroughness of documentation. Make sure you record:

• the date and time of the call
  
• the patient’s name
  
• the chief complaint and his or her disposition
  
• your assessment and any advice given
  
• necessary follow-up action
  
• requests for prescription refills
  
• and any symptoms that indicate that the patient should call back.⁷
  

For example, document that you told the patient to call back if certain serious symptoms result from a medication change, such as a rash after starting lamotrigine or signs of toxicity after increasing lithium. Otherwise, tell the patient you will call back.

How long you wait to call the patient depends on his or her condition. If he or she is fairly stable, you might call after 1 week; if the condition is more serious, you might call the next day.

Avoid managing high-risk patients over the phone. In the above cases, an urgent office visit or a recommendation to report to the nearest emergency room might have been prudent.

Discuss your phone policy during the initial visit. Ask the patient if you can leave a personal message and if his or her message service is private.

Also discuss whether you will charge for phone consultation. Insurance companies often consider telephone conversations “incidental” and usually do not reimburse them separately. From an ethical standpoint, you can charge the patient for such calls if you discuss payment during the initial treatment contact.⁶

Telephone calls to patients can be time-consuming. Although 86% of psychiatrists feel they should receive compensation for these calls, less than 1% do.²

Man attempts suicide after telephone consultations

Kitsap County (WA) Superior Court

A 38-year-old man was hospitalized after a suicide attempt. He was diagnosed as having bipolar affective disorder and treated with lithium and olanzapine. Over the next 3 months a psychiatrist treated him, discontinued olanzapine and lithium, and started valproic acid.

Four months after the suicide attempt, the patient’s wife called the psychiatrist. The patient claims his wife told the psychiatrist he was having paranoid delusions similar to those he had experienced before the suicide attempt. The psychiatrist says the wife reported only that the patient was confused. The psychiatrist told her that her husband should resume taking olanzapine and report the results in 1 to 2 days.

Two days later, the psychiatrist received a voice mail from the patient’s wife, who reported that her husband had improved. The psychiatrist testified that he returned the call and was told that the patient was doing well. The patient denied that this call was made.

The next day, the patient concealed a knife in his briefcase, drove to a wooded area, and stabbed himself three times, lacerating his heart, lung, and diaphragm. He underwent surgery and survived.

In court, the patient argued that if the psychiatrist had evaluated him in person instead of over the telephone, the psychiatrist would have recommended hospitalization. He also alleged that the psychiatrist did not obtain informed consent before stopping olanzapine.

The psychiatrist argued that the patient gave informed consent to withdraw olanzapine and that the second suicide attempt was sudden, unpredictable, and impulsive.

• The jury decided for the defense.
  

Called-in prescription fails to prevent suicide

Unknown Massachusetts venue

A woman with a history of depression, anxiety, and difficulty following prescriptions attempted suicide and was hospitalized after she and her husband separated.

After discharge and under the care of a psychiatrist, the patient became dependent on lorazepam. When she tried to renew her lorazepam prescription but could not reach the psychiatrist, she called the pharmacy and attempted to impersonate the psychiatrist. The pharmacy did not fill the prescription and notified the psychiatrist.

The psychiatrist called the patient that evening and spoke with the patient and her minister, who was with her. The psychiatrist informed the minister that the medication would be delivered to the house if the minister paid for it, administered it to the patient, and saw her to bed. The minister agreed and followed the psychiatrist’s instructions when the medication arrived.

Later that night, the woman broke into the minister’s church and was apprehended by police. She was released after the minister assured police that the break-in was not a criminal matter.

At home, the patient called the psychiatrist again and left a voice mail. Phone records indicate that she stayed on the line for 5 minutes. The psychiatrist reported that he did not receive the message until the next day. By that time, the patient had hanged herself with a leather strap.

The patient’s family claimed that the church break-in was a new, risky behavior that warranted an in-person evaluation. The psychiatrist argued that the patient often called his office, that the tone of her message did not suggest an imminent suicide attempt, and that neither the minister nor police feared she would harm herself. The psychiatrist’s records showed numerous office visits and telephone calls regarding the patient’s medication.

The family also claimed that the patient was extremely frustrated by her lack of progress. The psychiatrist countered that the patient refused his recommendations for further treatment.

• The case was settled for $600,000.
  

Dr. Grant’s observations

There are obvious benefits to dealing with patients over the telephone. First, phone consultations can prevent unnecessary office visits or a trip to the emergency room,¹ especially when a patient needs reassurance rather than an assessment.

Second, telephone contact can help you cost-effectively track an acute or chronic illness.² A short telephone conversation can spare some patients the expense of an office visit.

Recent data³ suggest that care management and psychotherapy via telephone may improve clinical outcomes for patients taking antidepressants for depression. Physician-patient telephone calls average 4.3 minutes and very few are considered urgent, so most calls will not result in a legal problem.⁴

The above cases reflect what many psychiatrists do routinely: assess a patient and change medication without seeing the patient. Roughly 25% of physician-patient interactions occur over the telephone.⁴ In one-third of these interactions, however, the physician and patient disagree on the reason for the call.⁵ Given this rate of miscommunication, beware of potential legal trouble when communicating with patients by telephone.

 

Phone management pitfalls

Improper diagnosis and treatment. The American Psychiatric Association (APA) considers starting a patient relationship without a face-to-face evaluation unethical, but office evaluations are not required when changing an established treatment plan.⁶ APA’s ethics committee suggests that face-to-face evaluations of established patients are required only if “clinically necessary,” so use your knowledge of the patient and the call to determine clinical necessity.

