What medications are effective for treating stress eating, including selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac) or sertraline (Zoloft)?

Medications for Stress Eating

For stress eating (binge eating disorder), cognitive-behavioral therapy should be first-line treatment, with lisdexamfetamine or an SSRI (fluoxetine 60mg daily or sertraline) added if psychotherapy alone fails or if the patient prefers medication. 1

Treatment Algorithm

First-Line Approach

• Start with eating disorder-focused cognitive-behavioral therapy (CBT) or interpersonal therapy, delivered individually or in groups 1
• CBT demonstrates effectiveness comparable to antidepressants for mood disorders with fewer adverse effects and lower relapse rates 2
• Psychotherapy should address normalizing eating behaviors, identifying triggers, and developing coping strategies 1

When to Add Medication

Add pharmacotherapy if:

• Minimal or no response to psychotherapy alone by 6 weeks 1
• Patient preference for medication 1
• Severe symptoms requiring immediate intervention 1

Medication Options for Binge Eating Disorder

Primary choices:

• Lisdexamfetamine (stimulant approved for binge eating disorder) 1
• Antidepressants (SSRIs or other classes) 1

SSRI Selection and Dosing

For bulimia nervosa specifically (which shares stress-eating features):

• Fluoxetine 60mg daily is the evidence-based dose—substantially higher than typical depression dosing 1
• This can be prescribed initially or added if psychotherapy shows minimal response by 6 weeks 1

Sertraline as an alternative:

• Effective for binge eating disorder in obese patients over 24 weeks 3
• Dose range: 100-200mg daily 3
• Produces significant improvement in binge eating scores and weight loss after 8 weeks, maintained through 6 months in responders 3

Comparative considerations:

• No significant efficacy differences between sertraline and fluoxetine for binge eating 3
• Both SSRIs are well-tolerated with good safety profiles 4
• Sertraline may have advantages for sleep disturbances and agitation 5

Critical Implementation Points

Timing expectations:

• Full therapeutic effect requires 8-12 weeks, though some improvement may appear earlier 6
• Assess response at 6-8 weeks before switching or augmenting 1, 3

Combination therapy:

• Combining SSRI with CBT provides superior outcomes compared to either alone 6
• This approach reduces relapse risk, as medication discontinuation leads to higher relapse rates than completed psychotherapy 2, 6

Common pitfalls to avoid:

• Using standard antidepressant doses instead of higher doses needed for eating disorders (fluoxetine requires 60mg, not 20mg) 1
• Stopping treatment prematurely before 6-8 weeks when initial response seems absent 3
• Prescribing anxiolytics (benzodiazepines) as primary treatment—these have weak effects and dependence risk 1

Monitoring and Safety

Essential monitoring:

• Track binge frequency, not just mood symptoms 3
• Monitor for suicidal thinking, especially in first months and after dose changes 6
• Watch for serotonin syndrome if combining with other serotonergic agents 6

Discontinuation:

• Taper gradually to minimize discontinuation symptoms 6
• Relapse is more common after medication discontinuation than after completed CBT 2, 6

Special Populations

When psychiatric comorbidity exists:

• SSRIs effectively treat comorbid anxiety and depression alongside eating behaviors 1
• Address underlying mood disorders, as depression is often undertreated in patients with eating disorders 1
• Consider psychiatric consultation for severe cases or treatment-resistant symptoms 1