Guest Post by Dr. Julie O'Toole
I am going to begin this blog with a quote from my own book Give Food A Chance, but I will be quoting from the only chapter (“Psychopharmacology”) which I did not write.
Here is Janiece Desocio RN, PhD, psychiatric mental health nurse practitioner (PMHNP) at Kartini Clinic, speaking: “rarely do we think about food as having pharmacological properties, but in fact, food is an essential source of the chemicals produced by our brains to stabilize mood, moderate anxiety, induce sleep, reduce pain, and regulate appetite…… the brain is a natural pharmacy”.
I want to begin a discussion of medication in the treatment of childhood anorexia nervosa with this quote and its emphasis on food and adequate weight restoration. Medication should not be used as a substitute for good food and plenty of it. Without weight restoration you will get nothing.
Many parents have written in to the Around The Dinner Table forum to discuss medication in their child’s treatment plan. They cite their experience, their reading, and ask good questions about which medications are helpful and why. They ask if some medications are helpful or no medications are best and if some are good, then is more than one advisable? As I read through these questions I asked myself whether there were some basic observations we could make and perhaps even guidelines we could come up with for general parental use. These are my thoughts.
1. Avoid polypharmacy. Polypharmacy refers to the use of many medications at the same time. This principle is one that comes naturally to pediatricians; typically children are not taking the laundry list of medications that older adults are. The exception to this can be eating disordered patients who have returned from inpatient psychiatric units or residential treatment centers. They often come to us with “something for sleep”, “something for heartburn or regurgitation”, “a short-acting anti-anxiety medication” “something for depression”, and often “something to treat inattention”. The first thing we do is (carefully) remove all of these drugs, while urgently addressing any short-fall in weight restoration.
Of course there are eating disordered patients with depression, anxiety, insomnia and ADHD who may eventually need medication for this. But remember, when a patient is starved they can look depressed, have difficulty concentrating, have poor sleep, get heartburn from the anxiety food causes, or even have psychotic or delusional symptoms. Never judge a child’s mental health during an episode of starvation. Even the non-stimulant ADHD drugs (e.g. Strattera) can cause decreased appetite and sleeplessness. First re-feed a child and then see which symptoms you are left with.
2. Avoid sleeping medication. Because the brain cannot manufacture needed hormones involved in sleep when you are starved, the most appropriate sleep medication is food. If anxiety is too severe to allow sleep for eating disordered reasons, the patient may need to begin a very small dose of Olanzapine. This will treat the delusional eating disorder anxiety and eradicate the insomnia all in one blow.
3. Know what you are treating. It is axiomatic that different drugs are used to treat different things, yet we sometimes see SSRIs thrown at anorexia nervosa, for example, even though there is no evidence that they help this condition. The reasons given are usually vague references to “depression” or “anxiety”. Depression will often respond to medications in the selective serotonin reuptake inhibitor (SSRI) category, such as Prozac (fluoxetine), Paxil, Zoloft, Celexa, Lexapro and others. But these drugs do not seem to have any effect on the course of anorexia nervosa itself. They should be used sparingly until a person has been re-fed both because once nutrition is adequate the symptoms of “depression” may disappear and because, absent the nutritional precursors for serotonin, the “reuptake inhibition” probably will not work. Anxiety disorders (including OCD) may also need and respond to an SSRI, but the same caveat applies: feed first. Eating disorder anxiety (anxiety specific to cognitions and delusions around fat, weight, getting fat etc.) seems to have its own biology and doesn’t respond to SSRIs the way general anxiety disorders or OCD do, in our experience.
So you can see that having the right diagnosis will be essential to knowing which medication to use.
4. The lowest dose, the shortest period of time. Our patients are children, after all, and our strong preference would be to avoid medication, therefore, once we have decided that medication is needed, it is incumbent on us to follow the guidelines above.
5. Monitor labs. If there are known side effects to a medication, such as liver toxicity or alterations in glucose metabolism, we should test for this.
6. Safety first: DOT /BB style/ S&S x2 This puzzling shorthand means: “directly observed therapy/ baby bird style/ swish and swallow twice”. If we are going to give children medication it must be done safely, they must get the right dose every time, with no skipped doses, which means parents in complete charge, having medication otherwise locked up, giving the medication directly into the child’s mouth (hence “baby bird”) and having the child swish and swallow twice afterwards.
Compliance studies have shown that only 50% of medications are taken as directed for as long as directed. This is simply not safe. We (F.E.A.S.T. parents) do not put children in charge of food and they should not be in charge of medication. I have written a more detailed blog to this point elsewhere, if you are interested.
7. You are the expert. To safely use medication it is important that the people whose observations are the best (parents) be giving the prescriber feedback. We are the experts in our own children. Read about the side effects and watch for them, closely but not neurotically. Do not accept “see you in three months” from a prescriber.
And my partner, Dr. Moshtael, herself a young mother, adds: “if it doesn’t make sense to you, get a second opinion.”
8. Avoid benzodiazepines. I don’t treat adults over 21 years of age, so I don’t know whether or not benzodiazepines should be regularly used for eating disorder anxiety in adults, but I feel they should not be used in children.
Xanax, Valium, Klonopin, Ativan are the trade names of some of the benzodiazepines. When used for sedation before procedures they are fine, but for long-term anti-anxiety use they are sedating, and addictive. We avoid them.
9. Do not fear Olanzapine. The purpose of any medication is to alleviate suffering and our patients are suffering. The eating disorder terrorizes the sufferer. We would not hesitate to use penicillin for painful strep throat and we should not hesitate to use a medication which can relieve some, if not all, of the crippling eating anxiety many of our patients experience. Some patient simply cannot allow themselves to accept food. Some berate themselves once they have eaten. Some become desperate after eating and try to harm themselves.
Olanzapine is an anti-psychotic and that is probably why it works where the SSRIs fail. Our patients are not psychotic in the usual sense, but they certainly can have fixed delusions about food and fat and often delusionally believe themselves to be gaining weight when they ingest even the smallest amount of food or drink. I am sure that the majority of people reading this blog know what I mean when I say that you can talk, persuade, cajole and argue with someone with anorexia nervosa, patiently explaining that they have nothing to fear, that they will not get fat and are not, in fact, fat --- to no avail. Anosognosia prevents them hearing you.
We are fortunate in the use of Olanzapine in several ways: younger children seem to metabolize it rapidly, and we are able to get good results with very low doses (2.5 mg- 7.5 mg/day) and a short treatment period (weeks to months, rather than years to lifetime). Because of the low dose and brief period of treatment we do not see the side effects mentioned in the literature. And because Kartini patients are all on our meal plan, we do not see the dreaded “weight gain”. We know how to make patients gain weight when we need to, we do not want medication for that.
Olanzapine will cause some sleepiness for the first three days or so that it is given, and patients old enough to drive should not be allowed to do so.
In order to safely and effectively use Olanzapine in children we need to carefully follow the precepts I have listed above: know what you are treating; use the lowest dose for the shortest period of time; monitor labs; parents in charge of all medication administration; and good communication with the prescriber about what you are noticing as the medication begins.
Those are our guiding lights. I hope they are helpful.