Although the available treatment research literature suggests that cognitive behavioral therapy (CBT) is an effective treatment for bulimia nervosa, there is evidence that CBT is often not available to patients outside of research protocols and that most therapists are not trained to deliver this technique. This observation may well hold true for many forms of psychotherapy, and speaks to a growing discrepancy between the manual based therapies that are being developed in academic centers and what is available in clinical practice. This study is designed to examine two treatment sequences to bulimia nervosa. The first includes cognitive behavior therapy, coupled to fluoxetine treatment for those who fail to respond to CBT alone, a treatment package that is currently the state-of- the-art treatment for this condition. The second sequence will be a potentially cost-effective stepped treatment approach comprising the use of supervised self-help followed by the use of antidepressant medication (fluoxetine) if remission isn't attained with self-help, and finally followed by CBT, if remission isn't attained with drug therapy. The first two steps could be made widely available in areas where patients currently have no ready access to CBT specific for bulimia nervosa, with referral for CBT for the more treatment resistant cases. We are proposing a sample size of 324 subjects. Considering the sample size requirements for this study, we are proposing a multisite study wherein patients will be recruited and treated at 4 treatment sites, one of which includes the data center. The treatment sites chosen range from large urban areas (e.g., New York City), to small city (e.g., Fargo) which draws extensively from rural areas. This strategy will also allow us to target enhanced minority recruitment. Outcomes of interest include relative effectiveness of the 2 intervention strategies, their cost-effectiveness, their ability to successfully hold patients in therapy and prevent attrition, and their ability to prevent the need for further treatment for those successfully treated (relapse prevention).