The above cases appear to stem from the psychiatrists’ failure to detect the severity of the patients’ problems and to offer more intensive interventions. Two limitations of telephone conversation can increase the risk of missed diagnosis and delayed or inappropriate treatment:

• Telephone assessments tend to be rushed and not as systematic as an office evaluation.
  
• Making a thorough assessment is difficult without seeing the patient’s nonverbal cues.
  

For example, an otherwise well-kempt person’s disheveled appearance or a previously nonpsychotic person’s apparent responses to internal stimuli would raise a red flag during an in-person visit.⁷

Breach of confidentiality occurs when a physician provides confidential medical information to someone other than the patient without the patient’s consent.⁷ In one study assessing physician telephone calls, the physician spoke to the patient in only 79% of cases.⁸

Disclosing information without consent could violate the patient’s privacy. When a caller identifies himself as your patient, make sure you know who’s on the phone. If the caller requests confidential information (such as HIV test results) and you’re not sure that the caller is your patient, tell him you’ll call back or ask the patient to come to your office for the test results. If the caller is giving but not requesting information, you are not violating the patient’s confidentiality.

In the above cases, the psychiatrists discussed symptoms and treatment with someone other than the patient. In the first case, the psychiatrist violated the patient’s confidentiality by discussing the patient’s medication needs not with him but with his wife. In the bargain, the doctor did not get informed consent. The psychiatrist should have spoken directly to the patient or asked him for permission to discuss care with his wife. The patient might have been too confused to talk with the psychiatrist, leading the psychiatrist to offer different treatment recommendations.

Changing medication or dosages requires a thorough discussion of the drug’s side effects, benefits, and alternatives with the patient.

Telephone protocol for your practice

Talk to the patient directly. As stated, discussing the patient’s treatment with a spouse or someone else without the patient’s permission violates the patient’s privacy. Also, be cautious when interpreting information provided by someone else.

Speaking with the patient directly is crucial to accurate assessment. Without visual cues, the patient’s words become crucial.

During the phone call, have the patient repeat any instructions you give.⁹ This will minimize the risk for error.⁵

Document the call. In one study of psychiatrists receiving or making calls, only 45% documented the calls in the patient’s chart.²

Your defense against a malpractice suit could hinge on the thoroughness of documentation. Make sure you record:

• the date and time of the call
  
• the patient’s name
  
• the chief complaint and his or her disposition
  
• your assessment and any advice given
  
• necessary follow-up action
  
• requests for prescription refills
  
• and any symptoms that indicate that the patient should call back.⁷
  

For example, document that you told the patient to call back if certain serious symptoms result from a medication change, such as a rash after starting lamotrigine or signs of toxicity after increasing lithium. Otherwise, tell the patient you will call back.

How long you wait to call the patient depends on his or her condition. If he or she is fairly stable, you might call after 1 week; if the condition is more serious, you might call the next day.

Avoid managing high-risk patients over the phone. In the above cases, an urgent office visit or a recommendation to report to the nearest emergency room might have been prudent.

Discuss your phone policy during the initial visit. Ask the patient if you can leave a personal message and if his or her message service is private.

Also discuss whether you will charge for phone consultation. Insurance companies often consider telephone conversations “incidental” and usually do not reimburse them separately. From an ethical standpoint, you can charge the patient for such calls if you discuss payment during the initial treatment contact.⁶

Telephone calls to patients can be time-consuming. Although 86% of psychiatrists feel they should receive compensation for these calls, less than 1% do.²

Say “eating disorders,” and young, thin, Caucasian women with anorexia or bulimia nervosa come to mind. Psychiatry outpatients, however, are more likely to have binge eating disorder (BED) or night eating syndrome (NES) and to be middle-aged, obese, male, or African-American.

Like anorexia and bulimia, BED and NES cause distress, impairment, and medical morbidity. But BED and NES are different because you can manage many patients without referring them to eating disorder treatment centers. You can improve patients’ function and quality of life by:

• correcting eating disorder behaviors and thoughts
• identifying and managing psychiatric comorbidity
• identifying and treating associated medical problems (usually obesity complications such as diabetes mellitus, hypertension, and dyslipidemia)
• helping them achieve and maintain a healthy (but realistic) body weight.

Characteristics of BED and NES

BED and NES are coded as eating disorder, not otherwise specified in DSM-IV-TR, and their diagnostic criteria are provisional. Research criteria for BED are listed in Appendix B of DSM-IV (Box 1); diagnostic criteria for NES are being developed (Box 2).

