Can a Psychiatric-Mental Health Nurse Practitioner (PMHNP) assess, diagnose, and treat Binge Eating Disorder (BED) with psychotherapy and pharmacotherapy?

Can PMHNPs Treat Binge Eating Disorder?

Yes, Psychiatric-Mental Health Nurse Practitioners (PMHNPs) can assess, diagnose, and treat Binge Eating Disorder with both psychotherapy and pharmacotherapy, as eating disorders require coordinated multidisciplinary care incorporating psychiatric, psychological, medical, and nutritional expertise. 1

Scope of Practice for PMHNPs in BED Treatment

PMHNPs function within the psychiatric specialty team that coordinates comprehensive eating disorder care. 1 While the American Psychiatric Association guidelines emphasize that psychiatry should coordinate the multidisciplinary treatment plan, PMHNPs practicing within their scope can:

• Conduct comprehensive psychiatric evaluations including measurement of vital signs (temperature, resting heart rate, blood pressure, orthostatic changes), documentation of height, weight, and BMI, and assessment for physical signs of purging behaviors 1
• Order and interpret laboratory studies including complete blood count, comprehensive metabolic panel with electrolytes, and electrocardiograms to detect medical complications 1
• Prescribe evidence-based pharmacotherapy for BED, including lisdexamfetamine (the only FDA-approved medication for moderate to severe BED) or antidepressants when psychotherapy shows minimal response by 6 weeks 1, 2
• Screen for psychiatric comorbidities including depression, anxiety, obsessive-compulsive disorder, substance use disorders, and suicidality, which are essential at every visit 1

Evidence-Based Treatment Algorithm for BED

First-Line Treatment

Initiate eating disorder-focused cognitive-behavioral therapy (CBT) or interpersonal therapy as the cornerstone of treatment. 3, 1 These psychotherapies can be delivered in individual or group formats and represent the primary treatment modality for all patients with BED. 1, 4, 5

Medication Addition at 6 Weeks

If psychotherapy shows minimal or no response by 6 weeks, add pharmacotherapy: 1, 2

• Lisdexamfetamine 50-70 mg daily (FDA-approved, first-choice medication) 2, 6
• Antidepressants (particularly SSRIs like fluoxetine) as an alternative when lisdexamfetamine is contraindicated 1, 6

Alternative Approach

For patients who prefer medication or request combination therapy from the start, lisdexamfetamine or an antidepressant can be prescribed initially alongside psychotherapy. 1, 2

Critical Prescribing Considerations and Contraindications

Absolute Contraindications

• Bupropion is absolutely contraindicated in BED (and bulimia nervosa) due to markedly increased seizure risk 1, 2
• History of anorexia nervosa or bulimia nervosa is an absolute contraindication for lisdexamfetamine due to seizure risk 2

Relative Contraindications

• Substance abuse history requires careful assessment before prescribing lisdexamfetamine, as it is a Schedule II controlled substance with high abuse potential 2

Medications to Avoid

Appetite suppressants and weight-loss agents (phentermine, orlistat, GLP-1 agonists) are contraindicated in eating disorder patients due to risk of worsening restriction and medical complications. 1 Weight gain-inducing medications like olanzapine, clozapine, mirtazapine, tricyclic antidepressants, and valproate should be avoided where possible. 6

Pre-Medication Medical Assessment Requirements

Before initiating any pharmacotherapy, PMHNPs must obtain: 1

• Complete blood count and comprehensive metabolic panel to detect hypokalemia, hyponatremia, or other electrolyte abnormalities
• Electrocardiogram in all patients to evaluate QTc interval and cardiac risk
• Vital signs including orthostatic pulse and blood pressure to identify cardiovascular instability
• Height, weight, and BMI documentation to guide dosing and monitor nutritional status

Special Population: Bipolar Disorder with BED

For bipolar patients with BED, ensure mood stabilization is achieved before adding lisdexamfetamine, as stimulants can precipitate manic episodes. 2, 7 Maintain mood stabilization with medications that do not cause weight gain while treating the eating disorder. 7

Treatment Monitoring and Follow-Up

• Reassess treatment response at 6 weeks for patients on medication; if response is minimal, optimize psychotherapy or adjust medication dosage 1
• Track binge eating frequency at regular intervals to assess treatment response 2
• Monitor blood pressure, heart rate, and watch for new or worsening psychiatric symptoms including psychosis, mania, or suicidality 2
• Serial QTc monitoring is advised for patients with ongoing restrictive eating or severe purging 1

Common Pitfalls to Avoid

• Never use medication monotherapy without concurrent psychotherapy, as psychotherapy remains the foundational treatment for all eating disorders 1
• Do not delay referral to multidisciplinary care to ensure coordinated medical, psychological, and nutritional management 1
• Do not prescribe bupropion or naltrexone/bupropion combination to individuals with BED due to markedly increased seizure risk 1
• Avoid focusing on weight loss as the primary treatment goal; prioritize normalization of eating patterns and psychological factors 7

Coordination with Multidisciplinary Team

While PMHNPs can provide comprehensive psychiatric care for BED, all patients require coordination with a multidisciplinary team including medical physicians, dietitians, and psychotherapists with eating disorder expertise. 1 PMHNPs should ensure patients have access to specialized eating disorder-focused psychotherapy, as this remains the cornerstone of treatment regardless of medication use. 3, 1