What is the recommended treatment plan for a patient with complex anxiety, depression, obsessive-compulsive symptoms, and eating behaviors, currently on Zoloft (sertraline) 200 mg and Wellbutrin XL (bupropion) 300 mg?

Treatment Plan for Complex Anxiety, Depression, OCD, and Eating Behaviors

This patient requires immediate optimization of her SSRI for OCD, continuation of CBT/EMDR, formal eating disorder assessment with specialized treatment, and consideration of discontinuing Wellbutrin due to potential anxiety exacerbation.

Immediate Medication Management

Optimize Sertraline for OCD

• Increase sertraline to the maximum dose of 200 mg daily specifically for OCD treatment, as she is already at this dose but may need reassessment of timing and adherence 1, 2
• Sertraline requires at least 8 weeks at maximum tolerated dose (up to 200 mg/day) before determining treatment response for OCD 1, 2
• The current 200 mg dose is appropriate as OCD typically requires higher SSRI doses than depression or generalized anxiety 1, 3

Evaluate Wellbutrin Continuation

• Strongly consider discontinuing or reducing Wellbutrin XL 300 mg, as the patient herself questions whether it exacerbates her anxiety 1
• Bupropion is contraindicated in eating disorders due to seizure risk, which is particularly concerning given her restriction-binge cycle 1
• Her primary symptoms (anxiety, OCD, eating behaviors) are not optimally treated by bupropion, and the risk-benefit ratio is unfavorable 1

Address Panic Symptoms

• Continue hydroxyzine 25 mg PRN for acute physical anxiety symptoms and sleep, as she reports this helps with chest tightness 1
• Avoid restarting scheduled benzodiazepines given her transition from episodic to constant anxiety, which suggests tolerance development 1

Psychological Treatment Optimization

Continue and Intensify CBT/EMDR

• Maintain current CBT and EMDR therapy with emphasis on exposure and response prevention (ERP) specifically for OCD symptoms 1
• ERP should target her compulsive checking behaviors (calling mother, tracking daughter's eating) with 10-20 sessions focused on exposure to uncertainty 1
• The patient is already engaged in appropriate evidence-based psychotherapy, which should continue as first-line treatment 1, 4

Monitor Treatment Response Systematically

• Assess treatment response using standardized instruments at 4 weeks and 8 weeks 1, 4
• If minimal improvement after 8 weeks despite good adherence, adjust the regimen by adding augmentation strategies 1

Eating Disorder Assessment and Treatment

Formal Eating Disorder Evaluation Required

• This patient requires comprehensive eating disorder assessment including vital signs, orthostatic measurements, BMI, complete blood count, comprehensive metabolic panel, and ECG 1
• Her restriction-binge cycle, body image distortion, guilt around food, and symptom worsening after stopping Zepbound indicate significant eating pathology requiring specialized intervention 1

Multidisciplinary Eating Disorder Treatment

• Refer to coordinated multidisciplinary team incorporating medical, psychiatric, psychological, and nutritional expertise 1
• Treatment should include eating disorder-focused CBT addressing both the restriction-binge cycle and body image disturbance 1
• Given the overlap between OCD and eating disorder symptoms (food preoccupation, tracking behaviors), integrated ERP targeting both conditions simultaneously is indicated 5

Pharmacotherapy for Eating Behaviors

• Consider lisdexamfetamine or antidepressant medication specifically for binge-eating behaviors if CBT alone is insufficient 1
• Continue current sertraline as SSRIs can help with eating disorder symptoms, though evidence is stronger for relapse prevention in weight-restored patients 6

OCD-Specific Interventions

Augmentation Strategy if Inadequate Response

• If no response after 8-12 weeks at maximum sertraline dose, add atypical antipsychotic augmentation (such as low-dose aripiprazole or risperidone) 1
• Alternative: switch to clomipramine if sertraline fails, though this requires careful monitoring for side effects 1
• Consider glutamate-modulating agents as third-line options 1

Target Specific OCD Symptoms

• ERP should specifically address her intrusive thoughts about daughter's nutrition, parents' safety, and body image 1
• Reduce time spent on obsessive thoughts (currently 2-3 hours daily) through structured response prevention 1
• Address compulsive checking behaviors (calling mother, tracking daughter's eating) with graduated exposure 1

Anxiety and Depression Management

Prioritize Depression Treatment

• When both depression and anxiety are present, prioritize treatment of depressive symptoms, as improvement in depression often reduces anxiety 1
• Her current "below baseline" mood with anhedonia, apathy, and passive suicidal ideation indicates undertreated depression 1

Address Generalized Anxiety

• The constant "mental loop" of self-doubt and guilt represents generalized anxiety that should respond to optimized SSRI therapy 1
• SSRIs (sertraline) and SNRIs (venlafaxine) are first-line pharmacotherapy for generalized anxiety disorder 1

Pregnancy Planning Considerations

Medication Stability Before Conception

• Patient's desire to stabilize mental health before pregnancy is appropriate and should guide aggressive treatment optimization now 2
• Document current medication regimen and response for future pregnancy planning 2
• Screen for bipolar disorder risk given family history and mood instability before continuing antidepressant monotherapy 2

Critical Monitoring Points

Safety Assessment

• Monitor for worsening suicidal ideation, particularly given passive suicidal thoughts and history of sexual trauma 1
• Assess for serotonin syndrome given multiple serotonergic medications (sertraline, potential future augmentation) 2
• Monitor for activation/hypomania given mood instability described as "roller coaster" and use of antidepressants without mood stabilizer 2

Treatment Response Evaluation

• Reassess at 4 weeks and 8 weeks using Yale-Brown Obsessive-Compulsive Scale for OCD symptoms 1
• Monitor eating disorder symptoms with validated measures (Eating Disorders Examination-Questionnaire) 1, 5
• Track depression severity with standardized instruments 1

Common Pitfalls to Avoid

• Do not use antidepressant monotherapy if bipolar disorder is suspected—her mood instability and "roller coaster" pattern warrant careful screening for bipolar spectrum disorder before continuing current regimen 2
• Do not continue bupropion in the setting of eating disorder behaviors—seizure risk is significantly elevated with restriction-binge patterns 1
• Do not undertreated OCD with subtherapeutic SSRI doses—OCD requires higher doses and longer trials than depression or generalized anxiety 1, 2
• Do not treat eating disorder symptoms without comprehensive medical evaluation—vital signs, orthostatic measurements, and laboratory assessment are essential 1
• Do not delay eating disorder referral—her symptoms have been present since age 19-20 and worsened postpartum, indicating chronic, severe pathology requiring specialized care 1