Box1

Box2

Prevalence. How common are these eating disorders? Two small studies examined BED and NES prevalence in outpatient psychiatric populations. A European study found 4% of 234 psychiatry clinic patients met criteria for BED,¹ whereas 12% in 399 patients in two U.S. clinics met criteria for NES (with possibly higher rates in patients who took atypical antipsychotics).²

Demographics. Men experience BED and NES nearly as often as women, and distribution among women is similar across age groups.³ Binge eating may be more common among African-Americans than Caucasians.⁴

Obesity. One-half or more of persons with BED or NES are obese, with body mass index (BMI) ≥30.^5,6 Obesity prevalence increases over time—from 22% at baseline to 39% 5 years later in one study of BED.⁷

Psychiatric comorbidity. Overweight or obesity increase the risk for early mortality and impaired quality of life.⁸ Persons with obesity plus BED have poorer physical and psychosocial function and lower quality of life than do obese persons without BED.⁹

Structured clinical interviews of 128 obese subjects found higher rates of psychiatric disorders in those with BED. Obesity with comorbid binge eating increased lifetime relative risk:

• >6-fold for major depression
• >8-fold for panic disorder
• >13-fold for borderline personality disorder, compared with obesity alone.¹⁰

Similarly, overweight patients with NES have more depression, lower self-esteem, and more difficulty losing weight than those without NES.¹¹ They meet criteria significantly more often for major depressive disorder, anxiety disorders, and substance use disorders.¹² Most NES patients view their nocturnal eating as shameful,¹³ and distress and guilt are among the diagnostic criteria for BED.

Fortunately, successful treatment of BED or NES almost always improves comorbid medical and psychiatric conditions as well. Ongoing treatment is critical for sustaining weight loss.¹⁴

Diagnosis and evaluation

Start by asking overweight patients if they binge eat or do most of their eating at night. Follow up with questions to assess whether they meet provisional diagnostic criteria for BED or NES and to rule out other disorders in the differential diagnosis (Box 3). These include bulimia and sleep-related eating disorder, which is generally regarded as a parasomnia.

 

Obtain a history of the patient’s eating disorder and weight, calculate BMI, and assess for psychiatric comorbidity.¹⁵ Make sure blood pressure and fasting lipids and glucose are monitored in patients who are overweight (BMI ≥27) or obese (BMI ≥30).¹⁶ Question patients with night eating about sleep disorder symptoms and use of hypnotics—especially short-acting benzodiazepines and zolpidem, which have been associated with sleep-related eating disorder.

Box 3

Controlling binge eating

Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), dialectical behavior therapy (DBT), and medications have treated BED effectively in randomized, controlled trials:

• The psychotherapies are equally effective in decreasing bingeing but have little impact on weight.
• Medications are less effective in reducing bingeing but are associated with modest weight loss.

Psychotherapy. The most-studied intervention for BED is CBT, which leads to remission (abstinence from bingeing ≥28 days) in 50% to 60% of patients.¹⁷ CBT techniques for BED adapt readily to self-help programs (Box 4).

In one study patients worked with a self-help manual while meeting biweekly with therapists for 15 to 20 minutes in individual sessions. They were randomly assigned to CBT, behavioral weight loss, or control (self-monitoring only) groups. At 12 weeks, remission rates were:

• 46% with CBT
• 18.4% with behavioral weight loss
• 13.3% for controls.

Patients in the intervention groups lost some weight, but no group showed significant changes in BMI.¹⁸ The manual used in this study is available in bookstores and online (see Related resources for patients and clinicians).

Although somewhat less effective than therapist-led CBT, guided self-help is easy to implement in a general psychiatric practice.

A randomized, controlled trial compared CBT with IPT in 20 weekly group sessions. Posttreatment remission rates were equivalent—79% for CBT versus 73% for IPT—and weight in both groups was essentially unchanged.¹⁹

Abstinence rates after group DBT were 89% in a randomized, controlled trial of 44 women with BED. Binge eating improved significantly more in those assigned to DBT, compared with wait-listed controls. Differences in weight and mood were not significant, and abstinence rates slipped to 56% 6 months after DBT ended.²⁰

Box 4

Medications evaluated for BED in randomized, placebo-controlled trials include selective serotonin reuptake inhibitors (SSRIs) and a tricyclic, obesity management agents (sibutramine and orlistat), and topiramate (Box 5). Binge eating remission rates were highest with antidepressants, and patients lost the most weight with orlistat and sibutramine.

Box 5

Combining CBT with medications or exercise has also been evaluated for BED in randomized, controlled trials:²¹

• Group CBT and fluoxetine, 60 mg/d, were compared with placebo in 108 patients. After 16 weeks, intent-to-treat remission rates were 22% (fluoxetine), 26% (placebo), 50% (CBT + fluoxetine), and 61% (CBT + placebo). Weight loss did not differ significantly among treatments but was associated with binge eating remission.
• Guided self-help CBT combined with orlistat, 120 mg tid, or placebo were compared in 50 patients. After 12 weeks, intent-to-treat remission rates were significantly higher with orlistat (64% versus 36%) but not 3 months later (52% each). Weight loss of ≥5% was seen in 36% of those taking orlistat and in 8% taking placebo.
• Binge eating abstinence doubled when exercise (45 minutes. 3 times/week) was added to CBT; weight loss and mood also improved.

 

Little is known about appropriate dosages and durations for treating BED. Based on bulimia studies, most experts recommend higher-than-usual SSRI dosing (such as fluoxetine, 60 mg/d) and continuing treatment at least 6 months.²²

Behavioral weight-loss programs have not been evaluated for BED in randomized, controlled trials. Obese persons with BED experience weight loss equivalent to that of those without BED, however, and more than one-half of persons with BED stop bingeing.⁹

Most programs combine reduced-calorie diets, increased activity, and behavior modification. Obese patients typically experience a 10% weight loss across 4 months to 1 year, but without continued intervention their weight returns to baseline.²³ Weight Watchers is one behavioral weight-loss program with documented efficacy in controlled trials.²⁴

Advocating calorie restriction for binge-eating patients has been controversial because dieting plays a role in triggering and maintaining bulimia nervosa. Recent evidence suggests, however, that binge eating disorder can be safely managed with dieting. In a randomized, controlled trial, 123 obese women without BED were randomly assigned to 3 groups:

• 1,000 kcal/d liquid meal replacement
• 1,200 to 1,500 kcal/d diet of conventional food
• a non-dieting approach to weight control.

