Medication for treatment of eating disorders and Directly Observed Therapy

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From the world of public health and the campaign against tuberculosis comes critical information relevant to our patients with eating disorders.  As many of you know, we have found the use of Olanzapine (Zyprexa) very helpful in the early part of treatment for anorexia nervosa in children, adolescents and young adults.  Obviously, anything worth doing is also worth doing correctly.  After all, it is dangerous (not to mention ineffective) for a child’s blood levels of a medication to gyrate up and down wildly because they sometimes “forget” or their parents “forget” or because they are “cheeking it” intentionally and then spitting it out. 

Studies have consistently shown that average compliance with prescribed medication in adults is no better than 50%; in other words people take only about half of any medication their doctor may have prescribed them.  Moreover, the effects of this non-compliance depend on which half they get: did they only take it for half as long (as in antibiotics) and run the risk therefore of creating relapse and resistant disease organisms? Or did they only take it on some days or less often during the day (as with blood pressure medication), thus running the risk of spiking and dropping their pressure erratically?  Either way, in the case of children, I say it is not worth the risk of doing half a job.  I say we must do it right.

Tuberculosis is a disease that responds to treatment, but if you take your medication erratically or for less time than you should, you run the risk of creating TB organisms that are resistant to most drugs. This endangers everyone.  Where medication adherence is essential to public health, public health nurses long ago came up with Directly Observed Therapy (DOT).  I swear, DOT could have been invented by my grandmother (or yours); it makes such intuitive sense.  It simply means that a responsible party observes the patient taking their medication each and every time.  In other words, it is enforced compliance.  Here is a report on the dramatic difference DOT makes in the case of TB.

For a discussion more relevant to caring for children with eating disorders you might want to read the conversation among parents on the F.E.A.S.T. website,  where one of the moderators wrote:  “My d was a master at palming meds.  Here I was focusing on what was in her mouth and like a good magician, she had somehow distracted me from seeing that she had dropped the pill into her hand no matter how convincingly she seemed to have tossed it into her mouth.” [Ed note: Dr. O’Toole serves on F.E.A.S.T.’s Professional Advisory Panel. Members of this panel are not compensated by F.E.A.S.T.]

One of the parents asked:  “Anyone got any helpful suggestions for ensuring the medicine is being taken??”

Well, yes.  At the Kartini Clinic we call it directly observed therapy, “baby-bird” style.

To begin with, at Kartini Clinic, parents are always in charge of medication for eating disorders.  Always.  Below are our guidelines for parents:

  1. Always observe directly, never leave medication by the bedside or on the table for your child to take.
  2. Have a glass of water handy.
  3. If the medication is dissolvable (e.g. Zydis, Zyprexa) place it into your child’s mouth directly, not into their hand.
  4. Let them tell you when it is dissolved and then ask them to take a drink of water, swish and swallow.  Repeat.
  5. If your medication is not dissolvable (e.g. regular Zyprexa), and your child has been resistance to taking it or been vocal about not wanting to do so, get a pill crusher from the pharmacist, crush the pill, mix it in a teaspoon of water or yogurt and give it to them; do not let them handle the spoon. You spoon and they swallow.  When they are finished, hand them water and ask them to swish and swallow. Repeat.

Sound overly rigid? Not when you consider the consequences of failure to take medication properly. After all, there’s a tremendous amount at stake when were talking about medicating our children.  We prescribe medication for eating disorders only when it’s medically necessary, but if it is we must do it correctly. Doing it correctly could easily mean the difference between getting the result you hope for and not getting it at all.