The stepped-care approach in anorexia nervosa and bulimia nervosa: progress and problems.

The stepped-care approach is based on the assumption that treatment should be less intensive and hence less expensive and intrusive at the start. Current data suggest that cognitive behaviour therapy (CBT) should be the preferred first treatment for bulimia nervosa (BN) patients. By comparison with the numerous trials supporting its efficacy, in fact, the evidence sustaining similar therapies, e.g. interpersonal psychotherapy (IPT) or pharmacological therapy, is weaker. There are now sufficient data to justify the use of less intensive and shorter treatment (i.e. psychoeducational groups and self-help) in less serious cases. If CBT fails, IPT, pharmacological treatment, alternative psychotherapies, modified CBT, day-hospital and inpatient treatments are available, though it is not clear which is the most efficacious second step. The lower level of stepped-care models seems inapplicable in anorexia nervosa (AN). Current data do not suggest first-choice therapies. Management of this disorder is very expensive and requires a very high level of professional treatment and the highest level of the service hierarchy (intensive outpatient treatment, day-hospital, or inpatient treatment). One of the major obstacles to the employment of the stepped-care approach in eating disorders is that few therapists are trained in CBT and IPT. Academic structures and the scientific societies of eating disorders should promote training and dissemination of these effective forms of treatment.