What is the recommended SSRI (Selective Serotonin Reuptake Inhibitor) for treating binge eating disorder and anxiety?

Recommended SSRI for Binge Eating Disorder and Anxiety

Fluoxetine (60mg daily) is the recommended SSRI for treating both binge eating disorder and comorbid anxiety, as it demonstrates superior efficacy in reducing binge eating frequency while also addressing anxiety symptoms. 1, 2

Treatment Algorithm for Binge Eating Disorder with Anxiety

First-Line Pharmacotherapy

• Fluoxetine: Start at 20mg daily and titrate up to 60mg daily over 4-6 weeks
  • Most effective SSRI for reducing binge eating frequency 2
  • Significantly reduces depression and anxiety symptoms 1, 3
  • Maintains effectiveness at 1-year follow-up when combined with CBT 4

Alternative SSRI Options (if fluoxetine is not tolerated)

1. Sertraline: Demonstrated significant reduction in binge eating frequency compared to placebo 2
2. Fluvoxamine: May enhance effects of CBT on eating behaviors 4

Dosing and Administration

• Begin with low doses and gradually increase to minimize side effects
• Fluoxetine's long half-life allows for once-daily dosing 5
• Expect:
  • Initial improvement within 2 weeks (statistically significant)
  • Clinically significant improvement by week 6
  • Maximal improvement by week 12 or later 5

Monitoring and Safety Considerations

Efficacy Monitoring

• Track frequency of binge episodes weekly
• Assess anxiety symptoms every 2-4 weeks
• Monitor weight changes (though SSRIs alone have limited effect on weight loss) 1, 2

Safety Monitoring

• Boxed warning: Increased risk of suicidal thinking/behavior through age 24
  • Risk difference of 0.7% compared to placebo (NNH = 143) 5
  • Close monitoring recommended in first months and after dose adjustments

Common Side Effects

• Gastrointestinal: dry mouth, nausea, diarrhea, heartburn
• Neurological: headache, somnolence, insomnia, dizziness
• Other: vivid dreams, appetite changes, weight fluctuations, fatigue, nervousness, tremor 5

Serious Adverse Effects to Monitor

• Suicidal ideation/behavior
• Behavioral activation/agitation (more common in anxiety disorders)
• Hypomania/mania
• Sexual dysfunction
• Abnormal bleeding
• Serotonin syndrome 5

Optimizing Treatment Outcomes

Combination Therapy

• Add cognitive-behavioral therapy (CBT) specifically focused on eating disorders
  • CBT + fluoxetine is more effective than medication alone 1, 4
  • Combination therapy shows better maintenance of treatment effects at 1-year follow-up 4

Treatment Duration

• Continue medication for at least 6-12 months after symptom remission
• Regular reassessment of need for continued pharmacotherapy

Special Considerations

Comorbidities

• Fluoxetine is particularly beneficial when BED co-occurs with depression and anxiety 1
• For severe cases or when fluoxetine is ineffective:
  • Consider duloxetine (SNRI) which modulates both serotonergic and noradrenergic pathways 1
  • Lisdexamfetamine is FDA-approved for BED but may not address anxiety 1, 6

Pitfalls to Avoid

• Focusing solely on weight loss rather than reducing binge eating episodes and improving eating disorder psychopathology 1
• Discontinuing medication too early (before 12 weeks) when maximum benefit may not yet be achieved 5
• Failing to monitor for behavioral activation/agitation, especially in anxiety disorders 5
• Rapid dose escalation, which may increase side effects without improving efficacy 5