Weight and depressive symptoms declined significantly among women in the two dieting groups but not in non-dieters. More episodes of binge eating were observed in subjects on the liquid diet at week 28, but no differences were seen at weeks 40 and 65, and no subjects in any group developed bulimia or binge eating disorder.²⁵

Surprisingly, a 2003 review found that weight loss treatment that ignores bingeing is as effective in reducing bingeing as treatment that focuses solely on that symptom.²²

Recommendations. A variety of treatments may be effective for BED, but no guidelines exist to help you choose among them. CBT is considered the treatment of choice, but most overweight BED patients require adjunctive exercise, medication, or behavioral weight-loss treatment.

We recommend that you base each patient’s treatment on five factors:

• treatment availability and cost
• past treatment response
• patient preference
• psychiatric and medical comorbidities
• BMI and past weight-loss experience.

For example, self-help CBT plus exercise or orlistat might benefit an obese man with bipolar disorder who was unable to tolerate adjunctive topiramate. An overweight depressed woman who needs weight-loss support could be given sertraline and encouraged to attend Weight Watchers.

Educate patients about realistic weight loss goals. A reasonable expectation is to lose 0.5 to 2 lbs/week, for a 10% loss across 6 months. Refer to guidelines for obesity risk assessment and treatment²³ when advising patients about exercise and weight loss.

Treating night eating syndrome

Research into NES is just beginning, and one small, randomized trial has been published. Twenty patients with NES were randomly assigned to sit quietly or practice progressive muscle relaxation 20 minutes/day for 1 week. Muscle relaxation was associated with improved stress, anxiety, and depression scores, along with trends toward reduced nocturnal eating.²⁶

This study supports a role for stress and anxiety in NES and suggests a potentially effective treatment. These results need to be replicated, however. In other preliminary work:

• After 12 weeks of sertraline therapy (average 188 mg/d), 17 obese patients with NES were eating less often at night, taking in fewer calories after the evening meal, and awakening less often. Five patients (29%) experienced remission, with an average weight loss of 4.8 kg.²⁷
• One of two NES patients treated with topiramate (mean dose 218 mg at night) experienced remission and the other a marked response. Sleep improved, and average weight loss was 11 kg across 8 months.²⁸
• One woman, age 51, with NES and nonseasonal depression experienced remission of depression and NES after 14 phototherapy sessions. NES returned when light therapy was discontinued.²⁹

Recommendations. Suggest that NES patients start progressive muscle relaxation (see Related resources for instructions, or patients can purchase audiotapes). If benefits are insufficient, consider adjunctive sertraline, topiramate, or phototherapy. The efficacy of self-help for NES has not been evaluated, although a manual is available (see Related resources).

Related resources

For clinicians

• Devlin MJ, Yanovski SZ, Wilson GT. Obesity: What mental health professionals need to know. Am J Psychiatry 2000;157:854-66.
• Instructions for progressive muscle relaxation. www.webmd.com/hw/health_guide_atoz/ta4146.asp?navbar=hw153409.

For patients and clinicians

• Anorexia and related eating disorders. www.anred.com (information about BED and NES).
• Self-help manuals available at bookstores or at Gürze Books (www.gurze.com):
  • Fairburn CG. Overcoming binge eating. New York: Guilford Press, 1995.
  • Allison KC, Stunkard AJ, Thier SL. Overcoming night eating syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger Publications; 2004.
• Weight Control Information Network (WIN). National Institute of Diabetes and Digestive and Kidney Diseases. http://win.niddk.nih.gov

Drug brand names

 

• Citalopram • Celexa
• Desipramine • Norpramin
• Fluoxetine • Prozac
• Orlistat • Xenical
• Sertraline • Zoloft
• Sibutramine • Meridia
• Topiramate • Topamax

Disclosures

Dr. Cloak owns Pfizer Inc. stock but otherwise reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Powers reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Say “eating disorders,” and young, thin, Caucasian women with anorexia or bulimia nervosa come to mind. Psychiatry outpatients, however, are more likely to have binge eating disorder (BED) or night eating syndrome (NES) and to be middle-aged, obese, male, or African-American.

Like anorexia and bulimia, BED and NES cause distress, impairment, and medical morbidity. But BED and NES are different because you can manage many patients without referring them to eating disorder treatment centers. You can improve patients’ function and quality of life by:

• correcting eating disorder behaviors and thoughts
• identifying and managing psychiatric comorbidity
• identifying and treating associated medical problems (usually obesity complications such as diabetes mellitus, hypertension, and dyslipidemia)
• helping them achieve and maintain a healthy (but realistic) body weight.

Characteristics of BED and NES

BED and NES are coded as eating disorder, not otherwise specified in DSM-IV-TR, and their diagnostic criteria are provisional. Research criteria for BED are listed in Appendix B of DSM-IV (Box 1); diagnostic criteria for NES are being developed (Box 2).

