What relapse‑prevention plan is recommended for a patient recently discharged after a three‑day starvation episode for an eating disorder who is currently taking sertraline (Zoloft) 50 mg?

Relapse Prevention After Eating Disorder Discharge

Establish a coordinated multidisciplinary treatment plan immediately upon discharge that includes eating disorder-focused psychotherapy, continued sertraline, close medical monitoring, and family involvement if available. 1, 2

Core Treatment Framework

Your patient requires a comprehensive, coordinated approach involving medical, psychiatric, psychological, and nutritional expertise. 1 The current sertraline 50 mg dose is subtherapeutic for eating disorders and needs adjustment based on the specific diagnosis.

Immediate Post-Discharge Actions

Medical Monitoring:

• Schedule vital sign assessment within 48-72 hours, measuring temperature, resting heart rate, blood pressure, and orthostatic changes (pulse and blood pressure). 1, 2
• Document weight and BMI at every visit to detect early relapse indicators. 1, 2
• Obtain ECG if not done during hospitalization, as three days of starvation places the patient at risk for QTc prolongation and sudden cardiac death. 1, 2
• Order comprehensive metabolic panel (electrolytes, liver enzymes, renal function) and complete blood count to identify hypokalemia, hyponatremia, or other abnormalities from the recent starvation episode. 1, 2

Critical caveat: Normal laboratory values do not exclude serious medical instability—approximately 60% of eating disorder patients show normal labs despite severe malnutrition. 2

Diagnosis-Specific Pharmacotherapy

The optimal medication strategy depends on which eating disorder your patient has:

For Bulimia Nervosa:

• Increase sertraline to 60 mg daily (the therapeutic dose for bulimia is higher than standard antidepressant dosing). 1, 2, 3
• Combine medication with eating disorder-focused cognitive-behavioral therapy from the outset. 1
• Reassess response at 6 weeks; if minimal improvement, optimize psychotherapy intensity before further medication adjustment. 1, 2

For Anorexia Nervosa:

• Continue sertraline 50 mg only if treating comorbid depression or anxiety, as no medication is effective for anorexia nervosa itself. 2, 3, 4, 5
• Some evidence suggests SSRIs may help prevent relapse in weight-restored patients, though data are limited. 4
• The cornerstone of treatment is eating disorder-focused psychotherapy that normalizes eating behaviors, restores weight, and addresses fear of weight gain and body image disturbance. 1, 2

For Binge-Eating Disorder:

• Sertraline 50 mg may be continued or increased to standard antidepressant dosing (50-200 mg). 2, 6
• Consider adding lisdexamfetamine if the patient prefers medication or has not responded to psychotherapy alone. 1, 2

Psychotherapy: The Foundation of Relapse Prevention

For Adults:

• Refer immediately to a therapist trained in eating disorder-focused psychotherapy (cognitive-behavioral therapy or interpersonal therapy). 1, 2, 3
• Therapy should explicitly target normalizing eating patterns, addressing psychological aspects of the disorder, and preventing return to restrictive behaviors. 1, 2

For Adolescents/Emerging Adults:

• Family-based treatment is first-line if a caregiver is available, with remission rates of 48.6% versus 34.3% for individual treatment (OR 2.08,95% CI 1.07-4.03). 1, 2, 7, 3
• Caregiver education should focus on normalizing eating behaviors and supervising meals. 1, 7

Medication alone without concurrent psychotherapy is inadequate and should be avoided. 2

Nutritional Rehabilitation

• Arrange urgent dietitian consultation with eating disorder expertise within one week of discharge. 1, 2
• Set individualized weekly weight gain goals and target weight. 1, 2, 7
• Implement slow, cautious refeeding with phosphorus supplementation to prevent potentially fatal refeeding syndrome, especially given the recent three-day starvation period. 2, 7
• Monitor weight at every visit; any weight loss or failure to gain indicates relapse and requires immediate intervention. 7

Psychiatric Comorbidity Screening

• Systematically assess for depression, anxiety, obsessive-compulsive disorder, and suicidality at every encounter. 2
• This is critical: suicide accounts for 25% of deaths in anorexia nervosa, and eating disorders have among the highest mortality rates of any mental illness. 2, 7, 3
• Screen for substance use disorders, as these influence medication safety and treatment planning. 2

Ongoing Cardiac Monitoring

• Perform serial ECGs if the patient has ongoing restrictive eating or purging behaviors to detect QTc prolongation. 1, 2
• Up to one-third of eating disorder deaths are cardiac-related, with sudden cardiac death being a frequent cause. 2
• Most cardiac abnormalities reverse completely with nutritional rehabilitation, but monitoring is essential during the recovery phase. 2

Medications to Avoid

Absolute contraindications:

• Bupropion or naltrexone/bupropion combinations are contraindicated due to markedly increased seizure risk in patients with bulimia nervosa or binge-eating disorder. 2
• All appetite suppressants and weight-loss agents (phentermine, orlistat, GLP-1 agonists) are contraindicated as they worsen restriction and medical complications. 2

Medications to minimize:

• Avoid weight-gain-inducing medications (olanzapine, clozapine, mirtazapine, tricyclic antidepressants, valproate) where possible, though olanzapine may have a role in severe, treatment-resistant anorexia nervosa. 5, 6

Red Flags Requiring Immediate Hospitalization

• Severe bradycardia, hypotension, or orthostatic instability. 2, 7
• Electrolyte abnormalities (hypokalemia, hyponatremia). 2, 7
• Suicidal ideation or intent. 2, 7
• Rapid weight loss or refusal to eat. 2, 7
• Medical instability from refeeding syndrome. 2, 7

Follow-Up Schedule

• Weekly visits for the first month to monitor weight, vital signs, eating behaviors, and medication response. 2
• Coordinate closely with the multidisciplinary team (psychiatrist, therapist, dietitian) to ensure integrated care. 1, 2
• Do not delay psychiatric referral; the psychiatrist should coordinate the overall treatment plan. 2

Common pitfall: Relying on patient or family denial of illness severity can be fatal. Eating disorders require aggressive early intervention regardless of patient insight. 2, 7