What is the best treatment approach for a 45-year-old patient with a history of adjustment disorder, major depressive disorder (MDD), and binge eating disorder, currently taking Vyvanse (lisdexamfetamine) for binge eating and hydroxyzine for anxiety?

Treatment Approach for 45-Year-Old with MDD, Adjustment Disorder, and Binge Eating Disorder on Vyvanse and Hydroxyzine

Continue Vyvanse (lisdexamfetamine) 50-70 mg daily for binge eating disorder as it is the only FDA-approved medication for moderate to severe BED, and add eating disorder-focused cognitive-behavioral therapy (CBT) as first-line treatment, while initiating an SSRI antidepressant for the major depressive disorder, replacing hydroxyzine with the SSRI for anxiety management. 1, 2, 3

Optimizing Binge Eating Disorder Treatment

• Ensure Vyvanse dosing is adequate: The target dose for BED is 50-70 mg once daily, taken in the morning, with maximum dose of 70 mg daily 3, 4
• Add eating disorder-focused CBT immediately: This should normalize eating patterns, address psychological factors driving binge eating, and target preoccupation with food and body image 1, 2
• If binge eating does not improve after 6 weeks of combined therapy, consider augmenting with topiramate or switching strategies, though discontinuation of Vyvanse should be considered if no improvement occurs 1, 3, 5
• Monitor binge eating frequency weekly: Quantify days per week with binge episodes to track treatment response objectively 1

Addressing Major Depressive Disorder

• Initiate SSRI therapy for MDD: Fluoxetine, sertraline, or citalopram are first-line options with similar efficacy for depression and can simultaneously address anxiety symptoms 1
• The SSRI serves dual purposes: It treats both the major depressive disorder and the anxiety symptoms currently managed by hydroxyzine, which is less effective than SSRIs for chronic anxiety in this context 1
• If minimal response to SSRI by 6 weeks: Consider switching to a different antidepressant (venlafaxine, bupropion, or mirtazapine) or augmenting with cognitive therapy 1
• Avoid tricyclic antidepressants and MAOIs: Second-generation antidepressants have lower toxicity and similar efficacy 1

Managing Medication Interactions and Safety

• Monitor cardiovascular status closely: Vyvanse requires assessment for cardiac disease history, vital signs including orthostatic blood pressure and heart rate, and ECG if indicated 1, 3
• Check for drug interactions affecting Vyvanse levels: Acidifying agents (vitamin C) decrease amphetamine levels while alkalinizing agents (antacids) increase levels; adjust Vyvanse dose accordingly 3
• SSRIs are compatible with Vyvanse: No major contraindications exist, though monitor for increased sympathomimetic effects 3, 5
• Obtain baseline labs: Complete blood count and comprehensive metabolic panel to identify electrolyte abnormalities before and during treatment 1

Monitoring Treatment Response

• Weekly assessment initially: Track binge eating days per week, depressive symptoms (using PHQ-9 or HAM-D), and anxiety levels 1
• Weight and vital signs at each visit: Document BMI, blood pressure, heart rate, and orthostatic changes given stimulant use 1, 3
• Screen for suicidality regularly: Eating disorders carry high mortality risk, with 25% of deaths in anorexia nervosa attributed to suicide; this vigilance applies across eating disorder spectrum 2
• Assess for treatment-emergent adverse events: Most common with Vyvanse include dry mouth, headache, and insomnia; these are typically mild to moderate 4, 5

Common Pitfalls to Avoid

• Do not use Vyvanse for weight loss: It is not indicated for obesity treatment, and sympathomimetic drugs for weight loss carry serious cardiovascular risks 3
• Do not continue Vyvanse indefinitely without response: If binge eating does not improve, discontinue rather than continuing ineffective treatment 3
• Do not overlook adjustment disorder: While less severe than MDD, it still requires therapeutic attention through psychotherapy, which the CBT for BED can partially address 1
• Avoid afternoon Vyvanse dosing: This increases insomnia risk, which is already a common side effect 3

Treatment Algorithm Decision Points

• At 6 weeks: If binge eating persists despite Vyvanse + CBT, consider topiramate augmentation (off-label but evidence-supported) 6, 5
• At 6 weeks: If depression shows minimal response to SSRI, switch to different antidepressant class or augment with cognitive therapy 1
• At 12 weeks: Reassess all three conditions; if BED in remission but depression persists, continue Vyvanse and optimize antidepressant strategy 1, 4
• Long-term (beyond 26 weeks): If BED remains in remission on Vyvanse, consider gradual taper with close monitoring for relapse, as withdrawal studies show marked increase in relapse risk off medication 4