Box1

Box2

Prevalence. How common are these eating disorders? Two small studies examined BED and NES prevalence in outpatient psychiatric populations. A European study found 4% of 234 psychiatry clinic patients met criteria for BED,¹ whereas 12% in 399 patients in two U.S. clinics met criteria for NES (with possibly higher rates in patients who took atypical antipsychotics).²

Demographics. Men experience BED and NES nearly as often as women, and distribution among women is similar across age groups.³ Binge eating may be more common among African-Americans than Caucasians.⁴

Obesity. One-half or more of persons with BED or NES are obese, with body mass index (BMI) ≥30.^5,6 Obesity prevalence increases over time—from 22% at baseline to 39% 5 years later in one study of BED.⁷

Psychiatric comorbidity. Overweight or obesity increase the risk for early mortality and impaired quality of life.⁸ Persons with obesity plus BED have poorer physical and psychosocial function and lower quality of life than do obese persons without BED.⁹

Structured clinical interviews of 128 obese subjects found higher rates of psychiatric disorders in those with BED. Obesity with comorbid binge eating increased lifetime relative risk:

• >6-fold for major depression
• >8-fold for panic disorder
• >13-fold for borderline personality disorder, compared with obesity alone.¹⁰

Similarly, overweight patients with NES have more depression, lower self-esteem, and more difficulty losing weight than those without NES.¹¹ They meet criteria significantly more often for major depressive disorder, anxiety disorders, and substance use disorders.¹² Most NES patients view their nocturnal eating as shameful,¹³ and distress and guilt are among the diagnostic criteria for BED.

Fortunately, successful treatment of BED or NES almost always improves comorbid medical and psychiatric conditions as well. Ongoing treatment is critical for sustaining weight loss.¹⁴

Diagnosis and evaluation

Start by asking overweight patients if they binge eat or do most of their eating at night. Follow up with questions to assess whether they meet provisional diagnostic criteria for BED or NES and to rule out other disorders in the differential diagnosis (Box 3). These include bulimia and sleep-related eating disorder, which is generally regarded as a parasomnia.

 

Obtain a history of the patient’s eating disorder and weight, calculate BMI, and assess for psychiatric comorbidity.¹⁵ Make sure blood pressure and fasting lipids and glucose are monitored in patients who are overweight (BMI ≥27) or obese (BMI ≥30).¹⁶ Question patients with night eating about sleep disorder symptoms and use of hypnotics—especially short-acting benzodiazepines and zolpidem, which have been associated with sleep-related eating disorder.

Box 3

Controlling binge eating

Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), dialectical behavior therapy (DBT), and medications have treated BED effectively in randomized, controlled trials:

• The psychotherapies are equally effective in decreasing bingeing but have little impact on weight.
• Medications are less effective in reducing bingeing but are associated with modest weight loss.

Psychotherapy. The most-studied intervention for BED is CBT, which leads to remission (abstinence from bingeing ≥28 days) in 50% to 60% of patients.¹⁷ CBT techniques for BED adapt readily to self-help programs (Box 4).

In one study patients worked with a self-help manual while meeting biweekly with therapists for 15 to 20 minutes in individual sessions. They were randomly assigned to CBT, behavioral weight loss, or control (self-monitoring only) groups. At 12 weeks, remission rates were:

• 46% with CBT
• 18.4% with behavioral weight loss
• 13.3% for controls.

Patients in the intervention groups lost some weight, but no group showed significant changes in BMI.¹⁸ The manual used in this study is available in bookstores and online (see Related resources for patients and clinicians).

Although somewhat less effective than therapist-led CBT, guided self-help is easy to implement in a general psychiatric practice.

A randomized, controlled trial compared CBT with IPT in 20 weekly group sessions. Posttreatment remission rates were equivalent—79% for CBT versus 73% for IPT—and weight in both groups was essentially unchanged.¹⁹

Abstinence rates after group DBT were 89% in a randomized, controlled trial of 44 women with BED. Binge eating improved significantly more in those assigned to DBT, compared with wait-listed controls. Differences in weight and mood were not significant, and abstinence rates slipped to 56% 6 months after DBT ended.²⁰

Box 4

Medications evaluated for BED in randomized, placebo-controlled trials include selective serotonin reuptake inhibitors (SSRIs) and a tricyclic, obesity management agents (sibutramine and orlistat), and topiramate (Box 5). Binge eating remission rates were highest with antidepressants, and patients lost the most weight with orlistat and sibutramine.

Box 5

Combining CBT with medications or exercise has also been evaluated for BED in randomized, controlled trials:²¹

• Group CBT and fluoxetine, 60 mg/d, were compared with placebo in 108 patients. After 16 weeks, intent-to-treat remission rates were 22% (fluoxetine), 26% (placebo), 50% (CBT + fluoxetine), and 61% (CBT + placebo). Weight loss did not differ significantly among treatments but was associated with binge eating remission.
• Guided self-help CBT combined with orlistat, 120 mg tid, or placebo were compared in 50 patients. After 12 weeks, intent-to-treat remission rates were significantly higher with orlistat (64% versus 36%) but not 3 months later (52% each). Weight loss of ≥5% was seen in 36% of those taking orlistat and in 8% taking placebo.
• Binge eating abstinence doubled when exercise (45 minutes. 3 times/week) was added to CBT; weight loss and mood also improved.

