The findings:
Binge-eating disorder (BED) is a prevalent and impairing psychiatric condition frequently comorbid with obesity, marked by recurrent episodes of consuming unusually large quantities of food with a subjective sense of loss of control. Increasingly, BED has been conceptualized through the lens of food addiction, due to its behavioral and neurobiological overlap with substance use disorders—particularly dysregulation in dopamine and norepinephrine systems. This addiction-based framework has informed growing interest in pharmacologic strategies targeting reward pathways, such as stimulant medications like lisdexamfetamine (LDX).

In a randomized controlled trial of 141 adults with BED and obesity, researchers evaluated the comparative effectiveness of cognitive-behavioral therapy (CBT), LDX, and their combination (CBT+LDX) over a 12-week period. All three treatments led to significant reductions in binge-eating frequency and eating-disorder psychopathology. However, the combination treatment was most effective, achieving a 96.1% reduction in binge episodes and a 70.2% remission rate, significantly outperforming CBT alone (89.5% reduction, 44.7% remission) and LDX alone (79.7% reduction, 40.4% remission). Regarding weight loss, meaningful reductions occurred only in the LDX and CBT+LDX groups. LDX yielded the greatest average weight loss (5.5%) and the highest proportion of patients achieving ≥5% loss (53.2%), followed by CBT+LDX (42.6%); CBT alone was largely ineffective on this metric (0.5% average loss, 4.3% ≥5% loss). Depression symptoms improved across all arms, though these gains were not sustained after treatment.

This study is the first to demonstrate that combining CBT with an FDA-approved medication for BED (LDX)yields superior clinical outcomes in terms of binge-eating remission, weight loss, and psychiatric symptom improvement. For clinicians—particularly those in consultation-liaison psychiatry—the findings underscore the relevance of addiction-informed models of BED and support integrated treatment approaches that address both behavioral and neurobiological mechanisms. This has implications for treatment planning in medically complex patients where obesity, impulsivity, and mood symptoms intersect.

Strength and weaknesses:
The trial is methodologically robust, utilizing manualized CBT delivered by trained clinicians, blinded independent outcome assessors, and standardized interviews (EDE) and validated questionnaires (BDI-II, EDE-Q). The design allowed for intention-to-treat analyses and incorporated real-world medication titration protocols for LDX. The sample included both moderate and severe BED cases, broadening clinical applicability. However, notable weaknesses limit generalizability and raise practical concerns. Most participants were highly educated (90.8% had some college), predominantly female (83.7%) and White (75.9%), which may not reflect the broader BED population or underserved groups with limited access to specialty care. LDX had a notable adverse event profile: 21.3% of participants in the LDX and CBT+LDX groups were medically withdrawn, a rate higher than dropout in the CBT arm (21.3% dropout, no medical withdrawals), suggesting tolerability concerns that must be weighed in clinical decision-making. The absence of a placebo or active psychotherapy control group (e.g., supportive therapy) limits interpretation of efficacy beyond specific mechanisms. Lastly, long-term outcomes are unknown; CBT has established durability, but LDX’s benefits post-discontinuation remain unclear.

Relevance:
For C-L psychiatrists, this study has several key implications: BED is often underrecognized in medically ill populations despite its high comorbidity with obesity, metabolic syndrome, type 2 diabetes, and mood disorders. This trial supports active screening and diagnosis of BED—particularly in patients presenting with treatment-resistant obesity or unexplained weight fluctuations—in both inpatient medical and outpatient specialty settings. The combined CBT+LDX treatment strategy offers a dual-action approach: CBT targets disordered cognitions and behavioral patterns, while LDX modulates dopaminergic/noradrenergic pathways implicated in reward and impulsivity. For medically complex patients, C-L psychiatrists must weigh LDX’s metabolic and psychiatric benefits against cardiovascular risks, stimulant sensitivity, and potential medication contraindications (e.g., concurrent MAOIs or bipolar disorder). Notably, because LDX did not outperform CBT in binge remission and had higher medical withdrawal rates, CBT remains a first-line treatment, particularly when weight loss is not the primary goal or stimulant risks are high. However, the additive benefit of LDX in promoting weight loss may be especially valuable in integrated behavioral-medical programs or bariatric surgery pathways. The study also reinforces the need for interdisciplinary coordination: pharmacologic strategies must be complemented by psychotherapy and medical monitoring to safely and effectively manage BED in patients with complex medical needs.