The Evidence Is There, Now Make It Work

Jacques, a friend and parent advocate, sent me an online summary of an article discussing the current evidence base for the use of Olanzapine in anorexia nervosa.  Keep in mind as you read the summary that, regardless of the evidence base for efficacy and safety of Olanzapine in general and with anorexia nervosa in particular, this is still an off label use of this drug.  Off label means it is a drug approved for one condition which is used by physicians to treat a different condition in a novel way.  This kind of use is extremely common throughout medicine and especially in psychiatry. ??

It’s all very well (and highly desirable) to have an evidence base for any treatment we use in children, however, no medication works unless it is actually taken. And although this sounds like “duh!”, you have to know that compliance with medication is somewhere around 50% under the best of circumstances.   Even though this dismal statistic is widely known, providers are still very reluctant to take the bull by the horns and advocate for directly observed, no-option medication administration in children, adolescents and young adults. Why?

??In the article quoted here, Dr Daniel LeGrange, a highly respected eating disorder treatment provider at the University of Chicago, is quoted as saying: “One challenge is finding a medication that patients with anorexia nervosa will agree to take regularly…… Patients are almost uniformly very skeptical and very reluctant to take any medication that could lower their resolve to refrain from eating……there are long-standing resistances, and I think researchers and clinicians have been very reluctant to embark on that course, since it’s just littered with obstacles.”

Agree to take? ??

We seem to have finally achieved a consensus opinion among those of us who practice a family-based approach to the treatment of eating disorders: that parents should be in charge of no-option re-feeding. So why are we so reluctant to extend this approach to medication? Food is medicine and…medication is also medicine!   The article quotes Stephanie Dulawa, PhD, assistant professor of Psychiatry & Behavioral Neuroscience at the University of Chicago and senior author of the study as saying  “Anorexia nervosa is the most deadly psychiatric disorder…”  Surely if that is true we should take very, very seriously the administration of a medication known to help? No doses should be missed.??

I have discussed this issue elsewhere and detailed how we manage this at Kartini Clinic.  What have the rest of you (parents, parent advocates, patients and providers) experienced?  What do you think?