 

Little is known about appropriate dosages and durations for treating BED. Based on bulimia studies, most experts recommend higher-than-usual SSRI dosing (such as fluoxetine, 60 mg/d) and continuing treatment at least 6 months.²²

Behavioral weight-loss programs have not been evaluated for BED in randomized, controlled trials. Obese persons with BED experience weight loss equivalent to that of those without BED, however, and more than one-half of persons with BED stop bingeing.⁹

Most programs combine reduced-calorie diets, increased activity, and behavior modification. Obese patients typically experience a 10% weight loss across 4 months to 1 year, but without continued intervention their weight returns to baseline.²³ Weight Watchers is one behavioral weight-loss program with documented efficacy in controlled trials.²⁴

Advocating calorie restriction for binge-eating patients has been controversial because dieting plays a role in triggering and maintaining bulimia nervosa. Recent evidence suggests, however, that binge eating disorder can be safely managed with dieting. In a randomized, controlled trial, 123 obese women without BED were randomly assigned to 3 groups:

• 1,000 kcal/d liquid meal replacement
• 1,200 to 1,500 kcal/d diet of conventional food
• a non-dieting approach to weight control.

Weight and depressive symptoms declined significantly among women in the two dieting groups but not in non-dieters. More episodes of binge eating were observed in subjects on the liquid diet at week 28, but no differences were seen at weeks 40 and 65, and no subjects in any group developed bulimia or binge eating disorder.²⁵

Surprisingly, a 2003 review found that weight loss treatment that ignores bingeing is as effective in reducing bingeing as treatment that focuses solely on that symptom.²²

Recommendations. A variety of treatments may be effective for BED, but no guidelines exist to help you choose among them. CBT is considered the treatment of choice, but most overweight BED patients require adjunctive exercise, medication, or behavioral weight-loss treatment.

We recommend that you base each patient’s treatment on five factors:

• treatment availability and cost
• past treatment response
• patient preference
• psychiatric and medical comorbidities
• BMI and past weight-loss experience.

For example, self-help CBT plus exercise or orlistat might benefit an obese man with bipolar disorder who was unable to tolerate adjunctive topiramate. An overweight depressed woman who needs weight-loss support could be given sertraline and encouraged to attend Weight Watchers.

Educate patients about realistic weight loss goals. A reasonable expectation is to lose 0.5 to 2 lbs/week, for a 10% loss across 6 months. Refer to guidelines for obesity risk assessment and treatment²³ when advising patients about exercise and weight loss.

Treating night eating syndrome

Research into NES is just beginning, and one small, randomized trial has been published. Twenty patients with NES were randomly assigned to sit quietly or practice progressive muscle relaxation 20 minutes/day for 1 week. Muscle relaxation was associated with improved stress, anxiety, and depression scores, along with trends toward reduced nocturnal eating.²⁶

This study supports a role for stress and anxiety in NES and suggests a potentially effective treatment. These results need to be replicated, however. In other preliminary work:

• After 12 weeks of sertraline therapy (average 188 mg/d), 17 obese patients with NES were eating less often at night, taking in fewer calories after the evening meal, and awakening less often. Five patients (29%) experienced remission, with an average weight loss of 4.8 kg.²⁷
• One of two NES patients treated with topiramate (mean dose 218 mg at night) experienced remission and the other a marked response. Sleep improved, and average weight loss was 11 kg across 8 months.²⁸
• One woman, age 51, with NES and nonseasonal depression experienced remission of depression and NES after 14 phototherapy sessions. NES returned when light therapy was discontinued.²⁹

Recommendations. Suggest that NES patients start progressive muscle relaxation (see Related resources for instructions, or patients can purchase audiotapes). If benefits are insufficient, consider adjunctive sertraline, topiramate, or phototherapy. The efficacy of self-help for NES has not been evaluated, although a manual is available (see Related resources).

Related resources

For clinicians

• Devlin MJ, Yanovski SZ, Wilson GT. Obesity: What mental health professionals need to know. Am J Psychiatry 2000;157:854-66.
• Instructions for progressive muscle relaxation. www.webmd.com/hw/health_guide_atoz/ta4146.asp?navbar=hw153409.

For patients and clinicians

• Anorexia and related eating disorders. www.anred.com (information about BED and NES).
• Self-help manuals available at bookstores or at Gürze Books (www.gurze.com):
  • Fairburn CG. Overcoming binge eating. New York: Guilford Press, 1995.
  • Allison KC, Stunkard AJ, Thier SL. Overcoming night eating syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger Publications; 2004.
• Weight Control Information Network (WIN). National Institute of Diabetes and Digestive and Kidney Diseases. http://win.niddk.nih.gov

Drug brand names

 

• Citalopram • Celexa
• Desipramine • Norpramin
• Fluoxetine • Prozac
• Orlistat • Xenical
• Sertraline • Zoloft
• Sibutramine • Meridia
• Topiramate • Topamax

Disclosures

Dr. Cloak owns Pfizer Inc. stock but otherwise reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Powers reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Say “eating disorders,” and young, thin, Caucasian women with anorexia or bulimia nervosa come to mind. Psychiatry outpatients, however, are more likely to have binge eating disorder (BED) or night eating syndrome (NES) and to be middle-aged, obese, male, or African-American.

Like anorexia and bulimia, BED and NES cause distress, impairment, and medical morbidity. But BED and NES are different because you can manage many patients without referring them to eating disorder treatment centers. You can improve patients’ function and quality of life by:

• correcting eating disorder behaviors and thoughts
• identifying and managing psychiatric comorbidity
• identifying and treating associated medical problems (usually obesity complications such as diabetes mellitus, hypertension, and dyslipidemia)
• helping them achieve and maintain a healthy (but realistic) body weight.

