Treatment Approach for Depression, Binge Eating Disorder, and ADHD
For this patient with depression, binge eating disorder, and ADHD, the most appropriate treatment is to continue bupropion 300 mg daily and add lisdexamfetamine for binge eating disorder and ADHD symptoms.
Current Clinical Picture Assessment
The patient presents with:
- Depression (diagnosed 2014, currently on Wellbutrin/bupropion 300 mg daily)
- Binge eating disorder (formally diagnosed recently)
- ADHD (diagnosed in 2021)
- History of poor tolerance to Adderall and Lexapro
- Current symptoms: rapid thoughts, task difficulty, dissociation, increased ideation frequency
Treatment Recommendations
For Binge Eating Disorder
- Add lisdexamfetamine (Vyvanse): The American Psychiatric Association (APA) suggests that adults with binge-eating disorder who have not responded to psychotherapy alone be treated with either an antidepressant medication or lisdexamfetamine 1.
- Lisdexamfetamine is currently the only FDA-approved medication specifically for moderate to severe binge eating disorder in adults 2.
- Recent research shows that lisdexamfetamine significantly reduces binge eating episodes and produces modest weight loss 3.
For ADHD Management
- Lisdexamfetamine will also address ADHD symptoms: Stimulants are recommended as first-line therapy for ADHD 1.
- Lisdexamfetamine has large effect sizes for reducing ADHD core symptoms with rapid onset of treatment effects 1.
- The patient's previous poor tolerance to Adderall (another stimulant) should be monitored, but lisdexamfetamine may be better tolerated due to its prodrug formulation.
For Depression Management
- Continue bupropion 300 mg daily: The patient is already showing some improvement on this medication 4.
- Bupropion is an effective antidepressant with a favorable side effect profile, particularly regarding sexual dysfunction 1.
- This combination approach addresses all three conditions simultaneously.
Dosing and Monitoring Plan
- Continue bupropion 300 mg daily as currently prescribed
- Start lisdexamfetamine at 30 mg daily in the morning
- Titrate lisdexamfetamine gradually over 2-4 weeks to an effective dose (typically 50-70 mg daily)
Monitoring Parameters:
- Blood pressure and pulse at each visit (both medications can affect cardiovascular parameters)
- Weight and appetite changes
- Sleep patterns
- Mood symptoms
- ADHD symptom improvement
- Frequency of binge eating episodes
- Suicidal ideation (especially during initial treatment period)
Evidence-Based Rationale
The combination of bupropion and lisdexamfetamine offers several advantages:
Synergistic effects: The most recent research shows that combination therapy (CBT plus lisdexamfetamine) produces the highest remission rates (70.2%) for binge eating disorder 3.
Dual-targeting mechanism: Lisdexamfetamine addresses both ADHD and binge eating disorder simultaneously, while bupropion continues to manage depression.
Avoids previous medication intolerances: The patient previously discontinued Adderall due to side effects and Lexapro due to undesirable effects. This approach avoids those specific medications.
Evidence-based approach: The APA guidelines specifically recommend lisdexamfetamine for binge eating disorder when psychotherapy alone is insufficient 1.
Potential Challenges and Mitigation
- Cardiovascular effects: Both medications can increase blood pressure and heart rate. Regular monitoring is essential.
- Sleep disturbances: Take lisdexamfetamine early in the day to minimize insomnia.
- Appetite suppression: While beneficial for binge eating, monitor for excessive weight loss.
- Anxiety/agitation: Start with lower doses and titrate gradually.
Alternative Options (If First-Line Fails)
If this approach is unsuccessful:
- Consider cognitive-behavioral therapy specifically for binge eating disorder
- Evaluate for topiramate as an alternative medication for binge eating
- Consider non-stimulant ADHD medications like atomoxetine if stimulants remain problematic
The evidence strongly supports this combined approach as the most effective strategy for addressing this patient's multiple conditions while building on the partial response already achieved with bupropion.