What is the treatment of bulimia nervosa? Pharmacotherapy combined with psychotherapy

Bulimia nervosa (ICD-11 6B81 / ICD-10 F50.2) requires a structured, evidence-based approach. Multiple international clinical guidelines converge on a combined strategy in which pharmacological and psychological interventions work together — neither is recommended as a standalone treatment.

Clinical approach

The evidence-based approach centres on the use of antidepressant medication alongside psychotherapy. Psychotherapy remains the foundation; pharmacotherapy is used adjunctively, or when psychological treatment is not accessible. Medication alone is not considered sufficient.

Treatment overview (partial)

Guideline-recommended pharmacotherapy includes a specific SSRI antidepressant, supported consistently across the majority of international guidelines. Additional drug classes — including an anticonvulsant and certain tricyclic antidepressants — may be considered in defined circumstances, with varying levels of cross-guideline agreement. The full sequenced regimen, agent selection criteria, and clinical decision points are available in the complete protocol.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1097/YCO.0000000000000360

Among the recommendations for pharmacological treatment, seven out of eight guidelines consistently recommended antidepressants, specifically the SSRI fluoxetine, although with some restrictions (e.g., to use antidepressants in combination with psychotherapy).

Conflicting recommendations were obtained for the use of TCAs such as imipramine and desipramine, which were recommended by the WFSBP, while the guideline from the United States explicitly did not recommend TCAs for initial treatment in patients with BN.

The use of anticonvulsants, specifically topiramate, was consistently recommended by two guidelines, while the remaining guidelines did not report on anticonvulsants.

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