Management of Depression in Patients with Eating Disorders

Pharmacological Treatment

Bupropion is contraindicated in patients with a history of seizure disorders and should be used with extreme caution in patients with factors that increase seizure risk, with a seizure incidence of approximately 0.1% at therapeutic doses, as noted by the American Gastroenterological Association 1
Bupropion lowers the seizure threshold, with eating disorders like anorexia nervosa and bulimia nervosa being significant risk factors for seizures, according to the American Gastroenterological Association 1
The FDA label and clinical guidelines specifically list eating disorders as contraindications for bupropion use, although the specific guideline society is not mentioned in the article, it is known that the FDA provides these recommendations 1

Fluoxetine is FDA-approved for bulimia nervosa at doses of 60mg daily; also effective for depression, however the FDA provides these recommendations, but no citation is provided
SSRIs (such as sertraline, escitalopram, or fluoxetine) are preferred for patients with anxiety disorders, particularly those with obsessive-compulsive features or intrusive thoughts, and should be started with a low dose and titrated gradually, allowing 4-6 weeks for full effect assessment, as recommended by the Nature Reviews Disease Primers and supported by the National Institute of Mental Health 2
SNRIs, such as duloxetine and venlafaxine, may have slightly higher efficacy than SSRIs but with more side effects, as reported by the American Academy of Family Physicians 3

Lisdexamfetamine is FDA-approved for binge eating disorder in some countries, however no citation is provided
Topiramate shows promise for reducing binge eating behaviors, however no citation is provided
Naltrexone-bupropion combination has shown effectiveness for binge eating disorder in controlled settings; however, should only be considered under close supervision due to the bupropion component, however no citation is provided

Cognitive behavioral therapy (CBT) should be offered alongside pharmacotherapy, as it has shown comparable efficacy to medication for anxiety disorders with potentially more durable effects, according to the Annals of Internal Medicine and the American Psychological Association 4
Interpersonal Therapy is particularly effective for bulimia nervosa and binge eating disorder, however no citation is provided
Nutritional counseling is an essential component of comprehensive treatment, however no citation is provided

Regular weight monitoring, assessment of eating behaviors and psychological symptoms, monitoring of vital signs, particularly in malnourished patients, and laboratory monitoring as indicated by specific medications and nutritional status, however no citation is provided
Patients on bupropion with any seizure risk factors require more frequent follow-up during dose titration, lower threshold for discontinuation if concerning symptoms develop, and consideration of discontinuation if other seizure risk factors develop during treatment, and patients and families should be educated about seizure warning signs and instructed to discontinue and seek medical attention if seizure occurs, as noted by 5

Never prescribe bupropion to patients with current or past eating disorders due to seizure risk, however no citation is provided
Avoid medications that may worsen eating disorder symptoms (e.g., stimulants in restrictive eating disorders), however no citation is provided
Don't focus exclusively on weight restoration without addressing psychological symptoms, however no citation is provided
Avoid abrupt discontinuation of antidepressants; taper gradually when changing medications, however no citation is provided