What are the best treatment options for a patient with depression, anxiety, and binge eating disorder, who is concerned about weight gain and has a history of eating disorders?

Treatment Options for Depression, Anxiety, and Binge Eating Disorder

For this patient with depression, anxiety, and binge eating disorder who has concerns about weight gain, the optimal treatment approach is cognitive-behavioral therapy (CBT) combined with fluoxetine 60mg daily, which addresses all three conditions while minimizing weight gain concerns. 1, 2

Assessment of Current Symptoms

The patient presents with:

• Depression (rated 7/10) with some improvement on current medication
• Binge eating behaviors without appetite changes
• Occasional anxiety/panic attacks (particularly premenstrual)
• History of eating disorders with concerns about medication-induced weight gain
• Poor concentration
• Inadequate response to hydroxyzine for anxiety

First-Line Treatment Approach

Psychotherapy

• Eating disorder-focused CBT should be initiated immediately as it effectively targets:
  • Binge eating behaviors
  • Depression symptoms
  • Anxiety symptoms
  • Distorted thoughts about food, weight, and body image 1, 2

Pharmacotherapy

• Fluoxetine 60mg daily is recommended as it:
  • Is specifically recommended by APA for bulimia nervosa and binge eating 1
  • Treats comorbid depression and anxiety symptoms
  • Has minimal weight gain compared to other antidepressants
  • Can be added initially or after 6 weeks if inadequate response to psychotherapy alone 1

Second-Line Medication Options

If fluoxetine is ineffective or poorly tolerated:

1. Lisdexamfetamine:

   • FDA-approved specifically for binge eating disorder
   • May help with concentration issues
   • Caution: Monitor for increased anxiety and cardiovascular effects 2

2. Bupropion:

   • Associated with weight loss rather than weight gain
   • Effective for depression
   • Contraindicated in patients with seizure disorders or eating disorders with purging behaviors 3

Management of Anxiety Symptoms

• Replace hydroxyzine (which the patient reports as ineffective) with:
  • Scheduled deep breathing exercises during high-anxiety periods
  • CBT techniques specifically targeting anxiety symptoms
  • Tracking premenstrual symptoms to implement preventive strategies before menstrual cycle

Addressing Binge Eating

Binge eating disorder requires specific attention as it:

• Mediates the relationship between depression/anxiety and caloric intake 4
• Is associated with reduced quality of life and increased health complications 5

Treatment should focus on:

• Normalizing eating patterns through structured meal planning
• Identifying emotional triggers for binge episodes
• Developing alternative coping strategies for emotional distress

Monitoring and Follow-up

• Weekly therapy sessions initially, with medication review every 2-4 weeks
• Track frequency of binge episodes, depression severity, and anxiety symptoms
• Monitor weight but emphasize that symptom reduction rather than weight loss is the primary goal 2
• Assess for side effects, particularly those that might trigger eating disorder concerns

Important Considerations

• Weight concerns: Acknowledge and address the patient's fear of medication-induced weight gain, as this is a legitimate concern given her history of eating disorders
• Comorbidity impact: Depression, anxiety, and binge eating disorder have bidirectional relationships, with each condition potentially worsening the others 6
• Negative emotions: Stress, depression, and anxiety are significant triggers for binge eating behaviors 7, 8

Technology-Based Support Options

Consider supplementing in-person treatment with:

• Guided computer/internet-based CBT interventions which have shown efficacy for eating disorders 1
• Mobile applications for mood and binge eating tracking
• Online support groups for additional accountability

By implementing this comprehensive treatment approach focusing on both psychological and pharmacological interventions, the patient can address her depression, anxiety, and binge eating while minimizing concerns about weight gain.