In a 20-year-old female with no prior psychiatric medication, a history of cutting, suicidal ideation, a recent suicide attempt by ingesting 15 acetaminophen tablets, and a history of binge‑eating, purging, and alcohol use, what medication should be initiated?

Initiate fluoxetine 60 mg daily for bulimia nervosa while immediately addressing acute suicide risk and acetaminophen toxicity.

Immediate Medical Priorities

First, ensure medical stabilization from the acetaminophen overdose – obtain acetaminophen levels, liver function tests, and consider N-acetylcysteine if indicated. Simultaneously assess for acute suicide risk requiring inpatient psychiatric hospitalization 1.

Medication Selection for Eating Disorder

For this patient with binge-purge behaviors, start fluoxetine 60 mg daily. The 2023 APA guidelines specifically recommend that adults with bulimia nervosa be treated with eating disorder-focused cognitive-behavioral therapy AND a serotonin reuptake inhibitor (specifically citing 60 mg fluoxetine daily), either initially or if minimal response to psychotherapy alone by 6 weeks 1.

Why Fluoxetine at This Dose:

• Fluoxetine is the only FDA-approved medication for bulimia nervosa 2
• The therapeutic dose for bulimia is 60 mg daily – higher than typical antidepressant dosing
• It addresses both the eating disorder pathology and comorbid depressive symptoms that contribute to suicidality 3

Critical Safety Considerations

Suicide Risk Management

This patient has multiple high-risk features:

• Recent suicide attempt
• History of non-suicidal self-injury (cutting)
• Binge-purge subtype eating disorder (independently associated with suicide attempts) 4, 5
• Alcohol use complicating impulsivity

The binge-purge pattern specifically increases suicide attempt risk beyond other eating disorder presentations 4, 5. Depression and psychiatric comorbidities are key drivers of suicidal ideation in eating disorders 3.

Pre-Medication Workup Required

Per APA guidelines, obtain 1:

• ECG – mandatory in patients with severe purging behavior (QTc prolongation risk)
• Complete blood count
• Comprehensive metabolic panel with electrolytes (purging causes hypokalemia, hypomagnesemia)
• Liver and renal function tests

Treatment Framework

Medication alone is insufficient. The guideline emphasizes a coordinated multidisciplinary approach 1:

1. Psychotherapy is primary treatment: Eating disorder-focused CBT should be initiated concurrently, not after medication trial
2. Fluoxetine augments psychotherapy: Can be started immediately rather than waiting 6 weeks for psychotherapy response given severity
3. Address alcohol use: Complicates both eating disorder and suicide risk
4. Monitor purging behaviors: Track frequency as both treatment outcome and medical safety indicator

Common Pitfalls to Avoid

• Don't underdose fluoxetine: 20-40 mg is inadequate for bulimia; 60 mg is the evidence-based dose
• Don't delay psychiatric hospitalization: Active suicidality with recent attempt requires immediate safety intervention
• Don't ignore electrolytes: Purging can cause life-threatening cardiac arrhythmias from electrolyte disturbances
• Don't prescribe bupropion: Contraindicated in eating disorders due to seizure risk

Medication Alternatives

If fluoxetine fails or is not tolerated, other antidepressants have evidence in binge-eating spectrum disorders 6, though fluoxetine remains first-line per guidelines. Lisdexamfetamine is FDA-approved for binge-eating disorder but not bulimia nervosa 2.