Table.
GRADE Evaluation of interventions for Bulimia nervosa.
| Important outcomes | Quality of life, Symptom improvement | ||||||||
| Studies (Participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of treatments for bulimia nervosa in adults? | |||||||||
| 1 (<77) | Symptom improvement | CBT for bulimia nervosa (CBT-BN) versus waiting list control, no treatment, or placebo | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, no intention-to-treat analysis, and incomplete reporting of results |
| 1 (<77) | Symptom improvement | CBT plus exposure/response prevention therapy (CBT-ERP) versus waiting list control | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, no intention-to-treat analysis, and incomplete reporting of results |
| 1 (39) | Symptom improvement | CBT-ERP versus CBT-BN | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, no intention-to-treat analysis, and incomplete reporting of results |
| 2 (101) | Symptom improvement | Pure or unguided self-help CBT versus waiting list, no treatment, or placebo medication | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and baseline differences in purging between groups. Directness point deducted for inclusion of co-intervention (contact with health professionals) |
| 1 (48) | Symptom improvement | Pure or unguided self-help CBT versus fluoxetine | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for inclusion of co-intervention (contact with health professionals) |
| 2 (143) | Symptom improvement | Guided self-help CBT versus CBT for bulimia nervosa (CBT-BN) | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (295) | Symptom improvement | IPT versus CBT for bulimia nervosa (CBT-BN) | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results. Consistency point deducted for different results for different outcomes |
| 1 (<78) | Symptom improvement | Hypnobehavioural therapy (HBT) versus no treatment, placebo, or waiting list | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and significant differences between groups at baseline |
| 1 (<78) | Symptom improvement | HBT versus CBT for bulimia nervosa (CBT-BN) | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, unbalanced groups at baseline, and incomplete reporting of results |
| 1 (31) | Symptom improvement | Dialectical behavioural therapy versus placebo, no treatment, or waiting list | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and unclear measurement of outcomes |
| 1 (68) | Symptom improvement | Motivational enhancement therapy versus CBT for bulimia nervosa (CBT-BN) | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, short-term follow-up, and no intention-to-treat analysis |
| at least 5 (at least 706) | Symptom improvement | SSRIs versus placebo or no treatment | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting of results and for different results for different outcomes |
| 2 (<111) | Symptom improvement | SSRIs versus CBT for bulimia nervosa (CBT-BN) | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and no intention-to-treat analysis |
| 4 (156) | Symptom improvement | Monoamine oxidase inhibitors (MAOIs) versus placebo or no treatment | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for different results for different outcomes |
| 3 (132) | Symptom improvement | Tricyclic antidepressants (TCAs) versus placebo | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for different results for different outcomes |
| 2 (<211) | Symptom improvement | TCAs versus CBT for bulimia nervosa (CBT-BN) | 4 | –1 | –1 | –1 | 0 | Very low | Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results. Directness point deducted for different regimens between studies |
| 1 (60) | Symptom improvement | Topiramate versus placebo | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and short-term follow-up. Directness point deducted for composite outcome |
| 1 (60) | Quality of life | Topiramate versus placebo | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, short-term follow-up, and incomplete reporting of results |
| 2 (<242) | Symptom improvement | CBT for bulimia nervosa (CBT-BN) plus tricyclic antidepressants (TCAs) versus TCAs alone | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for incomplete reporting and no statistical test between groups. Directness point deducted for conflicting results |
| 2 (<242) | Symptom improvement | CBT-BN plus TCAs versus CBT-BN alone | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (<76) | Symptom improvement | CBT-BN plus fluoxetine versus fluoxetine alone | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (<76) | Symptom improvement | CBT-BN plus fluoxetine versus CBT-BN alone | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (47) | Symptom improvement | Pure self-help CBT plus fluoxetine versus fluoxetine alone | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for inclusion of co-intervention (contact with health professionals) |
| 1 (43) | Symptom improvement | Pure self-help CBT plus fluoxetine versus self-help CBT alone | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and inclusion of co-intervention (contact with health professionals) |
We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.