Characteristics of BED and NES

BED and NES are coded as eating disorder, not otherwise specified in DSM-IV-TR, and their diagnostic criteria are provisional. Research criteria for BED are listed in Appendix B of DSM-IV (Box 1); diagnostic criteria for NES are being developed (Box 2).

Box1

Box2

Prevalence. How common are these eating disorders? Two small studies examined BED and NES prevalence in outpatient psychiatric populations. A European study found 4% of 234 psychiatry clinic patients met criteria for BED,¹ whereas 12% in 399 patients in two U.S. clinics met criteria for NES (with possibly higher rates in patients who took atypical antipsychotics).²

Demographics. Men experience BED and NES nearly as often as women, and distribution among women is similar across age groups.³ Binge eating may be more common among African-Americans than Caucasians.⁴

Obesity. One-half or more of persons with BED or NES are obese, with body mass index (BMI) ≥30.^5,6 Obesity prevalence increases over time—from 22% at baseline to 39% 5 years later in one study of BED.⁷

Psychiatric comorbidity. Overweight or obesity increase the risk for early mortality and impaired quality of life.⁸ Persons with obesity plus BED have poorer physical and psychosocial function and lower quality of life than do obese persons without BED.⁹

Structured clinical interviews of 128 obese subjects found higher rates of psychiatric disorders in those with BED. Obesity with comorbid binge eating increased lifetime relative risk:

• >6-fold for major depression
• >8-fold for panic disorder
• >13-fold for borderline personality disorder, compared with obesity alone.¹⁰

Similarly, overweight patients with NES have more depression, lower self-esteem, and more difficulty losing weight than those without NES.¹¹ They meet criteria significantly more often for major depressive disorder, anxiety disorders, and substance use disorders.¹² Most NES patients view their nocturnal eating as shameful,¹³ and distress and guilt are among the diagnostic criteria for BED.

Fortunately, successful treatment of BED or NES almost always improves comorbid medical and psychiatric conditions as well. Ongoing treatment is critical for sustaining weight loss.¹⁴

Diagnosis and evaluation

Start by asking overweight patients if they binge eat or do most of their eating at night. Follow up with questions to assess whether they meet provisional diagnostic criteria for BED or NES and to rule out other disorders in the differential diagnosis (Box 3). These include bulimia and sleep-related eating disorder, which is generally regarded as a parasomnia.

 

Obtain a history of the patient’s eating disorder and weight, calculate BMI, and assess for psychiatric comorbidity.¹⁵ Make sure blood pressure and fasting lipids and glucose are monitored in patients who are overweight (BMI ≥27) or obese (BMI ≥30).¹⁶ Question patients with night eating about sleep disorder symptoms and use of hypnotics—especially short-acting benzodiazepines and zolpidem, which have been associated with sleep-related eating disorder.

Box 3

Controlling binge eating

Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), dialectical behavior therapy (DBT), and medications have treated BED effectively in randomized, controlled trials:

• The psychotherapies are equally effective in decreasing bingeing but have little impact on weight.
• Medications are less effective in reducing bingeing but are associated with modest weight loss.

Psychotherapy. The most-studied intervention for BED is CBT, which leads to remission (abstinence from bingeing ≥28 days) in 50% to 60% of patients.¹⁷ CBT techniques for BED adapt readily to self-help programs (Box 4).

In one study patients worked with a self-help manual while meeting biweekly with therapists for 15 to 20 minutes in individual sessions. They were randomly assigned to CBT, behavioral weight loss, or control (self-monitoring only) groups. At 12 weeks, remission rates were:

• 46% with CBT
• 18.4% with behavioral weight loss
• 13.3% for controls.

Patients in the intervention groups lost some weight, but no group showed significant changes in BMI.¹⁸ The manual used in this study is available in bookstores and online (see Related resources for patients and clinicians).

Although somewhat less effective than therapist-led CBT, guided self-help is easy to implement in a general psychiatric practice.

A randomized, controlled trial compared CBT with IPT in 20 weekly group sessions. Posttreatment remission rates were equivalent—79% for CBT versus 73% for IPT—and weight in both groups was essentially unchanged.¹⁹

Abstinence rates after group DBT were 89% in a randomized, controlled trial of 44 women with BED. Binge eating improved significantly more in those assigned to DBT, compared with wait-listed controls. Differences in weight and mood were not significant, and abstinence rates slipped to 56% 6 months after DBT ended.²⁰

Box 4

Medications evaluated for BED in randomized, placebo-controlled trials include selective serotonin reuptake inhibitors (SSRIs) and a tricyclic, obesity management agents (sibutramine and orlistat), and topiramate (Box 5). Binge eating remission rates were highest with antidepressants, and patients lost the most weight with orlistat and sibutramine.

Box 5

Combining CBT with medications or exercise has also been evaluated for BED in randomized, controlled trials:²¹

• Group CBT and fluoxetine, 60 mg/d, were compared with placebo in 108 patients. After 16 weeks, intent-to-treat remission rates were 22% (fluoxetine), 26% (placebo), 50% (CBT + fluoxetine), and 61% (CBT + placebo). Weight loss did not differ significantly among treatments but was associated with binge eating remission.
• Guided self-help CBT combined with orlistat, 120 mg tid, or placebo were compared in 50 patients. After 12 weeks, intent-to-treat remission rates were significantly higher with orlistat (64% versus 36%) but not 3 months later (52% each). Weight loss of ≥5% was seen in 36% of those taking orlistat and in 8% taking placebo.
• Binge eating abstinence doubled when exercise (45 minutes. 3 times/week) was added to CBT; weight loss and mood also improved.

