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

Best SSRI for Binge Eating Disorder

SSRIs are not first-line treatment for binge eating disorder—lisdexamfetamine is the only FDA-approved medication and should be the first pharmacologic choice when medication is indicated. 1, 2, 3

Treatment Hierarchy

Primary Approach

• Psychotherapy, specifically eating disorder-focused cognitive-behavioral therapy (CBT) or interpersonal therapy, should be the initial treatment for BED 1, 2, 3
• Medication should be considered when patients prefer medication over psychotherapy or have not responded adequately to psychotherapy alone 1, 2, 3

First-Line Pharmacotherapy

• Lisdexamfetamine is the only FDA-approved medication specifically for moderate-to-severe binge eating disorder and represents the first-line pharmacologic choice 2, 3
• Lisdexamfetamine should be particularly considered when weight management is a treatment goal 2, 3

If SSRIs Are Chosen (Second-Line)

Best SSRI Option: Fluoxetine

Among SSRIs, fluoxetine demonstrates the strongest evidence for efficacy in binge eating disorder. 4

• Fluoxetine significantly reduces binge eating frequency and shows the greatest reduction in depression scores (HAMD) compared to other SSRIs 4
• Fluoxetine at 60 mg/day is FDA-approved for bulimia nervosa (which shares binge eating behaviors with BED), providing regulatory support for its use in eating disorders 5
• A network meta-analysis comparing SSRIs found fluoxetine to be the best choice when considering both efficacy and acceptability 4

Alternative SSRI: Sertraline

• Sertraline also significantly reduces binge eating frequency compared to placebo 4
• Head-to-head comparison showed no significant difference between sertraline (100-200 mg/day) and fluoxetine (40-80 mg/day) over 24 weeks 6
• Both medications produced significant improvement in Binge Eating Scale scores and weight loss after 8 weeks, maintained through 24 weeks in responders 6

Other SSRIs with Evidence

• Fluvoxamine (300 mg/day) combined with CBT may enhance effects on eating behaviors more than fluoxetine combined with CBT 7
• Citalopram has shown modest but significant reduction in binge eating frequency 8

Critical Limitations of SSRIs in BED

• All SSRIs show modest efficacy at best—they reduce binge eating frequency but are ineffective for weight loss 8, 4
• SSRIs work primarily in the short term; long-term efficacy data beyond 24 weeks are limited 8, 6
• Effect sizes are smaller than those seen with lisdexamfetamine or topiramate 1, 2

Medications to Avoid

• Mirtazapine and tricyclic antidepressants should be avoided in BED patients with obesity due to weight gain potential 1, 2, 3

Alternative Non-SSRI Options (Superior to SSRIs)

• Topiramate (often as phentermine/topiramate ER) has substantial evidence for reducing both binge eating behaviors and body weight 1, 2, 3
• Naltrexone/Bupropion (Contrave) is particularly useful for patients with food cravings or addictive eating patterns, and may benefit those with comorbid depression 1, 2, 3

Practical Algorithm

1. Start with CBT or interpersonal therapy 1, 2, 3
2. If medication is needed, choose lisdexamfetamine first (especially if weight management is a goal) 2, 3
3. If lisdexamfetamine is contraindicated or ineffective, consider topiramate or naltrexone/bupropion 1, 2, 3
4. If an SSRI is specifically needed (e.g., for comorbid depression), use fluoxetine 60 mg/day 4, 6
5. Monitor response at 8-12 weeks; if inadequate response (<5% weight loss or persistent binge eating), switch to alternative medication 2, 6