Not every young patient with anorexia nervosa will need medication, but many will. It has been our experience that the SSRIs such as Prozac, Zoloft, Paxil, etc are not very helpful when it comes to anorexic cognitions and anxieties, although they are helpful for other kinds of anxiety, panic disorder and obsessive compulsive disorder. The medications that do work for our patients are the so-called neuroleptics or anti-psychotics, specifically Olanzapine (Zyprexa/Zydis). And let's be clear: although there is some evidence base for the use of these medications in anorexia nervosa, all such use in children is off-label, meaning it has not yet been approved for this purpose in children.
What is the purpose of medication, this or any other? The primary purpose of any medication, be it pain medication, anesthetics, sedatives, sleeping agents, antibiotics, etc is to alleviate suffering. And patients with eating disorders are suffering; their anxiety around eating sufficient food can be painful to behold. Some people (adults and youth) who agonize over being re-fed, can be managed more humanely with the use of Zyprexa.
Dr. Moshtael, Dr Desocio and I have spent hours removing medication(prescribed elsewhere) from the daily regimens of children who are referred to us: they are on an SSRI, a neuroleptic, an anti-seizure medication (used for many psychiatric diagnoses), a sleeping medication,an antacid, a reflux medication, a benzodiazepine for acute anxiety. The list is nothing short of incredible. No one in our clinic needs that much medication, even when we do feel a neuroleptic is indicated. The effect of ordered eating, parental control over the household schedule and a calm home can work wonders on anxiety, sleep and even abdominal pain.
There is no medication without side effects, and if you read the label on Olanzapine (Zydis/Zyprexa) you will see scary things like movement disorders, appetite increase, EKG changes, weight gain (no, we do not like this), alterations in glucose metabolism, etc. No wonder some parents are concerned. We are concerned.
So how does one go about using such medications in children safely and effectively? We have come up with the following list of pointers,expanded further below:
- Do not give medication to solve eating disorder problems in the absence of ordered eating and adequate nutrition.
- Keep the formulary simple. There is no need to use the full array of ever-newer medications trialed by psychiatrists; stick to what you know. In our case that would be a few SSRIs and pretty much only Zydis/Zyprexa.
- Monitor side effects with an EKG and blood tests on initiation and about every 3-6 months and do a brief neurological exam every time you see them. Recruit the parents as the best observers of any changes in their child.
- Only refill medications for a month at a time and re-evaluate progress every visit. Do not start a child on a major medication and say "see you in a month".
- Keep the patient on the medication for as brief a period of time as possible (less than six months with Zyprexa)
- Use the lowest effective dose to minimize side-effects, including sleepiness—thankfully we get by with teeny doses of Zyprexa/Zydis (2.5 mg-7.5mg/ day).
- Explain any medication you propose to use to the parents (and the patient if they are old enough to process the information) until they are comfortable that they understand your rationale. And then explain again.
- ALWAYS give ANY medication DOT BB S&S x2 (explanation below)
OK, what is DOT BB S&S x2?
Well,when I was a young doctor working in American Samoa I learned an important thing from the wonderful public health nurses there. Those nurses went into people's homes—their people's homes—to administer medication when it was critical that they do so. This is called "Directly Observed Therapy" (the DOT above). DOT is used, for example, when non-compliance with medication (such as anti-tubercular drugs in multiply-resistant strains of TB) would endanger all of us.
Do you have any idea how bad compliance/adherence with medication is in general? I have seen numbers that suggest that patients only take medication as prescribed and for as long as prescribed 50% of the time. I don't know about you, but I have been guilty of stopping my antibiotic as soon as I feel better. And this is common. If we are going to give our children these powerful medications that affect the brain, we are going to do it right. It is dangerous to "forget" dose and then give them to a brain whose chemistry has been "jerked around" in this fashion. Consistency is important, abrupt transitions are not good.
Directly observed therapy (DOT), in our case, means that parents are responsible for giving the medication each and every time. BB means "baby bird". That means that a parent puts the medication directly into their child's mouth, never in their hand or on their plate or at their bedside. This removes any temptation to spit it out or "cheek it".
"My child would never do such a thing!" I hear some of you say. Well, you'd be surprised. Ambivalence—even downright anger—at having to take medication that "takes away anorexic thoughts" is very common, even among children who are otherwise completely cooperative and complaint. I can understand it, can't you?
So to remove any issues of who is and who is not complaint, ambivalent or agreeable, we give all children their medication "baby bird style". When everyone does it this way, no one should feel singled out.
OK, now the medication is in their mouth. In the case of the dissolvable Zydis, the patient says to the parent "it's dissolved" and then the parent gives them a sip of water which they "swish and swallow" twice (that's the S&S x 2). If the medication is a swallowable one, the patient says "I swallowed it", then they are given sips to swish and swallow, twice.
When medication is given this way (DOT BB S&Sx2) every time, compliance/adherence is 100%.
If a medication is worth giving to a child, it is worth giving in such a way that we know exactly what they have ingested and we are able to watch thoughtfully for side-effects. Anything else is careless and we just can't afford to be careless with their lives.