 

Little is known about appropriate dosages and durations for treating BED. Based on bulimia studies, most experts recommend higher-than-usual SSRI dosing (such as fluoxetine, 60 mg/d) and continuing treatment at least 6 months.²²

Behavioral weight-loss programs have not been evaluated for BED in randomized, controlled trials. Obese persons with BED experience weight loss equivalent to that of those without BED, however, and more than one-half of persons with BED stop bingeing.⁹

Most programs combine reduced-calorie diets, increased activity, and behavior modification. Obese patients typically experience a 10% weight loss across 4 months to 1 year, but without continued intervention their weight returns to baseline.²³ Weight Watchers is one behavioral weight-loss program with documented efficacy in controlled trials.²⁴

Advocating calorie restriction for binge-eating patients has been controversial because dieting plays a role in triggering and maintaining bulimia nervosa. Recent evidence suggests, however, that binge eating disorder can be safely managed with dieting. In a randomized, controlled trial, 123 obese women without BED were randomly assigned to 3 groups:

• 1,000 kcal/d liquid meal replacement
• 1,200 to 1,500 kcal/d diet of conventional food
• a non-dieting approach to weight control.

Weight and depressive symptoms declined significantly among women in the two dieting groups but not in non-dieters. More episodes of binge eating were observed in subjects on the liquid diet at week 28, but no differences were seen at weeks 40 and 65, and no subjects in any group developed bulimia or binge eating disorder.²⁵

Surprisingly, a 2003 review found that weight loss treatment that ignores bingeing is as effective in reducing bingeing as treatment that focuses solely on that symptom.²²

Recommendations. A variety of treatments may be effective for BED, but no guidelines exist to help you choose among them. CBT is considered the treatment of choice, but most overweight BED patients require adjunctive exercise, medication, or behavioral weight-loss treatment.

We recommend that you base each patient’s treatment on five factors:

• treatment availability and cost
• past treatment response
• patient preference
• psychiatric and medical comorbidities
• BMI and past weight-loss experience.

For example, self-help CBT plus exercise or orlistat might benefit an obese man with bipolar disorder who was unable to tolerate adjunctive topiramate. An overweight depressed woman who needs weight-loss support could be given sertraline and encouraged to attend Weight Watchers.

Educate patients about realistic weight loss goals. A reasonable expectation is to lose 0.5 to 2 lbs/week, for a 10% loss across 6 months. Refer to guidelines for obesity risk assessment and treatment²³ when advising patients about exercise and weight loss.

Treating night eating syndrome

Research into NES is just beginning, and one small, randomized trial has been published. Twenty patients with NES were randomly assigned to sit quietly or practice progressive muscle relaxation 20 minutes/day for 1 week. Muscle relaxation was associated with improved stress, anxiety, and depression scores, along with trends toward reduced nocturnal eating.²⁶

This study supports a role for stress and anxiety in NES and suggests a potentially effective treatment. These results need to be replicated, however. In other preliminary work:

• After 12 weeks of sertraline therapy (average 188 mg/d), 17 obese patients with NES were eating less often at night, taking in fewer calories after the evening meal, and awakening less often. Five patients (29%) experienced remission, with an average weight loss of 4.8 kg.²⁷
• One of two NES patients treated with topiramate (mean dose 218 mg at night) experienced remission and the other a marked response. Sleep improved, and average weight loss was 11 kg across 8 months.²⁸
• One woman, age 51, with NES and nonseasonal depression experienced remission of depression and NES after 14 phototherapy sessions. NES returned when light therapy was discontinued.²⁹

Recommendations. Suggest that NES patients start progressive muscle relaxation (see Related resources for instructions, or patients can purchase audiotapes). If benefits are insufficient, consider adjunctive sertraline, topiramate, or phototherapy. The efficacy of self-help for NES has not been evaluated, although a manual is available (see Related resources).

Related resources

For clinicians

• Devlin MJ, Yanovski SZ, Wilson GT. Obesity: What mental health professionals need to know. Am J Psychiatry 2000;157:854-66.
• Instructions for progressive muscle relaxation. www.webmd.com/hw/health_guide_atoz/ta4146.asp?navbar=hw153409.

For patients and clinicians

• Anorexia and related eating disorders. www.anred.com (information about BED and NES).
• Self-help manuals available at bookstores or at Gürze Books (www.gurze.com):
  • Fairburn CG. Overcoming binge eating. New York: Guilford Press, 1995.
  • Allison KC, Stunkard AJ, Thier SL. Overcoming night eating syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger Publications; 2004.
• Weight Control Information Network (WIN). National Institute of Diabetes and Digestive and Kidney Diseases. http://win.niddk.nih.gov

Drug brand names

 

• Citalopram • Celexa
• Desipramine • Norpramin
• Fluoxetine • Prozac
• Orlistat • Xenical
• Sertraline • Zoloft
• Sibutramine • Meridia
• Topiramate • Topamax

Disclosures

Dr. Cloak owns Pfizer Inc. stock but otherwise reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Powers reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.